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PROCEEDINGS 



or Tm 



American M e dico Paychologic aJ- Association 



SEVENTIETH ANNUAL MEETING 



HELD ni 



BALTIMORE, MD., MAY 26-29, 1914 



PUBUSHID BY 

AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 
1914 



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OFFICERS OF 

American Medico-Psychological Association 



:i 



FOR 1918-1914 



COUNCIL 

PRESIDENT CARLOS F. MAC DONALD, M.D. 

Vice-President S. E. SMITH, M.D. 

Sbcrbtaby and Treasuber ... CHARLES G. WAGNER, M. D. 

H. C EYMAN, M.D. 



V 

^' Auditors 



MAURICE C ASHLEY, M.D. 
ELBERT M. SOMERS, M.D. 



COUNCILORS FOR THREE YEARS 

James V. Angun, M. D. Harris M. Carey, M. D. 

J. Percy Wade, M. D. J. M. Buchanan, M. D. 



COUNCILORS FOR TWO YEARS 

Henry M. Hurd, M. D. James V. May, M. D. 

M. L. Perry, M. D. T. J. W. Burgess, M. D. 



COUNCILORS FOR ONE YEAR 

H. W. Mitchell, M.D. J. W. Babcock, M.D. 

W. H. Hancker, M. D. Charles Gorst, M. D. 

281977 



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OFFICERS OF 

American Medico-Psychological Association 



FOR 1914-1915 



COUNCIL 

President SAMUEL E. SMITH, M. D. 

Vice-President EDWARD N. BRUSH, M.D. 

Secretary and Treasuim - - - CHARLES G. WAGNER, M.D. 

MARCUS B. HEYMAN, M.D. 
AuDiTOKS -! H. C EYMAN, M.O. 

MAURICE C ASHLEY, M. D. 



COUNCILORS FOR THREE YEARS 

Henry R. Stedman, M. D. W. M. English, M. D. 

Edwabd M. Green, M. D. Charles F. Applegate, M. D. 



COUNCILORS FOR TWO YEARS 

James V. Angun, M. D. J. Percy Wade, M. D. 

Harris M. Carey, M. D. J. M. Buchanan, M. D. 



COUNCILORS FOR ONE YEAR 

Henry M. Hurd, M. D. M. L. Perry, M. D. 

James V. May, M. D. T. J. W. Burgess, M. D. 



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TABLE OF CONTENTS 



List of Members 9 

List of Life Members 43 

List of Honorary Members 44 

Mortuary 45 

Resignations 46 

Presidents of the Association 47 

Secretaries of the Association 48 

MeetinfiT places of the Association 49 

Geographical Distribution of Members and Institutions 50 

Constitution 79 

By-Laws 84 

Proceedings of the Seventieth Annual Meeting 87 

Presidential Address. Caklos F. MacDonald, M. D 147 

Annual Address. The Relations of Internal Medicine to Psychiatry. 

Lewellys F. Barxkr, M. D 159 

General Paralysis as a Public Health Problem. Thomas W. Salmon, 

M. D 175 

The Pathology of General Paralysis. Charles B. Dunlap, M. D 185 

Differential Diagnosis of General Paresis. Aoolf Meyer, M. D 193 

A Report of Five Cases of the Intracranial Injection of Auto-Sero- 

Salvarsan. Drew M. Wardner, M. D. 201 

Discussion 213 

Report of a Case of Cerebellar Tumor. W. M. Engush, M. D 217 

Discussion 222 

Qinical and Anatomical Analysis of Eleven Cases of Mental Disease 

Arising in the Second Decade, with Special Reference to a Certain 

Type of Cortical Hyperpigmentation in Manic-Depressive Insanity. 

E. E. Southard, M. D., and E. D. Bond, M. D 223 

Anatomical Findings in the Brains of Manic-Depressive Subjects. E. E. 

Southard, M. D 237 

What is Paranoia? E. Stanley Abbot, M. D 275 

Discussicm 286 

Is there an Increase Among the Dementing Psychoses? Charles P. 

Bancroft, M. D 287 

A Criticism of Psychanalysis. Charles W. Burr, M. D 303 

Discussion 318 

The Medical Examination of Mentally Defective Aliens ; Its Scope and 

Limitations. L. L. Williams, M. D 325 

Discussion 336 



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8 CONTENTS 

Some Notes on Expert Testimony by Alienists and Neurologists. C. A. 

PosTEous, M. D., and H. V. Robinson, M. D 339 

Discussion 390 

Organization of the Work of the Henry Phipps Psychiatric Qinic, The 
Johns Hopkins Hospital, with Special Reference to the First Year's 

Work. Adolf MEviot, M. D 397 

The Role of the Psychiatric Dispensary : A Review of the First Year's 
Work of the Dispensary of the Phipps Psychiatric Qinic. C. 

Macpie Campbell, M. D 405 

KorsakoVs Psychosis Occurring During Pregnancy. David K. Hen- 
derson, M. D 425 

The Integrative Functions of the Nervous System Applied to Some 
Reactions in Human Behavior, and Their Attending Psychic Func- 
tions. Edward J. Kemff, M. D 449 

The Modem Treatment of Inebriety. Irwin H. Nbpf, M. D 463 

Applied Eugenics. Sanger Brown, M. D 473 

Insanity in Giildren. John H. W. Rhein, M. D 483 

Legislation in Reference to Sterilization. Hubert Work, M. D 501 

The Present Status of the Application of the Abderhalden Dialysis 

Method to Psychiatry. Samuel T. Orton, M. D 505 

Epileptic Dementia. Alfred Gordon, M. D 513 

The Translation of Symptoms into Their Mechanism. Chester L. 

Carusle, M. D 521 

Insanity with Cerebral Disease. H. P. Sights, M. D 551 

Some Remarks upon the Methods and Results of Study of the Psychop- 
athies of Children. (Abstract) L. Pierce Clark, M. D 557 

Discussion 558 

The Prevention of Suicide. Tom A. Williams, M. D 563 

Memorial Notices: 

Dr. George S. Adams. H. O. Spalding, M. D 577 

Dr. Henry S. Upson. Henry C. Eyman, M. D'. 579 

Dr. Emmet Hall Pomeroy. Henry M. Hurd, M. D 581 

Dr. Harry Ashton Tomlinson. W. A. Jones, M. D 583 

Dr. Silas Weir Mitchell. Charles W. Burr, M. D 585 

Dr. Ralph Lyman Parsons. Theodore H. Kellogg, M. D 587 

Dr. Edwin Warren King. F. W. Hatch, M. D 591 

Dr. Thomas J. Moher. George C. Kidd, M. D 594 

Index 595 



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LIST OF MEMBERS 

—07 THI — 

AMESICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 
March, 1915 



(This list printed on gummed paper, for mailing purposes, may be obtained 
from the Secretary. Price 50c.) 



X895 Abbot, S. Stanley, M.D^ Assistant Physician McLean Hospital, 
Wavcrley, Mass. 

X907 Abbot, Florence Hale, M. D., Assistant Physician Dr. Melius' Private 
Hospital, Newton, Mass. 

1904 Adama, Geo. Sheldon, M. D., Assistant Superintendent South Dakota 
Hospital for the Insane, Yankton, S. D. 

19x4 Adler, Herman M., M.D., Chief of Staff Psychopathic Hospital, 
Boston, Mass. 

1903 Allen, Charles Lewis, M.D. (formerly Pathologist New Jersey State 
Hospital, Trenton), Physician-in-Giarge Psychopathic Hospital, 
Los Angeles, Cat 

X9za Allen, Fredrick £., M.D., Assistant Physician Mendocino State 
Hospital, Talmage, Cal. 

X893 Allen, Henry D., M. D., Superintendent Invalids Home, Milledgeville, 
Ga. 

19x3 Allen, J. Berton, M. D., Assistant Physician Central Islip State Hos- 
pital, Central Islip, N. Y. (Associate,) 

zgza Allison, W. Lb, M. D., Superintendent Arlington Heights Sanitarium, 
Fort Worth, Tex. 

Z913 Alspaugh, Paul J., M. D., First Assistant Physician Massillon State 
Hospital, Massillon, O. (Associate.) 

19x3 Amaden, George S., M. D., Assistant Physician Bloomingdale Hospital, 
White Plains, N. Y. (Associate.) 

x9za Andrew!, Barton F., M. D., iMount Morris, N. Y. (Associate.) 

Z903 Andrews, Cla3rton 6., J£. D. (formerly First Assistant Physician Ver- 
mont State Hospital, Waterbury, Vt), Canton, N. Y. (^^^0- 
ciate.) 

Z894 Anglin, James V., M. D., Medical Superintendent the Provincial Hos- 
pital, Fairville, St John'5 Co., New BrunsMrick. 

X895 Applegate, Charles F., BCD., Medical Superintendent Mt. Pleasant 
State Hospital, Mt Pleasant, la. 

1910 Ard, George P^ M. D., Assistant Phjrsician State Institution for the 
Feeble-Minded and Epileptic, Spring City, Pa. (Associate.) 



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lO AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

Z9Q3 Armitrons, George G^ ILD^ Senior Assistant Physician Buffalo 

State Hospital Buffalo, N. Y. (Associate,) 
X913 Annatrong^ Samuel T^ M. D.^ Physidan-in-Charge Hillbourne Gub, 

Katonah. N. Y. 
X900 Arthur, Daniel H^ ILD^ Medical Superintendent Gowanda State 

Homeopathic Hospital, G>llin8, N. Y. 
1904 Ashley, Maurice C^ M. D^ Medical Superintendent Middletown State 

Homeopathic Hospital, Middletown, N. Y. 
X910 Athon, W.L^M.])^ Marshall, Clark Co^ III 
1906 Atkins, Henry 8^ HD^ Superintendent Gty Insane Asylum, St 

Louis, Mo. 
X890 Atwood, Charlea E^ IL D^ 14 East 6oth St, New York, N. Y. 

B 

z888 Babcock, J. W., M. D^ Medical Superintendent Waverley Sanitarium, 
G>lumbia, S. C 

19XX Baber, Armitage, ILD^ Superintendent Dajrton State Hospital, Day- 
ton, O. 

19x3 Baker, Amot T^ M.D^ Associate Physician, West Hill, a6ist St & 
Broadway, New York, N. Y. (Associate,) 

Z904 Baker, Benjamin W^ M. D., Superintendent New Hampshire School 
for Feeble-Minded Children, Laconia, N. H. 

Z899 Baker, Jane Rogers, M. D^ Private Sanitarium, The Tower House, 
West Chester, Pa. 

Z896 Baldwin, Henry C, M. D^ 126 Commonwealth Ave., Boston, Mass. 

X909 Baldwin, Louis B., ILD., Superintendent University Hospital, Uni- 
versity of Minnesota, Minneapolis, Minn. 

X898 Ballintine, Eveline P., ILD., Assistant Physician Rochester State 
Hospital, Rochester, N. Y. (Associate.) ^ 

X896 Bamford, Thos. B., M. D., 304 Delaware St, Syracuse, N. Y. 

X883 Bancroft, Chat. P., ILD., Medical Superintendent New Hampshire 
State Hospital, Concord, N. H. (President, 1908.) 

X890 Bannister, Henry M., ILD. (formerly Assistant Physician Illinois 
Eastern Hospital for the Insane), S28 Judson Ave., Evanston, 
IlL (Honorary,) 

X9xa Barber, Bmce B., IL D., Assistant Physician Columbus State Hospital, 
Columbus, O. (Associate,) 

19x4 Barber, W. C, ILD., Superintendent Simcoe Hall, Barrie, Ont, 
Canada, 

19x3 Barlow, Charles A, ILD., Superintendent Second Hospital for In- 
sane, Spencer, W. Va. 

X9xa Bamet, B. C^ ILD., Assistant Physician Homewood Sanitarium, 
Guelph, Ont (Associate.) 

1909 Bamet, Francis M., Jr., M.D., Assistant Professor Nervous and 
Mental Diseases, St Louis University Medical School, 506 
Humboldt Bldg., St Louis, Mo. 



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LIST OF MEMBERS II 

29x4 BArahArdt, Wm. K^ M.D^ Assistant Physician Central IsUp State 

Hospital, Central Islip, N. Y. (Associate,) 
1898 Barrett, Albert M., ILD^ Professor of Psychiatry and Neurology 

University Hospital, Ann Arbor, Mich. 
19x4 Barry, H. Grant, IL D^ Worcester State Hospital, Worcester, Mass. 

(Associate.) 
X9xa Barstow, Jamee IL, BLI)., St Bernards Hospiul, Council Bluffs, la. 
19x9 Bartram, KeU W^ M.D.y Assistant Physician Kings Tuxk State 

Hospital, Kings Park, N. Y. (Associate,) 
19x4 Baskett, George T., M. D^ Assistant Superintendent St Peter State 

Hospital, St Peter, Minn. 
19x3 Bats, T. B., ILD^ Superintendent Texas State Epileptic Colony, 

Abilene, Tex. 
1909 Beach, Lena A., M. D^ Woman Assistant Physician Cherokee Sute 

Hospital, Cherokee, Iowa. 
1900 Becker, W. F., M.D., Consulting Neurologist Milwaukee County 

Hospital, 604 Goldsmith Building, Milwaukee, Wis. 
x89a Beemer, Nelson H., M.D., Superintendent Mimioo Hospital for the 

Insane, Toronto, Ont 
X9oa Bdingy CMstopher C, M.D. (formerly Assistant Physician New 

Jersey State Hospital, Morris Plains, N. J.), 109 Clinton Ave., 

Newark, N. J. 
19x3 Bellinger, Clarence H., ILD., Assistant Physician Binghamton State 

Hospital, Binghamton, N. Y. (Associate.) 
X9X4 Bemis, John IL, M. D., Superintendent Private Hospital for Insane, 

Worcester, Mass. 
X893 Berkley, Henry J., M. B., 1305 Park Ave., Baltimore, Md. 
X904 Betts, Joseph B., M.D., Assistant Physician Buffalo State Hospital, 

Buffalo, N. Y. (Associate.) 
X899 Beutler, W. F., M.D., Medical Superintendent Milwaukee Asylum 

for the Chronic Insane, Wauwatosa, Wis. 
X9X3 Beverly, A. Fitzhugh, M.D., Resident Physician Texas School for 

Defectives, Austin, Tex. 
X898 Biddle, Thomas, M. D., Superintendent Topeka State Hospital, To- 

peka, Kansas. 
X9X3 BlaisdeU, Rnssell E., M.D., Assistant Physician Kings Park State 

Hospital, Kings Park, N. Y. (Associate.) 
X9X4 Blauvelt, John H^ M. D., Assistant Physician Matteawan State Hos- 
pital, Beacon, N. Y. (Associate,) 
X9X4 Blet, Victor Au, M. D., Assistant Physician Elgin State Hospital, Elgin, 

111. (Associate.) 
1912 BI088, James R., M.D., Assistant Physician West Virginia Asylum, 

Huntington, W. Va. (Associate.) 
x8M Blumer, G. Alder, M.D., Medical Superintendent Butler Hospital, 

Providence, R. I. (President, 1903*) 
X909 Bond, Earl D^ M. D^ Senior Assistant Physician Pennsylvania Hos- 
pital for Insane, Philadelphia, Pa. (Associate.) 



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12 AMERICAN MEDICX>-PSYCHOLOGICAL ASSOCIATION 

1907 Bond, George F. M., M. D^ Proprietor Dr. Bond's House, 960 North 

Broadway, Yonkers, N. Y. 

189a Bondniant, Engene D., BCD. (formerly Assistant Superintendent 
Alabama Bryce Hospital), 166 Conti St, Mobile, Ala. 

19x3 Borden, P. G., BCD., Bu£Falo State Hospital, Buffalo, N. Y. (Asso' 
date.) 

1912 Boyd, Wm. A., M. D., 114 W. Franldin St, Baltimore, Md. 

1904 Bradley, Isabel A., M. D., 221 Ash St, Akron, O. 

19x4 BraunUn, Edgar L., M. D., First Assistant Physician Dayton State 
Hospital, Dayton, O. (Associate,) 

X9X0 Brewster, George F., M. D., Senior Assistant Physician State Homeo- 
pathic Hospital, Middletown, N. Y. (Associate.) 

X907 Briggs, L. Vernon, M.D., Executive Secretary Massachusetts State 
Board of Insanity, 64 Beacon St, Boston, Mass. 

X9X3 Brill, A A^ M. D., 55 Central Park W., New York, N. Y. 

1906 Brochu, IL D., ILD., Superintendent Beauport Asylum for Insane, 
Beauport, Que. 

1910 Brooks, Swepaon J., IL D., Physidan-in-Charge St Vincent's Retreat 
Harrison, N. Y. 

19x4 Brothers, J. £., M. D., Assistant Physician State Hospital, Goldsboro, 
N. C. (Associate.) 

19x3 Brown, G. W., M. D., Superintendent Eastern State Hospital, Williams- 
burg, Va. 

1914 Brown, Louis R., M.D., Assistant Physician Hospital for Insane, 
Middletown, Conn. (Associate.) 

X883 Brown, Sanger, ILD., Kenilworth Sanitarium, Kenilworth, 111. 

X9X3 Brown, Sanger, n, M. D., Assistant Physician Bloomingdale Hospital, 
White Plains, N. Y. (Associate.) 

X9xa Brown, Sherman, M. D^ Superintendent Kenilworth Sanitarium, Ken- 
ilworth, HI. (Associate.) 

X899 Brown, W. Stuart, M. D., Physidan-in-Charge Sanford Hall, Flush- 
ing, New York, N. Y. 

X899 Brownrigg, Albert Bdward, M. D., Medical Superintendent Highland 
Spring Sanatorium, Nashua, N. H. 

X9ia Bnmdage, Howard M., M. D., 112 E. Broad St, Columbus, O. (Asso- 
ciate.) 

1908 Brunk, Oliver C, M. D., 405 K Grace St., Richmond. Va. 

X89X Brush, Edward N., M.D., Physician-in-Chief and Superintendent 
Sheppard and Enoch Pratt Hospital, Towson, Md. ( Vice-Presi- 
dent, 1915.) 

i9xa Bryan, Wm. A, M. D^ Assistant Physician Cherokee State Hospital, 
Cherokee, la. (Associate.) 

X895 Bryant, Percy, M. D. (formerly Medical Superintendent Male Depart- 
ment Manhattan (N. Y.) State Hospital), Bowdoin Park, Rah- 
way, N. J. 

X89X Buchanan, J. M., M. D^ Superintendent East Mississippi Insane Hos- 
pital, Meridian, Miss. 



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UST OF MEMBERS I3 

191S Buckley, AIb«rt C, M.J>^ Friends' Asylum, Frankfordt Philadelphia, 
Pa. (Associate.) 

X898 Bndday, Jamet IL, D.D., UUD., Morristown, N. J. (Honorary.) 

zQoa Bollard, B. In, M.D. (formerly Superintendent Wisconsm State 
Hospital for the Insane, Mendota, Wis.), Physidan-in-Charge 
Chestnnt Lodge Sanitarium, Roclcville, Md. 

1905 Burdick, Charles M., M. D., Senior Assistant Physician Central Islip 
State Hospital, Central Islip, L. I., N. Y. (Associate.) 

19x3 Burdaall, Elijah 8., BLI)., Assistant Physician Middletown State 
Homeopathic Hospital, Middletown, N. Y. (Associate.) 

1890 Burgesi, T. J. W., M. B., Medical Superintendent Protestant Hospital 
for the Insane, New P. O. Box aaSo, Special Bag, Montreal, Que. 
(President, jgoS') 

1909 Burlingame, C. C, J£. D., Assistant Superintendent Fergus Falls State 
Hospital, Fergus Falls, Minn. (Associate.) 

X894 Burnet, Anne, M. D., 513 La Salle St, Wausau, \^s. 

19x3 Burnett, S. Gnnrer, M. B., Medical Superintendent The Burnett Sani- 
tarium, 3100 Euclid Ave., Kansas Qty, Ma 

X9X4 Bums, Geoffrey C. H., M. B., Senior Assistant Physician Central Islip 
State Hospital, Central Islip, N. Y. (Associate.) 

1890 Burr, C. B., ILB., Medical Director CHdc Grove Hospital, Flint, 
Mich. (President, 1906.) 

X907 Burr, Chaa. W., ILB., Professor of Mental Diseases University of 
Pennsylvania, 1918 Spruce St, Philaddphia, Pa. 

X90X Buaey, A P., M. D., Superintendent Colorado State Home and Train- 
ing School for Mental Defectives, Ridge, Colo. 

X9XX Buase, Bdward P., BCD., Medical Superintendent Southeastern Hos- 
pital for Insane, Cragmont, Madison, Ind. 

X9X0 Butterfield, George SL, ILD., State Colony, North Grafton, Mass. 
(Associate.) 



x9oa Calder, Daniel H., M. D., Superintendent State Mental Hospital, Provo 
Qty, Utah. 

X907 Callaway, L. H., M.D. (formerly Superintendent State Hospital No. 
3), 535 West Arch St, Nevada, Mo. 

X907 Campbell, Earl H., M.B., Superintendent Upper Peninsula Hospital 
for the Insane, Newberry, Mich. 

1899 Campbell, George B., IL D., First Assistant Physician Utica State Hos- 
pital, Utica, N. Y. 

X885 Campbell, Michael, M. D., Medical Superintendent Eastern Hospital 
for the Insane, Bearden, Tenn. 

19x4 Canavaa, Myrtelle M., M. D., Pathologist Boston State Hospital, Bos- 
ton, Mass. (Associate.) 

X90X Caples, Byron M., BCD., Medical Superintendent Waukesha Springs 
Sanitarium, Waukesha, Wis. 



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14 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

1909 Ca^oiit Artimr J^ BCD., Phytkiiii-iii-Charge Glenmary Samtaiitmi, 
Owcgo, N.-Y. 

19x4 C«x«7, Charlei J^ BLD^ Superintendent Eastern Shore State Hos- 
pital, Cambridge, Md. 

1905 Carey, Haxiia May, M. D., P. O. Box 83, Odessa, Delaware. 

1903 Carlisle, Chester Lee, BCD., Senior Assistant Physician Kings P^rk 
State Hospital, Kings Park, N. Y. {Associate.) 

19XX Carpenter, Howard P., M. D., Assistant Physician Hudson River State 
Hospital, Poughkeepsie, N. Y. (Associate.) 

X906 Caxriel, Henry R, BCD., Superintendent Jacksonville State Hos^tal, 
Jackson^le, IlL 

X9XX Carroll, Robert S., ]C.D.» Medical Director Highland Hospital, Ashe- 
viUe. N.C. 

X9X3 Casamajor, Louis, IL D., 342 W. 56th St, New York, N. Y. 

X909 Cavanangh, William J., ICD^ Senior Assistant Phjrsidan Hudson 
River State Hospital, Poughkeepsie, N. Y. (Associate.) 

xl9a Chaddock, Chas. G., IL D^ 3705 Delmar Boulevard, St Louis, Mo. 

X896 Chagnon, £. Philippe, IC. D., Physician to Notre Dame Hospital, 201 
Esplanade Ave^ Montreal, Que. 

x88o Chaiming, Walter, BCD., Chamung Sanitarium, Brookline, Mass. 

X867 ChapiUy John B., M. D. (formerly Physician and Superintendent Penn- 
sylvania Hospital for the Insane), (Retired), 244 Main St, 
Canandaigua, N. Y. (President, 1889.) 

19x2 Chapman, Rosa McC., HD., Assistant Physician Binghamton State 
Hospital, Binghamton, N. Y. (Associate.) 

X883 Chaae, Robert H., ILD., Medical Superintendent Friends' Asylum, 
Frankford, Philadelphia, Pa. 

X914 Cheney, Clarence 0., IC. D., Assistant Physician Manhattan State Hos- 
pital, Ward's Island, N. Y. 

X9xa Child, Howard T., M. D., Pathologist Kankakee State Hospital, Kan- 
kakee, IlL (Associate.) 

X895 Chilgren, 0. A., M. D., 406^ Jefferson St, Burlington, Iowa. 

1892 Christian, Edmund A., M. D., Medical Superintendent Pontiac State 
Hospital, Pontiac, Mich. 

19x3 Christian, Frank L., IL D., Assistant Superintendent New Yoric State 
Reformatory, Elmira. N. Y. 

X907 Clark, Charles H., BCD., Superintendent Geveland State Hospital, 
Qeveland, Ohio. 

X9X0 Clark, Fred P., M. D., Superintendent State Hospital, Stockton, CaL 

X898 Clark, Joseph Clement, M. D., Superintendent Springfidd State Hos- 
pital, Sykesville, Md. 

X906 Clark, L. Pierce, BCD., G>nsulting Neurologist Central Islip State 
HospiUl, 84 East 56th St, New York, N. Y. 

X885 Clarke, Chas. K., ILD., Medical Superintendent Toronto (General 
Hospital, Toronto, Ont 

X904 Clarke, Homer £., M. D., Assistant Medical Director, Oak Grove Hos- 
pital, Flint, Mich. (Associate.) 



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UST OF MEMBERS 



15 



x88l 



X898 

X905 

29x3 

X9X3 

X90X 

1906 
X909 

X9xa 
X894 
X894 
x89a 
X9xa 
X9X4 

X903 
X908 
X909 

X909 

igos 

x88x 

X9X4 

X9xa 

X908 

X9X3 

X9X3 



Ckrastoiit Sir Thot. 8^ M.D.9 F.H.C.P.S. of UUD^ Bdia. and Abcr. 

(formerly Physidan-Superintendent Edinburgh Royal Asylum), 
26 Heriot Row, Edinburgh, Scotland. {Honorary,) 

Coe^ Henry W., M. D., Medical Director Crystal Springs, 516 Selling 
Boilding, Portland, Ore. 

Coggina, Jeiae C, ILD., Medical Director The Laurel Sanitarium, 
Laurel, Md. 

Cohn, Engen, M. D., Assistant Superintendent Kankakee State Hos- 
pital, Kankakee, III 

Cohoon, E. H., M. D., Assistant Physician, State Hospital for Insane, 
Howard, R. L (Associate.) 

Colebnrn, Arthur B., M. D., Assistant Physician G>nnecticut Hospital 
for the Insane, Middletown, G>nn. {Associate,) 

Coles, William W., M. D., Keene, N. H. 

Collier, G. Kirby, HD., Assistant Physician Craig Colony for Epi* 
leptics, Sonyea, N. Y. 

Colnon, A. T., M.D.y Assistant Physician St Lawrence State Hos- 
pital, Ogdensburg, N. Y. {Associate,) 

Cook, S. Harrey, M. D., Physidan-in-Chief Oxford Retreat, Oxford, 
Ohio. 

Cook, Robert 0., M. D., Resident Physidan Brigham Hall, Canandai- 
gua,N. Y. 

Copp, Owen, M. D., Physician and Superintendent Pennsylvania Hos- 
pital for the Insane, Philaddphia, Pa. 

Corcoran, David, M. D., Assistant Phjrsidan Central Islip State Hos- 
pital, Central Islip, N. Y. {Associate,) 

Corey, Herman W., M.])., Assistant Physician St Peter State Hos- 
pital, St Peter, Minn. {Associate.) 

Coriat, Isador H., M. D., 416 Marlborough St, Boston, Mass. 

ComtU, William B., M. D., 401 Garrett Bldg., Baltimore, Md. 

Cort, Paul Lange, BCD., 144 West State St, Trenton, N. J. {Asso- 
ciate,) 

CoMitt, H. Anitin, M. D., 146 West 70th St, New York, N. Y. {Asso- 
ciate,) 

Cotton, Henxy A., M. D., Medical Director New Jersey State Hospitol, 
Trenton, N. J. 

Cowleo, Sdwar^ BCD. (formerly Medical Superintendent McLean 
Hospital, Waverley), Plymouth, Mass. {President, 189$,) 

Cofad, H. Irving, M. D., Ginical Director Fair Oaks Villa, Cuyahoga 
Falls, O. {Associate,) 

Craig^ Anna, M. D., Assistant Physician Kings Park State Hospital, 
Kjnga Park, N. Y. {Associate.) 

Crittenden, Samvel W., IL D., Assistant Superintendent Boston State 
Hospital, Dorchester Centre, Mass. {Associate,) 

Crooks, Wm. A., ILD., Superintendent Watertown State Hospital, 
Watertown. HL 

Croat, Albert M., M. D., Assistant Physidan The Southern Indiana 
Hospital for the Insane, Evansville, Ind. {Associate,) 



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l6 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

189a Cnunbacker, W. P., M. D^ Medical Superintendent Independence State 
Hospital, Independence, la. 

19x3 Curry, Marcus A., M. D^ Assistant Physician New Jersey State Hos- 
pital, Morris Plains, N. J. (Associate.) 

19x3 Curtis, Barbara, M. D., Hudson River State Hospital, Pouglikeepsie, 
N. Y. (Associate.) 



X9X4 Darling, Ira A., M.D., Assistant Physician State Hospital, Warren, 
Pa. (Associate.) 

X899 Darling, W. H., M. D., Superintendent The Sanatorium, Hudson, Wis. 
(Associate.) 

1902 Damall, Holland F., BCD., Qinical Director and Assistant Superin- 
tendent State Hospital for Nervous Diseases, Little Rock, Ark. 

X9X3 Davies, George W., M. D., Essex Gmnty Hospital for Insane, Cedar 
Grove, N. J. (Associate.) 

X909 Do Jamette, J. S., M. D., Medical Superintendent Western State Hos- 
pital, Staunton, Va. 

X899 Delacroiz, Arthur C, M. D.^ Douglas, Alaska. (Associate.) 

X9X3 DeLaHoyde, T. Grover, M.D., Assistant Physician Hudson River 
State Hospital, Poughkeepsie, N. Y. (Associate.) 

X9xa Doming, Ralph, M. D., Mercer, N. Dak. (Associate.) 

X909 Donnos, Blanche, IL D., Assistant Physician Hudson River State Hos- 
pital, Poughkeepsie, N. Y. (Associate.) 

X9xa Devlin, Francis £., M. D., Assistant Superintendent Hospital St Jean 
de Dieu, Gamelin, Que. (Associate.) 

igii Do Wooso, Cornelius, J£. D., Medical Director The Laurel Sanitarium, 
Laurel, Md. 

X890 Dowey, Chas. G., M.D.y Examining Physician Registration Depart- 
ment City of Boston, 44 Alban St, Dorchester, Boston, Mass. 

x89a Dowey, Richard, ILD., Physidan-in-Charge Milwaukee Sanitarium, 
Wauwatosa, Wis. (President, 1896.) Chicago oflScc, 34 Wash- 
ington St, Venetian Building, Wednesdays, 11.30 a. m. to i p. m. 

19x3 Dozter, Roger, M. D., Assistant Physician Dannemora State Hospital, 
Dannemora, N. Y. (Associate.) 

X900 Diofondorf, Allen Ross, M. D., 29 College St, New Haven, Conn. 

19x4 Disbrow, 6. Ward, M. D., Assistant Physician Springfield State Hos- 
pital, Sykesville, Md. (Associate.) 

X9xa Dobson, Wm. M., M.D., Boston State Hospital, Dorchester Centre, 
Mass. (Associate.) 

X9xa Dodge, Percy L., ILD., Assistant Physician Hudson River State 
Hospital, Poug^eepsie, N. Y. (Associate.) 

X907 Dohorty, Chaxloo E., M.D., Superintendent Public Hospital for In- 
sane, New Westminster, B. C, Canada. 

xlga Dold, William E., M. D., Physician-in-Charge River Crest Sanitarium, 
Astoria, L. I., N. Y. 616 Madison Ave, New York Qty. 



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UST OF MEMBERS 1/ 

1908 DoUoffy Charles H^ BLD^ First Assistant Phjrsidan New Hsmpshire 
State HosiMtal, Concord, N. H. (Associate.) 

X908 Bottolioe, George, M. D^ Superintendent Cherolm State Hospital, 
Cherokee, Iowa. 

Z903 DoiugtMBt A. E., M. D^ Superintendent Central Hospital for the Insane, 
Nashville, Tenn. 

Z907 Downing^ Dana Fletcher, M. D^ Warren, 111. 

1893 Drewry, William F., ILD., Medical Superintendent Central State 
Hospital, Petersburg, Va. (President, 19JO.) 

19x4 Dunham, Sydney A^ M.D., Resident Physician and Proprietor Dr. 
Dunham's Sanitarium, 1392 Amherst St, Buffalo, N. Y. 

19x3 Dniming, Ralph H^ M. D., 2020 James St, Eastwood, N. Y. (Asso- 
ciate.) 

X896 Dunton, Wm. Rash, Jr^ BCD., First Assistant Physician Sheppard 
and Enoch Pratt Hospital, Towson, Md. 

19x2 Durgiii, Delxner D., ILD., Assistant Physician Kings Park State 
Hospital, Kings Park, N. Y. (Associate.) 

X899 Durham, Albert, M. D., Piedmont Bldg., Charlotte, N. C (Associate.) 



Z909 Sail, H. D., ILD^ First Assistant Physician North Dakoto State 
Hospital, Jamestown, N. D. 

19x2 Battman, Frederic C, ILD., 1268 Bergen St, Brooklyn, N. Y. 

19x2 Saton, Richard G., M. D., Assistant Physician River Crest Sanitarium, 
Astoria, L. I., N. Y. (Associate,) 

X9X4 Eckel, John L^ M. D^ 145 Allen St, Buffalo, N. Y. 

X896 Edenharter, Geo. F., BCD., Medical Superintendent Central Indiana 
Hospital for the Insane, Indianapolis, Ind. 

X893 Sdgetly, J. Frank, M. D., i Mt Vernon Terrace, Newtonville, Mass. 

X894 Edwardi, John R, M. D. (formerly Medical Superintendent Wiscon- 
sin State Hospital), 311 Goldsmith Building, Milwaukee, Wis. 

X9X3 Eirley, Clara, M. D^ State Hospital, St Peter, Minn. (Associate.) 

X899 Elliott, Hiram, ILD. (formerly Superintendent Marshall Sani- 
tarium), 58 Willett St, Albany, N. Y. 

X897 Elliott, Robert IL, M.D., Medical Superintendent Willard State 
Hospital, Willard, N. Y. 

X9X3 Emexick, E. J., fL, D^ Superintendent Institution for Feeble-Minded, 
Columbus, O. 

X9X3 Emerson, Ernest B., M. D., Medical Director State Hospital, Bridge- 
water, Mass. 

X892 Emerson, Justin E^ ILD., Attending Physician St Joseph's Retreat 
Dearborn, Midt; Attending Neurologist Harper Hospital and 
Children's Free Hospital, Detroit, 128 Henry St, Detroit Mich. 

X909 Engliih, W. M., ILD^ Medical Superintendent Hospital for Insane, 
Hamilton, Ont 



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l8 AMERICAN MBDICOPSYCHOUX^ICAL ASSOCIATION 

Z893 Sraat, B. D^ BLD^ Medical Director New Jersey State HosiMtal, 

Morris Plains, N. J. 
1914 Brarts, Arrah B^ M.D^ Assistant Physician Government Hospital 

for Insane, Washington, D. C. {Associate.) 
X908 Bveiett, Bdward A^ M. D^ Senior Assistant Physician Norwich State 

Hospital, Norwich, Conn, 
xgxa BwinSv Halle Laura, ILD., Assistant Physician Nd)raska Hospital 

ioT Insane, Lincoin, Neb. {Associate.) 
1892 Byman, H. C, M. D., Medical Superintendoit MassiUon State Hos- 

pitalt Massillcm, Ohio. 



X907 Faiion, W. W., M. B., Superintendent Stote Hospital, Goldsboro, N. C 

X914 FaxiSy George T., IL B., Assistant Physician Pennsylvania Hospital for 
Insane, Philadeli^ia, Pa. {Associate.) 

X9za Fazoa, Bora W., ILB^ Taunton Sute Hospital, Taunton, Mass. 
{Associate.) 

X898 Felty, John C, M. B., Assistant Physician New Jersey State Hospital 
Trentop, N. J. {Associate.) 

X907 Femald, Guy G., IL B., Physician Massachusetts Reformatory, Con- 
cord Junction, Mass. 

Z895 Femald, Walter E., M. B., Superintendent Massachusetts School for 
the Feeble-Minded, Waverley, Mass. 

X909 Ferria, Albert Warren, M. B., State Reservation Conunission, Saratoga 
Springs, N. Y. 

X913 Finlayson, Alan B., M. B., Assistant Physician Warren State Hospital, 
Warren, Pa. {Associate.) 

Z9xa Fish, Bmry In, IL B., Kankakee State Hospital, Hospital, HI. {Asso* 
date.) 

1907 Fisher, B. Moore, IL B., Assistant Physician New Jersey State Hos- 
pital, Morris Plains, N. J. {Associate.) 
Fiahac^ Theodore W., ILB. (formerly Medical Superintendent Boaton 
State Hospital), Boston, Mass. 

z89a Fitsgerald, John F., ILB., General Medical Superintendent King's 
County Hospital, Brooklyn, N. Y. 

X907 Fitsgerald, John G., ILB., Associate Professor Bacteriology Uni- 
versity of California, Berkeley, CaL {Associate.) 

i9xa Fletcher, Christopher, M. B., Assistant Physician Buffalo State Hos- 
pitol, Buffalo, N. Y. {Associate.) 

X899 Flint, Austin, M.B., Consulting Physician Manhattan State Hos- 
pital, 118 E. I9tli St, New York, N. Y. 

1900 Flood, Everett, ILB., Superintendent Monson State Hospital, Pal- 
mer, Mass. 

X9ia Foley, Bdward A., ILB*, Assistant Physician Jacksonville State 
Hospital, Jacksonville, 111. {Associate.) 

19x1 Fordyce, 0. 0., ILB., Superintendent Athens State Hospital, 
Athens, O. 



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UST OF MEMBERS I9 

X9Z3 Forft«rj> JjunM M^ M. D^ Medical Superintendent Hospital for Insane, 
Toronto, Ont. 

X908 FxasOf Shepherd L, A. B^ Ph. D., Psychologist and Scientifk Direc- 
tor, Government Hospital for Insane, Washington, D. C (Hon- 
orary,) 

19x3 Freeman, George H., M.D^ Superintendent State Hospital for In- 
ebriates, Willihar, Minn. 

1897 French, Edward* M.1>^ Superintendent Medfield State Asylum, 
Harding, Mass. 

19x4 Pxlnki Horace W., M. D., i W. 83d St, New York, N. Y. 

X899 Froat, Henry P., M. D.* Superintendent Boston State Hospital, Dor- 
chester Centre, Mass. 

X9X3 Fuller, Daniel H., M.])., Pennsylvania Hospital for Insane, Phila- 
delphia, Pa. 

x9oa Fuller, Solomon Carter, IL D., Pathologist Wesfborough State Hof* 
pital, Westborough, Mass. (Associate.) 

X908 Ftrnkhouser, Edgar B., IL 1>^ Second Assistant Physician New Jersey 
State Hospital, Trenton, N. J. (Associate,) 

1914 Fnrman, Isaac J.* IL D., Assistant Physician Kings Park State Hos- 
pital, Kings Park, N. Y. (Associate.) 



X91X Gale, George Bancroft, M.D., Medical Director Bancroft Health 
Resort, Butler, N. J. 

19x3 Gardner, Wm. E^ M. D., Superintendent Central State Hospital, Lake- 
land, Ky. 

X900 GarUck, J. H^ M.D^ Assistant Physician Western State Hospital, 
Staunton, Va. (Associate.) 

X905 Garrett, S. Edward, M.D^ Assistant Physician Maryland Hospital 
for the Insane, Catonsville, Md. (Associate.) 

X909 George, John Cecil, M. D., Orchard Springs Sanitarium, Dayton, Ohio. 
(Associate.) 

X9xa Gesregen, Wm. E., M.D., Resident Physician Belle Mead Farm 
Colony and Sanatorium, Belle Mead, N. J. 

X9X4 Gibson, Horatio G., Jr., M. D., Assistant Physician Central Islip State 
Hospital, Central Islip, N. Y. (Associate.) 

X909 Gilleapie, Edward, M.D., Senior Assistant Physician Binghamton 
State Hospital, Binghamton, N. Y. (Associate.) 

1907 Gillefpie, Robert L^ M.D., Medical Director Crystal Springs Sani- 
tarium, Portland, Ore. 

x9xa GtUiam, Charles F., BCD., Superintendent Columbus State Hospital, 
Columbus, O. 

X9X3 Qinabnrg, Samuel, M. D., Assistant Physician St Lawrence State Hos- 
pital, Ogdensburg, N. Y. (Associate.) 

X893 Givens, A. J., M.D., Proprietor Dr. Givens' Sanitarium, Stamford, 
Conn. 



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20 AMERICAN MBDIOO-PSYCHOLOGICAL ASSOCIATION 

Z895 GiTena, John W.^ BLD^ Medical Superintendent Northern Idaho 
Insane Asylum, Orofino, Idaho. 

1910 Olatcock, Alfred, M. D^ Senior Assistant Physician Government Hos- 
pital for the Insane, Washington, D. C (Associate,) 

Z914 Glueck, Bernard, M. D^ Senior Assistant Physician Government Hos- 
pital for Insane, Washington, D. C. (Associate.) 

1903 Goodwill, V. L^ M.])., and CH, Medical Superintendent Falcon- 
wood Hospital for the Insane, Charlottetown, P. R I. 

191a Gordon, Alfred, M. D., 1812 Spruce St, Philadelphia, Pa. 

Z9xa Gorxill, George W^ ILD., First Assistant Physician Buffalo State 
Hospital, Buffalo, N. Y. (Associate.) 

1906 Gont, Charlet, M. D^ Superintendent State Hospital for the Insane, 
Mendota, Wis. 

1894 Gorton, Eliot, IC D^ Fair Oaks Sanatorium, 26 New England Ave., 
Summit, N. J. 

1898 Goaa, Arthur V., M.'D^ Superintendent Taunton State Hospital, 
Taunton, Mass. 

Z9ia GoM^ H. In, ILD., Assistant Physician Osawatomie State Hospital, 
Osawatomie, Kans. (Associate.) 

1886 Granger, Wm. D., M. D., Vernon House, Bronxville, N. Y. 

1905 Gfoen, Bdward IL, M. D^ Qinical Director Georgia State Sanitarium, 
Milledgeville, Ga. 

1909 Greene, Bdward C, M. D^ Northampton State Hospital, Northampton, 

Mass. (Associate.) 

1910 Greene, Jamea L^ BLD^ Superintendent State Hospital for Nervous 

Diseases, LitUe Rock, Ark. 
1914 Gregg, Donald, ILD., Resident Physician Channing Sanitarium, 

Brookline, Mass. 
1908 Gregory, Menas S., M. D., Resident Alienist Bellevue Hospital, New 

York, N. Y. 
19x3 Griffin, D. W., M. D., Superintendent Oklahoma Hospital for Insane, 

Norman, Okla. 
1913 GroU, Bdward W., M.D^ Assistant Physician Binghamton State Hos- 
pital, Binghamton, N. Y. (Associate.) 
1913 Groom, Wirt C^ M. D., Assistant Physician Willard State Hospital, 

Willard, N. Y. (Associate.) 
19x4 Grover, Milton M., M. D., Central Islip, State Hospital, Central Islip, 

N. Y. (Associate.) 
X910 Guibord, Alberta S. B., M. D., Laboratory of Social Hygiene, Bedford 

Hills, N. Y. 
X900 Gundry, Alfred T., M. D^ Medical Director The Gundry Sanitarium, 

Catonsville, Md. 
X908 Gundry, Lewie H., BCD., Superintendent Relay Sanitarium, Relay, 

Baltimore Co., Md. 



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UST OF MEMBERS 31 

189a Gnodxy, Richard F^ M.D^ Medical Director and Proprietor the 
Richard Gundry Home, Harlem Lodge, Catonsville, Md. 

X899 Guthrie, L. V^ M. D^ Saperintendent West Virginia Asylum, Hunt- 
ington, W. Va. 

H 

X914 Haherman, J. Victor, M.D^ Instructor in Neurology and Therapy 
P. and S^ Columbia University, New York, N. Y. 

29x2 Haight, Julius S^ M.D^ Assistant Physician Utica State Hospital, 
Utica, N. Y. (Associate.) 

1891 Hall, 0. Staoleyt Ph.D^ LL.D^ President Clark University, Wor- 
cester, Mass. (Honorary.) 

x886 Han, Henry C, M.D., Assistant Physician Butler Hospital, Provi- 
dence, R. I. (Associate.) 

191 X Halaey, Lufhar IL, M. D^ Chairman Medical Committee, New Jersey 
State Hospital, Williamstown, N. J. 

Z899 Hamilton, Arthur S., M. D^ Instructor in Nervous and Mental Dis- 
eases and Neuropathology, College of Medicine and Surgery, 
University of Minnesota, 513 PiUsbury Building, Minneapolis, 
Minn. 

19x4 Hamilton, Claude D., li.D., Assistant Physician Springfield State 
Hospital, Sykesville, Md. (Associate.) 

1907 Hamilton, Gilbert V., M.D., Montecito, Cal. 

X907 Hamilton, Samuel W., M. D., Senior Assistant Physician Utica State 
Hospital, Utka, N. Y. 

19x2 Hamfflfln, Jamea S., ILD., Assistant Physician State Hospital, 
Danville, Pa. (Associate.) 

X908 Hammond, Frederidc S., ILD., Assistant Physician and Pathologist, 
New Jersey State Hospital, Trenton, N. J. (AsA>ciate.) 

X908 Hammond, Graeme M., M. D., Professor of Mental Diseases, 60 West 
56th St, New York. N. Y. 

X893 Haacker, W. H., li.D., Medical Superintendent Delaware State 
Hospital. Famhurst, Del 

X906 Hanes, Bdward L., M. D., 748 Main St, E., Rochester, N. Y. 

19x3 Hanson, Wm. T., M.D., State Board of Insanity, Arlington, Mass. 
(Associate.) 

X904 Harding, George T., Jr., M.D. (Neurologist to Grant Hospital, St 
Anthony's Hospital and St Qair Hospital), 318 £. Sute St» 
Columbus, O. 

X89X Hannon, P. W., ILD., Medical Superintendent Longview Hospital, 
Cincinnati, Ohio. 

X894 Harrington, Arthur H., M.D., Superintendent State Hospital for 
Insane, Howard, R. I. 

19x3 Harrington, John J., M. D., 504 W. 112th St, New York, N. Y. 

X9X3 Harris, George P., M. D., Assistant Physician Buffalo State Hospital, 
Buffalo^ N. Y. (Associate.) 

xa99 Hania, Idiam G., M.D., Superintendent Mohansic State Hospital, 
Yorktown, N. Y. 



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22 AMERICAN MEDICX>-PSYCHOLOGICAL ASSOCIATION 

x888 Haifiaoa, Daniel A^ ILJ)^ Breezdiuret Terrace, Whitestone, L. L, 

N. Y. 
19x3 EaiUng, Arthur P.» M. D^ Official Examiner of Indigent Insane, Hud- 
son Co^ 318 Montgomery St, Jersey City, N. J. 
19x4 Haisally James C^ IL D^ Assistant Physician Government Hospital 

for Insane, Washington, D. C. (^Associate.) 
X9X0 Hatch, P. W^ M.D.9 General Superintendent of California State 

Hospitals, Sacramento, Cal. 
X9X3 Hatcher, George S., M. D., First Assistant Physician Central Hospital 

for the Insane, near Nashville, Tenn. (Associate.) 
X894 Eattie, W. H., M.D^ Inspector of Humane and Penal Institutions, 

Halifax, N. S. 
X899 Haviland, C. Floyd, M.D^ First Assistant Physidaa Kings Park 

Sute Hospital, Kings Park, N. Y. 
X9X4 Haviland, Walter C^ IL D^ 11 Elm St, Worcester, Mass. 
X908 Hawke, W. W^ ILIX, "The Eyrie,** Oifton Heights, Delaware Co^ 

Pa. 
X9X0 Hedin, Carl J., M.D., Superintendent Maune School for Feeble- 

Minded, W. Pownal, Me. 
X9xa Helmer, Rosa D., M.D., Assistant Physician Hudson River State 

Hospital, Poughkeepsie, N. Y. (Associate,) 
X9X3 Henderson, Estelle H., M. D., Southwestern State Hospital, Marion, 

Va. (Associate,) 
X9xa Henry, Hugh Carter, ILD., First Assistant Physician Central State 

Hospital, Petersburg, Va. (Associate,) 
tgii Hentchel, Louis K., M.D^ Senior Assistant Physician and Pa- 
thologist New Jersey Sute Hospital, Morris Plains, N. J. 

(Associate.) 
igii Herring, Arthur P^ M. D., Secretary State Lunacy Commission, 330 

North Charles St, Baltimore, Md. 
X894 Heyman, Marcus B., M.D., First Assistant Physician Central Islip 

State Hospital, Central Islip, L. I., N. Y. 
X9XX HickUng, D. Percy, M.D., "^siting Physician Washington Asylum 

and Jail, 1304 Rhode Island Ave., N. W., Washington, D. C 
1883 Hill, Chat. 0., M.D., Physidan-in-Chief Mt Hope Retreat, Balti- 
more, Md. (President, J907.) 
1883 Hill, Gerihom H., M. D^ Superintendent ** The Retreat," Des Moines, 

la. 
X899 Hin, S. S., M.D., Superintendent State Asylum for the Chronic 

Insane, Wemersville, Pa. 
X897 Hills, Frederick L., ILD., Superintendent Bangor State Hospital, 

Bangor, Me. 
x886 Hinddey, L. S., M.D. (formerly Medical Superintendent Essex 

County Hospital), 183 Clinton Ave., Newark, N. J. 



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LIST OF MEMBERS 23 

1913 Hinton, Ralph T., M. D., Superintendent Elgin State Hospital, Elgin, 

IlL 
1900 Hixachy Wa^ M.D^ Nenrologist to the German Poliklinic, 53 £. 

Sixty.f onrth St, New YcmIc, N. Y. 
1900 Hitchcodc, Chaa. W., M.D^ Attending Neurologist Harper Hospital, 

270 Woodward Ave., Detroit, Mich. 

1903 HobbSy Alfred T., M.J>^ Superintendent Homewood Sanitarium* 

Guelph, Ont 
ii95 Hoch, Aaguatt M. D^ Director Psychiatric Institute, Ward's Island, 
New York, N. Y. 

1904 Bockf Theodoxt A., 1LI>^ Assistant Physician McLean Hospital, 

Waverley, Mass. (Associate,) 

19x4 Hodflkin, Morgan B., M. D., Assistant Physician Monson State Hos- 
pital, Palmer, Mass. (Associate.) 

19x4 Hoffman, Harry F., ILD., Assistant Superintendent Homeopathic 
State Hospital, Allentown, Pa. (Associate,) 

1900 Hollej, Snrlngy ILD., Assistant Physician Long Island State Hos- 
pital, Brooklyn, N. Y. (Associate,) 

X913 Honman, Hiram L., M.I>., Assistant Physician Worcester State Asy- 
lum, Worcester, Mass. (Associate.) 

1913 Hotchkiaa, W. M., M.D^ Superintendent State Hospital for Insane, 
Jamestown, N. Dak. 

X894 Houfton, John A^ M. D., Medical Superintendent Northampton State 
Hospital, Northampton, Mass. 

X894 Howard, A. B^ M.D, (formerly Medical Superintendent Qeveland 
State Hospital), 736 Rose Building, Qeveland, Ohio. 

x888 Howard, Sugene H., M. D., Medical Superintendent Rochester State 
Hospital, Rochester, N. Y. 

1894 Howard, Herbert B., M.D^ Superintendent Peter Brent Brigham 
Hospital, 697 Huntington Ave., Boston, Mass. 

X9xa Hubbard, 0. S., M.D., Assistant Superintendent Kansas State Hos- 
pital for Epileptics, Parsons, Kans. (Associate.) 

X8O7 Hughes, Chaa. H., M. D^ 3858 West Pine Boulevard, St Louis, Mo. 

X907 Hmnmfliv Henry H^ M. D., Siq»erintendent Asylum for Insane Indians, 
Canton, South Dakota. 

X899 Hun, Henry, M.D., Albany, N. Y. (Honorary,) 

1894 Hwd, Arthur W^ li.D^ Medical Superintendent Buffak> State Hos- 
pital, Buffalo, N. Y. 

X879 Hurd, Heazy M., 1LI>., Secretary Johns Hopkins Hospital, 1210 
Fidelity Bmlding, Baltimore, Md (President, 1S99.) 

xt97 Hntckiags^ Hidiard H^ M. D^ Medical Superintendent St Lawrence 
State Hospital, Ogdensburg, N. Y. 

X899 HwtcMiiBii, Anna S., M. D^ Woman Assistant Physidaa Manhattan 
State Hospital, Ward's Island, New York, N. Y. (Associate.) 

XS85 HvtcUaaoa, Henry A., IL D., Medical Superintendent The Dixmont 
Hospital for the Insane, Dixmont, Pa. 



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24 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

I 
xgoi Inch, Geo. Frmklin, M.D., First Assistant Physician Kalamazoo 

State HosiMtal, Kalamazoo, Mich. (^Associate,) 
9x3 Ingram, Robert, M. D., Neurologist Qndnnati Hospital, Gndnnati, O. 
gza Isham, Mary Ke]rt, M. D., Assistant Physidan G)lumbas State Hos- 
pital, Columbus, O. (Associate.) 

J 

9x3 Jackson, J. Alien, M. D., Chief Resident Physician Philadelphia Hos- 
pital for Insane, Philadelphia, Pa. 

9x3 Jacobs, Wilma H., ILD., Kankakee State Hospital, Hospital, IlL 
(Associate,) 

9x3 Jacoby, J. Ralph, M. D., 54 West .88th St., New York, N. Y. 

908 JeUiffe, Smith Sly, M.D., Visiting Neurologist City Hospital, 64 

West s6th St, New York, N. Y. 
903 Jelly, Arthur C, M. D., 10 Arlington St., Boston, Mass. 
1909 Jones, L. H., M.D., Superintendent Georgia State Sanitarium, Mill- 

edgeville, Ga. 

909 Jordan, M. H., M.D., Assistant Physician Westborougfa State Hos- 
pital, Westborough, Mass. (Associate.) 

K 

906 Karpai, Morris J., ILD., Psychopathic Pavilion, Bellevue Hospital, 
New York, N.Y. (Associate.) 

9x4 Keatley, Harry W., M. D., Assistant Physician West Virginia Asylum, 
Huntington, W. Va. (Associate.) 

87a Kellogg, Theo. H., M. D., Riverdale Lane and Albany Postroad, River- 
dale, New York, N. Y. 

9x3 Kelly, Wm. E., M. D., Assistant Physician Middletown State Homeo- 
pathic Hospital, Middletown, N. Y. (Associate.) 

9x4 Kempf, Edward J., IL D., Assistant Resident Physician Phipps Clinic, 
Johns Hopkins Hospital, Baltimore, Md. (Associate.) 

890 Kenitton, J. H., M. D., Assistant Physician Connecticut Hospital for 
the Insane, Middletown, Conn. (Associate.) 

9x4 Keough, Peter L., M. D., Assistant Physician State Hospital, Crowns- 
ville, Md. (Associate.) 

9xa Kern, W. B., M. D., 412 W. 6th St, Los Angeles, Cal. 

9x0 Kieb, Raymond F. C, M.D., Superintendent Matteawan State Hos- 
pital, Beacon, N. Y. 

890 Kilboume, Arthur F., M, D., Medical Superintendent Rochester State 
Hospital, Rochester, Minn. (President, 1909.) 

895 IDndred, J. J., M.D., Proprietor and Consulting Physkian of the 
River Crest Sanitarium, Astoria, L. I., N. Y. 

19x3 Kineon, G. G., M.D., Superintendent Ohio Hospital for Epileptics, 
Gallipolis, O. 

9xa IDng, Florence A., ILD., Hudson River State Hospital, Pougfa- 
keepsie, N. Y. (Associate.) 



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UST OF MEMBERS 2$ 

1908 Kia& G«€fK» W.f M.D^ County Phyndan, Court House, aa9^ 

Second St, Jersey Qty, N. J. 
1910 Klog» Jolin CX, li.D.9 Superintei^ent Southwestern State Hospital, 

Marion, Va. 
zgia King; Robert, ILD^ Assistant Physician Buffalo State Hospital, 

BuflFalo, N. Y. (Associate.) 
1914 EhLgfiey, Alfred C, M.J>., Superintendent Arizona State Hospital, 

Phoenix, Ariz. 
X90X XSmieyy C. Spencer, M. D., Proprietor Easton Sanitarium, Easton, Pa. 
xgxo Kirby, George H^ H.D^ Director Clinical Psychiatry Manhattan 

State Hospital, Ward's Island, New York, N. Y. 
X905 Kline, George M^ ILD^ Superintendent Danvers State Hospital, 

Hathome, Mass. 
Z900 Klopp, Henry L, M. D^ Superintendent State Homeopathic Hospital, 

Allentown, Pa. 
1899 Knapp, John Rudolph, M.D., Assistant Physician Manhattan State 

Hospital, Ward's Island, New York, N. Y. (Associate,) 
1913 Knight, Arthur Clyde, M. D., Superintendent Montana State Hospital, 

Warm Springs, Mont. 
X894 Knowlton, W. IL, M.D., Channing Sanitarium, Brookline, Mass. 
1902 Kuhlman, Helene J. C, M.D., Assistant Physician Buffalo State 

Hospital, Buffalo, N. Y. (Associate.) 
Z907 Knhn, William P., M.D. (formerly Superintendent State Hospital 

No. 2, St Joseph, Mo.), Room 1025 Rialto Building, Kansas 

City, Mo. 



X90X Lamb, Robert B., M. D., 447 Third Ave., Troy, N. Y. 

X900 La Moure, Chas. T., M. D., Superintendent Connecticut School for Im- 
beciles, Lakeville, Conn. 

19x1 La Moure, Howard A., ILD., Superintendent Colorado State Insane 
Asylum, Pueblo, CoL 

X908 Landers, George B., M. D., Second Assistant Superintendent Presby- 
terian Hospital, 70th St. and Madison Ave., New York, N. Y. 
(Associate.) 

191a Lane, Arthur G., M.D^ Assistant Physician St Lawrence State 
Hospital, Ogdensburg, N. Y. (Associate.) 

1892 Lane, Edward B., M. D., Resident Physician Adams Nervine Asylum, 
419 Bpylston St, Boston, Mass. 

X9X3 Lang, Walter S., M. D^ Senior Assistant Physician Homeopathic State 
Hospital, Allentown, Pa. (Associate.) 

X903 Langflow, P. W., M.D., Medical Director Cincinnati Sanitarium, at 
Collie Hill ; Professor of Psychiatry, University of Cincinnati ; 
College of Medicine, 4003 Rose Hill Ave., Cincinnati, Ohio. 

X9ia Langdon, Fletcher, M. D., 4003 Rose Hill Ave^ Cincinnati, Ohio. 

X906 Laughlin, Chazlet S., M.D., Superintendent Southern Indiana Hos- 
pital for the Insane, Evansville, Ind. 



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26 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

X907 tawlor, Fred E^ IL D^ Superintendent Nova Scotia Hospital, Hali- 
fax. N. S. 

i88a Lawtoiit Sludl«r IL, M.D^ Medical Superintendent Brattleboro 
Retreat, Brattleboro, Vt 

19x1 Leader, Pauline M^ ILD^ Woman Ph3rsictan Clarinda State Hos- 
pital, Qarinda, Iowa. (Associate.) 

19x3 Leahy, Sylvester K., M.D^ Assistant Physician Manhattan State 
Hospital, Ward's Island, N. Y. (Associate,) 

X90X Leak Soy L^ M. J>,, 1048 Lancaster Ave., Sjrracuse, N. Y. 

xgxa Leavitt, William, U. D., Assistant Physician Central Islip State Hos- 
pital, Central Islip, N. Y. (Associate.) 

X9X4 Lee Hexbert, M.D., Resident Physician Dr. Woodson's Sanitarium, 
St Joseph, Mo. (Associate.) 

19x4 Lediman, Helena 6., U. D^ Assistant Physician Essex County Hos- 
pital, Cedar Grove, N. J. (Associate,) 

X9X3 Leonard, Edward F., M.D., 3501 N. Hermitage Ave^ Chicago. IlL 

19x3 Levin, Hyman L., M.D., St Lawrence State Hospital, Ogdensburg, 
N. Y. (Associate.) 

X900 Lewis, J. M., M.D. (formerly Superintendent Cleveland State Hos- 
pital), 436 Rose Bldg., Geveland, Ohio. 

X9X4 Lind, John E., ILD., Assistant Physician Government Hospital for 
Insane, Washington, D. C. (Associate.) 

19x0 Lindsay, S. C, ILD., Assistant Physician State Hospital, Inde- 
pendence, Iowa. (Associate.) 

X9X3 Littlewood, Thomas, M.D., Assistant Superintendent Gardner State 
Colony, Gardner, Mass. (Associate.) 

X899 Logie, Benjamin Rush, ILD., 1836 Connecticut Ave., Washington, 
D. C 

X909 Long, T. L^ M.D., Assistant Physician Cherokee State Hospital, 
Cherokee, Iowa. 

X9XX Lorens, William F., M. D., First Assistant Ph]rsician Wisconsin State 
Hospital for Insane, Mendota, Wis. (Associate.) 

X909 Love, George S., M. D., Superintendent Toledo State Hospital, Toledo, 
Ohio. 

X9X3 Lowe, Chariot S^ M. D., Jadcsonville State Hospital, Jadcsonville, IlL 
(Associate.) 

X903 Ludlum, Seymour DeWitt, M.D., Merion, Pa. (Associate.) 

X9xa Luitig, Daniel D., M.D., 146 Grant Ave., San Francisco, Cat 

19x3 Lyon, Chades 6., M. D^ Superintendent Dr. Lydn's Sanitarium, Bing- 
hamton, N. Y. 

x88a Lyon, Samuel B^ li.D^ " Shadytide," Prospect St and Howard 
Place, White Plains, N. Y. 



x89a Kabon, ^Hlliam, M. D^ Superintendent and Me<fical Director Man- 
hattan Sute Hospital, Ward's Island, New York, N. Y. 



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LIST OF MEMBERS 2/ 

Z874 KacDoBald, Carlot F^ M. D., 15 E. Forty-dghtfa St, New York., N. Y. 
(President, J914,) 

1924 Macdonald, Joha B., M. !>., Assistant Physidan Danvers State Hos- 
pital, Hathorne, Mass. (Associate,) 

19x3 Hack, Clifford W., IL D^ Agnew State Hospital, Agnew, CaL (AssO' 
date.) 

1907 Kaddiiy M. Cluurles, M.D., Assistant Physician State Hospital for 
Inebriates, Knoxville, la. (Associate,) 

1906 MacMiitoghy J. A.y M. J>^ Inverness Farm, R. D. No. 3, Easton, Md. 

Z9xa Hadfanshtoiiy Peter, M.D^ Assistant Superintendent Hospital for 
Insane, Hamilton, Ont (Associate.) 

2909 Maq^haU, Andiew, ILD., M.S.C.S.9 Sag., L.tLCV^ London; Pro- 
fessor of Pathology and Bacteriology University of Bishop's 
College, Mcmtreal; Consulting Pathologist to Protestant Hos- 
pital for the Insane, Montreal, 216 Peel St, Montreal, Que. 

X909 KcAUatter, Benjamin S^ M.D. (formerly Superintendent State 
Hospital for Insane, Jamestown, N. D.), King City, Mo. 

X894 McBride, James H., M.D., 489 Bellefontaine St, Pasadena, Cal. 

Z909 McCafferty, Smit L^ M.D., Assistant Superintendent Mt Vernon 
Hospital, Mt Vernon, Ala. 

X9Z0 McCampbell, Jolm, M. D., Superintendent State Ho^ital, Morganton, 
N. C 

X909 XcCaxthy, D. J^ li.D^ Professor of Medical Jurisprudence Uni- 
versity of Pennsylvania and Woman's Medical College, Phila- 
deli^ia. Pa. 

1903 McDonald, ismiiam, Jr., IL IX, 188 Blackstone Boulevard, Providence, 
R. I. 

Z909 XcGaffla, Charlea Oibooi, M. D^ Pathologist and Assistant Physician 
Kings Park SUte Hospital, Kings Park, N. Y. 

Z9XX McBLay, Jamas G., M.IX, Assistant Physician Hospital for Insane, 
New Westminster, B. C (Associate.) 

X905 McKelway, John Irviae, M. D., Second Assistant Superintenaent 
Eastern Oregon State HoH>ital, Pendleton, Ore. 

X907 McKlnniss, Clyde S., M. D., Superintendent Pittsburgh Gty Hospital, 
Bc^ce Sution, Pa. 

X897 ICacy, Wm. Austin, M. D., Medical Superintendent Kings Park State 
Hosintal, Kings Park, L. I., N. Y. 

X9xa Mahan, H. P., M. D., Assistant Physician Kansas State Hospital for 
l^eptics, Parsons, Kans. (Associate.) 

X9xa MaUMnrti, Josi A., M.D., Malberti's Sanitarium, Havana, Cuba. 

XS98 Kallon, Peter S^ M.D^ Assistant Physician New Jersey Stete Hos- 
pitsl, Morris Plains, N. J. 

1900 Xsnton, Walter P., M. D., Gynecologist Eastern and Northern Michi- 
gan Asylums; Consulting Gynecologist St Joseph's Retreat, 33 
Adams Ave., West, Detroit, Mich. 



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28 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

igzi Matthews, Adelbert C^ ILD^ First Assistant Physician Napa State 
Hospital, Napa, CaL (Associate.) 

xgza Matsinger, Herman 0., M. J>., go Soldier's Place, Buffalo, N. Y. 

1904 Bfazfield, Geo. K, M. D., Soldiers' Home, Chelsea, Mass. (Associate,) 

igxa May, Herman F., M.D., Assistant Physician Buffalo State Hospital, 
Buffalo, N. Y. (Associate.) 

zgio Kay, James V., M. D., Medical Member State Hospital Commission, 
Albany, N. Y. 

1894 Kaybeny, Chaa. B., ILD., Superintendent Hospital for the Insane 
of the Central Poor District of Luzerne County, Retreat, Lu- 
zerne Co., Pa. 

190a Mayer, Edward E., ILD., Qinical Professor of Neurology Univer- 
sity of Pittsburgh, Keenan BIdg., Pittsburgh, Pa. 

1893 Mead, Leonard C, M.D., Medical Superintendent South Dakota 
Hospital for the Insane, Yankton, S. D. 

igxa Melius, Edward, M. D., Superintendent Dr. Melius' Private Hospital, 
419 Waverley Ave., Newton, Mass. 

1891 Meredith, Hugh B., M. D., Medical Superintendent State Hospital for 
the Insane, Danville, Pa. 

igxa Meiriman, Willis S., M. D., Assistant Physician Hudson River State 
Hospital, Poughkeepsie, N. Y. (Associate.) 

1893 Mesrer, Adolf, M.D., Professor of Psychiatry Johns Hopkins Uni- 
versity, loi Edgevale Road, Roland Park, Md. 

1907 Meyers, Donald Campbell, M.D., Superintendent Dr. Meyers' Hos- 
pital, 72 Heath St, Toronto, Canada. 

X914 Mikels, Frank IL, M. D., Assistant Physician New Jersey State Hos- 
pital, Morris Plains, N. J. (Associate.) 

19x4 Miller, C. Ross, U. D., Assistant Physician St Lawrence State Hos- 
pital, Ogdensburg, N. Y. (Associate.) 

1904 Miller, Henry W., U. D., ** Mountainbrook," Brewster, N. Y. 

1893 Mills, Chaa. K, M.D., Professor of Neurology University of Penn- 
sylvania, 190P Chestnut St, Philadelphia, Pa. 

1907 Millspaugh, Daniel T., M. D., Superintendent " Riverlawn," 47 Totowa 
Ave, Paterson, N. J. 

1899 Mitchell, H. W., M. D., Superintendent Warren State Hospital, War- 
ren, Pa. 

1912 Mitchell, John C, M.D., Superintendent Hospital for the Insane, 
Brockville, Ont. 

Z908 Mitchell, Roy E., M. D., Boberg Building, Eau Claire, Wis. 

191 z Mobley, John W., ILD., Assistant Physician State Sanitarium, Mill- 
edgeville, Ga. (Associate.) 

1903 Montgomery, Wm. H., M.D., Senior Assistant Physician Willard 
State Hospital, Willard, N. Y. (Associate.) 

1906 Moody, 6. H., M.D., Superintendent Dr. Moody's Sanitarium, 315 
Brackenridge Ave, San Antonio, Texas. 



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UST OF MEMBERS 29 

:9xa Koon^ Artlnir S^ M.D^ Assistant Phjrsidan Middletown State Hos- 
pital, Middletown, N. Y. (Associate.) 
914 Moore, Joseph W^ M. D^ First Assistant Physician Matteawan State 

Hospital, Beacon, N. Y. (Associate.) 
896 Korel, Jules, M.D., Medical Superintendent State Asylum; G>m- 

missioner in Lnnacy, 56 Boulevard Leopold, Ghent, Belgium. 

(Honorary,) 
9x3 Morris, John N., M.D^ Springfield State Hospital, Sykesville, Md. 

(Associate.) 
9x3 Morse, Mary S., M.D., Worcester State Hospital, Worcester, Mass. 

(Associate.) 

893 MMher, J. Montgomery, M. D., 170 Washington Ave., Albany, N. Y. 
:88x Motet, A« M., MD., 161 Rue de Charonne, Paris, France (Hon' 

orary.) 

889 Moulton, A« S., M D., 5431 Locust St, Philadelphia, Pa. 
;886 MunaOD, Jamoo D., M. D., Medical Superintendent Northern Michigan 

Asylum, Traverse Qty, Mich. 
907 Munaon, James F., M.D., Resident Pathologist Craig G)lony for 

Epileptics, Sonyea, N. Y. 
1909 Murdock, J. Morehead, M. D., Superintendent State Institution Feeble- 

Minded of Western Pennsylvania, Polk, Pa. 
914 Murphy, Wm. A., M.D., Assistant Physician State Hospital, Golds- 

boro, N. C (Associate.) 
igia Myers, Glenn E^ M.D., Psychiatric Institute, Ward's Island, New 

York, N. Y. (Associate.) 

N 

914 Nairn, B. Ross, M. D., 512 Franklin St., Buffalo, N. Y. 

9x0 Neely, James J., M. D., Superintendent Western Hospital for Insane, 
Bohvar, Tenn. 

896 Neff, Irwin H., M. D., Superintendent Norfolk State Hospital, Pond- 
ville, Mass. 

9x3 Neff, Mazy Lawson, M.D., State Board of Administration, Spring- 
field, III 

9x4 Neuhans, George B., M.D., Superintendent Mt Airy Sanatorium, 
Denver, Col. 

[905 Nevin, Ethan A., MD., Superintendent Custodial Asylum, Newark, 
N. Y. 

9x3 Nevin, John, M. D., North Hudson Hospital, Jersey Gty, N. J. 

9x3 Nevitt, C. A., M. D., Superintendent Elmwood Sanitarium, Lexington, 
Ky. 

900 Nichols, John H., M. D., Resident Physician and Superintendent State 
Hospital, Tewksbury, Mass. 

9x3 Nickenon, Mary A., M D., Rochester State Hospital, Rochester, N. Y. 
(Associate.) 

886 Nimt, Edward B., M.D. (formerly Superintendent Northampton In- 
sane Hospital), 40 Harvard St., Springfield, Mass. 



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30 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

1892 Nobto, Alfred L, ILD^ Snperixiteiidefit Kakmaxoo State Ho8i»itaL 
Kalamazoo, Mich. 

i9za Noble, Smy C^ 1LJ>^ Assistant PhyiBidan Boston State Hospital 
Dorchester Centre, Mass. (.Associate.) 

igxa Noble, Mary S. Gill, M.D., Assistant Physician Boston State Hoe- 
pital, Dorchester Centre, Mass. {AuociaU.) 

1903 Norbviy, Frank P., M. J>^ Medical Director, The Norbury Sanatorium, 
Jacksonville, III 

xgza Norqnay, H. C, M. D., Assistant Superintendent Selkirk Hospital for 
Insane, Selkirk, Manitoba, Canada. {Associats.) 

190O Nottli, Charles H., M. D., Superintendent Dannemora State Hospital, 
Dannemora, N. Y. 

19x4 North, Bmerson A., M. D., Resident Physician Cincinnati Sanitarium, 
Cincinnati, O. {Associate.) 

1907 Norton, Eben C, M.D., Physidan-in-Charge Norwood Private Hos- 
pital for Mental Diseases, Norwood, Mass. 

X898 Noyes, William, IL D. (formerly Superintendent Boston State Hos- 
pital, Mattapan, Mass.), n St John St, Jamaica Plain, Mass. 



1904 O'Brien, John D., M. D., New Pomerene Building, Canton, O. iAsso^ 

date.) 
29x3 O'Brien, John P., ILD., Taunton State Hospital, Taunton, Mass. 
(Associate.) 

1905 O'Hanlon, George, IL D., Bellevue Hospital, New York, N. Y. 

X9XS O'Harrow, Marian, M. D., Friends' Asylum, Frankford, P. O. Box ao. 
Station F, Philadelphia, Pa. (Associate.) 

1908 OUalley, Mazy, M.D., Woman Assistant Physidan, Government 
Hospital for Insane, Washington, D. C (Associate.) 

X889 Orth, H. L., M. D., Superintendent and Physician Pennsylvania State 
Lunatic Hospital, Harrisburg, Pa. 

Z907 Orton, Samuel T., M.D., Qinical Director and Pathdogist Pennsyl- 
vania Hospital for Insane, Philadelphia, Pa. (Associate.) 

igio Osbom, W. S., M. D., 605 Fleming Bldg., Des Momes, la. 

X898 Ostrander, Herman, M. D., Assistant Superintendent Kalamazoo State 
Hospital, Kalamazoo, Mich. 

19x3 Overholser, M. P., M. D., Superintendent State Hospital No. 3, Nevada, 
Mo. 



X907 Packard, Frederidc H., M.D., Assistant Physidan McLean Hospital, 

Waverlcy, Mass. (Associate.) 
X904 Packer, Flavius, ILD., Physician-in-Charge, West Hill, 961st St 

and Broadway, New York, N, Y. 
X889 Page, Charles W^ M. D., 94 Woodland St, Hartford, Conn. 



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LIST OF MEMBERS 3I 

Z894 Paga^ H. W^ M.D^ Saperintendent Hospital Cottages for Children, 

Baldwinville, Mass. 
i9xa Paine, Harlan L^ ILD^ Assistant Superintendent Gardner State 

Colony, Gardner, Mass. (Associate,) 
X887 Paine, N. Emmons, M.D. (formerly Superintendent Westborougfa 

State Hospital), The Newton Sanatorium, West Newton, Matss. 
29x4 Palmer, E., IL D., Assistant Physician Northern Hospital for Insane, 

Logansport, Ind. (Associate.) 
X897 Palmer, Harold L., M. D., Superintendent Utica State Hospital, Utica, 

N. Y. 
X894 Parant, A« Victor, M. D., Toulonse, France. (Honorary.) 
29x2 Parker, Charles S^ M.D., Assistant Physician Kings Park State 

Hospital, Kings Park, N. Y. (Associate.) 
X9Z3 Parker, George M^ M. D., St. Vincent's Hospital, New York, N. Y. 
1905 Parsons, Frederidc W^ ILD., First Assistant Physician Hndson 

River State Hospital, Poughkeepsie, N. Y. (Associate.) 
X913 Parsons, Skhard H^ M. D^ Burlington Co. Hospital for Insane, Mt 

HoUy, N. J, 
X909 Partlow, William D., ILD., Assistant Superintendent The Bryce 

Hospital, Tuscaloosa, Ala. 
19x3 Patterson, Christopher J., M. D., Physician-in-Charge, Marshall Sani- 
tarium, Troy, N. Y. 
1922 Payne, Guy, M.D., Medical Superintendent Essex Co. Hospital for 

Insane, Cedar Grove, N. J. 
X897 Pease, Caroline S^ M.D., Assistant Physician St Lawrence State 

Hospital, Ogdensburg, N. Y. (Associate.) 
29XS Podval, Joseph P., M.D., Superintendent Chicago State Hospital, 

Dulming, 111. 
290X Peny, Middleton L., M.D., Superintendent Kansas State Hospital 

for Epileptics, Parsons, Kans. 
2893 Peterson, Frederick, M.D., Professor of Psychiatry Columbia Uni- 
versity, ao W. soth St, New York, N. Y. 
292a Peterson, Jessie M., M.D^ Resident Physician Department for 

Women, State Hospital, Norristown, Pa. 

2923 Petexy, Arthur K., M. D., State Hospital for the Insane, Norristowxi, 

Pa. (Associate.) 

292a Pettibone, Ralph S., M.D., Assistant Physician Willard State Hos- 
pital, Willard, N. Y. (Associate.) 

292a Pettijohn, Abra C, M. D., Room 24, Masonic Temple, Brookfield, Mo. 

2924 Pf eiifer, J. A« F., M. D., Government Hospital for Insane, Washington, 

D. C. (Associate.) 
2923 Phelpe^ K. H., M.D., Superintendent St Peter State Hospital, St 

Peter, Minn. 
292a Phillips, Horace, M.D., 905 Land Title Building, care of B. Griffith 

Jones, Philadelphia, Pa. (Associate.) 
2920 Pieraon, Clarence, M, D., Superintendent East Louisiana Hospital for 

Insane, Jackson, La. 



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32 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

29x4 Pienon, Helenii B.» M. D^ Assistant Physician Kings Park State Hos- 
pital, Kings Park, N. Y. (Associate.) 
19x3 Pierton, Sarah 6^ M. D^ Rochester State Hospital, Rochester, N. Y. 

(Associate,) 
X9X3 Pietrowics, Stephen S^ ILD^ Superintendent Dunning Institutions, 

Chicago, HI. 
1890 Pilgrim, Chaa. W., M. D., Superintendent Hudson River State Hos- 
pital, Poughkeepsie, N. Y. (President, 191 1-) 
X9X0 Pitman, Mason W. BL, M. D., Riverdale-on-Hudson, New York, N. Y. 
X9X4 Poate, Ernest M ., M. D., Senior Assistant Physician Manhattan State 

Hospital, Ward's Island, New York. (Associate.) 
X914 Podall, H. C, IL D., Assistant Physician State Hospital, Norristown, 

Pa. (Associate.) 
19x2 Pogne, Mary S^ M. D^ Physidan-b-Charge, Oak Leigh Sanitarium, 

Lake Geneva, Wis. 
X9X0 Pollock, Heniy M., M.D., Superintendent Norwich Hospital for the 

Insane, Norwich, Conn. 
X90S Porteous, Carlyle A^ M.D., Assistant Superintendent Protestant 

HospiUl for the Insane, New P. O. Box 2280, Special Bag, 

Montreal, Canada. 
X9XX Porter, William C, ILD., Assistant Physician Hudson River State 

Hospital, Poughkeepsie, N. Y. (Associate.) 
X9xa Potter, Clarence A«, M.D., First Assistant Physician Gowanda State 

Hospital, Collins, N. Y. (Associate.) 
1893 Potter, Esra B., ILD., First Assistant Physician Rochester State 

Hospital, Rochester, N. Y. 
X9X3 Potter, Frederick C, IL D., Pathologist Central Indiana Hospital for 

Insane, Indianapolis, Ind. (Associate.) 
X913 Powers, Herbert Wm., M. D., Milwaukee Sanitarium, Wauwatosa, Wis. 
X906 Preston, John, M.D., Superintendent State Lunatic Asylum, Austin, 

Tex. 
1908 Priddy, A« S., M. D., Superintendent Virginia State Epileptic Colony, 

Madison Heights, Va 
X9X3 Priestman, Gordon, M. D., Assistant Physician, Willard State Hospital, 

WiUard, N. Y. (Associate.) 
X9X4 Pritchard, John A., M.D., Senior Assistant Physician St Lawrence 

State Hospital, Ogdensburg, N. Y. (Associate.) 
19x3 Pritchard, William B., M. D., New York City Hospital, Blackwell's 

Island, New York, N. Y. 
X908 Pritchard, William H., M. D., 501 Second Ave., Gallipolis, O. 
1898 Prout, Thos. P., IL D., Fair Oaks Sanitarium, Summit, N. J. 
X9xa Purdum, Harry D., M.D., Assistant Physician Springfield State Hos- 
pital, Sykesville, Md. (Associate.) 
i8q8 Putnam, Emma, M. D., Poughkeepsie, N. Y. 



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LIST OF MEMBERS 33 



1879 Qoiiiby, Hoaea M^ M. D. (formerly Medical Superintendent Worces- 
ter State Hospital), Worcester, Mass. 



19x0 Ramsey, William E^ M.D^ Perth Amboy, N. J. 

2909 Sandolpb, James H^ ILD., St James Building, Jadcsonville, Fla. 
(Associate,) 

X894 Katliff, J. M^ M. D^ Medical Superintendent Grandview Sanitarium, 
Price Hill, Gndnnati, O. 

19x3 Katliff, Thomas A., M. J),, Grandview Sanitarium, Price Hill, Cincin- 
nati, O. 

X909 Kaynor, Mortimer W^ M.D^ Senior Assistant Physician Hudson 
River State Hospital, Poughkeepsie, N. Y. (AssociaU.) 

X9xa Ready Charles F., M.D^ Assistant Superintendent Kankakee Sute 
Hospital, Hospital, IlL (Associate.) 

19x3 Reed, Ralph 6^ ILD^ Assistant Physician State Hospital, Central 
Islip, N. Y. (Associate.) 

X896 R^gis, Emmanuel, M.D^ Bordeaux, France. (Honorary.) 

X9X4 Reid, Eva C, M. D., After-Care Physician California State Hospitals, 
University of California Hospital, San Francisco, Cal. (Asso- 
ciate.) 

X9X4 Reily, John A., M. D., Superintendent Southern California State Hos- 
pital, Patton, Cal. 

19x1 Shein, John H. W^ M.D^ Professor Diseases of Mind and Nervous 
System, Philadelphia Polyclinic and College of Medicine, 1732 
Pine St, Philadelphia, Pa. 

X9xa Richards, Cyril 6., IL D., Assistant Physician Long Island Hospital, 
Boston Harbor, Mass. (Associate.) 

X91X Richards, Robert L., M. D., Superintendent Mendocino State Hospital, 
Talmage, Cal. 

X904 Richardson, Wm. W., M. D., Medical Director The Mercer Sanitarium, 
Mercer, Pa. 

X908 Ridcsher, Charles, M. D., Assistant Physician State Psychopathic Insti- 
tute, Kankakee, 111. 

X9X3 Ridgway, R. F. L., M. D., Pennsylvania State Lunatic Hospital, Harris- 
burg, Pa. (Associate.) 

x9oa Riggs, Charles Eugene, M. D., Professor of Nervous and Mental Dis- 
eases and Chief of Department Neurology and Psychiatry, 
University of Minnesota, 10 Crocus Hill, St Paul, Minn. 

X9XX Riggs, George Henry, M.D., Superintendent Riggs Cottage- Sanita- 
rium, Ijamsville, Md. 

19x0 Ripley, Horace 0., M.D., Assistant Superintendent State Hospital, 
Taunton, Mass. 



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34 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

1899 Hittif Antoine, M.D^ Honorary Physkian-in-Chief Maison Nadon- 
ale de Charentoiv 68 Boulevard Exelmans, Paris, France. (Hon- 
orary.) 

X901 SobertMn, Frank W^ M.D. (formerly General Sttperintendent New 
York State Reformatory at Elmira), 422 West End Ave., New 
York. 

X908 Sobini, William L., M. D^ 1700 13th St, N. W., Washington, D. C 

191 X Robinson, 6. Wilse, M.D., Superintendent The Punton Sanitarium, 
Kansas City, Mo. 

19x3 Robinson, Hedley V., M.D., Assistant Physician Protestant Hospital 
for the Insane, New P. O. Box 2280, Montreal, Que. (Asso^ 
ciate.) 

X909 Robinson, W. J., M. J>^ Superintendent Asylum for the Insane, Lon- 
don, Ontario. 

X9xa Rogers, Arthur W., M.D., Superintendent Oconomawoc Health 
Resort for Nervous and Mental Diseases, Oconomawoc, Wis. 

X907 Rogers, Chas. B., M. D., Physidan-in-Charge Fair Oaks Villa, Cuya- 
hoga Falls, O. (Associate.) 

X9X3 Rogers, John B., M. D., Assistant Physician Napa State Hospital, Napa, 
CaL (Associate.) 

X9xa Rooks, J. T., ILD., Assistant Physician Kankakee State Hospital, 
Hospital, 111. (Associate,) 

X909 Rosanoff, A« J., M.D., First Assistant Physician Kings Park State 
Hospital, Kings Park, N. Y. 

X907 Rosi, Dcoald L., M.D., Superintendent Connecticut Colony for Epi- 
leptics, Mansfield Depot, Conn. 

X9xa Rosi, John R., M. D., First Assistant Phjrsidan Dannemora State Hos- 
pital, Dannemora, N. Y. (Associate.) 

X899 Rowe, John T. W., M. D., First Assistant Physician Manhattan State 
Hospital, Ward's Island, New York, N. Y. 

X9XX Rowe, Melvin J., M.D., Monrovia, CaL (Associate.) 

X9XS Rowland, George A., M. D., Assistant Physician Columbus State 
Hospital, Columbus, O. (Associate.) 

19x3 Ruggles, Arthur H., M. D., Assistant Physician Butler Hospital, Provi- 
dence, R. I. (Associate.) 

X907 Ruland, Frederidc D., M.D., Proprietor Dr. Ruland's Sanitarium, 
Westport, Conn. 

X9XS Runyon, Wm. D., M. D., Assistant Physician State Sanatorium for 
Treatment of Tuberculosis, Oakdale, la. (Associate.) 

X9X3 Russell, Clarence L., M.D., Assistant Physician Hudson River State 
Hospital, Poughkeepsie, N. Y. (Associate.) 

X9xa Russell, Rose A., M.D., Assistant Physician Cherokee State Hos- 
pital, Cherokee, la. (Associate.) 

X898 Russell, Wm. L., IL D., Superintendent Bloomingdale Hospital, White 
Plains, N. Y. 

X907 Ryan, Edward, ILD., Superintendent Rockwood Hospital for the 
Insane, Kingston, Ontario. 



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UST or MEMBERS 35 

X899 SyoBy Walter 6^ M. D^ Medical Inspector for State Hospital Com- 
mission, Albany, N. Y. 

s 

1894 Sach^ B^ M.D^ 116 W. 59th St, New York. N. Y. 

xgxa Salmon, Thomas W^ M. D^ National Committee for Mental Hygiene, 
SO Union Square, New York, N. Y. 

X908 Sandy, William C^ M. D^ Assistant Physician Kings Park State Hos- 
pital, Kings Park, N. Y. (Associate.) 

xgia Saaford, Walter H^ ILD^ Assistant Physician Kings Park State 
Hospital, Kings Park, N. Y. (AssociaU.) 

29x3 Sargent, George P., M.D^ Assistant Physician Sheppard and Enoch 
Pratt Hospital, Towson, Md. (Associate.) 

X9X3 Samiders, Eleanora B., M. D^ Waverley Sanitarium, Columbia, S. C 
(Associate,) 

1909 Scanland, J. M^ M. D^ Warm Springs, Montana. 

X9X3 Schenkelberger, Frederick P^ M. D., Gowanda State Hospital, Collins, 
N.Y. (Associate.) 

Z909 Schlapp, Max 6., M. J)., Lecturer on Neuro-Histology and Pathology, 
Cornell University, 40 E, 41st St., New York City. 

19x4 Schley, S. Montf ort, M. D., 267 Elmwood Ave., Buffalo, N. Y. 

1894 Schmid, H. Ernest, M.D., White Plains, N. Y. 

19x2 Schneider, C. von A^ M.D., Assistant Physician Gowanda State 
Hospital, Collins, N. Y. (Associate.) 

igio Schwixm, George H^ M.D., Government Hospital for the Insane, 
Washington, D. C (Associate.) 

1912 Scott, Thompson P^ M.D., First Assistant Physician Topdca State 
Hospital, Topeka, Kans. (Associate.) 

1386 Sciibner, Ernest V^ M.D., Medical Superintendent Worcester State 
Hospital, Worcester, Mass. 

X893 Searcy, James T., M.D., Medical Superintendent The Alabama In- 
sane Hospitals, Tuscaloosa, Ala. (President, 1913.) 

X894 Searl, Wm. Il, M. D., Medical Director Fair Oaks Villa, Cuyahoga 
Falls, Ohio. 

1889 Sefton, Fxederick, IL D^ The Pines, Auburn, N. Y. 

X897 Semelaigne, Rto6, M, D^ Medecin en Chef Maison de Sant6, NeuiUy 
sur Seine, Paris, France, (Honorary,) 

189a Sample, John M., M. D., Superintendent Eastern Washington Hospital 
for the Insane, Medical Lake, Wash. 

1908 Seybert, Frank T., M.D^ Alienist St Bernard's Hospital, 532 First 
Ave., Council Bluffs, Iowa. 

Z903 Shanahan, Wm. T., M. D., Medical Superintendent Craig Colony for 
Epileptics, Sonyea, N. Y. 

1903 Sharp, Edw. A., M. D., 481 Franklin St, Buffalo, N. Y. 

19x3 Shaw, Arthm: L., M.D., Assistant Physician Craig Colony for Epi- 
leptics, Sonyea, N. Y. (Associate.) 



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36 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

19x4 Sheehaii, Robert F^ M. D^ Government Hospital for Insane, Wash- 
ington, D. C. {Associate,) 

1909 Skellenberger, Edward B^ M.D.y Assistant Physician State Hospital 
for Insane, Danville, Pa. (Associate.) 

X904 Shepherd, Arthur F., M.D., Ohio State Board of Administration, 
Columbus, Ohio. 

x9xa Sherman, Adin, M. D., Superintendent Northern Hospital for Insane, 
Winnebago, Wis. 

X905 Shirrea, David Alexander, M.D^ Consulting Neurologist to the 
Protestant Hospital for the Insane, 670 W. Sherbrooke St, 
Montreal, Can. 

19x2 Sights, H. P., M.D., Superintendent Western Kentucky Asylum, 
Hopkinsville, Ky. 

X9X4 Simon, Theodore W., M.D., Senior Assistant Physician State Hos- 
pital, Central Islip, N. Y. (Associate.) 

x89a Simpson, J. C, M. D., 1421 Massachusetts Ave., Washington, D. C. 

X9X0 Skiimer, WiUiam W., M.D., Consulting Surgeon State Hospital, 
Willard, N. Y., 449 Main St, Geneva, N. Y. 

X905 Skoog, A. L., M.D., Associate Professor of Neurology, University 
of Kansas, 1004 Rialto Building, Kansas Gty, Mo. 

X904 Slocnm, Clarence J., M.D., Resident Physician Dr. MacDonald's 
House, Central Valley, Orange County, N. Y. (Associate.) 

X885 Smith, Edwin Everett, M.D. (formerly Medical Director New 
Jersey State Hospital), Kensett, Norwalk, Conn. 

X898 Smith, Oeo. A, M.D^ Medical Superintendent Central Islip State 
Hospital, Central Islip, L. I., N. Y. 

x9oa Smith, Gilbert T., M. D., Box 91, Stamford, Conn. (Associate.) 

igi% Smith, H. M., M.D., Superintendent New Mexico Insane Asylum, 
Las Vegas, N. Mex. 

X9X3 Smith, H. V. A^ M. D., Superintendent Hudson Co. Hospital for In- 
sane, Jersey City, N. J. 

X9X3 Smith, J. Anaon, M. D., Camden County Hospital for Insane, Blade- 
wood, N. J. 

X9X3 Smith, J. 0. Fowble, M.D., Assistant Physician Springfield State 
Hospital, Sykesville, Md. (Associate,) 

X9XX Smith, Joseph, M.D., Assistant Physician Long Island State Hos- 
pital, Brooklyn, N. Y. (Associate.) 

19x4 Smith, R. W. Brace, M. D., Inspector of Hospitals and Public Chari- 
ties, Parliament Building, Toronto, Ont 

X9xa Smith, Robert P., M. D., Cobb Building, Seattle, Wash. 

X89X Smith, S. E., M.D., Medical Superintendent Eastern Indiana Hos- 
pital for the Insane, " Easthaven," Richmond, Ind. (President, 
mS') 

X885 Smith, Stephen, M.D., 300 Central Park, West, New York, N. Y. 
(Honorary.) 



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UST OF MEMBERS 37 

19x4 Smitlisoiit Wm. W., M.D^ Superintendent State Insane Hospital, 
Jackson, Miss. 

xgzz SaMYtSjf Sari H^ M.D., Assbtant Physician Essex County Hospital 
for Insane, Cedar Grove, N. J. (Associate,) 

X908 Soliery Charles H^ M.D.9 Superintendent State Hospital, £vanston» 
Wya 

X898 Somersy Elhert M., M.D., Superintendent Long Island State Hos- 
pital, Brooklyn, N. Y. 

19x3 Somenrilley WilUam 0., M.D., Neurologist Gty Hospital, Memphis, 
Tenn. 

X907 Southard, Elmer E., M. D., Director Psychopathic Department, Bos- 
ton State Hospital, 70 Francis Ave., Cambridge, Mass. 

19x3 Spaldingy Harry 0., M. D., Acting Superintendent Westboroug^ State 
Hospital, Westborough, Mass. 

X9X4 Spear, Irving J., M. D., 1810 Madison Ave., Baltimore, Md. 

X899 Spence, Jamea Beveridge, M. D., S. U. L, M. Ch., Resident Physician 
and Superintendent Staffordshire County Asylum, Bumtwood, 
near Litchfield, England. {Honorary.) 

X894 S^agne, Geo. P., M. D., Superintendent High Oaks Sanitarium, Lex- 
ington, Ky. 

19x4 Stack, S. S., M.D., Superintendent Sacred Heart Sanitarium and 
St Mary's Hill Hospital, Milwaukee, Wis. 

19x4 Stancell, W. W., M. D., Assistant Physician State Hospital, Raleigh, 
N. C. {Associate,) 

x89a Stanley, Charles E., M.D., Assistant Phsrsician Connecticut Hospital 
for the Insane, Middletown, Conn. (Associate.) 

X9X3 Steams, Albert Warren, M.D., 520 Commonwealth Ave., Boston, 
Mass. (Associate,) 

X898 Steams, Wm. G., M. D., 25 £. Washington St., Chicago, 111. 

19x4 Steckel, Harry A., M. D., Assistant Physician Kings Park State Hos- 
pital, Kings Park, N. Y. (Associate,) 

X884 Stedman, Henry R., M.D., Boumewood Private Hospital for Nerv- 
ous and Mental Diseases, South St., Brookline, Mass. 

X895 Stevens, Frank T., M.D., 609 Exchange National Bank Building, 
Colorado Springs, Colo. 

X894 Stewart, Nolan, M.D. (formerly Superintendent State Insane Hos- 
pital), Jackson, Miss. 

19x4 Stewart, Robert A., M. D., 539 W. Main St, Lock Haven, Pa. (Asso- 
date,) 

X907 Stick, H. Louis, M.D., Superintendent Worcester State Asylum, 
Worcester, Mass. 

X9X0 Stocking, Leonard, M. D., Superintendent State Hospital, Agnew, CaL 

X904 Stockton, Geo., M. D. (formerly Superintendent Columhus State Hos- 
pital), 151 & Broad St, Columbus, O. 

X909 Stone, Elmer E., M.D. (formerly Superintendent Napa State Hos- 
pital, Napa, (TaJ.), 291 (kary St, San Francisco, Cal. 



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38 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

X89S StoiM, William A^ M. D. (formerly Assistant Superintendent Midii- 
gan Asylum for the Insane) » Iioa W. Main St, Kalamazoo, 
Mich. 

19x4 Stiecker, Edward A., M. D., Assistant Physician Pennsylvania Hos- 
pital for Insane, Philadelphia, Pa. (Associate.) 

19x3 Stuigis, Karl B^ M. D., Assistant Physician Maine Insane Hospital, 
Augusta, Me. (Associate.) 

igi% Snlliyan, F. J., M. D., Kankakee State Hospital, Hospital, III (Asso- 
date,) 

X903 Swift, Henry M., M. D., 655 Congress St, Portland, Me. 

X9X4 Swift, Walter B., M. D., no Bay State Road, Boston, Mass. 

X894 Sylvester, William E., M.D.9 Lincoln Wood-on-Canandaigua Lake, 
N. Y. 



X899 Taddiken, Paul Gerald, M. J>^ First Assistant Physician St Lawrence 
State Hospital, Ogdensburg, N. Y. (Associate.) 

x88x Tamburini, A., M. D., Rcggio-Emilia, Italy. (Honorary.) 

X9X4 Taylor, Herbert W., M.D., First Assistant Physician Brattleboro 
Retreat, Brattleboro, Vt (Associate.) 

1992 Taylor, Isaac M., M.D., Superintendent Broadoaks Sanatorium, Mor- 
ganton, N. C 

X9X0 Terfling^y Fred. W., M.D., Medical Superintendent Northern Hos- 
pital for Insane, Logansport, Indiana. 

X9X4 Thomas, John N., M. D., Superintendent Louisiana Hospital for In- 
sane, Pineville, La. 

X906 Thompson, Charles E., M. D., Superintendent Gardner State Colony, 
Gardner, Mass. 

X89X Thompson, J. L., M.D., Assistant Physician State Hospital for the 
Insane, Columbia, S. C. (Associate.) 

X9xa Thompson, Nelson W., M.D., Flower Hospital, 450 E. 64th St, 
New York. (Associate.) 

X896 Thompson, Whitefleld N., M. D., Medical Superintendent The Hart- 
ford Retreat, Hartford, Conn. 

X9X3 Thomson, A. W., M. D., 91 Garden St, Poughkeepsie, N. Y. (Asso- 
date.) 

19x4 Thome, Frederic H., M.D., Pathologist New Jersey State Hospital, 
iMorris Plains, N. J. (Associate.) 

X9xa Throckmorton, Tom B., M.D., 407 Equitable Building, Des Moines, 
la. (Associate.) 

X9X4 Thnrlow, A. A., M. D., First Assistant Physician Oklahoma Hospital 
.for Insane, Norman, Okla. (Associate.) 

X9xa Tiffany, William J., ICD., Assistant Physician Binghamton State 
Hospital, Binghamton, N. Y. (Associate.) 

X9xa Todd, Leona E., ICD^ Woman Physician Hudson River State Hos- 
pital, Poughkeepsie, N. Y. (Associate.) 



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LIST OF MEMBERS 39 

X9XS Toomey, Joseph H^ M. D., State Hospital for Insane, Howard, R. I. 
(Associate.) 

X90X Tomeyy Geo. E^ Jr., H. D., Boamewood Hospital, South St, Brook- 
line, Mass. 

xgoa Toolonte, Bdonard, M.D., Physician-in-Chief to Villejuif Asylum; 
Director Revue de Psychiatrie; Director of Laboratory of Ex- 
perimental Psychology, FEcole des Hautes Etudes, Paris; Ville- 
juif (Seine), France. (Honorary.) 

X899 Townsend, Theodore Irving, ICD., First Assistant Physician Bing- 
hamton State Hospital, Binghamton, N. Y. 

19x3 Tx»der, Wm. N.^ ICD.^ Assistant Physician Craig Colony for Epi- 
leptics, Sonyea, N. Y. (Associate.) 

19x4 Tx«yi8, John SL, M. D., Assistant Physician Danvers State Hospital, 
Hathome, Mass. (Associate.) 

X9xa Treadway, Walter L^ M.D., Assistant Sm-geon U. S. Public Health 
Service, Ellis Island, New York. 

X9xa Treokley Henry L., M.D., Physician-in-Charge Knickerbocker Hall, 
AmityviUe, L. I. (Associate,) 

19x4 Tmeman, Nelson 0., M. D., Assistant Physician Danvers State Hos- 
pital, Hathome, Mass. (Associate.) 

X9xa Tndtty S. P.* M.D.y Clinical Director East Louisiana Hospital for 
Insane, Jackson, La. 

X90X Turnery John 8., H. D., 326-27 linz Bldg., Dallas, Texas. 

19x3 Tnner, Reeve, H. D., 522 West 149th St, New York, N. Y. 

1899 Tnttle, Geo. T^ M.D., Medical Superintendent McLean Hospital, 
Waverley, Mass. 

X908 Twohey, John J., ILD., Physidan-in-Charge Providence Retreat, 
Buffalo, N. Y. 

X909 Tyson, Forrest C, M. D., Superintendent Augusta State Hospital, Au- 
gusta, Me. 

u 

X909 Uhla, L. L.y M. D., The Uhls Sanitarium, Overland Park, Kans. 

19x4 Ullxnan, Albert E., M. D., Senior Assistant Physician State Hospital, 

Central Islip, N. Y. (Associate.) 
X899 Urquhart, Alexander R., M.D., F.R.C.P.E., Superintendent Royal 

Asylum, Perth, Scotland. (Honorary.) 



X9XX TaaWart, Roy McLean, M. D., Visiting Physidan to Nervous Wards 
of Charity Hospital, 1126 Maison Blanche Building, New 
Orleans, La. 

X907 Tani^ias, P. H. S., M. D., Yarmouth, Me. 

19x3 yaux; Charlea L., M.D., Senior Assistant Physidan, State Hospital, 
Central Islip, N. Y. (Associate.) 



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40 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

191a Veeder, Willard H^ ICD., Assistant Phsrsician Rochester State Hos- 
pital, Rochester. N. Y. (Associate.) 

1896 ViUeneuve, George, M. D., Medical Superintendent Saint Jean de Dieu 
Hospital, New P. O. Box 2947, Montreal, Que. 

1893 Voldeng, M. Nelson, M. D^ Superintendent State Hospital and Colony 
for Epileptics, Woodward, Iowa. 

i9xa Vosburghy Stephen E., M. D., Assistant Superintendent Maine Insane 
Hospital, Augusta, Me. (Associate,) 

W 

X895 Wade, J. Percy, M.D., Medical Superintendent Spring Grove Hos- 
pital for the Insane, Catonsville, Md. 

Z890 Wagner, Charles G., M. D., Medical Superintendent Binghamton State 
Hospital, Binghamton, N. Y. (Secretary and Treasurer.) 

igi2 Walker, Eloiee, M. D., Woman Physician, Binghamton State Hospital, 
Binghamton, N. Y. (Associate.) 

Z905 Walker, Irving Lee, M. D., Assistant Physician Rochester State Hos- 
pital, Rochester, N. Y. (Associate.) 

1905 Walker, Lewis M., M.D., First Assistant Physician Medfield State 
Asylum, Medfield, Mass. 

19x4 Walker, N. P., M. D., Assistant Physician Georgia State Sanitarium, 
MiUedgeville, Ga. (Associate.) 

19x3 Wardner, Drew M., Essex County Hospital for Insane, Cedar Grove, 
N. J. (Associate.) 

X9xa Washburn, Philip C, ICD., Assistant Physician Kings Park State 
Hospital, Kings Park, N. Y. (Associate.) 

igi% Waterman, Chester, ICD^ Assistant Physician Willard State Hos- 
pital, Willard, N. Y. (Associate.) 

19x4 Waterman, Paul, ICD., Assistant Neurologist Hartford Hospital, 
Hartford, Conn. 

19x3 Webster, B. S^ M. D., Assistant Physician Matteawan State Hospital, 
Beacon, N. Y. (Associate.) 

19x0 Weeks, David F., M.D., Medical Superintendent and Executive Of- 
ficer New Jersey State Village for Epileptics, Skilhnan, N. J. 

X9X3 Weiienburg, T. H., M. D., 2030 Chestnut St, Philadelphia, Pa. 

X893 Welch, 0. 0., H. D., Medical Superintendent Fergus Falb State Hos- 
pital, Fergus Falls, Minn. 

x89a Wentworth, Lowell F., M. D., Deputy Executive Officer State Board 
of Insanity, 36 State House, Boston, Mass. 

X9X4 Wescott, Adeline M., M.D., State Hospital, Central Islip, N. Y. 
(Associate.) 

X904 West, Calvin B., M. D., Senior Assistant Physician Kings Park State 
Hospital, Kings Park, N. Y. (Associate.) 

X9xa Weston, Paul 0., M.D., Pathologist State Hospital, Warren, Pa. 
(Associate.) 



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LIST OF MEMBERS 4I 

X904 Wheny, J. W^ M. D. (formerly Medical Superintendent " Glenwood," 
Dansville, N. Y.)» Los Gatos, California. (Associate,) 

xgza White, F. S^ M.D^ Superintendent Southwestern Insane Asylum, 
San Antonio, Tex. 

1906 White, Grace E., M.D., Wood Lea Sanitarium, joo Ardmore Ave, 

Ardmore, Pa. {Associate.) 

Z89Z White, M. J., M.D^ Medical Superintendent Milwaukee Hospital 
for the Insane, Wauwatosa, Wis. 

XQoa White, Wm. A., H. D^ Superintendent Goyemment Hospital for the 
Insane, Washington, D. C 

1909 White, William Riiahmore, ICD^ Superintendent Patapsco Manor 
Sanitarium, Ellicott City, Md. 

igza Whitney, Ray L^ M. D., First Assistant Physician McLean Hospital, 
Waverley, Mass. (Associate.) 

19x4 Wholey, Comeliua C^ H. D., 4616 Bayard St, £. £., Pittsburgh, Pa. 

1903 WUcoZy Franklin 8., H. D., Assistant Superintendent Southern Cali- 
fornia State Hospital, Patton, Cal (Associate.) 

X898 Wilgus, Sidney D., H. D., Superintendent and Proprietor The Ransom 
Sanitarium, Box 304, Rodcf ord, BL 

19x3 VnUiams, B. F., M. D., Superintendent Nebraska Hospital for Insane, 
Lincoln, Neb. 

X906 Williamfl, Berthold A., M.D., Senior Resident Physician, Cincinnati 
Sanitarium, College Hill, Ohio. 

X904 Williamfl, G. SL, ICD., Assistant Physician Columbus State Hos- 
pital, Columbus, Ohio. 

X9xa Williama, Hairy D., ICD., Assistant Physician New Jersey State 
Hospital, Trenton, N. J. (Associate.) 

19x0 Williama, Tom A, M. D., 1705 N St., N. W., Washington, D. C. 

X884 Williamsony Alonzo P., M. D., 842 N. Second St., Santa Monica, Cal 

x888 Wila^, 0. J., M. D., Physidan-in-Charge Long Island Home, Amity- 
viUe, N. Y. 

19x4 Wilson, Anita A, H. D., Government Hospital for Insane, Washing- 
ton, D. C (Associate.) 

19x0 Wilson, William T., M. D., Superintendent Hospital for the Insane, 
Penetanguishene, Ont. 

1907 Winterode, Robert P., H. D., Superintendent Crownsville State Hos- 

pital, Crownsville, Md. 
19x2 Wiseman, John I., M. D., Assistant Physician Boston State Hospital, 

Dorchester Centre, Mass. (Associate.) 
19x3 Wirp^all, Edward H., M. D., Proprietor Wellesley Nervine, Wellesl^« 

Mass. 
X895 Witte, H. E., M. D., Medical Superintendent Clarinda State Hospital, 

Clarinda, la. 
1909 Wolfe, Mary Moore, M. D., 29 S. 3d St, Lewisburg, Pa. 
19x3 Wolff, George B., M. D., Qinical Assistant Sheppard and Enoch Pratt 

Hospital, Towson, Md. (Associate.) 



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42 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

19x3 Wood, H. Walton, H. D., Boumewood Hospital, Brookline, Mass. 
19x0 Woodlrary, Frank, ICD., Secretary Committee on Lunacy State of 

Pennsylvania, 717 Bulletin Building, Philadelphia, Pa. 
X907 Woodman, Robert C, ICD., First Assistant Physician Middletown 

State Homeopathic Hospital, Middletown, N. Y. (AssociaU.) 
X890 Woodson, C. S., M. D., Dr. C R. Woodson's Sanitarium, St Joseph, 

Mo. 
19x1 Woodward, Either S. B., ICD., Assistant Physician Norwich State 

Hospital, Norwich, Conn. (Associate.) 
X906 Worceit^, Samvel, H. D., Assistant Superintendent Dr. Wadsworth's 

Sanitarium, Moss Hill Villa, South Norwalk, Conn. 
X90X Work, Hubert, ICD., Superintendent Woodcroft Hospital for Nerv- 
ous Diseases, Pueblo, CoL (President, 1912,) 
X893 Wright, W. E., M. D., 204-206 State St., Harrisburg, Pa. (AssociaU.) 
19x2 Wright, Wm. W^ ICD., Psychiatric Institute, Ward's Island, New 

York, N. Y. (Associate.) 



19x2 Tarbrough, T. H., M.D., Assistant Physician Georgia State Sani- 
tarium, Milledgeville, Ga. (Associate.) 

1907 Teaman, Ifalcolm H., M. D., Beechurst Sanitarium, Louisville, Ky. 

X894 Tellowlees, David, M.D., L.R.C.8., EdiiL, F.F.P.8. andLL.D., 
Glasgow (formerly Physician Superintendent Glasgow Royal 
Asylum, Gartnavel), 6 Albert Gate, Dowanhill, Glasgow, Scot- 
land. (Honorary.) 

X9xa Teretdan, K. H., ICD., Assistant Physician Columbus State Hos- 
pital, Columbus, O. (Associate.) 

X906 Toung, David, M.D. (formerly Superintendent Asylum for the In- 
sane, Selkirk, Manitoba, Canada), 494 Camden Place, Wiimipeg, 
Manitoba, Canada. 

X9X4 Toung, Hugh Hampton, M.D., President State Lunacy Commission 
of Maryland, 330 N. Charles St, Baltimore, Md. (Honorary.) 

X906 Youngling, George S., M. D., Consulting Riysician Central Islip State 
Hospital, 453 West 34th St, New York, N. Y. 

X9X3 Yule, Lome W., M. D., Assistant Physician Northern Hospital for In- 
sane, Logansport, Ind. (Associate.) 

Z 

X906 Zeller, George A., M.D., Alienist State Board of Administration, 
Peoria, 111. 



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UFE MEMBERS 43 



LIFE MEMBERS 



1883 Charles P. Bancroft, M. D^ Concord, N. H. 

1883 Sanger Brown, M. D., Kenilworth, HI. 

1880 Walter Clianning, M. D., Brookline, Mass. 

X867 John B. Chapin, M. D., Canandaigna, N. Y. 

X883 Robert H. Chaae, M. D., Philadelphia, Pa. 

x88x Edward Cowlei, M. D., Plymouth, Mass. 

X883 Charles 6. Hill, M. D., Baltimore, Md. 

X883 Gershem H. Hill, M. D., Des Moines, la. 

1867 Charles H. Hvgfaei, M. D., St Louis, Mo. 

X879 Henry M. Hnrd, M. D., Baltimore, Md. 

187a Theodore H. EeUogg, M. D., New York, N. Y. 

x88a Shailer E. Lawton, M. D., Brattleboro, Vt 

x88a Samuel B. Lyon, M. D., White Plains, N. Y. 

X874 Carlos F. MacDonald, M. D., New York, N. Y. 

X879 Hosea M. Qninby, M. D., Worcester, Mass. 

X884 Henry IL Stedman« M. D., Brookline, Mass. 

X884 Alonso P. Williamson, M. D., Santa Monica, Cat 



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AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 



HONORARY MEMBERS 



Z890 Henry H. Banniiter, VLJ)^ Evanston, IlL 

Z898 Jjunes H. Buckley, D. D., LL. D., Morristown, N. J. 

i88z T. S. Clouston, M. D^ F. R. C. P^ F. S. 8. E^ Edinburgh, Scotland. 

1908 Shepherd L Franz, A. B., Ph. D., Washington, D. C 

Z89Z G. Stanley Hall, Ph.D., LL.D., Worcester, Mass. 

1899 Henry Hun, ICD., Albany, N. Y. 

Z896 Jnlet Morel, M.D., Ghent, Belgium. 

x88z A. Motet, M. D., Paris, France 

1894 A. Victor Parant, M.D.y Toulouse, France 

1896 Emmanuel R6gi8, M.D., Bordeaux, France. 

X899 Antoine Sitti, M. D., Charenton, pr^ Paris, France. 

X897 Mn6 Semelaigne^ M.D., Paris, France 

X885 Stephen Smith, M.D., New York, N. Y. 

X899 jAmes Beveridge Spence, M.D., R.n.LM.Ch., Bumtwood, England. 

x88z A Tambitrini M.D., Reggio-Enulia, Italy. 

1902 Edouard Toulouse, M. D., Villejuif, France 

Z899 Alexander R. Urquhart, M.D., F.R.C.P.E.9 Perth, Scotland. 

1894 Dayid Yellowlees, M.D., F.F.P.8., LL.D., Glasgow, Scotland. 

19x4 Hugh Hampton Tonng, M. D., Baltimore, Md. 

Total Membership: 

Active 457 

Associate 289 

life 17 

Honorary 19 

Total 782 

The following tabulation shows the membership of the Association for 
the past decade : 



Members 


1906 


1907 


1908 


1909 


1910 


1911 


1912 


1913 


1914 


1915 


Active 


?d 


286 
109 


307 
119 


325 
117 


339 
134 


337 
134 


360 
133 


398 
203 


457 
250 


289 
17 
19 


Associate 

Life 


Honorary 


22 


24 


24 


24 


24 


22 


21 


20 


19 


Total 


421 


419 


450 


466 


497 


493 


514 


621 


726 


782 



Note. — It will be observed that the list of members as here printed shows 
the date when each member became identified with the Association. This 
arrangement is believed to be a valuable addition to the list which will be 
appreciated. 



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MORTUARY 45 

MORTUARY 



John A. Beamibampf H. D^ Nashville, Tenn. Died Feb. 27, 1910. 
James Ruthezf ord, H. D., Dumfries, Scotland. Died Mar. 8» 1910. 
0. M. Dewins, H. D., Brooklyn, N. Y. Died Mar. 14, 191a 
Bii^elow T. Sanborn, H. D., Augusta, Me. Died Apr. 18, 191a 
James B. A3rer, H. D., Boston, Mass. Died May 14, 1910. 
Louis C. Pettity H. D., New York, N. Y. Died June 10^ 1910. 
Dwight IBL Burrell, VL D., Canandaigua, N. Y. Died June i8» 191a 
Georse F. Cook, H. D., Oxford, Ohio. Died Sept 21, 191a 
William P. Letchworth, LL. D., Castile, N. Y. Died Dec. i, 1910. 
Presley C Hunt, H. D., Washington, D. C Died Dec 15, 1910. 
Uranus 0. Wingate, H. D., Milwaukee, Wis. Died February i8» 1911. 
L W. Blackburn, H. D., Washmgton, D. C. Died June 18, 191 1. 
A. J. Lyons, M.D., Spencer, W. Va. Died June i, 1911. 
J. Blvin Courtney, M.D., Denver, G)l. Died June 22, 1911. 
J. N. Whitaker, H. D., MiUedgeville, Ga. Died August 11, 1911. 
Robert £• Doian, H. D., Brooklyn, N. Y. Died Sept. 23, 191 1. 
George F. Jelly, M. D., Boston, Mass. Died Oct 24, 1911. 
D, S. Wallace, M. D., Waco, Tex. Died Nov. 22, 191 1. 
Merritt B. Campbell, ILD., Heber, Cal. Died Dec i, 191 1. 
James McKee, M.D., Raleigh, N. C Died January 10^ 1912. 
Moirit S. GutJi, H. D., Erie, Pa. Died March 27, 1912. 
Horace W. Eggleston, ICD., Binghamton, N. Y. Died April 11, 1912. 
Thomas J. Mitchell, M. D., Jackson, Miss. Died Sept 16^ 1912. 
Daniel Clark, H. D., Toronto, Ont Died Sept., 1912. 
George H. Knight, M.D., Lakeville, Conn. Died Oct 4, 1912. 
George C. Crandall, H. D., St Louis, Mo. Died Dec 5, 1912. 
Henry S. Upson, M. D., Qeveland, O. Died April 23, 1913. 
H. A. Tomlinson, H. D., Willmar, iMinn. Died May 30, 1913. 
R. H. Pomeroy, M. D., Bradentown, Fla. Died June 22, 1913. 
S. Weir Mitchell, M. D., Philadelphia, Pa. Died Jan. .4, 1914. 
Edward W. King, M. D., San Francisco, Cat Died Jan. 11, 1914. 
Thomas J. Moher, M. D., Cobourg, Ont Died Feb. 24, 1914. 
Ralph L. Parsons, M. D., Ossining, N. Y. Died Feb. 26, 1914. 
George Smith Adams, M. D., Stamford, Ct Died March 16, 1914. 
R. J. Dysart, M. D., Winnebago, Wis., Died May 26, 1914. 
Brooks F. Beebe, M. D., Cincinnati, O. Died May 29, 1914. 
WuL B. Moseley, M. D., Brooklyn, N. Y. Died June 26, 1914. 
Samuel F. Mellon, M. D., Poughkeepsie, N. Y. Died July 15, 1914. 
Oscar R. Long, M. D., Ionia, Mich. Died Sept 9, 1914. 
Wesley MiUs, M. D., Montreal, Que. Died 1915. 



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46 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 



RESIGNATIONS 



Harry Lee Bamei, M. p^ Wallutn Lake. R. L 
James R. Bolton^ M. D^ Fishkill-on-Hudson, N. Y. 
George V. N. Dearborn, M. D^ Boston, Mass. 
Hush H. Dorr, M. D^ Batesville, O. 
Charles A. Drew, M. D^ Worcester, Mass. 
Bernard Feldstein, M. D., Kings Parle, N. Y. 
Charles M. Frankliii, M. D., Baltimore, Md. 
Frank R. Fry, M. D., St. Louis, Mo. 
S. Adolphus Knopf, M. D., New York, N. Y. 
John J. Mac Phee, M. D., New York, N. Y. 
Elisabeth Spencer McCall, M. D., Bryn Mawr, Pa. 
John Pnnton, M. D., Kansas Gty, Mo. 
Arthur E. Simonis, M. D., Pennhurst, Pa. 
W. A. Taylor, M. D., Trenton, N. J. 



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PRESIDENTS OF THE ASSOCIATION 47 

PRESIDENTS OP THE ASSOCIATION 



Stmvtl B. Woodward, M.D^ Worcester, MaM 1844-1848 

William W. AwI^lLD^ Columbas, Ohio 1848-1851 

Luther y. Ben, H. D^ Somervine, Mass 1Q51-1855 

Isaac Ray, M.D^ Providence, R. I : i85S-i8S9 

Andrew MeParlaiid,M.D^ Concord, N. H 1859-1862 

Thoiiiaaam]khride,M.D^ Pbilade^hia, Pk 1863-1^ 

Johns. Bntler, M.D., Hartford, Ct 1870-1^3 

Charles H. Nichols, ICD., Bloomingdale, N. Y 1873-1879 

Gement A. Walker, M. D^ Boston, Mass 1879-1882 

JohnHCaUender, lI.D.,NashviUe,Tenn 1882-1883 

John P. Gray, M.D., Utica, N. Y 1883-1884 

Pliny Sarle, M.D^ Northampton, Mass 1884-1885 

Orphena Brerts, M.D., Cincinnati, Ohio 1885-1886 

H. H.BnttoIph,M.D., Short HiUs, N.J 1886-1887 

Eugene Griasom, M. D^ Raleigh, N. C 1887-1888 

JohnB.Chapin,lI.D., Philadelphia, P*. 1888-1889 

W. W. Godding, M.D., Washington, D. C 1889-1890 

H. P. Steams, M.D., Hartford, Ct 1890-1891 

Daniel Clark, M.D., Toronto, Canada 1891-1893 

J. B. Andrews, M.D^ Buflfalo, N. Y 1893-1893 

John Cnrwen, H. D^ Warren, Pa 1893-1894 

Bdward Cowles, M.D., Somerville, Mass 1894-1895 

Richard Dewey, ICD^ Wauwatosa, Wis 1895-1896 

TheophilvsO. Powell, ICD^Milledgeville, Ga 1896-1897 

Richard H Bncke^ ICD., London, Ontario 1897-1898 

Henry H. Hmd, M.D., Baltimore, Md 18^1899 

Joseph G. Rogers, M. D., Logansport, Ind 1899-1900 

Peter M:Wiae,M.D., New Yoric, N. Y 1900.1901 

Rirt^ert J. Preston, M.D^ Marion, Va 1901-1902 

6. Alder Blnmer, M.D., Providence, R. 1 1902-1903 

A. B. Richardson, M. D^ Washington, D. C. \ . . (died before taking office) 

A.B. Xacdonald, M.D^ New York, N. Y.. J 19(^-1904 

T, J. W. Burgees, M.D, Montreal, Canada.... 1904-1905 

CB. Burr, HD., Flint, Mich 1905-1906 

Charles G. Hill, M.D., Baltimore, Md 1906-1907 

Charles P. Bancroft, M.D., Concord, N. H 1907-1908 

Arthnr F. Slbonme, ICD., Rochester, Minn 1906-1909 

William P. Drewry, H. D., Petersburg, Va 1909-1910 

Chadea W. Pilgrim, M. D., Pougfakeepsie, N. Y 1910-1911 

Hubert Wo«k, M.D., Pueblo, Col.. 1911-1912 

James T. Searcy, M.D., Tuscaloosa, Ala 1912-1913 

Carlos F. MacDonald, M.D., New York, N. Y 1913-1914 

Samuel B. Smith, H. D., Richmond, Ind 1914-1915 



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48 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 



SECRETARIES OP THE ASSOCIATION 



Thomas S. Kirkbride, M.D^ Philadelphia, Pa 1844-1852 

H. H. Bnttolph, M. D^ Short Hills, N. J 1852-1854 

Cliarles H. Nichols, M. D^ Washington, D. C 1854-1858 

John Cmwen, H. D^ Warren, Pa 1858-1893 

Henry M. Hnrd, M.D^ Baltimore, Md 1893-1897 

C. B. Burr, M. D^ Flint, Mich 1897-1904 

E. C. Dent, M. D^ New York, N. Y 1904-1906 

Charles W. Pilgrim, M. D^ Poughkeepsie, N. Y 1906-1909 

Charles G. Wagner, M. D^ Binghamton, N. Y 1909- 



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MEETING PLACES 



49 



MEETING PLACES OF ASSOCIATION OF MEDICAL 
SUPERINTENDENTS OF AMERICAN IN- 
STITUTIONS FOR THE INSANE 



itt 1844 Philadelphia, Pa., Jones 

Hotel, Oct 16^ 1844. 

Pres., Dr. Samuel B. Woodward. 

Vice-Pres., Dr. Samuel White. 

Sec-Treas., Dr. Thomas S. 

Kirld>ride. 

1845 No meeting held. 
2d 1846 Washington, D. C 

1847 No meeting held. 
3d 1848 New York. N. Y. 
4th 1849 Utica, N. Y. 
5th i^ Boston, Mass. 
6th 1851 Philadelphia, Pa. 
7th 1852 New York, N.Y. 
8th 1853 Baltimore, Md. 
gth 1854 Washington, D. C 
lodi 1855 Boston, Mass. 
nth 1856 Cincinnati, Ohio. 
I2th 1857 New York. N.Y. 
13th 1858 Quebec, Que. 
14th 1859 Lexington, Ky. 
15th i860 Philadelphia, Pa. 

1861 No meeting held on ac- 
count of the disturb- 
ed condition of the 



i6th 1862 

17th 1863 

i8th 1864 

19th 1865 

20Ch 1866 

2ist 1867 

sad 1868 

23d 1869 

24di 1870 

25th i^i 

a6th 1^72 

27th 1873 

28th 1874 

29th i?75 

30th 1S76 

32d 1878 

33d 1^9 



country. 
Providence, R. I. 
New Yorl^ N. Y. 
Washington, D. C. 
Pittsburgh, Pa. 
Washington, D. C. 
Philadelphia, Pa. 
Boston, Mass. 
Staunton, Va. 
Hartford, Conn. 
Toronto, Ont 
Madison, Wis. 
Baltimore, Md. 
Nashville, Tenn. 
Auburn, N. Y. 
Philadelphia, Pa. 
St Louis, Mo. 
Washington, D. C. 
Providence, R. I. 



34th 

3Sth 

36th 

37th 

38th 

39th 

40th 

41st 

42d 

43d 

44th 

45th 

46th 



1880 
1881 
1882 
1883 
1884 
1885 
1886 
1887 
1888 
1889 
1890 
1891 
1892 



Philadelphia, Pa. 

Toronto, Ont 

Cincinnati, Ohig. 

Newport, R. I. 

Philadelphia, Pa. 

Saratoga, N. Y. 

Lexington, Ky. 

Detroit, Mich. 

Fortress Monroe, Va. 

Newport, R. I. 

Niagara Falls, N. Y. 

Washington, D. C 

Washington, D. C 
New constitution adopted. 
Name changed to American 
Medico-Psychological Ass'n. 
47th 1893 Chicago, IlL 
50th 1894 Philadelphia, Pa. 

Fiftieth year since foundation. 
Semi-centennial. 
Number of meetings changed. 
Proceedings published in separ- 
ate volume. 
189s Denver, Col. 

Boston, Mass. 

Baltimore, Md. 

St Louis, Mo. 

New York, N. Y. 

Richmond, Va. 

Milwaukee, Wb. 

Montreal, Que. 

Washington, D. C. 

St. Louis, Mo. 

San Antonio, Tex. 

Boston, Mass. 

Washington, D. C 

Cincinnati, Ohio. 

Atlantic City, N. J. 

Washington, D. C 

Denver, Col. 

Atlantic City, N. J. 

Niagara Falls, Ont 

Baltimore, Md. 

Fortress Monroe, Va. 



5i8t 

52d 

53d 

S4th 

55th 

56th 

57th 

58th 

59th 

60th 

6ist 

62d 

63d 

64th 

6sth 

66th 

67th 

68th 

69th 

70th 

7i8t 



1896 

1897 
1898 

I8p9 
1900 
1901 
1902 

1903 
1904 

1905 
1906 
1907 
1908 
1909 
1910 
191 1 
1912 
1913 
1914 
1915 



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50 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

GEOGRAPHICAL DISTRIBUTION 

-or* 

MEMBERS AHD IHSTITnTIONS 



A 

ALABAMA— Thi Alabama Insani Hospitals. 

Thb Brycb Hospital, Tuscaloosa. 

James T. Staxcyp M.D^ Medical Superintendent 
William D. Partlow, M. D^ Assistant Superintendent 

Thi Mx VntNON Hospital (for Nbgsobs), Mt. Virnon. 
Jamea T. Searcy^ M. 1>^ Superintendent 
Emit L. McCaifertyy M. D., Assistant Superintendent 



Eugene D. Bondnrant, M. D., Mobile. 

ALASKA— 

Arthur C. Delacroiz, M. D., Douglas. 

ABIZONA— State Insane Asylum, Phoenix. 

Alfred C. Kingsley, M. D., Superintendent 
U. S. Government Hospital, Leupp. 
No members. 

ARKANSAS— State Hospital for Nervous Diseases, Little Rock. 
James L. Greene, M. D., Superintendent 
R. F. Damall, M. D., Clinical Director. 



CALXFORNIA— Agnbw State Hospital, Agnbw. 

Leonard Stocking^ M. D., Superintendent 

Clifford W. Mack, M. D., Assistant Physician. 
California State Hospitals. 

F. W. Hatch, M.D., General Superintendent, Sacramento. 
MENDoaNO State Hospital, Talmagb. 

Robert L. Richards, M.D., Superintendent 

Frederick E. Allen, M. D., Assistant Physician. 
Napa State Hospital, Napa. 

Adalbert C Matthews, M. D., First Assistant Physician. 

John B. Rogers, M. D., Assistant Physician. 
Southern California State Hospital, Patton. 

John A. Reily, M. D., Superintendent 

Franklin S. Wilcoz, M.D., Assistant Superintendent 



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GEOGRAPHICAL DISTRIBUTION 51 



CALntOVSlA'-Contmued. 

Stockton Stats Hospital^ Stockton. 
Fired. P. CUrky M. D., Saperintendent 



Chailes L. Allen^ M. D., Los Angeles. 
John G. Fitf serald, M. D., Berkeley. 
Elmer JL Stone, M. D., San Francisco. 
Gilbert V. Hamflton, ILV^ Montedto. 
W. B. Kern, M. D., Los Angeles. 
Daniel D. Lnstig, TUL D., San Francisco. 
James BL McBride, 11 D., Pasadena. 
Era C. Reid, M. D., San Francisco. 
J. W. Wherry, M. D., Los Gatos. 
Alonzo P. Williamson, M. D., Santa Monica. 
Melvin J. Rows, M. D., Monrovia. 

COLORADO — Colorado Stati Home and Tkaining School for Mental 
DEFBcnvEs, Ridge. 
A. P. Bnsey, M. D., Superintendent. 
Colorado State Insane Asylum, Pueblo. 

Howard A. La Moure, TUL D., Superintendent 
MoiHYT AiSY Sanatorium, Denver. 

George S. Neuhaus, M. D., Superintendent. 
Woodcroft Hospital, PuzBLa 

Hnhert Work, M. D., Superintendent 

Frank T. Stevens, M. D., Colorado Springs. 
COHHXCnCTJT— Connecticut Hospital for the Insane, Middlktown 

Charles B. Stanley, M. D., Assistant Physician. 

Arthur B. Colebum, IL D., Assistant Physician. 

J. IL Keniston, M.D., Assistant Physician. 

Louis R. Brown, M. D., Assistant Physician. 
Hospital for the Insane, Norwich. 

Henry IL Pollock, IL D., Superintendent 

Edward A. Everett, IL D., Senior Assistant Physician. 

Esther S. B. Woodward, ILD., Assistant Physician. 
Connecticut Colony for Epileptics, Mansfield Depot. 

Donald L. Ross^ M. D., Superintendent 
CoNNEcncuT School fob Imbbolxs, Laxevillb. 

Charles T. La Moure, IL D., Superintendent 
Dr. Givxns' Sanitarium, Stamfordl 

Amos J. Givens, M.D., Proprietor. 
Dr. Rulakd's Sanitarium, Westport. 

Frederick D. Ruland, IL D., Proprietor. 
Dr. Waosworth's Sanitarium, South Noswaix. 

Samuel Worcester, M. D., Assistant Superintendent 



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52 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

CONNECTICUT— Conh'nMfi. 

Ths Haxtfosd Retreat, HASTrosa 

Whitefield N. Thompson, M. D^ Superintendent 



Allen Sou Dief endorf , IL D^ New Haven. 

Charles W. Page, M.D., Hartford. 

Edwin Eyerett Smith, ILD., Kensett, Norwalk. 

Gilbert E. Smith, M. D., Stamford. 

Paul Waterman, M. D., Hartford. 

D 
DELAWARE— Delawase Stats Hospital. Farnhurst. 
W. H. Hancker, M. D., Superintendent 



Harris M. Carey, M. D., Odessa. 

DISTRICT OF COLUMBIA— Government Hospital for the Insane, 
Washington. 
William A. White, M.D., Superintendent 
Shepherd L Frans, A. B., Ph. D., Scientific Director. 
Bernard Glneck, M. D., Senior Assistant Physician. 
Mary O'Malley, M. D., Woman Assistant Physician. 
Alfred Glascock, M. D., Assistant Physician. 
George H. Schwinn, M.D., Assistant Physician. 
James C. Hassall, M. D., Assistant Physician. 
John K Lind, M. D., Assistant Physician. 
Arrah B. Evarts, M. D., Assistant Physician. 
AniU A. Wilson, M.D. 
J. A. F. Pf eiffer, M. D., Histopathologist 
Rohert F. Sheehan, M. D. 



D. Percy Hickling, M. D., Washington. 
Benjamin R. Logie, M.D., Washington. 
Wm. L. Rohins, M. D., Washington. 
J. C. Simpson, M.D., Washington. 
Tom A. Williams, M. D., Washington. 

P 
FLORIDA— Asylum for Indigent Insane, Chattahoocheb. 
No members. 



James H. Randolph, M. D., Jacksonville. 



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GEOGRAPHICAL DISTRIBUTION 53 



GSORGIA — State Sanitarium, Milledgevilli. 
L. IL Jonei, IL D^ Superintendent 
Edward M. Green, IL D^ Qinical Director. 
John W. Mobley, M. D., Assistant Physician. 
Y. BL Tarhronghy IL D., Assistant Physician 
N. P. Walker, M. D., Assistant Physician. 
Invalids' Home, Milledgeville. 

Henry D. Allen, M.D., Superintendent 

I 
IDAHO— Idaho Nokthekn Insane Asylum, OtonNo. 
jOlui W. Giyeua, IL D., Superintendent 

ILLINOIS— Anna State Hospital, Anna. 

No members. 
Chester State Hospital, Menash. 

No members. 
Chicago State Hospital, Dunning. 

Joseph P. Pedval, M.D., Superintendent 
Elgin State Hospital, Elgin. 

Salph T. Hinton, M. D., Superintendent 

Victor A. Bles, M. D., Assistant Physician. 
Kenilwosth Sanitarium, Kenilworth. 

Sanger Brown, IL D., Chief of Medical Staff. 

Sherman Brown, M. D., Superintendent 
jAcxsoNvnxB State Hospital, Jacksonville. 

Henry B. Carriel, M. D., Superintendent 

Edward A Foley, M.D., Assistant Physician. 

Charles H. Lowe, IL D., Assistant Physician. 
Kankakee State Hospital, Hospital. 

Charles F. Read, ILD., Assistant Superintendent 

Bngen Cohn, IL D., Assistant Superintendent 

F. J. Snlliyan, M.D., Assistant Physician. 

Drvy L. Fish, M. D., Assistant Physiciaa 

Wilma H. Jacobs, ILD., Assistant Physician. 

J. T. Rooks, M. D., Assistant Physician. 

Howard T. Child, M. D., Pathologist. 
Norbury Sanatorium, Jacksonville. 

Frank P. Norbury, M.D., Medical Director. 
PftouA State Hospital, Peorl^ 

No members. 
State Psychopathic Institute, Kankakee. 

Charles Ricksher, ILD., Pathologist 



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54 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

ILLnXOlS—Continued. 

Thb Ransom Sanitabium, Rockpqrd. 

Sidney D. Wilgof, M. D, Superintendent and Proprietor. 
Watsstown Stat« Hospital, Watiktown. 

Wm. A. Crooks, M.P^ Superintendent 



W. L. Athon, ILD., Marshall. 
Henry M. Bannister, M. D^ Evanston. 
Dana F. Downing, M. D., Warren. 
Edward F. Leonard, M. D., Chicago, 
liary Lawson Nelf, M. D., Springfield. 
Stephen R. Pietrowics, M. D., Chicago. 
William G. Steams, M. D^ Chicago. 
George A. Zeller, M. D., Peoria. 

IHDIAHA— Central Indiana Hospital foi the Insane^ Indianapous. 

George F. Sdenharter, IL D., Superintendent 

Frederick C. Potter, M. D., Pathologist 
Eastern Indiana Hosptfal pob the Insane^ Richmond. 

S. B. Smith, ILD., Superintendent 
NoKTHERN Indiana Hospital for the Insane Longclipp, Logansfort. 

Fred. W. Terflinger, ILD., Superintendent 

Lome W. Tnle, M. D., Assistant Physician. 

B. Palmer, M. D., Assistant Physician. 
Southeastern Hospital for Insane, Cragmont, Madison. 

Edward P. Busse, M. D., Superintendent 
Soxjthern Indiana Hospital for the Insane, Evansville. 

Charles B. Langhlin, M. D., Superintendent 

Alhert M. Cross^ M. D., Assistant Physician. 



IOWA— Cherokee State Hospital, Cheroi 

M. Helaon Voldeng, M. D., Superintendent 
Lena A. Beach, IL D^ Woman Assistant Physiciaa 
T. L. Long, ILD., Assistant Physician. 
Wm. A. Bryan, M.D., Assistant Physician. 
Rose A. Russell, M.D., Assistant Physician. 

Clarinda State Hospital, Clarinda. 
M. B. Witte, M.D., Superintendent 
Pauline M. Leader, M. D., Woman Physician. 

Independence State Hospital, Independence. 
W. P. Cmmbacker, M. D., Superintendent 
S. C Lindsay, M. D., Assistant Physician. 

Mt. Pleasant State Hospttal, Mt. Pleasant. 
Charles F. Applegate, M. D., Superintendent 

St. Bernard's Hospital, Council Bluffs. 

James M. Barstow, M. D., Attending Physician. 



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GEOGRAPHICAL DISTIUBUTION 55 



IOWA— ConftHM^if. 

Stats Hospital for Inebuatss, Khoxvilix 
George Donohoe, ILD^ Superintendent 
M. Charles Msckin, M. D^ Assistant Physician. 

State Sanatorium for Tuberculosis, Oakdalb. 
Wm. D. Runyoiiy M.D., Assistant Physician. 

Tbb Rxtsbat, Dbs Monrss. 

Gershom H. Hill, M. D., Superintendent 



G. A. Chilsren, M. D., Burlington. 
W. S. Oshom, M. D., Des Moines. 
Frank T. Seybert, 11 D., Council Bluffs. 
Tom B. Throdanorton, M.D.9 Des Moines. 



KAHSAS— Osawatomis State Hospital, Osawatomis. 

H. L. G088, M. D., Assistant Physician. 
State Hospital por EpiLipncs, Parsohs. 

M* L. PefTy, IC D., Superintendent 

0. S. Hubbard, M.D^ Assistant Superintendent 

H. P. Mahan, M. D^ Assistant Physician. 
TopKKA State Hospital, Topbka. 

Thomas Biddle, ILD.9 Superintendent 

Thompson P. Scott, M.D., First Assistant Physician. 
The Uhls Sanitarium, Overland Park. 

L. L. Uhls, M. D., Proprietor. 

KXNTUCK7— Eastern Kentucky Lunatic Asylum, Lexington. 

No members. 
Elmwood Sanitarium, Lexington. 

C. A. Heritt, ILD., Superintendent 
Bbechurst Sanitarium, LoxnsvnxE. 

Malcolm H. Yeamaa, IL D. 
Central State Hospital, Lakeland. 

Wm. E. Gardner, M.D.« Superintendent 
High Oaks Sanitarium, Lexington. 

George P. Spragua, M. D., Superintendent 
Western Kentucky Asylum por the Insane, Hopkinsville. 

H. P. Sights, M.D., Superintendent 



R. L. WUlis, M. D., Crab Orchard. 



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56 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

L 

LOUISIAlf A— East Louisiana Hospital fob the Insane, Jackson. 
Clarence Pienon, M.D., Superintendent 
Ralph P. Trnitt, M. D., Qinical Director. 
Louisiana Hospital for the Insane, Pineville. 
John N. Thomas, M. D., Superintendent. 
Roy McLean VanWart, M. D., New Orleans. 

M 

MAINE — Augusta State Hospital, Augusta. 
Forrest C. Tyson, M. D., Superintendent 
Stephen E. Vosbnrgh, M. D., Assistant Superintendent 
E:arl B. Sturgis, M.D., Assistant Physician. 

Bangor State Hospital, Bangor. 

Frederick L. Hills, M. D., Superintendent 

Maine School for Feeble-Minded, West Pownau 
Carl J. Hedin, M. D., Superintendent. 



P. H. S. Vaoghan, M. D., Yarmouth. 
Henry M. Swift, M.D., Portland. 

MARYLAND^— Chestnut Lodge Sanitarium, Rockvillx. 

Ernest L. Bnllard, M. D., Physidan-in-Charge. 
City Detention Hospital for the Insane, Baltimore. 

No members. 
Eastern Shore State Hospital, Cambridge. 

Charles J. Carey, M. D., Superintendent 
Johns Hopkins Hospital, Baltimore. 
Henry Phipps Psychiatric Cunic. 

Adolf Meyer, M. D., Director. 

Edward J. Kempf, M.D., Assistant Resident Physician. 

Mount Hope Retreat, Baltimore. 

Charles G. Hill, M.D., Physidan-in-Chief. 
Spring Grove Hospital for the Insane, Catonsville. 

J. Percy Wade, M. D., Superintendent 

R. Edward Garrett, M.D., Assistant Physician. 
Crownsville State Hospital, Crownsville. 

Roht P. Winterode, M.D., Superintendent. 

Peter L. Keongh, M. D., Assistant Physician. 
Patapsco Manor SANrrARiuM, Eluoott City. 

William Rnshmore White, M. D., Superintendent. 



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GEOGRAPHICAL DISTRIBUTION 57 

UARYLAND-^-Continued. 

R1GG8 Cottai»-Sanitakium, Ijamsvillb. 

Georgt Henry Kisgty M. D^ Superintendent 
Relay Sanitaxium, Relay. 

Lewis H. Otmdry, IL D., Superintendent 
SniNGFiELD Stats Hospital, Sykesvillx. 

Joaeph Clement Claxk, M. D., Superintendent 

Harry D. Purdum, BLD., Assistant Physician. 

John N. Morris, M. D., Assistant Physician. 

J. G. Fowble Smith, M. D., Assistant Physician. 

G. Ward Disbrow, M. D., Assistant Physician. 

Claude D. Hamilton, M. D., Assistant Physician. 
Sheppasd AMD Enoch Pkatt Hospital, Towson. 

Edward H. Brush, M. D., Physician-in-Chief and Superintendent 

W. R. Dunton, Jr., M. D., First Assistant Physician. 

George F. Sargent, BL D., Assistant Physician. 

George B. Wolff, M. D., Assistant Physician. 
The Gundry Sanitarium, Catonsville. 

A. T. Gundry, IID., Medical Director. 
The Laurel Sanitarium, Laurel. 

Jesse C Coggins, M. D., Medical Director. 

Cornelius BeWeese, M. B., Medical Director. 
The Richard Gundry Home, Harlem Lodge, Catonsville. 

Richard F. Gundry, IL B., Medical Director and Proprietor. 



Henry J. Berkley, 11 B., Baltimore. 
Wm. A. Boyd, M. B., Baltimore. 
Wm. B. Cornell, M. B., Baltimore. 
Arthur P. Herring, M. B., Baltimore. 
Henry M. Hurd, M. B., Baltimore. 
J. A. Macintosh, M. B., Easton. 
Adolf Meyer, M. B., Roland Park. 
Irving J. Spear, M. B., Baltimore. 
Hugh Hampton Toung, M. B., Baltimore. 

MASSACHUSETTS — ^Adams Nervine Asylum, Boston. 
Edward B. Lane^ M.B., Resident Physiciaa 

Asylum for Insane Criminals, State Farm. 
No members. 

Boston State Hospital, Dcwchester Centre. 
Henry P. Frost, M. B., Superintendent 
SamL W. Crittenden, M. B., Assistant Supenntendent 
Wm. M. Bobson, M. B., Assistant Physician. 
Ermy C. Noble, M.B., Assistant Physician. 
Mary E. Gill-Noble, M. B., Assistant Physician. 
John L Wiseman, M. B., Assistant Physician. 



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58 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

MASSACBJJSETLS'-ConHnued. 

Boston State Hospital^ Dgbcbmstesl Cejxtbe,— Continued. 
Psychopathic Dbpastmskt. 

S. B. Southard, Director. 

Herman M. Adler, Chief of Staff. 

Myrtelle M. Canavan, M. D., Pathologist 
BouKNKwooi) PaiVAis Hospital* Bkookunb. 

Henry fi. Stedman, M. D., Physician-in-Charge. 

Geo. H. Tomey, Jr., M. D. 

H. Walton Wood, M. D. 

BlIDGEWATER StaTI HOSPITAL, BrIDGBWATER. 

Ernest B. Smerton, ILP., Medical Director. 

ChANNINO SaNITABIUM, BaOOKUNB. 

Walter Channing, ILD., Superintendent 

Donald Gregg, M. D., Resident Physician. 

W. M. Knowlton,lLD. 
Danvess State Hospital, Hathorne. 

George M. Kline, M. D., Superintendent ' 

John B. Macdonald, M. D., Assistant Ph3rsician. 

John H. Travis, M. D., Assistant Physician. 

Nelson G. Tmeman, M. D., Assistant Physician. 
FoxBOKouGH State Hospital, Foxbosouoh. 

Irwin H. Neff, M. D., Superintendent 
Gasdnes State Colony, Gardner. 

Charles B. Thompson, M. D., Superintendent 

Harlan L. Paine, M. D., Assistant Superintendent 

Thomas Littlewood, M. D. 
Hospital Cottages for Children, Baldwinstille. 

H. W. Page, M. D., Superintendent 
Massachusetts Reformatoty, Concord Junction. 

Guy G. Femald, M. D., Phjrsidan. 
Massachusetts School por Feeble-Minded* Waverley. 

Walter B. Femald, ILD^ Superintendent 
McLean Hospital, Waterlxy. 

George T. Tnttle, M. D., Superintendent 

Ray L. Whitney, TUL D., First Assistant Physician. 

B. Stanley Ahhot, IL D., Assistant Physidaa 

Frederick H. Packard, M. D., Assistant Phjrsidan. 

Theodore A. Hoch, M.D., Assistant Physician. 
Medpield State Asylum, HARDiNa 

Edward French, M.D., Superintendent 

Lewis M. Walker, IL D., Assistant Physician. 
MoNSON State Hospftal, Palmer. 

Brerett Flood, M. D., Superintendent 

Morgan B. Hodskin, M. D., Assistant Physician. 



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<^xx;raphical distribution 59 

Ds. Mellus' Private Hospital, Newton. 

Edward MellvB, M.D., Superintendent 

Wlanac% H. Abbot, IL J>^ Assistant Physician. 
The Newton Sanat(»ium, West Newton. 

H. Smmons Paine, M. D., Superintendent 
Norfolk State Hospital, Wrentham. 

No members. 
Nobthampton State Hospital, Northampton. . 

John A. Houston, IL D., Superintendent 

Edward C. Greene, M. D. 
Norwood Private Hospffal, Norwood. 

Sben C Norton, M. D., Physidan-in-Charge. 
Peter Brent Brigham Hospital, Boston. 

Herbert B. Howard, M.D., Superintendent. 
Private Hospital for Insane, Worcester. 

John Merrick Bemis, IL D., Superintendent 
State Hospital, T^wksbury. 

John H. JEHchola, M. D., Superintendent 
Taunton State Hospital, Taunton. 

Arthur V. Goss, IL D., Superintendent 

Horace G. Kipley, M.D.y Assistant Superintendent 

John F. (rarien, M. D., Assistant Physician. 

Dora W. Faxon, M. D., Assistant Physician. 
Westborough State Hospital, Westborough. 

Harry 0. Spalding, IL D., Acting Superintendent 

Solomon Carter Fuller, M.D., Pathologist 

M. IL Jordan, ILD., Assistant Physician. 
The Wellesley Nervine, Wellssley. 

Edward H. Wiswall, M. D., Proprietor. 
Worcester City Hospital, Worcester. 

No members. 
Worcester State Asylum, Worcester. 

H. Louis Stick, ILD., Superintendent 

Hiram L. Horsman, M. D., Assistant Physician. 

Worcester State Hospital, Worcester. 
Ernest V. Scribner, M. D., Superintendent 
R. Grant Barry, M. D., Assistant Physician. 
Mary E. Morse, M. D. 



Henry C Baldwin, IL D., Boston. 
L. Venion Briggs, M. D., Boston. 
Geo. E. Butterfield, M. D., N. Grafton. 
Isador H. Corlat, IL D., Boston. 
Edward Cowlea, M. D., Plymouth. 



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6o AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

ICASSACHUSSTTS— Con^iiiMfi/. 

Cluurles G. Dewey, M. D^ Dorchester. 
J. F. Bdgerlejt M. D., Newtonville. 
T. W. Fisher, M.D., Boston. 
Wm. T. Hanson, M.D., Arlington. 
Walter C. Haviland, M. D., Worcester. 
Arthur C. Jelly, M. D., Boston. 
George H. Mazfield, M. D., Chelsea. 
Edward B. Nims, M.D., Springfield. 
William Ifoyei, M. D., Jamaica Plain. 
Hosea H Qninhy, BLD., Worcester. 
Cyril G. Richards, M. D., Boston. 
Albert Warren Steams, TUL D., Boston. 
Walter B. Swift, M. D., Boston. 
Lowell F. Wentworth, H D., Boston. 



MICHIGAN— Home foi thb Feeble-Minded and Epileptic, Lapbek. 
No members. 

Ionia State Hosptfal, Ionia. 
No members. 

Kalamazoo State Hospital, Kalamazoo. 
Alfred L Noble, M. D., Superintendent 
Herman Ostrander, M. D., Assistant Superintendent 
George F. Inch, M. D., Assistant Physician. 

Northern Michigan Asylum, Traverse City. 
James D. Mnnson, ILD., Superintendent 

Oak Grove Hospital, Funt. 

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

Homer £. Clarke^ BL D., Assistant Medical Director. 

PoNTtAC State Hospital, Pontiac 

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

St. Joseph's Retreat, Dearborn. 

J. S. Bmenon, M.D.» Attending Physician. 

Upper Peninsula Hospital for the Insane; Newberry. 
Earl H. Campbell, IL D., Superintendent 



Albert M. Barrett, M. D., Ann Arbor. 
Charles W. Hitchcock, M. D., Detroit. 
Walter P. Manton, BL D., Detroit 
William A. Stone, M. D., Kalamazoo. 



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GEOGRAPHICAL DISTRIBUTION 6l 

MnmSSOTA— FkBGUS Falls Stats Hospital* Fergus Falls. 

G. 0. Weldi, M. J}^ Superintendent 

C. C Bvxliagamt, ILV^ Assistant Superintendent 
Rochester State Hospital, Rochester. 

Arthur F. Kilboume, M. D., Superintendent 
St. Pkier Stats Hospital* St. Pkier. 

R. M. Phelps, BL D.* Superintendent 

George T. Baskett, M. D., Assistant Superintendent 

Henuan W. Corey* M. D., Assistant Physician. 

Clara Eirley* M. D.* Woman Physician. 
Stats Hospital for Inebriates, Willmar. 

George BL Freeman* IL D.* Superintendent 
University Hospital, Minneapous. 

Louis B. Baldwin* M. D.* Superintendent 



Arthur S. Hamilton* M. D.* Minneapolis. 
C Eugene Riggi* H. D.* St Paul 

MISSISSIPPI^East Mississippi Insanb Hospttal, Meridian. 
J. IL Buchanan* ILD.* Superintendent 
State Insane Hospital* Asylum P. O. 
W. W. Smithson* M. D.* Superintendent. 
Nolan Stewart* m D.* Jackson. 

MISSOURI— City Asylum, St. Louis. 

Henry S. Atkins* M. D.* Superintendent 
OxjONY for Feeblb-Minped and Epileptic* Marshall. 

No members. 
Dr. C R. Woodson's Sanitarium, St. Joseph. 

C R. Woodaon* IL D.* Physidan-in-Charge. 

Herbert Lee* M. D.* Resident Physician. 
Stats Hospital Na i* Fulton. 

No members. 

Stats Hospttal Na a* St. Joseph. 
No members. 

Stats Hospital Na 3* Nevada. 

M. P. Orerholser* M. D.* Superintendent 

Stats Hospital No. 4, Fasmington. 
No members. 

St. Vincent Institution pos the Insane* St. Louis. 

No members. 
The Burnett Sanitarium, Kansas City. 

S. Grover Burnett* M. D.* Medical Superintendent 



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62 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

MlSSOTnOr-Continuid, 

The Punton Sanitauum, Kansas City. 
0. Wilte Sobinton, M. D., Superintendent 



Francis M. Bazneiy Jr., M. D., St Louis. 
L. BL Callaway, M. D., Nevada. 
Charles 6. Chaddock, M. D., St. Louis. 
Charles BL Hughes, M. D., St. Louis. 
William F. Knhn, M.D., Kansas City. 
Benjamin R. McAllaster, M.D., King City. 
Abra C. Pettijohn, M. D., Brookfield. 
A. L. Skoog, M. D^ Kansas City. 

MONTANA— Montana State Hospital for the Insane, Warm Springs. 
Arthur C. Knight, M.D., Superintendent 



J. M. Scanlandy M.D., Warm Springs. 

N 
NEBRASKA— Nebraska Hospital ior Insane, Lwooln. 
B. F. Williams, M. D., Superintendent 
Halle L. Swing, M.D., Assistant Physician. 
Nebraska State Hospital, Inglesiiie. 

No members. 
NoBFOLK Hospital for the Insane Norfolk. 
No members. 

NBYADA— Nevada Hospital for Mental Diseases, RENa 
No members. 

NBW HAMPSHIRS— Highland Spring Sanatorium, Nashua. 

Albert Edward Brownrigg, M. D., Superintendent 
New Hampshire State HospriAL, CoNCORa 

Charles P. Bancroft, M. D., Superintendent 

Charles H. DoUoff, M. D., Assistant Physician. 
State School for F&eble-Mindbd Children, Laconia. 

Benjamin W. Baker, M.J>^ Superintendent 



Wm. W. Coles, M. D., Keane. 

NEW JERSEY— Bancroft Health Resort, Butler. 
George Bancroft Gale, M. D., Medical Director. 
Essex CbUNTv Hospital for the Insane, Cedar Grove, Essex County. 
Guy Payne, M. D., Medical Superintendent 
Earl H. Suavely, M. D., Assistant Physician. 
George W. Daviea, BLD., Assistant Physician. 
Drew M. Wardner, M.D., Assistant Physician. 
Helene G. Leehman, M. D., Assistant Physician. 



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GEOGRAPHICAL DISTRIBUTION 63 

HEW TBRSEY-^onHnued. 

BxLLB Mead Fasm Colony and Sanatorium, Bkllx Mkar 

J. J. Kindled, M. D., Proprietor and Consulting Physician. 

William JL Gearegen, M. D^ Resident Physician. 
BuBUNGTON County Hospital for Insane, Mt. Holly. 

Sichard BL Panona, M. D., Physician. 
Camden County Hospital for Insane, Blackwood. 

J. Anson Smith, M. D., Physician. 
Fair Oaks Sanatorium, Summit. 

Sliot Gorton, M. D. 

Thomaa P. Pxoiit, IL D. 
Hudson County Hospital for Insane, Secaucus, Jersey City. 

H. y. A. Smith, M. D., Superintendent 
New Jersey State Hospital, Morris Plains. 

B. D. Xrana, M. D., Medical Director. 

Peter S. Hallon, ILD., Assistant Physician. 

S. Moore Fiaher, ILD., Assistant Physician. 

Louis E. Henachel, M. D., Assistant Physician and Pathologist. 

Marcus A. Curry, M. D., Assistant Physician. 

Frederic H. Thome, M. D., Pathologist 

Frank M. Mikels, M. D., Assistant Physician. 
New Jersey State Hospital, Trenton. 

Henry A. Cotton, M. D., Medical Director. 

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

Edgar B. Funkhouser, M.D., Second Assistant Physician. 

Frederick S. Hammond, M. D., Assistant Physician and Pathologist 

Harry D. Williams, M. D., Assistant Physician. 
New Jersey State Village for Epileptics, Skillman. 

David F. Weeks, M. D., Superintendent 
North Hudson Hospital, Jersey City. 

John Nevin, M. D., Consulting Physician. 
** Riverlawn " Sanitarium, Paterson. 

Daniel T. MUlspaugh, M. D., Superintendent 



Christopher C. Beling, M. D., Newark. 

Percy Bryant, M. D., Rahway. 

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

Paul Lange Cort, M.D., Trenton. 

Luther M. Halsey, M. D., Williamstown. 

Arthur P. Basking, M. D., Jersey City. 

L. S. Hinckley, M. D., Newark. 

George W. King, M.D., Jersey City. 

William S. Ramsey, M.D., Perth Amhoy. 

HEW MEXICO— New Mexico Insane Asylum, Las Vegas. 
H. M. Smith, M. D., Superintendent 



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64 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

NBW TOHK— BiMGHAMTON Stats Hospital, Bimghamton. 

Chazles 0. Wagner, M. D^ Superintendent 

Theodore L Townsend, M. D^ First Assistant Physician. 

Edward Gillespie, M. D^ Senior Assistant Physician. 

Rosa McC. Chapman, M.D^ Senior Assistant Physician. 

Wm. J. Tiffany, M. D., Senior Assistant Physician. 

Eloise Walker, M. D., Woman Physician. 

C. H. Bellinger, M.D^ Assistant Physician. 

Sdward W. GroU, M. D., Assistant Physician. 
Bloomingdalb Hospital, White Plains. 

William L. Russell, M. D., Superintendent 

George S. Amsden, M. D., Assistant Physician. 

Sanger Brown, II, M. D., Assistant Physician. 
Bkibzehurst Terrace, Whitbstone, L. I. 

Daniel A. Harrison, M. D., Resident Physician. 
Brigham Hall, Canandaigua. 

Robert G. Cook, IL D., Resident Physician. 
Buffalo State Hospttal, Buffalo. 

Arthnr W. Hnrd, M. D., Superintendent 

Geo. W. Gorrill, M.D., First Assistant Physician. 

Joseph B. Betta, M. D., Senior Assistant Physician. 

George G. Armstrong, M.D., Senior Assistant Physician. 

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

Robert King, M. D., Senior Assistant Physician. 

Christopher Fletcher, M.D., Senior Assistant Physician. 

Herman F. May, BL D., Assistant Physician. 

P. G. Borden, M.D., Assistant Physician. 

George F. Harris, M. D., Assistant Physician. 
Central Isup State Hospital, Central Isup, L. L 

George A. Smith, M.D., Superintendent 

Harcna B. Heirman, ILD., First Assistant Physician. 

Charles M. Bnrdick, M. D., Senior Assistant Physician. 

David Corcoran, M. D., Senior Assistant Physician. 

Wm. Leavitt, M.D., Assistant Physician. 

J. Berton Allen, M.D., Assistant Physician. 

Ralph G. Reed, M. D., Assistant Physician. 

Charles L. Vanz, TUL D., Senior Assistant Physician. 

Albert E. Ullman, M. D., Senior Assistant Physician. 

Theodore W. Simon, m D., Senior Assistant Physician. 

Geoffrey C. H. Bums, M. D., Senior Assistant Physician. 

Horatio G. Gibson, Jr., Senior Assistant Physician. 

Milton BL Grorer, H D. 

Wm. N. Bamhardt, M. D., Assistant Physician. 

Adeline M. Wescott, M. D. 
Cornwall Sanitarium, Cornwall-on-Hudson. 

No members. 



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GEOGRAPHICAL DISTRIBUTION 65 

NEW YORK-^ontinued, 

Crajg Coloky fob Epileptics, Sonyka. 

WilliAm T. Shanahaw, M. D., Medical Superintendent 
James F. Munaon, M. D., Pathologist 

G. Kirby Collier, M. D., Assistant Physician. 

Arthur L. Shaw, M.!)^ Assistant Physician. 

Wm. N. Trader, Jr., M. D., Assistant Physician. 
Custodial Asylum, Newask. 

Ethan A. Nevin, M. D., Superintendent 
Dankzmosa Stats Hospital, Dannemora. 

Charles BL North, M.D., Superintendent 

John R. Ross, M. D., First Assistant Physician. 

Roger Dexter, M. D., Assistant Physician. 
Ds. Bond's House, Yonkers. 

George F. M. Bond, ILD., Proprietor. 
Dr. Dunham's Sanitarium, Buffalo. 

Sydney A. Dunham, M. D., Resident Physician and Proprietor. 
Dr. Kellogg's House, Riverdalx, New York City. 

Theo. H. Kellogg, M. D., Physician-in-Charge. 
Dr. Lyon's Sanitarium, Binghamton. 

Charles G. Lyon, M.D., Superintendent 
Dr. MacDonald's House, Central Valley. 

Carlos F. MacDonald, M. D., Proprietor and Physician-in- Charge. 

Clarence J. Slocum, M. D., Resident Physician. 
Glenmary Sanitarium, Owsgo. 

Arthur J. Capron, M. D., Physidan-in-Charge. 
GowANDA State Homeopathic Hospital, Coluns. 

Daniel H. Arthnr, M.D., Superintendent 

Clarence A. Potter, M.D., First Assistant Physician. 

C. Yon A Schneider, M. D., Assistant Physician. 

Frederick P. Schenkelberger, M. D., Assistant Physician. 
Greenmont-on-Hudson, Ossinino p. O. 

No members. 
HiLBouRNE Club, Katonah. 

Samuel T. Armstrong, M. D., Physician-in-Charge. 
Hudson River State Hospital, Poughkeepsis. 

Charles W. Pilgrim, M. D^ Superintendent 

Frederick W. Parsons, M.D., First Assistant Physician. 

Mortimer W. Raynor, BL D., Senior Assistant Physician. 

Blanche Dennes, M. D., Assistant Physician. 

William J. Cavanaugh, M. D., Senior Assistant Physician. 

Howard P. Carpenter, IL D., Senior Assistant Physician. 

Percy L. Dodge, M.D., Assistant Physician. 

Ross D. Helmer, M. D., Assistant Physician. 

Florence A. King, M. D., Assistant Physician. 



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66 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

NEW YORK— CofiftnKf J. 

Hudson River State Hospital, Pouchkeepsie.— ConHnned. 

Willis B. Mexrimaii, M. D., Assistant Physician. 

Leona E. Todd, M. D^ Woman Physician. 

Wm, C. Porter, M. D., Senior Assistant Physician. 

T. Grover DeLaHoyde, M.D^ Assistant Physician. 

Barbara Curtis, M. D., Woman Physician. 

Clarence L. Russell, M.D., Assistant Physician. 
Kings County Hospffal, Brooklyn. 

John F. Fitzgerald, M. D., Medical Superintendent. 
Kings Park State Hospital, Kings Park. 

William Austin Macy, M. D., Superintendent 

C. Floyd Haviland, M. D., First Assistant Physician. 

A. J. Rosanoff, M. D., First Assistant Physician. 

Chester Lee Carlisle, M.D., Senior Assistant Physician. 

Calvin B. West, M. D., Senior Assistant Physician. 

Nell W. Bartram, M.D., Assistant Physician. 

Charles G. McGalBii, M. D., Pathologist and Assistant Physician. 

Russell E. Blaisdell, M. D., Assistant Physician. 

Anna Craig, M.D., Assistant Physician. 

Delmer D. Durgin, M.D., Assistant Physician. 

Isaac J. Furman, M. D., Assistant Physician. 

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

Helena B. Pierson, M. D., Assistant Physician. 

Charles S. Parker, M« D., Assistant Physician. 

Walter H. Sanford, M.D., Senior Assistant Physician. 

Philip C. Washburn, M.D., Senior Assistant Physician. 

Wm. C. Sandy, M. D., Assistant Physician. 
Knickerbocker Hall, Amityville. 

Henry L. Trenkle, M. D., Physician-in-Charge. 
Long Island Home, Amityville. 

0. J. Wilsey, M. D., Physidan-in-Charge. 
Long Island State Hospital, Brooklyn. 

Elbert M. Somers, M. D., Superintendent. 

Erring HoUey, M. D., Assistant Physician. 

Joseph Smith, M. D., Assistant Physician. 
Marshall Sanitarium, Troy. 

Christopher J. Patterson, M.D., Physician-in-Charge. 
Manhattan State Hospital, Ward's Island^ New York City. 

William Mabon, M. D., Superintendent and Medical Director. 

John T. W. Rowe, M. D., First Assistant Physician. 

George H. Kirby, M. D., Director Clinical Psychiatry. 

John R. Knapp, M. D., Assistant Physician. 

Anna E. Hutchinson, M. D., Woman Assistant Physician. 

Ernest M. Poate, M. D., Senior Assistant Physician. 

Clarence 0. Cheney, M. D., Assistant Physician. 

Sylrester R. Leahy, M. D., Assistant Physician. 



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GEOGRAPHICAL DISTSIBUTION 67 

HIW YORK— C<Ni/tiif»«d. 

Matteawan State Hospital* Bbaook. 

Ra3rxnond F. C. Kieb, M. D^ Superintendent 

Joeeph W. Moore, JUL D^ First Assistant Physician. 

John H. Blavyelty M. D^ Assistant Physician. 

B. R. Webster, M. D., Assistant Physician. 
Mddutown Stats Homeopathic Hospital* Miudlsiown. 

Mamice C. Ashley, M. J>^ Superintendent 

Robert C Woodman, M. D., First Assistant Physician. 

George F. Brewster, M. D., Senior Assistant Physician. 

Arthur 8. Moore, M. D., Assistant Physician. 

Elijah S. Burdsall, M. D., Assistant Physician. 

Wm. S. Kelly, M. D., Assistant Physician. 
MoHANsic State Hospttal, Yokktowm. 

Isham 0. Haxris, M. D., Superintendent 
Pxesbytesian Hospital, New York. 

George B. Landers, M. D., Second Assistant Superintendent 
Psychiatric Institute, Ward's Island, New York Cmr. 

August Hoch, M. D., Director. 

Glenn E. Myers, M.D., Assistant Physician. 

Wm. W. Wright, M. D., Assistant Physician. 
Providence Retreat, BuFPALa 

John J. Twohey, M. D., Physician-in*Charge. 
River Crest Sanitarium, Astoria. 

J. Joseph Kindred, M. D., Proprietor and Consulting Physician. 

William E. Dold, M.D., Medical Superintendent 

Richard 6. Eaton, M. D. 
Rochester State Hospital, Rochester. 

Eugene H. Howard, M. D., Superintendent 

Ssra B. Potter, M. D., First Assistant Physician. 

Willard H. Veeder, M. D., Senior Assistant Physician. 

Irving Lee Walker, M. D., Assistant Physician. 

Eveline P. Ballintine, M. D., Assistant Physidaa 

Mary A. Nickerson, M.D., Assistant Physician. 

Sarah 0. Pierson, M.D., Assistant Physicianl 
Sanpord Hall, FLusHma 

W. Stuart Brown, M. D., Physician-in-Charge. 
St. Lawrence State Hospital, OcDENSBURa 

R. H. Hutchings, M. J>^ Superintendent 

Paul Gerald Taddiken, M. D., First Assistant Physician. 

Caroline S. Pease, M.D., Assistant Physician. 

A T. Colnon, M. D., Assistant Physician. 

Arthur 0. Lane, M. D., Assistant Physician. 

Samuel Oinsburg, M. D., Assistant Physidan. 
Hyman L. Levin, M. D., Assistant Physidan. 
John A. Pritchard, M. D., Senior Assistant Physidan. 
C. Ross Miller, M. D., Assistant Physician. 



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68 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

HXW YORK^-Continutd. 

St. Vincent's Reiuat, Hasuson. 

Swepson J. Brooki, M. D., Physidan-in-Chargc. 
The Pine8» Auburn. 

Frederick Sefton, H. J>^ Physidan-in-Charge. 
Utica State Hospital, Utica. 

Harold L. Palmer, M. D., Superintendent 

George B. Campbell, M. D., First Assistant Physician. 

Samuel W. Hamilton, M. D., Senior Assistant Physician. 

Jnliui E. Haight, M. D., Assistant Physician. 
Vernon House, Bronxvillb. 

William D. Granger, M. D^ Physician-in-Charge. 
West Hnx, a6iST St. and Broadway, New York City. 

FlaTina Packer, M.D., Physidan-in-Charge. 

Amos T. Baker, H. D., Associate Physician. 

WiLLARD Stats Hospital, Willard. 

Robert M. BUiott, M. D^ Superintendent 

Wm. H. Montgomery, M.D., Senior Assistant Physician. 

Salph S. Pettibone, M. D., AssisUnt Physician. 

Chester Waterman, M. D., Senior Assistant Physician. 

Wirt C. Groom, M. D., Assistant Physician. 

Gordon Priestman, M.D., Assistant Physician. 



Barton F. Andrews, M. D., Mt Morris. 

Clayton G. Andrews, M. D., Canton. 

Charles S. Atwood, M. D., New York. 

Thomas S. Bamford, M. D., Syracuse. 

A. A. Brill, M.D., New York. 

Louis Casamajor, M. D., New York. 

John B. Chaphi, M. D., Canandaigua. 

Frank L. Christian, M. D., Elmira. 

L. Pierce Clark, M. D^ New York. 

E. Austin Cossitt, ILD^ New York. 

Ralph H. Dunning, M. D., Eastwood. 

Frederic C. Bastman, M.D^ Brooklyn. 

John L. Bckel, M. D^ Buffalo. 

Hiram BUiott, M. D., Albany. 

Albert Warren Ferris, M. D., Saratoga Springs. 

Austin Flint, M.D., New York. 

Horace W. Frink, M. D., New York. 

Kenas 8. Gregory, H. D., New York. 

AlberU S. B. Guibord, H D., Bedford Hills. 

J. Victor Haberman, M. D., New York. 

Graeme M. Hammond, M. D., New York. 

Edward L. Banes, M. D^ Rodiester. 



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GEOGRAPHICAL DISTRIBUTION 69 

irSW YORK^^ontinued. 

John J. Hairington, M. D^ New York, 
^niliam Hinch, M. D^ New York. 
J. Ralph Jacoby, M. D., New York. 
Smith Sly Jelliffe, M.D., New York. 
Morris J. Karpas, M. D., New York. 
Robert B. Lamb, M. D., Troy. 
Roy L. Leak, M. D., Syracuse. 
Samuel B. Lyon, M.D., White Plains. 
John Irrine McKelway, M. D., New York. 
Herman 6. Matzinger, M.D., Buffalo. 
James Y. May, M. D., Albany. 
Henry W. Miller, M. D., Brewster. 
J. M. Mosher, M. D^ Albany. 
B. Ross Nairn, M. D., Buffalo. 
George (raanlon, M. D., New York. 
George M. Parker, M. D., New York. 
Frederick Peterson, M. D., New York. 
Mason W. H. Pitman, M.D., New York. 
Wm. B. Pritchard, M. D., New York. 
Frank W. Robertson, M. D., New York. 
Walter G. Ryon, M. D., Albany. 
B. Sachs, M. D^ New York. 
Thomas W. Salmon, M.D., New York. 
Max G. Schlapp, M. D., New York. 
R. Montfort Schley, M. D., Buffalo. 
H. Ernest Schmid, M. D., White Plains. 
Edward A. Sharp, M. D., Buffalo. 
William W. Skinner, M. D^ Geneva. 
William B. Sylvester, M. D., Canandaigua. 
A. W. Thomson, M. D., Poughkeepsie. 
Nelson W. Thompson, M. D., New York. 
Walter L. Treadway, M. D., New York. 
Reeve Turner, M.D., New York. 
George S. Youngling, M. D., New York. 

NORTH CAROLINA— Bboadoaks Sanatorium, Mobganton. 

Isaac M. Taylor, M. D^ Superintendent 
Highland Hospfial, Asheville. 

Robert S. Carroll, M. D., Medical Director. 
Statb Hospital, GoLDSBoaa 

W. W. Faison, M. D^ Superintendent 

J. S. Brothers, M. D., Assistant Phjrsician. 

Wm. A. Murphy, M. D., Assistant Physician. 

Statb Hospital, Morgantdn. 

J6ha McCampbell, M. D., Superintendent 



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70 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

HOSTH CAROLDXA-^onHnued. 

Stais Hospital, Dix Hill, Raleigh. 

W. W. Stancelly M. D^ Assistant Physician. 



Albert Dvrliainy M. D., Charlotte. 

NORTH DAKOTA— Stats Hospital for the Insami; Jambstowm. 
W. M. Hotchkiss, M. D., Superintendent 
H. D. Baxlt M. D., First Assistant Physician. 



Salph Deming, H. D., iMercer. 

O 

OHIO— Athens State Hospital, Athens. 

0. 0. Fordyce, M. D., Superintendent. 

Cincinnati Sanitabittm» CmaNNAn. 

F. W. Langdon, H. D., Medical Director. 

Berthold A. Williams, H D., Senior Resident Physician. 
Emenon A. North, M. D., Resident Physician. 

Cleveland State Hospital* Cleveland. 
Charles H. Cladc, M. D., Superintendent 

Columbus State Hospital* Columbus. 

Charles F. Gilliam, M. D., Superintendent 

G. H. Williams, M. D., Assistant Physician. 
Bmce B. Barber, M. D., Assistant Physician. 
Mary Keyt Isham, M. D., Assistant Physician. 
George A. Rowland, M.D., Assistant Physician. 
K. H. Teretdan, M. D., Assistant Physician. 

Dayton Sanitabium, Dayton. 

No members. 
Dayton State Hospital* Dayton. 

Armitage Baber, M. D., Superintendent 

Edgar L. Brannlin, M. D., First Assistant Physician. 
Faib Oaks Villa, Cuyahoga Falls. 

William A. Searl, M.D., Medical Director. 

Chas. B. Rogers, M. D., Physidan-in-Charge. 

H. Irving Cosad, M. D., Qinical Director. 
QtANDviEw Sanitabium, Cinonnatl 

J. M. Ratliir, M. D., Superintendent 

Thomas A. RatliiE, K.D. 
Institution pob Feeble-Minded, Columbus. 

S. J. Emerick, M.D., Superintendent 
Lake Side Hospital^ Cleveland. 

No members. 



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GEOGRAPHICAL DISTRIBUTION Jl 



OElO-^ontinutd. 

LoNcnxw Hospital, Cincinnatl 

F. W. Hannon, H. D^ Superintendent 
Massillon Stats Hospital, Massillon. 

E. C Synuuit M. D^ Superintendent 

Paul J. Alspaui^ M. D^ Assistant Physician. 
Ohio Hospital for Epiupncs, Galufous. 

6. G. Kineon, M.D., Superintendent 
OscHAso Sfkings Sanitarium, Dayton. 

John Cecil George, M. D., Physician-in-Charge. 
Oxford Rktrbat, Oxford. 

R. Harvey Cook, M.D., Physician-in-Chief. 
TouDo Stats Hosptfal, ToLEoa 

George S. Lore, M. D., Superintendent 



Isahel A. Bradley, H. D., Akron. 
Howard M. Bnmdage, M. D., Columbus. 
George T. Harding, M. D., Columbus. 
A B. Howard, M.D., Qeveland. 
Robert Ingram, M. D., CindnnatL 
Fletcher Langdon, M.D., Cincinnati. 
J. M. Lewis, M. D., Qeveland. 
John D. O'Brien, M. D^ Canton. 
WOliam H. Pritchard, M. D., Gallipolis. 
Arthur F. Shepherd, H. D^ Columbus. 
George Stockton, M. D., Columbus. 

OKLAHOMA— Stats Hospital for thb Insane, Norman. 
D. W. Griffin, M. D., Superintendent 
A. A. Thurlow, M. D., First Assistant Physician. 

OSXGON— Crystal Springs, PosiLANa 

Henry Waldo Coe, H. J>^ Medical Director. 
Robert L. Gillespie^ H. D., Medical Director. 
Stats Insanx Asylum, Salxm. 
No members. 

P 

PKHNSTLVAIflA— Chxstxr County Hospital for Insani, Embrxkvillx. 

No members. 
DixMONT Hospital for the Insanx, Dixmont. 

Henry A Hntchinaoat M. D^ Superintendent 
Easton Sanitarium, Easton. 

C Spencer SsMy, M. D^ Proprietor. 



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72 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

VKmSYLYAmA-^ontinued, 

FuENDs' Asylum for the Insaks, Frankfobd^ Philadelphia 

Robert H. Cliaie» H. D^ Superintendent 

Albert C. Buckley, M. D., Assistant Physician. 

Marian O'Hanow, M.D. 
Hospital for the Insane of Luzerne County, Retreat. 

Charlei B. Maybeny, M.D^ Superintendent 
The Mercer Sanitarium, Mercer. 

Wm. W. Richardson, M.D., Physician-in-Chargc. 
Pennsylvania Epileptic Hospital, OAKSointNE. 

No members. 
Pennsylvania Hospital for the Insane, Philadelphia. 

Owen Copp, M. D., Superintendent 

Samuel T. Orton, M. D., Qinical Director and Pathologist 

Earl D. Bond, M. D., Senior Assistant Physician. 

Daniel H. Fuller, M. D^ Assistant Physician. 

George T. Paris, M. D., Assistant Physician. 

Edward A. Strecker, M. D., Assistant Physician. 
Philadelphia Hospital for Insane, Philadelphia. 

J. Allen Jackson, M.D., Chief Resident Physician. 
State Asylum for the Chronic Insane, Wernersville. 

8. S. Hill, M. D^ Superintendent 
State Hospital for the Insane, Danville. 

Hugh B. Meredith, M.D., Superintendent 

James S. Hammers, M. D., Assistant Physician. 

B. B. Shellenberger, M. D., Assistant Physician. 
State Hospital for the Insane, Norristown. 

Arthur K. Petery, M. D. 

H. C. Podall, M. D., Assistant Physician. 

Jessie M. Peterson, M.D., Resident Physician, Department for 
Women. 

State Hospital for the Insane, Warren. 

H. W. Mitchell, M. D., Superintendent. 

Paul G. Weston, M. D., Pathologist. 

Alan D. Finlayson, M. D., Assistant Physician. 

Ira A. Darling, M. D., Assistant Physician. 
State Institution for Feeble-Mi nded, Polk. 

J. Morehead Murdock, M. D., Superintendent. 
State Institution for Feeble-Minded, Spring City. 

George P. Ard, M. D., Assistant Physician. 
State Homeopathic Hospital, Allentown. 

Henry L Klopp, M. D., Superintendent 

Harry F. Hoffman, M. D., Assistant Superintendent 

Walter E. Lang, M. D., Senior Assistant Physician. 



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GECXSRAPHICAL DISTRIBUTION y^ 

Staib LuNAnc Hospital^ Hasusbubg. 

H. L. Orth, M. D^ Superintendent 

B. F. L. Ridgway, M.D^ First Assistant Physician. 
Stonyhubst Sanitaxiuh, Holmesbukg, Philadelphia. 

No members. 
Wood Lxa Sanitarium, Abdmobe. 

Grace S. White, M. D. 
•* The Eyrie,'' Clipton Heights. 

W. W. Hawke, M. D. 



Jane Rogers Baker, M.D., West Chester. 
Charles W. Burr, H. D^ Philadelphia. 
Alfred Gordon, M. D., Philadelphia. 
Seymour De Witt Lndlnm, M. D., Merion. 

D. J. McCarthy, M.D., Philadelphia. 
Clyde R. McKinniss, M. D., Boyce Station. 
Edward E. Mayer, M. D., Pittsburgh. 
Charles K. Mills, M.D., Philadelphia. 
Horace Phillips, M.D., Philadelphia. 
Albert R. Monlton, M. D., Philadelphia. 
John H. W. Rhein, M. D., Philadelphia. 
Robert A. Stewart, M. D., Lock Haven. 
T. H. Weisenburg, M. D., Philadelphia. 
Cornelius C. Wholey, M. D., Pittsburgh. 
Mary M. Wolfe, M. D., Lewisburg. 
Frank Woodbuiy, M. D., Philadelphia. 
W. S. Wright, M. D., Harrisburg. 

' R 
RHODE ISLAKI)— Butler Hospital, Pbovidencb. 
G. Alder Blumer, M.D., Superintendent 
Henry C. Hall, M. D., Assistant Physician. 
Arthur H. Ruggles, M.D., Assistant Physician. 
Rhode Island State Sanatorium, Wallum Lake. 

No members. 
State Hospital for Insane, HowARa 

Arthur H. Harrington, M. D., Superintendent 

E. H. Cohoon, M. D., Assistant Physician. 
Joseph H. Toomey, M. D., Assistant Physician. 



William McDonald, M. D., Providence. 



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74 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

s 

SOUTH CASOLnrA— Stais Hospital rok thb In same, Columbia. 
J. L. ThompaoBy M. D^ Assistant Physidaa 

WavERLEY SaNITAKIUM, C6LUMBIA. 

J. W. Babcock, M. D., Superintendent 
Eleanora B. Saunders, M. D. 

SOUTH DAKOTA— South Dakota Hospital for thx Insakb, Yankton 
L. C. Kead» M. D^ Superintendent 
Georgo Sheldon Adama, M.D^ Assistant Superintendent 
Asylum for Insane Indians, Canton. 

Henry S. Hummer, M.D^ Superintendent 

T 

TBNIIESSBS— Central Hospital for thx Insani; NashVillb. 

Albert B. Douglas, M. D.^ Superintendent 

George B. Hatcher, M. D., First Assistant Physician. 
Eastern Hospital for thb Insane, Bbardbn. 

Michael CampbeU, M. D., Superintendent 
Western Hospital for Insane, Bouvab. 

James J. Neely, M. D., Superintendent 



Wm. 0. SomenriUe, M. D., Memphis. 

TBXAS— AsuNGTON Heights Sanitarium, Fort Worth. 

W. F. Allison, H. D., Superintendent 
Dr. Moody's Sanitarium, San ANioNia 

G. H. Hoody, M. D., Superintendent 
North Texas Hospital for the Insane, Terrell. 

No members. 
Southwestern Insane Asylum, San Antonkx 

F. S. White, M.D., Superintendent 
Statb EpiLEPnc Colony, Abilene. 

T. B. Bass, M.D., Superintendent 
State Lunatic Asylum, Austin. 

John Preston, M.D., Superintendent 
Texas School for Defectives, Austin. 

A. Fitshugh Beverly, M. D., Resident Physician. 



Jdm 8. Tmaar, M. D., Dallas. 

U 
UTAH— Utah State Mental Hospital, Pbovo Cmr. 
Daaiel H. Gaidar, M.D^ Superintendent 



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GEOGRAPHICAL DISTRIBUTION 75 

V 

VBfiMOlIT— Brattlibobo RffniAT, BR^VTiLXBOia 
Shaller S. Lawton, M.D^ Superintendent 
Herbert W. Taylor, M. D^ First Assistant Physician. 
Stats Hospital for the In8ams» Watkkbuiy. 
No members. 

VIROIIIIA— Central State Hospital* FfeiERSBUia 

^niliam F. Drewry, HLD^ Superintendent 

Hugh Carter Henry, M. D., First AssisUnt Physician. 
Eastern State Hospital* WnuAMSBUia 

6. W. Brown, M.D., Superintendent 
Southwestern State Hospftal, Marion. 

John C. King^ M. J>^ Superintendent 

Estelle H. Henderson, K. D., First Assistant Physician. 
State Epileptic Colony, Madison Heights. 

A. 8. Priddy, M. D., Superintendent 
Western State Hospital, Staunton. 

J. S. De Jamette, M. D., Superintendent 

J. H. Garlick, M. J>^ Assistant Physician. 



Oliyer C. Bnmk, M. D., Richmond. 

W 

WASHINGTON— Eastern Washington Hospital por the Insane, Med- 
ical Laze. 
John M. Semple, M. D., Superintendent 
Western Washington Hospital for the Insane, Fort Steilaooom. 
No members. 



Robert P. Smith, M.D., Seattle. 

WEST VIRGINIA— Second Hospttal for the Insane, Spencer. 

Charles A Barlow, M. D., Superintendent 
West Virginia Asylum at Huntington, Huntington. 

L. y. Onthriey M. J>^ Superintendent 

James R. Bloss, M. D., Assistant Physician. 

Harry W. Keatley, M. D., Assistant Physician. 
West Virginia Hospital for the Insane at Weston. 

No members. 

WISCONSIN— -Lake Geneva Sanitarium, Lake Geneva. 
No members. 
Milwaukee Asylum for the Chronic Insane, Wauwatosa. 
William F. Bentler, M. D., Superintendent 



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76 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

WISCONSIN— CoMftiiM^d. 

Milwaukee Hospital for the Insane, Wauwatosa 

M. J. White, M. D^ Superintendent 
Milwaukee Sanitaiuuh, Wauwatosa 

Sidiard Dewey, M.D^ Physician-in-Charge. 

Herbert Wm. Powers, M. D. 
Northern Hospital por the Insane, WiNNEBAca 

Adin Sherman, M.D^ Superintendent 
Oak Leigh Sanitarium, Lake Geneva. 

Mary E. Pogne, M. D., Physician-in-Charge. 
OcoNOMAwoc Health Resort, Oconomawoc 

Arthur W. Rogert, M. D^ Superintendent. 
Palmyra Sanitarium, Palmyra. 

No members. 
The Sanatorium, Hudson. 

W. H. Darling, M. D., Superintendent 
Waukesha Springs Sanitarium, Waukesha 

Bsrron M. Caplet, M. D., Superintendent 
Wisconsin State Hospital for the Insane, Mkndota 

Charles Gorst, M. D., Superintendent 

William F. Lorenx, M. D., First Assistant Physician. 



William F. Becker, M. D., Milwaukee. 
Anne Burnet, M. D., Wausau. 
John B. Edwards, M. D., Milwaukee. 
Roy E. Mitchell, M. D., £au Claire. 
S. S. Stack, M. D., Milwaukee. 

WYOMING— State Hospital for the Insane, Evanston. 
Charles H. Solier, M. D., Superintendent 

BRITISH AMERICA. 

BRITISH COLUMBIA— PuBUc Hospital for Insane, New Westminster. 
Charles Edward Doherty, M.D., Superintendent 
James G. McKay, M. D., Assistant Physician. 

MANITOBA— Asylum for the Insane, Selkirk. 

H. C. Norquay, M.D., Assistant Superintendent 



David Young, M. D., Winnipeg. 

NEW BRUNSWICK— The Provincial Hospital, Fairville, St. John's 
County. 
James Y. Anglin, M. D., Superintendent 



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GEOGRAPHICAL DISTRIBUTION 77 

IfEWFOUUDLAHD— Asylum roB tbm, In8ans» St. John's. 
No members. 

HOYA SCOTIA— -Nova Scotia Hospital, Halifax. 
Frederick E. Lawlor, M. D., Superintendent 



W. H. Hattie, M. D., Halifax. 

OHTAfilO— Asylum for thb Insanb, Cobouig. 

No members. 
Asylum for the Insanb, London. 

W. J. Robinsost M. J>^ Superintendent 
Asylum f(» thb Insanb, Pbnxtanguishsni. 

William T. Wilson, H D., Superintendent 
HoMswooD Sanitarium, Guilfh. 

Alfred T. Hobbs, M. J>^ Superintendent 

E. C. Barnes, M.D., Assistant Physician. 
Hospital for thb Insanb, Brockvillb. 

John C. Mitchell, M. D., Superintendent 
Hospital for thb Insane, Hamilton. 

W. M. Sngllsh, M.D.9 Superintendent 

Peter MacNaughton, M. D., Assistant Superintendent. 
Hospital rok the Insane, Toronto. 

James M. Fortter, M. D., Superintendent 
MiMiGO Hospital for the Insane, Toronto. 

Nelson H. Beemer, M.D., Superintendent 
Dr. Meyers' Hospital, Toronto. 

Donald Campbell Meyers, M. D., Superintendent. 
RocKWOOD Hospital for the Insanb, Kingston. 

Edward Ryan, HD., Superintendent 
SiMCOE Hall, Barrib. 

W. C Barber, M. D., Superintendent. 
Toronto General Hospital, Toronto. 

Charles E. Clarke, M. D., Medical Superintendent 



R. W. Bmce Smith, M.D., Toronto. 

PRINCE EDWARD ISLAND— Falconwood Hospital for Insane, Char- 
LomrowN. 
v. L. Goodwill, M.D., Superintendent 

QUEBEC— Bbauport Asylum for thb Insane, Beaufort, Quebec 
M. D. BrodtUy M.D., Superintendent 
Saint Jean de Dieu Hospffal, Montreal. 
George YOlenewe, M. D., Superintendent 
Francis E. Derlin, M.D., Assistant Superintendent. 



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78 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

QUEBEC— Continued. 

PitonsTANT Hospital for ths Insams» Montreal 
T. J. W. Bnrgesa, H. D^ Superintendent 
Carlyle A. Porteoua, M. D., Assistant Superintendent 
Andrew Macphail, M. D^ Consulting PaUiologist 
David Alexander Shirrea, M. D., Consulting Neurologist 
Hedley V. Roliinson, M.D^ Assistant Physician, 



S. Philippe Chagnon^ M. D., Montreal 

CUBA.— MALBERTf s Sanitarium, Havana. 

J086 A. Malhertiy M. D^ Physician-in-Charge. 

POSTO RICOd— Insane Asylum, San Juan. 
No members. 



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AMERICAN MEDICO-PSYCHOLOGICAL 
ASSOCIATION. 



CONSTITUTION. 



Article I. 
This organization shall be known as tiie American Medico- 
{^SYCHOLOGiCAL ASSOCIATION, this name being adopted in 189a 
by ''The Association of Medical Superintendents of American 
Institutions for the Insane/' founded in 1844. 

Article IL 
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 five 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) Life members; (4) Honorary members; 
and (5) Corresponding members. 

Article IV. 

The officers of the Association shall consist of a President, 

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

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.— The Association of Medical Superintendents of American Institu- 
tions for the Insane was founded in 1844 by the original thirteen members. 
In i8pi, 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 throug[h its records. The proposition was ag[reed to, and at the 
annual meeting in Washington, in 1892, there were unanimously adopted the 
following Constitution and By-Laws, with the change of name to the 
American Mkdico-Psychological Association. 



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8o 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 
Life members shall be such Active members as shall have been 
members of the Association for a consecutive period of thirty (30) 
years ; the Honorary members shall include those so designated in 
that list; the Associate members shall include all the assistant phy- 
sicians 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 Corrc- 
spondmg 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- 



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CONSTITUTION 8l 

ing such appointments. After holding such an appointment three 
years, an Associate member may become an Active member by 
making application, in writing, to the Council, and upon its 
approval, being elected in the manner heretofore prescribed* 

Article VI. 

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 eflForts 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. Life, Honorary and Corresponding 
members shall be exempt from all payments of annual dues to the 
Association. 

Article VH. 

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 VHI. 

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- 

6 



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82 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCLATIOK 

ately* The election shall be made as the meeting may determine, 
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 b^^inning 
of the term for which their successors are elected One Auditor 
shall be elected for one year, one for two years, and one for three 
years. The Secretary and Treasurer and one Auditor arc 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 thereafter 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 Offi- 
cers 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 Cotmdl, 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 
office, and such other duties as may be prescribed for him by the 
Cotmdl ; 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 



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CONSTITUTION 83 

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 tfie preceding year, to the Council at its 
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 ftmds 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 rq^^lar 
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. 



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84 AMERICAN MEDIC0-PSYCH0LCX3ICAL ASSOCIATION 



BY-LAWS. 



Article I. 

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 annotmcements 
sent to each member at least three months previous to the meeting. 

The Council 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 be 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. 



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NOTE. 

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

CHARLES G. WAGNER, 

Secretary, 

BiNGHAMTON, N. Y., 

March i, 1915, 



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AMERICAN MEDICO-PSYCHOLOGICAL 
ASSOCIATION. 

PROCEEDINQS OF THE SEVENTIETH ANNUAL MEETING. 

Baltimore, Md., Tuesday, May 26, 1914. — Fntsr Session. 

The Association convened at 10 a. m. in the Convention Hall of 
the Hotel Belvedere, Baltimore, Md., and was called to order by 
the President, Dr. Carlos F. MacDonald, of New York. 

The PREsmsNT.— FW/ow Members and Guests: Your President deems 
it a great privilege and a great honor, as well as a pleasant duty, to call 
the Seventieth Annual Meeting of the American Medico-Psydiological 
Association to order, and in doing so, he would say to each and every 
member present, as well as to our guests, welcome, welcome, thrice welcome. 

A glance at our program, with its bristling array of titles of scientific 
papers of a high order, together with the names of their respective authors, 
indicates that our meeting is to be favored on the scientific side with a 
continuous "all-star" performance, while on the social side our efficient 
and industrious local committee of arrangements has set before us an 
equally attractive array of good things to be sandwiched in between our 
scientific sessions, thus sustaining Baltimore's well-known reputation for 
hospitality with which many of us are familiar from former experiences. 
1 now declare the Seventieth Annual Meeting open for the transaction of 
business. 

We will first have the pleasure of listening to the invocation by the Right 
Reverend John Gardner Murray, Bishop of Maryland. 

The invocation was then g^ven by Bishop Murray of Maryland. 

Thk PBSsn«NT.— The Association is to be congratulated on being honored 
by the presence here to-day of such a galaxy of distinguished citizens of the 
^ate of Maryland, who have come to bid us welcome to Baltimore— fit 
representatives of a commonwealth which, in proportion to its size, has 
done as much, if not more, to advance the interests of psychiatry and to 
modernize the care and treatment of the insane than any other state in 
the union. 



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88 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

I may mention first a gentleman who comes of a long line of phjrsidans, 
and who has been actively interested in the welfare of the insane in the 
State of Maryland, having lent the influence of his high office to the sup- 
port of the officers oi his state who are charged with the supervision of the 
institutions for the insane, upholding the hands of the State Lunacy Com- 
mission in its efforts to improve these institutions and, best of all, he has 
allowed politics to play no part in the administration of his office as regards 
the interests and welfare of the insane and feeble-minded. 

I have very great pleasure in presenting the Hon. Phillips Lee Golds- 
borough, Governor of the State of Maryland. (Applause.) 

Governor GoLDSBOROUGH.~lfr. President, and Gentlemen of the Ameri- 
can Medico-Psychological Association: Allow me, on behalf of the people 
of Maryland to extend you a most hearty welcome to this state. If I 
were to attempt to give you reasons in support of the wisdom which 
brought about the decision to hold your Seventieth Annual Meeting in 
this city, I should not have a difficult task, for no one visits this fair land, 
sees its attractions, learns of its resources and meets its people without 
completely understanding that he has in truth found the real Garden 
of Eden; and that this statement may not be challenged, of course, 1 
saw to the appointment of a Committee on Arrangements, the personnel 
of which for chivalry, courtesy, and making one have a good time, "all 
the way round," to use a localism, is certainly not to be excelled, and I 
doubt equalled; and especially is this so when I confess that the silent 
and advisory member of that committee is my and everybody's good and 
genial friend, Dr. Hugh Hampton Young. To the tender mercies of this 
committee I commit you, feeling convinced that they will see to it that the 
cares of the inner man are fully satisfied, and that the days of your visit 
to us shall be those of real pleasure and happiness, such, if you will 
pardon me for saying it, as are only found in the realms of true Southern 
hospitality. 

Now, you must not think I am saying more than I mean — I am not— 
but when one sees from the program that there are to be four speeches 
of welcome — merely an evidence of our great happiness in having you 
with us — he is admonished "to put his words close together '* and weigh 
well their meaning, else in the general result of what may be said by so 
many official "welcomers," the charge may be made of exaggerated 
promises and the expression of biased and egotistical opinions. But, be 
this as it may, I feel that in the end you will agree that such promises 
as have been made you will be wisely and honestly fulfilled. 

The topics or subjects with which your Association will deal— those 
touching the insane and feebleminded — ^may not be pleasing to think upon 
Indeed, they are those of much sadness. Nevertheless, it is the duty of 
our people to face these problems, to discuss them, and finally, in so far as 
we can, find their solution. It is a pleasure to note that the citizens and 
taxpayers of this state have now awakened to a proper realization of the 
obligations resting upon them in the care of these tmfortunates, and Mary- 



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PROCEEDINGS 89 

land for some years past, under the leadership of those who make up 
the membership of the State Lunacy Commission, has been endeavoring, 
and honestly so, to provide sufficient accommodation and adequate treat- 
ment for the indigent sick and insane and feebleminded of the state. 
There is a yearly increase of about 200 insane in the state, whom we 
are endeavoring to care for in state hospitals, and we take quite a bit 
of pride in our institutions known as Springfield State Hospital, located 
in Carroll County, Spring Grove State Hospital, located in Baltimore 
County, and Crownsville State Hospital, located in Anne Arundel County, 
the latter being exclusively for the care of colored insane. At all of 
these institutions are modem and up-to-date methods, the open-door sys- 
tem, and kind and humane treatment There doubtless are similar insti- 
tutions as well conducted as these, but somehow we feel that the belief 
is justified when we say that they are excelled by none. Maryland is 
not a rich state, but the General Assembly of the state has appropriated 
approximately $2,000,000.00 in recent years for new buildings, which has 
enabled us to establish two new hospitals for the insane. The cost of 
maintenance for the year 191 5 is estimated at about $2,000,000.00; quite 
a tax upon a state with an income not large, not to be compared to such 
states as New York, Pennsylvania, Ohio, Illinois, and others that might 
be mentioned. Still we have a duty to discharge to this class of people, 
and that we are endeavoring to do fully. 

It does not require any special figuring to demonstrate the enormous 
cost it is to the state to provide simply food and shelter for this vast 
army of the mental unfit. Then, certainly the most important question 
that we have to consider is that relating to preventive measures and using 
every means not only to increase the efficiency of our state institutions, 
but also to maintain the high standard which all desire. I conceive that 
it is a well recognized fact the world over that the earlier a patient 
suffering from any disease, whether mental or physical, comes under 
proper treatment, the greater is that patient's chance of recovery. It has 
been the custom, not alone in Maryland, but in other states, to keep a 
mentally afflicted person out of a hospital as long as possible, and recourse 
to a hospital has been had only when the patient has become dangerous to 
himself or friends. 

The modem conception of the treatment of the insane is entirely differ- 
ent Now prevention and early treatment are the requisites in all cases of 
bsanity. It is preposterous for a layman to stand and talk on this sub- 
ject to such a distinguished body as the one before me, but it is done 
simply as an opportunity to express my thanks to you for the magnificent 
work that has been done by your Association and its members in teaching 
us in this state, yea in all states, what our duty is in this behalf. It has 
been said to me that I was a Governor more largely controlled by the 
medical men of the state; that their influence weighed more heavily with 
my administration than any other dass of professional or business men in 
the state. It may be true, I will not deny it, because of all sciences, that of 
medicine and surgery in the past half century has made the greatest prog- 



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90 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

ress. I take off my hat to you gentlemen, and I say in the words of Goethe: 

"Energy will do anything ^at can be done in the world; and no dr- 
cumstances» no opportunities, will make a man without it" 

You have taught us that we must have proper hospital buildings, in 
charge of well trained psychiatrists, with ample medical assistance, and 
a corps oi well trained nurses ; that there must be a thoroughly orgamized 
medical staff where the physicians are required to do more ^an simple 
routine work. There must be daily staff conferences omceming tiie 
patients admitted and discharged, and a well equipped medical library 
accessible to the staff, laboratories where investigations may be carried on, 
and a competent director of occupation and recreation must be on duty. 
We must do more than simply house, clothe and feed the insane. We must 
prevent insanity; we must cure whenever possible. Again, you gentlemen 
arc teaching us how to inaugurate a movement, known as the " Preventive 
or Fore- and After-Care Movement" I am glad to tell you that from a 
private source a fund has been established in this state which has enabled 
its Lunacy Commission to employ a well trained psydiiatrist to devote 
his time to this work) and it is believed his efforts will result in getting 
patients to hospitals early to be placed under treatment, and in removing 
from the hospitals patients who have sufficiently recovered their mental 
health to live satisfactorily, quietly and peacefully outside of the institu- 
tions ; finding homes for them or returning them to their own homes, and 
thus relieving the state of their constant support and preventing diem from 
ending their days in the state institutions. I stand for opening the hospitals 
and judiciously inviting the public to visit them more frequently, and edu- 
cating the public through the social service and eugenics department and 
by papers or lectures read by iht staffs to gatherings in the communities, 
as well as having visitors from the community; for thus, in my humble 
judgment, will these steps tend to educate the public in the right direction. 
These lessons your Association is implanting in the minds of the people 
of the nation. I have learned what little I have here said from diose 
who have charge of this work in Maryland, members of your Association, 
and so strongly have they put this work before me that I have endeavored 
in my feeble way to have Maryland do her full duty to this unfortunate 
class of people found within her confines. 

I thank you, gentlemen, for visiting this state and city. I know that 
the result of your deliberations will be of benefit to those who so sadly 
need it I know full well how zealously you have striven in your profes- 
sion for the uplift of the mentally afflicted of mankind, and I can only 
urge you to keep on, knowing full well that no mean measure of success 
awaits you. 

I close with a proverb of King Solomon : 

"Seest thou a man diligent in business? He shall stand before longs; 
he shall not stand before mean men." (Applause.) 

The PBEsnxBNT.— The City of Baltimore is represented here to-day by a 
gentleman who, among his other and varied activities in the public service, 
is noted for his interest in sick and suffering humanity, and who at present 



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PROCEEDINGS 91 

is especially interested in promoting the success of the coming celebration 
of the Centennial Natal Day of Kmr National Anthem, " The Star Spangled 
Banner." 

I have very much pleasure in introducing his Hoiu)r, James H. Preston, 
Mayor of the Qty of Baltimore. 

Mayos Preston.— Jfr. President, Ladies and Gentlemen: I came here 
to say a word of welcome to you and to express our appreciation in having 
you in Baltimore on this occasion, and I hope your deliberations may 
result in great benefit to mankind. I shall not make an extended speech 
here this morning, but I am reminded of a story, in which an Irishman 
once came over to this country, and on arriving in New York he met an 
Irish friend who, in explaining the various advantages that New York 
had over other countries, told him that for one thing they did not hang 
people here for murder, whereupon the visiting Irishman said : " How do 
you punish them?" '^ Oh 1 " said the other, " We docute them." I shall 
not " elocute " you to-day. 

We are doing a good deal here, ladies and gentlemen, for the cause in 
which you are all interested and are laboring. We have some very promi- 
nent men in our midst who are doing a great work in the line in which you 
are engaged. We have Dr. Charles G. Hill, Dr. J. Percy Wade, Dr. J. 
Qement Clark; we have Dr. Brush and Dr. Herring, all great men among 
us, who are doing good work in the various institutions to which they are 
attached. I, of cotu-se, do not know anything about psychology or psy- 
chiatry; I do not know much about insanity, but from a very limited expe- 
rience, I am convinced and believe that the increase in insanity of which 
we are all aware, is very largely due to our mode of life. I believe that 
if we would live a rational, simple life for a generation, instead of gaining 
in numbers, instead of the percentage of insanity rising, it would fall I 
believe the rush to the great cities, the strain of our American life in our 
large cities, the ambition to succeed in the lines in which we are endeavor- 
ing, especially with the people in ^e great cities, is the cause very largely 
of the broken down nervous systems and the consequent destruction of 
mental power and rational forms of thought This degeneration, it 
seems to me, must take place with the degeneration of the general 
nervous system. I know that in the country with which I am most 
familiar, where the people retire early, where they get up early, where they 
do manual labor, where there is not this struggle for a livelihood, and 
where there is not a strain on the nervous system, there is a much smaller 
percentage of insanity, and I believe we can remedy this to a certain extent 
without giving the matter any very definite study. If our interests were 
diversifi^ and we would lead a simple life, after a generation or two there 
would be a tremendous reduction in the number of insane patients in our 
institutions. We have here in Baltimore three or four admirable institu- 
tions—you gentlemen will of course give these careful inspection. I also 
wish briefly to call your attention to the fact that we have some beautiful 
parks, our system of parks is unexcelled, perhaps, in the world; our 



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92 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

harbors and railroad systems, their facilities second to none in the United 
States as a terminal, making Baltimore one of the great ports of the 
Atlantic coast. It may be that in between your labor, by way of diversion, 
you may be able to look over these advantages of otirs ; to consider oar 
parks, our educational institutions, our harbor and our other facilities; if 
you can give all these features some thought, some consideration, I feel 
sure you will take back with you a kind word for Baltimore, and that kind 
word I reciprocate now, and bid you welcome to Baltimore. (Applause.) 

The Pkesidbnt.— We have also with us to-day a gentleman, a physician 
of international reputation in the chosen branch of his profession, both as 
a teacher of and operator in urology at Johns Hopkins University, and 
Surgeon-in-Chief of the Brady Urological Clinic, who has also shown an 
active interest in the welfare of the insane and feebleminded in the State of 
Maryland, and who, as a public spirited citizen, has given freely of his time 
in furthering the interests of the Maryland institutions for the insane, and 
in obtaining appropriations for carrying them on. 

I have very much pleasure in introducing to you Dr. Hugh Hampton 
Young, President of the Maryland State Lunacy Commission. 

Dr. Hugh Hampton Young. — As President of the Lunacy Commission 
of the State of Maryland, it gives me great pleasure to come here for the 
purpose of welcoming you to our city. I wish first to thank you for the 
very great honor you have done me in making me an honorary member of 
your society, as I understand this is an honor that has not been granted in 
a number of years. I am, therefore, quite overwhelmed. 

It is really remarkable what great reforms have been brought about 
by this society, which has been one of the most active medicsil societies in 
this country, throughout its very long existence. I was really amazed 
when I read a partial record of its accomplishments. The care of the 
insane in Maryland has been an extremely slow development A State 
Lunacy Commission was not organized until 1886 and for many years it 
was given very feeble powers; there was no general state-care and no 
effort on the part of the state to take comprehensive care of the insane, 
until 1910, when we put through our present state-care act. At the same 
time additional power and increased appropriations were given to the 
Lunacy Commission by the first bond issue for the insane ($600,000) 
granted at that time. This enabled us to begin a hospital for the negro 
insane (Crownsville) and to start emptying the county jails and alms- 
houses. We had a terrible fight in the legislature to get these laws. The 
idea was repeatedly advanced that it was giving the Lunacy Commission 
far too much power; that the result would be unfavorable to various 
private institutions, etc We had to face a great deal of prejudice from 
those who were trying to prevent our getting this state-care act through, 
but since this was granted, in 1910, the state legislature has been very 
generous indeed, and it has required very little effort on our part to get 
large appropriations and further extensions of our laws that were found 
to be needed. 



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PROCEEDINGS 93 

In 1912, by unanimous vote of both houses, wc were granted $800,000 for 
new buildings at the various hospitals and to begin the Eastern Shore State 
Hospital, which is to take care of the indigent insane on the Eastern 
Shore of Maryland; and also to erect modern psychiatric hospitals at 
our Springfield and Spring Grove institutions. The legislature in 1914 
granted us $418,000, so that we should now be able to practically complete 
our hospitals and to carry out the aim of the state-care act of 1910, which 
was to take care of all the feeble-minded and insane in the state of Mary- 
land. This has been a great step forward for the institutions in this 
state. I almost hesitate to tell you how serious conditions were. Our 
hospitals were caring for the insane then as best they could, but most of 
the insane were housed in almshouses, jails and places where no human 
being, in fact no animal, should be allowed to live. Through the e£Forts 
of Dr. Herring, our most able and efficient secretary, and the assistance 
of the daily press, it was possible to demonstrate the need of, and to get 
the state-care act through the legislature, and to gradually take care of all 
the insane and feeble-minded in our regular state institutions. I may say 
the Ltmacy Commission in this state is extremely fortunate in the heads 
of these various state hospitals; we have a splendid group of men in 
Doctors Qark, Wade, Winterode, Gary, and Keating, and they are doing 
great things for this state. It has also been a great thing for Maryland 
to have the Sheppard and Enoch Pratt Hospital near this dty, tmder the 
care of Dr. Brush. Dr. Hurd, as you know, one of the greatest alienists, 
has been the greatest help and inspiration to us. The inauguration of the 
Phipps Psychiatric Qinic means much for the development of psychiatry 
and, we feel sure, will place Maryland in the very forefront in psychiatry. 
I hope to see close co-operation between the Phipps Psychiatric Qinic and 
our various state hospitals and feel sure that great progress will be made 
in Maryland as a result The steady increase in insanity and the great 
cost of maintaining these institutions are our greatest stumbling blocks. 
When we go back to the legislature, year after year, we are at once con- 
fronted with a demand that something be done to diminish the number of 
insane. I hope your deliberations will take up preventive measures, in- 
cluding sterilization. Many of our legislators are interested in that very 
question, and I hope that your deliberations will throw light on the matter 
and make it possible to have some measure of undoubted constitutionality 
drafted that can be adopted by the various states. There can certainly 
be no doubt of the great efficacy of those simple operations and their 
widespread use would very greatly diminish the births of feeble-minded and 
insane children. Your society and the Society for Mental Hygiene have 
a wonderful work ahead in the way of instruction in eugenics, the 
teaching of proper living, and the avoidance of worry. I agree with 
Governor Goldsborough that the simple life, regular habits, etc, would 
tend to bring about a diminution in the increase of insanity. It remains 
for your society to lead the way, but I feel sure that in the near future 
these great psychiatric hospitals and laboratories, with men devoting them- 



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94 AMERICAN MEDICO-PSYCHOUXHCAL ASSOCIATION 

selves to research, will accomplish wonderful things, and that this meeting 
will give evidence of that great progress which has already been made, 
and that otir Lunacy Commission will be the great beneficiary as ^e 
result Applause. 

The PwEsiiMtNT. — I am sure that we all appreciate very much the force 
of Dr. Young's remarks, especially those of us who have been through ^e 
struggle and labor incident to transforming a bad system of caring for 
the insane into a modem one, by establishing a system of ** State care " for 
the dependent insane and caring for all these patients in hospitals organized 
and equipped on a hospital basis. 

Dr. Young, I thank you on behalf of the Association for your remarks. 

We are sdso favored to-day by the presence of another distinguished 
member of the medical profession who has kindly consented to come here 
and tender us a few words of welcome on behalf of the medical profession 
of Baltimore. 

I take great pleasure in introducing Professor Randolph Winslow, 
President of the Medical and Chirurgical Faculty of Maryland, and Pro- 
fessor of Surgery at the Maryland University. 

Prof. Wivsuyw.-^Mr, President, Gentlemen of the American Medico- 
Psychological Association, Ladies and Gentlemen: I am glad your Presi- 
dent remarked that I would deliver " a few words of welcome," for that 
is what I shall do, and I am sure you will say, " That is the best address 
of the whole," for this reason. 

Through a fortuitous circumstance it has fallen to my lot to have an 
insignificant, but nevertheless agreeable, place assigned to me on the pro- 
gram of this important meeting of your Association. We appreciate 
the honor of having you hold your sessions in our midst, and we wish to 
give you a most cordial welcome.^ His Excellency, the Governor of Mary- 
land, has extended to you the courtesies of the State, and his Honor, the 
Mayor of Baltimore, those of the dty; Dr. Hugh H. Young has bid you 
welcome to our institutions for the insane, and there is not much left for 
me to welcome you to. However, as President of the Medical and Chirur- 
gical Faculty of Maryland, in the name of the medical profession of the 
State, I again bid you welcome. 

We are glad to see you, and we hope that your deliberations may not 
only be of interest to yourselves, but of permanent benefit to that class of 
unfortunate sufferers to whose amelioration you have devoted your lives. 
As wonderful advances have been made in the diagnosis and treatment of 
mental diseases as in any other department of medicine. It is a far cry 
from the despairing inquiry of Macbeth, " Cans't thou not minister to a 
mind diseased?" and the hopeless answer of the doctor: "Therein the 
patient must minister to himself." 

With the recognition that mental aberration is dependent upon dis- 
eased processes comes the hopeful reply to the above quoted inquiry, that 
much may be done to minister to a mind diseased. 



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PROCEEDINGS 9$ 

May it be your good fortune, gentlemen, to advance still further the 
outposts of your specialty and to bring into subjection hitherto uncon- 
quered territory. (Applause.) 

The Psesidsnt. — ^It is said that a speaker who captivates and entrails 
his audience creates an optical illusion that he is about six inches taller 
than he really is. If this is true, and I have no reason to doubt it, the elo- 
quence of the speakers to whom we have just had the pleasure of listening 
must make them appear to this audience to be at least twelve inches taller 
than they really are. 

The pleasing effect of the words of welcome, so eloquently expressed, 
which we have just heard, is too apparent to call for a formal motion for a 
vote of thanks. Knowing, therefore, that I voice the unqualified sentiments 
of each and every member of the Association in doing so, I take the liberty 
on behalf of the Association of conveying to you, gentlemen, our sincere 
thanks for your cordial words of welcome, and I may add that we felicitate 
ourselves on having selected for our Seventieth Annual Meeting your 
charming city, which is famed for its beautiful streets and residences, for 
its fair women, for its culture and refinement, and as a great center of 
medical education. Then, too, happy coincidence, we are meeting on the 
centennial anniversary of the birth of our national air, " The Star Spangled 
Bamier," composed by that illustrious son of Maryland, Francis Scott Key, 
whose name and fame we all admire. Gentlemen, again we thank you. 

Ds. BxTBGBSS. — I would, on behalf of the members of this Association, 
especially those outside of Maryland, ask that a hearty vote of thanks be 
extended the gentlemen who have addressed us so ably. I do not think in 
the many meetings I have attended, dating back to '71, that I have ever 
heard more able and interesting addresses than those we have listened to 
this morning, and I for one feel that we should tender the speakers a vote 
of thanks. 

This motion was duly seconded and .unanimously carried by 
rising vote. 

The PRBsn)BNT. — In the absence of Dr. Wagner, who is detained in a 
medico-legal case in central New York, Dr. Herring has kindly consented 
to act as Secretary pro tem. 

The first order of business is the report of the Committee of Arrange- 
ments, of which Dr. Wade is chairman. 

« Report op C6mmittee op Akrangbmbnts. 

Mr. President, and Members of the Association: It is indeed very 
gratifying to see so many of our members present at this our Seventieth 
Annual Meeting, and it is especially pleasing to see so many of the ladies 
present We wish to take this opportunity to thank the members of the 
Association for their hearty co-operation in arranging for this meeting, 
which has enabled us to arrange the program, both for business and enter- 



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96 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

tainment We sincerely hope it will prove enjoyable to all, and that the 
memory of the Seventieth Annual Meeting in Baltimore may linger long 
and ever be a pleasant one. 

In making our report, we b^ to submit the following: 

This, Tuesday, afternoon, the Ladies' Reception Committee has arranged 
a tea to be given at the Baltimore Country Qub, to which all the ladies of 
the Association are most cordially invited. Preceding the tea there will be 
an automobile drive through Druid Hill Park, one of Baltimore's most 
attractive points of interest Automobiles will be provided for those who 
wish to attend, leaving the Hotel Belvedere at 3 o'clock this afternoon. 

On Wednesday afternoon we have planned a trip down Chesapeake Bay. 
The party will leave Hotel Belvedere at i p. m. on special cars, arriving at 
the wharf at the foot of Calvert street, where the dty boat, Latrohe, which 
has kindly been placed at our disposal by the Mayor, will convey the 
members down the Bay, passing en route many points of historical interest 
We are especially fortunate in having with us on this trip Professor A. B. 
Bibbins, Executive Chairman of the National Star Spangled Banner Cen- 
tennial, who will give a brief talk concerning the points of historical 
interest which we pass. A buffet Itmcheon will be served on board, and 
music will be furnished by the Physicians' Orchestra. The boat will 
return to the dty at 5.30; special cars will be in readiness to convey the 
party back to the hotel, reaching there at 6 p. m. 

On Wednesday evening, at 8.30, in Osier Hall, Dr. Lewellys F. Barker, 
Professor of Medicine, Johns Hopkins University, will deliver an address 
on "The Relation of Internal Medidne to Psychiatry." The committee 
feels particularly fortunate in being able to secure so well known a phy- 
sidan, and one who, as President of the Mental Hygiene Committee, has 
also been in touch with the work of this Assodaion. 

On Wednesday evening, immediately following Dr. Barker's address, 
there will be a cabaret and vaudeville entertainment in the banquet hall of 
the Hotel Belvedere, to which the ladies are invited. 

On Thursday afternoon, upon invitation of the trustees of the Johns 
Hopkins Hospital, the Assodation is invited to visit the Henry Phipps 
Psychiatric Clinic Upon arrival at the hospital luncheon will be served. 
Spedal cars will be provided to convey the members to and from the hos- 
pital, which is located on Broadway and Monument street 

On Friday, at 2 p. m., the Association will be tendered a reception and 
luncheon at the Sheppard and Enoch Pratt Hospital, by the board of 
trustees and superintendent. Special cars will be in readiness to convey 
the members to the institution. Notice of the time of departure will be 
posted on the bulletin board. 

Baltimore is fortunate in having several of the State hospitals and many 
private sanitariums located in its immediate vidnity, the boards of managers 
and superintendents of which desire to extend through this committee a 
most cordial invitation to the members of the Association to visit these 



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PROCEEDINGS 97 

various institutions at ttieir pleasure. Particulars as to route of cars, etc., 
will be given out by members of the Committee of Arrangements. 

The board of governors of the Arundel Qub, the leading Woman's 
Gub of the city, also has extended the privileges of their dub to the 
visiting ladies, where they will be very pleased to receive them. The 
Arundel Club is located just one block south of the hotel on the corner of 
Charles and Read streets. 

The cards presented to the members of the Association upon their regis- 
tration are not reqtiired to be presented at any of the above-mentioned 
entertainments, but are to serve merely as a reminder as to dates of the 
different entertainments. 

All members of the Association are urgently requested to register 
promptly at the registration desk, directly opposite the elevator on the 
twelfth floor of the hotel. 

Respectfully submitted, 

J. Percy Wade, Chairman, 
Charles G. Hill, 
Edward N. Brush, 
Arthur P. Herring, 
J. Clement Clark. 

The President. — You have heard the report of the Committee of Ar- 
rangements, what is your pleasure in regard to it? 

On motion, duly seconded, the report of the Committee of 
Arrangements was accepted and adopted. 

The President. — The next order of business is the report of the Council, 
by the Secretary. 

Rbpgbt of the Council to the American Medico-Psychological 
AssoaATioN. 

Baltimore, Md., May 26, 1914. 

The Council met on the evening of May 25, 1914, at the Hotel Belvedere, 
Baltimore, Md. In the absence of Dr. Wagner, Dr. A. P. Herring was 
appointed Secretary pro tem. 

The Council has received and transmits herewith the report of the 
Treasurer for the current year ; also a statement of the membership of the 
Association to date. 

The Council recommends for election to active membership the following 
named physicians. This list was presented to the Association a year ago, 
and these names are now submitted for final consideration : 

Herman Morris Adler, M. D., Boston, Mass. ; W. C. Barber, M. D., Barrie, 
Ont ; George T. Basket, M. D., St Peter, Minn. ; T. Merrick Bemis, M. D., 
Worcester, Mass.; Charles J. Carey, M.D., Sykesville, Md.; Sydney A. 
Dunham, M. D., BuflFalo, N. Y.; John L. Eckel, M. D., Buffalo, N. Y.; 
Horace W. Frink, M. D., New York, N. Y. ; Donald Gregg, M. D., Brook- 
line, Mass.; J. Victor Haberman, M.D., New York, N. Y.; Walter C 
Haviland, M. D., Worcester, Mass. ; Alfred C. Kingsley, M. D., Phoenix, 



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98 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

Ariz.; B. Ross Nairn, M.D., Buffalo, N. Y.; George E. Neuhaus, M.D., 
Denver, Colo.; John A, Reily, M.D., Patton, CaL; R. Montfort Schley, 
M.D., Buffalo, N. Y.; R. W. Bruce Smith, M.D., Toronto, Ont; William 
W. Smithson, M.D., Jackson, Miss.; Irving J. Spear, M.D.. Baltimore, 
Md.; S. S. Stack, M. D., Milwaukee, Wis.; Walter B. Swift, M.D., Boston, 
Mass.; John N. Thomas, M.D., Pineville, La.; Paul Waterman, M.D., 
Hartford, Conn. ; Cornelius C. Whaley, M. D., Pittsburgh, Pa. 

The Council recommends for election to honorary membership in the 
Association : Hugh Hampton Young, M. D., Baltimore, Md. 

The Cotmcil recommends the transfer of the following named associate 
members to the active class : 

Francis M. Barnes, Jr., M.D., St Louis, Mo.; W. A. Boyd, M.D., Balti- 
more, Md.; R. F. Damall, M. D., Little Rock, Ark.; John J. Harrington, 
M.D., New York, N. Y.; Raymond F. C Kieb, M.D., Beacon, N. Y.; 
Fletcher Langdon, M.D., Cincinnati, O.; F. E. Lawlor, M. D., Halifax, 
N. S.; R. Leighton Leak, M.D., Syracuse, N. Y.; Edward F. Leonard, 
M.D., Chicago, 111.; William S. Osbom, M.D., Des Moines, la.; T. A. 
Ratliff, M.D., Dayton, O.; Walter L. Treadway, M.D., Ellis Island, New 
York; Forrest C. Tyson, M. D., Augusta, Me. 

The Council recommends that the following named physicians be elected 
to associate membership : 

William N. Bamhardt, M.D., Central Islip, N. Y.; R. Grant Barry, 
M.D., Kings Park, N. Y.; John Hudson Blauvelt, M.D., Beacon, N. Y.; 
Victor A. Bles, M.D., Elgm, 111.; J. E. Brothers, M.D., Goldsboro, N. C; 
Louis R. Brown, M. D., Middletown, Conn. ; Geoffrey C. H. Bums, M. D., 
Central Islip, N. Y.; Myrtelle M. Canavan, M.D., Boston, Mass.; Clarence 
O. Cheney, M.D., New York, N. Y.; Herman Walter Corey, M.D., St 
Peter, Minn.; H. Irving Cozad, M.D., Cuyahoga Falls, O.; Ira A. Darlmg, 
M.D., Warren, Pa.; G. Ward Disbrow, iM.D., Springfield, Md.; Arrah B. 
Evarts, M.D., Washington, D. C; George T. Paris, M.D., Philadelphia, 
Pa. ; Isaac J. Furman, M. D., Kings Park, N. Y. ; Horatio G. Gibson, Jr., 
M.D., Central Islip, N. Y.; Bernard Glueck, M.D., Washington, D. C; 
Milton M. Grover. M.D., Central Islip, N. Y.; Claude D. Hamilton, M.D., 
Sykesville, Md.; James C. Hassall, M.D., Washington, D. C; Harry F. 
Hoffman, M.D., Allentown, Pa.; Harry W. Keatley, M.D., Huntington, 
W. Va.; Peter L. Keough, M.D., Crownsville, Md.; Edward J. Kempf, 
M.D., Baltimore, Md.; Herbert Lee, M.D., St Joseph, Mo.; Helcne G. 
Leehman, M.D., Cedar Grove, N. J.; John E. Lind, M. D., Washington, 
D. C; John B. Macdonald, M. D., Hathome, Mass.; Frank M. Mikels, 
M.D., Morris Plains, N. J.; C Ross Miller, M.D., Ogdcnsburg, N.Y.; 
Joseph W. Moore, M. D., Beacon, N. Y. ; Wm. Alexander Murphy, M. D., 
Goldsboro, N. C; Emerson A. North, M.D.. Cincinnati, O.; J. A. F. 
Pfeiffer, M.D., Washington. D.C; Helena B. Pierson, iM.D., Kings Park, 
N. Y.; H. C. Podall, M.D., Norristown, Pa.; John A. Pritchard, M.D., 
Ogdensburg, N. Y.; Theodore W. Simon, M.D., Central Islip, N. Y.; 
W. W. Stancell, M.D., Raleigh, N. C; Harry A. Steckel, M.D., Kings 
Park, N. Y.; Robert A. Stewart, M.D., Mt Pleasant, la.; Edward A. 
Strcckcr, M.D., Philadelphia, Pa.; Herbert W. Taylor, M.D., Brattldwro, 



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PROCEEDINGS 99 

Vt; Frederic H. Thome, M.D., Greystone Park, N. J.; A. A. Thurlow, 
M. D., Norman, Okla. ; John H. Travis, M. D., Hathome, Mass. ; Nelson G. 
Trueman, M. D., Hathome, Mass. ; Albert £. Ullman, M. D., Central Islip, 
N. Y.; Adeline M. Wescott, M.D^ Central Islip, N. Y.; Anita Alvera 
AA^lson, M. D., Washington, D. C. 

The Council has received the following applications for active member- 
ship. In accordance with the constitution, final consideration of these will 
be deferred until next year : 

Albert Anderson, M.D., Raleigh, N. C; F. A. Carmichael, M.D., Osa- 
watomie, Kans. ; Guy L. Connor, M. D., Detroit, Mich. ; O. H. Cobb, M. D., 
Syracuse, N. Y.; H. H. Drysdale, M.D., Qeveland, O.; S. J. Fort, M.D., 
Baltimore, Md, ; Robert Henry Haskell, M. D., Ann Arbor, Mich. ; Kenneth 
B. Jones, M.D., Baltimore, Md.; William A. Jones, M. D., Minneapolis, 
Minn.; Grover A. Kempf, M.D., New York, N. Y.; Hersey G. Locke, 
M.D., Syracuse, N. Y.; Convas L. Markham, M. D., Amityville, N.Y.; 
Eugene H. Mullan, M. D., Ellis Island, New York; Michael Osnato, M. D., 
New York, N. Y.; Charles F. Sanborn, M. D., Cincinnati, O.; Carl W. Saw- 
yer, M. D., Marion, O.; Haigt Sims, M. D., Montreal, Que.; L. Gibbons 
Smart, M. D., Lutherville, Md.; Wesley Taylor, M. D., Detroit, Mich.; 
Harold W. Wright, M. D., Santa Barbara, Cal; Herbert C deV. Corn- 
well, M. D., New York, N. Y.; Frank W. Keating, M. D., Owings Mills, 
Md.; Walter C. Van Nuys, M. D., New Castle, Ind. 

The Council has received the resignations of the following members, 
and recommends that they be accepted in so far as their dues are paid 
to date: 

Harry L. Barnes, M.D., Wallum Lake, R. I.; James R. Bolton, M.D., 
Ftshkill-on-Hudson, N. Y. ; George V. N. Dearborn, M. D., Boston, Mass. ; 
Hu^ H. Dorr, M. D., Batesville, O. ; Charles A. Drew, M, D., Worcester, 
Mass.; Bernard Feldstein, M.D., Kings Park, N. Y.; Charles M. Franklin, 
M.D., Baltimore, Md.; Frank R. Fry, M.D., St Louis, Mo.; John J. 
MacPhee, M.D., New York, N. Y.; Elizabeth .Spencer McCaU, M.D., 
Bryn Mawr, Pa.; John Punton, M.D., Kansas City, Mo.; Arthur E 
Simonis, M. D., Pennhurst, Pa.; W. A. Taylor, M. D., Trenton, N. J. 

The Council further recommends that the Secretary be instructed to 
notify those in arrears for dues that on payment of same their resignations 
will be accepted as of members in good standing, otherwise their names 
will be dropped from the membership list of the Association. 

The Council has received copy of resolutions relative to alien insane, 
which were adopted by the Medical Society of the State of New York, with 
the request that this Association take some action in regard to them. 

It is reconmiended by the Council that a committee of three members of 
the Association be appointed to draft resolutions making them international 
in character. 

On motion, duly seconded, the Council voted that the preambles and 
resolutions to be submitted by the President of the Association, in his 
address, be approved by the Council, and commended. to the Association 
for consideration and action at the session Wednesday in6riung|.' ; ' 



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lOO AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

The Council recommends that the Secretary be instructed to write Dr. 
N. Emmons Paine, of West Newton, Mass., authorizing him to make a 
group photograph of the members of the Association, as per his letter to 
the Secretary of the Association. 

Respectfully submitted, 

Arthur P. Herring, 

Secretary Pro Tern, 

Dr. Brush.— I move the report of the G>uncil be accepted and that the 
resolutions contained in the report be made a special order of business, 
and I move that these resolutions be adopted. 

Dr. Henry M. Hubd. — ^I beg to call Dr. Brush's attention to the fact 
that these resolutions were to be made a special order of business for 
Wednesday; I do not think he understood this. 

Dr. Brush. — ^I withdraw my motion. 

The President. — ^I was about to say that Dr. Brush's motion was in 
order except in so far as it referred to the resolutions. 

This motion was duly seconded and carried, and the report of 
the council was accepted and adopted, except the part referring 
to the resolutions, which will come before the Association for 
action on Wednesday morning. 

Dr. Brush. — I would like to move that the Health Officer, the Secre- 
tary of the Board of Health, and other professional gentlemen of 
Baltimore be invited to attend this meeting and take part in the discussions. 

The President.— The chair will take the liberty of seconding that 
motion. 

Carried. 

Dr. S. E. Smith. — It occurs to me that under the constitution it will 
be necessary to take some formal action on the list of candidates presented 
for membership in the Association; as I understand it they must lie on 
the table twenty-four hours, and should therefore be referred to the 
Association for action to-morrow morning. Am I not right? I would 
move that the list of physicians proposed for election come up for final 
action to-morrow in regular course. 

Which motion was duly seconded and carried. 

The Presii«nt. — ^We will now hear the report of the Treasurer. 

Before submitting his report, the Treasurer desires to make the fol- 
lowing statement of the membership of the American Medico- Psycho- 
logical 'w^9ioci^tioo ^oc date : 



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PROCEEDINGS 10 1 

Honorary Members. 

Former number 20 

Died I 

Present number 19 

Active Members. 

Former number 398 

Associate to Active 16 

Admitted 46 

Resigned i 

Dropped i 

Died 6 

Present number 452 

AssoaATE Members. 

Former number 203 

Admitted 64 

Associate to Active 16 

Dropped i 

Present number 250 

Total membership May 26, 1914 721 

Report op Treasurer, 1913-1914. 

DEBITS. 

Balance on hand June i, 1913 $3»489.95 

Received for dues: 

Active members 2,200.00 

Associate members 480.00 

Advance dues 44-oo 

Interest on bank deposits 7i*9B 

Gummed lists of members '. 10.50 

Copy of Transactions 1.50 

Discount .50 

Total $6,298.43 

I913 CREDITS. 

June 20. F. H. Severance (Honorarium), (Lecture on Niagara 

Frontier) $50.00 

20. Stenographer (expenses annual meeting Niagara Falls, 

Ont) 4120 

21. Clifton Hotel (express on typewriter) .50 

21. W. M. English (Niagara Falls exhibit) 69.50 

July 3. Lord Baltimore Press (Transactions and List of Mem- 
bers) 1,334.8s 

9. Baggage transfer (Niagara Falls) i.oo 

la Armory Press (printing ballots) 2.00 

19. Postage 400 



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I02 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

Aug. 6. £. S. Grancy (express and telegrams) 2.85 

20. Stamped envelopes 42.16 

Sept 2. E. S. Graney (express on reprints) 3-23 

8. Lord Baltimore Press (express on Transactions) 17.59 

11. Armory Press (printing bill-book and envelopes) iixx> 

2a Johns Hopkins Press (reprints from Journal of Insan- 
ity) 34.00 

Oct. 4. Armory Press (letter-heads, notices and envelopes) . . . 27.00 

la Postage laoo 

15. One-cent stamped envelopes 11.00 

Nov. 3. Armory Press (typewritten letters in re program) 3-50 

4. Henry M. Hurd (History account) 10242 

21. Edward N. Brush (Index account) iSaoo 

Dec 2. Thos. W. Salmon (Mental Hygiene exhibit, Niagara 

Falls) 62.88 

13. Oharles G. Wagner (expenses of conference in re 1914 

program) 17.50 

24. Qerical services 10.00 

1914 

Jan. 2. Henry M. Hurd (History account) 148.90 

13. Edward N. Brush (Index account) 50.00 

Feb. 16. Edward N. Brush (Index account) 50.00 

18. Stamped envelopes 2144 

20. Gharles G. Wagner (telephone, telegrams and car- fares) y^Z 

Mar. 2. Henry M. Hurd (History account) 123.02 

6. Postage 2aoo 

6. Frank Woodbury (over payment dues) 5.00 

2a Edward N. Brush (Index account) 5000 

Apr. 2. Preliminary programs, notices and envelopes 19.25 

9. O. P. Giase (postage and car-fares) 8.20 

22. Edward N. Brush (Index account) 50.00 

30. Henry M. Hurd (History account) 16645 

May II. Margaret M. Bloxham (reporting and typewriting pro- 
ceedings annual meeting at Niagara Falls, 1913) . • • 75-oo 

12. Postage 8.00 

12. Edward N. Brush (Index account) 5aoo 

14. Margaret M. Bloxham (services stenographer and type- 

writer for year to May 25, 1914) 120.00 

14. Progrrams and envelopes 70.00 

14. O. P. Chase (clerical services to June i, 1914) 350O 

25. Balance on hand as follows: 

Emigrant Industrial Savings Bank 1,853-98 

City National Bank, Binghamton, N. Y.'. 1,362.58 

Total $6,29843 

Respectfully submitted, 

Charles G. Wagner, Treasurer, 



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PROCEEDINGS IO3 

The President. — ^You have heard the report of the Treasurer; if there 
be no objection this report wll be referred to the Auditors. 

The next order of business is the report of the Editors of the Ameri- 
can Journal op Insanhy. 

To the American Medico-Psychological Association, — The Members of 
the Editorial Board of the American Journal of Insanity beg to report 
that the Journal is in a prosperous condition and that the work of the 
Journal during the past year has been unusually active. Since the last 
meeting of the Association five numbers of the Journal have appeared, 
namely, the four regular numbers and a special number, being number 5 
of volume 69, containing the addresses and papers delivered at the opening 
of the Henry Phipps Psychiatric Qinic of The Johns Hopkins Hospital 
in April, 1913. This extra ntunber also contains the index of volume 69. 
The volume completed by this number comprises 1068 pages. The sub- 
scribers to the Journal have received this extra ntunber without extra 
compensation on their part, although its publication caused considerable 
expenditure. 

Volume 70, which closed with the April number, contained all the papers 
read at the last meeting of the Association, together with the Secretary's 
report of the proceedings, and comprises s>94 pages. 

It would seem that if the Journal is to continue to publish all the 
papers that are read, which are increasing in number, as well as a selec- 
tion of the papers which are offered with increasing frequency by con- 
tributors who have not presented their papers to the Association, some 
arrangement will be necessary either to control the number of papers 
published or the length of the papers or the increasing number of illustra- 
tions which are offered with papers which involve a large outlay. The 
editors hesitate to decline important papers which are presented by 
contributors from all over the United States, as well as from abroad, and 
yet they feel that the Journal is the organ of the Association and must 
devote as much of its space as possible to the publication of papers 
presented at the meeting of the Association. They have, therefore, 
decided in the case of papers requiring considerable illustration to require 
that the authors pay at least one half the cost of the preparation of 
plates and in printing of the illustrations, and in the case of papers in 
which the authors make extensive changes in proof, introducing matter 
not appearing in the manuscript, or changing in a very large measure the 
proof, which involves always considerable expense, to require the authors 
to pay a part of the cost of such changes, which are always charged in 
the printing offices by the hour. 

The editors realize that, notwithstanding the fact that the price of 
the Journal to members of the Association has been reduced to three 
dollars, there are a large number of members who do not subscribe 
for the Journal, and also that there are a large number of hospitals 
in whose libraries the Journal does not appear. The Board therefore 
urges the members of the Association not only to subscribe personally 



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I04 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

for the Journal, but to see that the Journal is taken by the institution 
with which they are connected. 

Members of the Association can also be of material aid in increasing 
the prosperity of the Journal by suggesting to manufacturers of apparatus 
used in hospitals, makers of instruments, publishers of books, etc, that 
they advertise in the Journal. An increase in our advertising patronage 
would materially aid the Journal. 

The editors feel that the Association can look upon its Journal with 
pride and satisfaction and that it should receive the hearty support of all 
the members of the Association, whose property the Journal really is. 

Respectfully submitted, 

Edward N. Brush, 

For the Editorial Board. 

Dr. Hancker. — I move that the report of the Editors of the American 
Journal of Insanity be accepted and the financial part of it referred to 
the Auditors. 

Motion was duly seconded and carried. 

Dr. Brush.— I would ask that the report itself be referred to the 
Council for such advice as they think best in regard to the suggestions 
which are made therein. 

The President. — ^The Chair takes occasion to say in this connection that 
Dr. Wagner has written me in regard to the cost of printing the index 
to the Journal op Insanity and has presented an array of figures which, 
if correct, would bankrupt the Association. Now, the Chair has no 
definite information of its own on the subject and regrets that Dr. Wagner 
is not here to lay these facts before the Association, but he will probably 
arrive some time to-day and it will be proper to have him make a state- 
ment to you in regard to this matter. 

What was your motion, Dr. Brush? 

Dr. Brush. — I made the request that the report of the Editors of the 
American Journal op Insanity be referred to the Council for such 
advice as they may see fit to give on the various recommendations therein 
made. 

The President. — If there is no objection it will be so referred. 

The next in order is the report of the Committee on History of Insti- 
tutional Care of the Insane in the United States and Canada, by Dr. Henry 
M. Hurd, Chairman. 

To the American Medico-Psychological Association: The Committee 
on the ''Institutional Care of the Insane" desires to make the following 
report : 

As usually follows in all such undertakings involving the collection ot 
material from every part of the United States and Canada, the committee 
has found considerable difficulty in securing uniform results. AlthougH 



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PROCEEDINGS 10$ 

all persons have been appealed to in a similar manner, by circulars and 
sample histories, the replies which have been received have varied in 
character. 

In many states officers of institutions have responded cheerfully and 
promptly to the appeal which has been made. In other states it has been 
difficult to secure any co-operation or even a reply to all letters of inquiry. 

The present status of the " History " is as follows : 

The general chapters relating to the Early and Colonial Care of the 
Insane; The Law of Insanity; Administration and Control of Hospitals; 
County Care of the Insane; The Chronic and Incurable Insane; The 
Wisconsin System; History of the Association; History of the Journal 
OF Insanity; Hospital and Asylum Periodicals; Early Care of the 
Insane in Delaware, Pennsylvania, New Hampshire, Rhode Island, Mary- 
land, Connecticut, South Carolina, New Jersey, New York, Massachusetts ; 
State Care ; Immigration a Problem in the Care of the Insane ; The Care 
of the Private Insane; Dorothea Lynde Dix; The Establishment of 
Training Schools for Nurses in Hospitals for Mental Diseases; Govern- 
ment of Institutions for the Insane; Reforms in Caring for the Insane; 
Development of Hospital Architecture; The "Propositions"; The Non- 
Medical Treatment of the Insane; Experimental Removals; Employment 
for the Insane ; Individual Treatment ; Admissions of Voluntary Patients ; 
The Care of the Criminal Insane; Commitment of the Insane; Condi- 
tions Accompanying the Discharge of Patients from Institutions; Immi- 
gration and the Alien Insane, are practically ready for publication. 

As frequently happens in such histories, it will be seen that a number 
of topics not originally contemplated in the "History" have developed, 
which add materially to the amount of preliminary material, and which 
it is hoped will also add to the interest of the publication. A few of 
these chapters may need further investigation and labor, but the general 
chapters are substantially complete. 

The committee also has in hand a fair amount of material for the 
history of individual states and provinces, although some are still lacking 
because of the failure of co-operation on the part of those who should 
be interested. 

To furnish specific information as to individual states, the committee 
would report from the following states: From Alabama, the history is 
complete; all the institutions of California, except a few general details 
presented by Dr. F. W. Hatch, the General Superintendent, are lacking; 
Colorado is complete, Connecticut also, with the exception of the one 
State institution at Norwich; Delaware is complete; District of Columbia 
is complete; Florida presents no history of the Tallahassee State Hos- 
pital; Georgia is complete; Idaho is complete, with the exception of the 
institution at Blackfoot; from Illinois, through the active efforts of Dr. 
Dewey, we have histories of Jacksonville State Hospital and the Elgin 
State Hospital; Dr. Dewey has also assumed the responsibility of the 
Anna State Hospital, the Chester State Hospital, the Chicago State 
Hospital, the Kankakee State Hospital, Peoria State Hospital and Water- 



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I06 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

town Hospital; Indiana is complete; Iowa, with the exception of the 
institution at Mt. Pleasant; Kansas is complete; Kentucky has presented 
no history of the Eastern State Hospital at Lexington; Louisiana has 
presented the history of a single State hospital, brief and imperfect, that 
at Jackson; Maine is complete; Maryland is complete, with the exception 
of the Spring Grove Hospital, the Crownvillc Hospital, the Sheppard- 
Pratt Hospital, the Mt. Hope Retreat and the Eastern Shore Hospital; 
Massachusetts is complete, with the exception of the Northampton State 
Hospital, the Colony at Gardner and the Tewksbury State Hospital; 
Michigan is complete, with the exception of the hospital at Ionia; Minne- 
sota is complete, with the exception of the histories of the Anoka State 
Hospital and the Hastings State Hospital; Missouri is complete, but all 
the histories are fragmentary and give a very inadequate account of 
institutions of an important state; Mississippi is complete; Nebraska is 
complete, with the exception of the State Hospital at Lincoln, the history 
of which is incomplete ; Nevada is complete ; New Hampshire is complete ; 
New Jersey has supplied only the history of the Essex County Hospital; 
the State hospital at Morris Plains has furnished a large amount of 
excellent material, but it has been impossible to edit it in such a manner 
as to present a connected history of the institution; there is no history 
of the hospital at Trenton nor of several other important county hospitals ; 
New Mexico is complete; New York is complete; in North Carolina all 
the histories have been obtained except that at Morganton, which has 
been promised; Ohio is practically complete; Oklahoma has furnished a 
history of the State hospital at Norman, but the histories of the institu- 
tions at Supply and Vinita are lacking; in Oregon the two state hospitals 
are insufficiently reported, only a few data being obtained from a recent 
report; Pennsylvania is complete with the exception of the Harrisburg 
State Hospital and the Danville State Hospital ; Rhode Island is complete ; 
South Carolina is complete; in South Dakota the hospital at Yankton 
has furnished no history, although one is promised; Tennessee is com- 
plete, with the exception of the institution at Bolivar; Texas and Utah 
are complete and Virginia is nearly complete; in Washington the history 
of the institution at Medical Lake has been furnished, but that at Fort 
Stoilacoom is lacking; West Virginia is complete; in Wisconsin the 
Wisconsin State Hospital at Mendota and the Northern Hospital at 
Winnebago are promised by Dr. Dewey, but the history of the Milwaukee 
Hospital at Wauwatosa and the Milwaukee Asylum are lacking; Wyoming 
is lacking. 

Private Institutions, — ^The work of collecting the histories of private 
institutions has been very kindly undertaken by Dr. Richardson of Mercer, 
Pa., who has spent much time and effort in securing adequate histories. 
He reports that he has in hand at present about forty histories of private 
institutions, and many more are promised. 

Biographies. — It has been possible to compile from the Journal of 
Insanity, from general medical biographies and from biographies written 
and sent by persons interested in the various states, about 250 biographies 



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PROCEEDINGS 10/ 

of founders of institutions, superintendents, assistant physicians and other 
oflBcers. 

Canada. — In Canada the work has fallen very largely upon Dr. T. J. W. 
Burgess, whose original paper on the care of the insane in Canada has 
served as a ground work for the early history of the care of the insane 
in Canada. Through his efforts and those of other superintendents 
it has been possible to secure an excellent summary of the laws governing 
the commitment of the insane in Canada. The committee has also in 
hand as a result of his efforts, excellent histories of the care of the insane 
in British Columbia, Alberta, Saskatchewan and Nova Scotia ; Dr. Burgess 
also has in active preparation some other histories. 

Although much effort has been made to secure material in regard to 
the early history of Canada prior to the establishment of hospitals for 
the insane, the effort has not been crowned with much success. 

The history of the insane in New Foundland has not been written 
because no one could be found who would undertake it All letters to 
interested parties have failed to receive any reply. 

Publication, — The committee recommends that in the matter of publica- 
tion tlie same size of page and the same general style be adopted as has 
been adopted for the past twenty years in the annual volume of " Trans- 
actions," and that authority be given to publish as many volumes as 
may be required to place in the hands of members the material which 
has been collected. The committee will not relax any efforts to fill up 
the gaps which exist in the material which has been reported to you. 
The members of the committee are under many obligations to those 
members of the Association who have spent much time and effort to 
assist them in the arduous work of preparing the history. The recom- 
mendation is further made that the matter of publication be left to the 
committee with the addition of the President and the Secretary-Treasurer. 

Unless action is taken to the contrary, the committee will plan to 
insert photographs and ground plans of institutions where they will serve 
to illustrate the text. 

Respectfully submitted, 
Henry M. Hurd, 

In Behalf of the Committee, 

The President. — Gentlemen, the report of Dr. Hurd is before you; 
what disi>osition will you make of it? 

Dr. C. G. Hnx. — I move that the report be accepted with thanks to Dr. 
Hard for the labor already performed, and that the committee be 
continued. 

Dr. Hurd. — ^I would suggest that the motion be amended to read 
"accepted and referred to the Council." 

Motion as amended, was duly seconded and carried. 

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I08 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

The President. — ^The Chair would appoint as a Nominating Committee 
the following members : 

Dr. Henry M. Hurd, Maryland; Dr. William Mabon, New York; Dr. 
C. B. Burr, Michigan. 

Dr. Herring.. — I have been requested to read the following report made 
by the Secretary : 

In compliance with the instructions received at Niagara Falls last year, 
copies of the report of the Committee on Applied Eugenics, as submitted 
by the Chairman, Dr. Hubert Work, have been distributed through the 
mail by the Secretary of the Association, to all the members of the 
American Medico-Psychological Association; to a large number of physi- 
cians in this country and abroad; to many judges and lawyers in the 
United States and Canada; to the prominent medical journals and daily 
newspapers in this country and abroad and to many libraries in this 
country and Canada; copies have also been sent to the members of the 
Cabinet at Washington, and to the Governors of all the states and terri- 
tories throughout the United States. 

Respectfully submitted, 

Charles G. Wagner, Secretary. 

The PREsroENT. — ^We will now take a short recess for the purpose of 
registration of members and visitors. The Chair would suggest that 
those who have not registered do so at once. 

The following members registered and were in attendance 
during the whole or a part of the meeting : 

Abbot, E. Stanley, M. D., Assistant Physician McLean Hospital, Wa- 
verley, Mass. 

Allen, H. D., M. D., Superintendent Allen's Invalid Home, Milledgc- 
ville, Ga. 

Allen, J. Berton, M. D., Assistant Physician State Hospital, Central 
Islip, L. I., N. Y. 

Amsden, G. S., M. D., Assistant Physician Bloomingdale Hospital, 
White Plains, N. Y. 

Anglin, James V., M. D., Medical Superintendent The Provincial Hos- 
pital, St Johns, N. B., Canada. 

Applegate, C. F., M. D., Superintendent Mt Pleasant State Hospital, 
Mt. Pleasant, la. 

Baber, Armitage, M. D., Superintendent Dayton State Hospital, Day- 
ton, O. 

Bancroft, Charles P., M. D., Superintendent New Hampshire State Hos- 
pital, Concord, N. H. 

Barlow, Charles A., M. D., Superintendent Second Hospital for the 
Insane, Spencer, W. Va. 

Beling, Christopher C, M. D., 109 Qinlon Ave., Newark, N. J. 

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



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PROCEEDINGS IO9 

Biddle, Thomas C, M. D., Superintendent Topeka State Hospital, 
Topeka, Kans. 

Bond, Earl D., M. D., Senior Assistant Physician Penna. Hospital for 
Insane, 4401 Market St., Philadelphia, Pa. 

Briggs, L. Vernon, M. D., 64 Beacon St., Boston, Mass. 

Brown, George W., M. D., Superintendent Eastern State Hospital, 
Williamsburg, Va, 

Bro¥m, Sanger, Sr., M. D., Kenilworth Sanitarium, Kenilworth, 111. 

Brown, Sanger, II, M. D., Assistant Physician Bloomingdale Hospital, 
White Plains, N. Y. 

Brush, Edward N., M. D., Physician-in-Giief and Superintendent Shep- 
pard and Enoch Pratt Hospital, Towson, Md. 

Buckley, Albert C, M. D., Assistant Physician Friends Asylum, Frank- 
ford, Philadelphia, Pa. 

Bullard, E. L., M. D., Physician-in-Charge Chestnut Lodge Sanitarium, 
Rockville, Md. 

Burgess, Thos. J. W., M. D., Superintendent Protestant Hospital for 
the Insane, Montreal, Que., Canada. 

Burnet, Anne, M. D., Wausau, Wis. 

Burr, C. B., M. D., Medical Director Oak Grove, Flint, Mich. 

Burr, Charles W., M. D., 1918 Spruce St, Philadelphia, Pa. 

Busse, R P., M. D., Superintendent Southeastern Hospital for Insane, 
Madison, Ind. 

Calder, D. H., M. D., Superintendent State Mental Hospital, Provo, 
Utah. 

Caples, Byron M., M. D., Superintendent Waukesha Springs Sani- 
tarium, Waukesha, Wis. 

Carey, Charles J., M. D., Superintendent Eastern Shore State Hospital, 
Cambridge, Md. 

Carey, Harris May, M. D., Odessa, Del. 

Carlisle, Chester L., M. D., Assistant Physician State Hospital, Kings 
Park, L. I., N. Y. 

Carroll, Robert S., M. D., Medical Director Highland Hospital, Ashe- 
villc, N. C. 

Casamajor, Louis, M. D., 342 West s6th St., New York, N. Y. 

Chase, Robert H., M. D., Superintendent Friends Asylum, Frankford, 
Philadelphia, Pa. 

Clark, Charles H., M. D., Superintendent Qeveland State Hospital, 
Qeveland, O. 

Qark, J. Qement, M. D., Superintendent Springfield State Hospital, 
Sykesville, Md. 

Clark, L. Pierce, M. D., 84 East 56th St., New York, N. Y. 

Coggins, Jesse C, M. D., Medical Director Laurel Sanitarium, Laurel, 
Md. 

Cook, Robert G., M. D., Physidan-in-Chargc. Brigham Hall, Canan- 
daigua, N. Y. 

Copp, Owen, M. D., Superintendent Penna, Hospital for Insane, 4401 
Market St, Philadelphia, Pa. 



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no AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

Cornell, W. B., M. D., Executive Secretary Mental Hygiene Committee 
of Maryland, Towson, Md. 

Cotton, Henry A., M. D., Medical Director New Jersey State Hospital, 
Trenton, N. J. 

Crumbacker, W. P., M. D., Superintendent State Hospital, Independ- 
ence, la. 

Davies, George W., M. D., Assistant Physician Essex County Hospital, 
Cedar Grove, N. J. 

De La Hoyde, T. Grover, M. D., Assistant Physician Hudson River 
State Hospital, Poughkeepsie, N. Y. 

DeWeese, Cornelius, M. D., Medical Director Laurel Sanitarium, Laurel, 
Md. 

Disbrow, G. Ward, M. D., Assistant Physician Springfield State Hos- 
pital, Sykesville, Md. 

Donohoe, George, M. D., Superintendent State Hospital for Inebriates, 
Knoxville, la. 

Drewry, Wm. Francis, M. D., Superintendent Central State Hospital, 
Petersburg, Va. 

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

English, W. M.,. M. D., Superintendent Hospital for Insane, Hamilton, 
Ont, Canada. 

Evans, Britton D., M. D., Medical Director New Jersey State Hospital, 
Greystonc Park, N. J. 

Faison, W. W., M. D., Superintendent State Hospital, Goldsboro, N. C 

Faris, G. T., M. D, Assistant Physician Pennsylvania Hospital for 
Insane, 4401 Market St., Philadelphia, Pa. 

Fisher, E. Moore, M. D., Assistant Physician New Jersey State Hos- 
pital, Greystone Park, N. J. 

Fordyce, O. O., M. D., Superintendent Athens State Hospital, Athens, O. 

Freeman, George H., M. D., Superintendent Hospital Farm for Inebri- 
ates, Willmat, Minn. 

Frost, Henry P., M. D., Superintendent Boston State Hospital, Dor- 
chester Centre, Mass. 

Fuller, Daniel H., M. D., Assistant Physician Pennsylvania Hospital 
for Insane, Philadelphia, Pa. 

Gilliam, Charles F., M. D., Superintendent Columbus State Hospital, 
Columbus, O. 

Glueck, Bernard, M. D., Assistant Physician Government Hospital for 
Insane, Washington, D. C. 

Gordon, Alfred, M. D., 1812 Spruce St., Philadelphia, Pa. 

Gorst, Charles, M. D., Superintendent State Hospital for Insane, 
Mendota, Wis. 

Green, Edward M., M. D., Clinical Director Georgia State Sanitarium, 
Milledgeville, Ga. 

Guibord, Alberta S. B., M. D., Psychiatrist Bureau of Social Hygiene, 
Bedford Hills, N. Y. 



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PROCEEDINGS III 

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

Gundry, Lewis H., M. D., Superintendent Relay Sanitarium, Relay, Md. 

Gundry, Richard F., M. D., The Richard Gundry Home, Catonsville, Md. 

Guthrie, L. V., M. D., Superintendent West Virginia Asylum, Hunt- 
ington, W. Va. 

Hamilton, C. D., M. D., Assistant Physician Springfield State Hospital, 
Sykcsville, Md. 

Hamilton, Samuel W., M. D., Assistant Physician Utica State Hospital, 
Utica, N. Y. 

Hammers, James S., M. D., Assistant Physician State Hospital, Dan- 
ville, Pa. 

Hancker, Wm. H., M. D., Superintendent Delaware State Hospital, 
Famhurst, Del. 

Harding George T., Jr., M. D., 318 E. State St, Columbus, O. 

Harmon, F, W,, M. D., Superintendent Longview Hospital, Cincin- 
nati, O. 

Harrington, Arthur H., M. D., Superintendent State Hospital for 
Insane, Howard, R. I. 

Haskell, Robert H., M. D., First Assistant Physician State Psycho- 
pathic Hospital, Ann Arbor, Mich. 

Haviland, C. Floyd, M. D., First Assistant Physician State Hospital, 
Kings Park. L. I., N. Y. 

Hawke, W. W., M. D., 218 S. i6th St., Philadelphia, Pa. 

Henry, Hugh C, M. D., First Assistant Physician Central State Hos- 
pital, Petersburg, Va. 

Herring, Arthur P., M. D., Secretary State Lunacy Commission, 330 
N. Charles St, Baltimore, Md. 

Heyman, M. B., M. D., Asssistant Superintendent State Hospital, Cen- 
tral Islip, L L, N. Y. 

Hickling, D. Percy, M. D., 1304 R. L Ave., Washington, D. C. 

Hill, Charles G., M. D., Physician-in-Chief Mt Hope Retreat, Arling- 
ton, Md. 

Hill, Samuel S., M. D., Superintendent State Asylum for Insane, 
Wemersville, Pa. 

Hills, Frederick L., M. D., Superintendent Bangor State Hospital, 
Bangor, Mc. 

Hitchcock, Charles W., M. D., 270 Woodward Ave., Detroit, Mich. 

Hoch, August, M. D., Director Psychiatric Institute, Ward's Island, 
New York City. 

Hodskin, M. B., M. D., Assistant Physician Monson State Hospital, 
Palmer, Mass. 

Howard, Herbert B., M. D., Superintendent Peter Bent Brigham Hos- 
pital, 697 Huntington Ave, Boston, Mass. 

Hummer, H. R., M. D., Superintendent Asylum for Insane Indians, 
Canton, S. D. 

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



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112 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

Hurd, Henry M., M. D., 1210 Fidelity Building, Baltimore, Md. 

Jackson, J. Allen, M. D., Chief Residence Physician Philadelphia Hos- 
pital for Insane, Philadelphia, Pa. 

Jones, L. M., M. D., Superintendent Georgia State Sanitarium, Mill- 
edgeville, Ga. 

Kempf, Edward J., M. D., Assistant Residence Physician Phipps Psy- 
chiatric Qinic, Baltimore, Md, 

Keough, Peter L., M. D., First Assistant Physician Crownsville State 
Hospital, Crownsville, Md. 

Kieb, Raymond F. C, Superintendent Matteawan State Hospital, Beacon, 
N. Y. 

King, George W., M. D., County Physician, Jersey City, N. J. 

Kirby, George H., M. D., Manhattan State Hospital, New York City. 

Klopp, Henry, I., M. D., Superintendent Homeopathic State Hospital, 
Allentown, Pa. . 

Knopf, S. Adolphus, M. D., 16 West 95th St., New York, N. Y. 

Lamb, Robert B., M. D., Troy, N. Y. 

La Moure, Charles T., M, D., Superintendent Connecticut School for 
Imbeciles, Lakeville, Conn. 

La Moure, H. A., M. D., Superintendent Colorado Insane Asylum, 
Pueblo, Colo. 

Laughlin, C. E., M. D., Superintendent Southern Indiana Hospital for 
Insane, Evansville, Ind. 

Lawton, S. E., M. D., Superintendent Brattleboro Retreat, Brattleboro, 
Vt, 

Long, T. L., M. D., Assistant Physician Cherokee State Hospital, 
Cherokee, la. 

Love, George R., M. D., Superintendent Toledo State Hospital, 
Toledo, O. 

Ludlum, S. DeW., M. D,, 216 S. 15th St., Philadelphia, Pa. 

Mabon, William, M. D., Superintendent Manhattan State Hospital, 
Ward's Island, New York City. 

MacDonald, Carlos F., M. D., Physician-in-Charge Dr. MacDonald's 
House, Central Valley, N. Y. 

McCafferty, Emit L., M. D., Assistant Superintendent Alabama Insane 
Hospitals, Mt. Vernon, Ala. 

McCall, Elizabeth Spencer, M. D., Bryn Mawr, Pa, 

McKinniss, C. R., M. D., Residence Physician State Hospital for 
Insane, Norristown, Pa. 

Mellen, Samuel F., M. D., Assistant Physician Hudson River State 
Hospital, Poughkeepsie, N. Y, 

Melius, Edward, M. D., Superintendent Newton Nervine, West Newton, 
Mass. 

Meredith, H. B., M. D., Superintendent State Hospital for Insane, 
Danville, Pa. 

Meyer, Adolf, M. D., Johns Hopkins Hospital, Baltimore, Md. 

Mitchell, H. W., M. D., Superintendent State Hospital, Warren, Pa. 



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PROCEEDINGS II3 

MitcheU, J. C, M. D., Superintendent Hospital for Insane, Brockville, 
Ont, Canada. 

Morris, John N., M. D., Residence Physician Springfield State Hospital, 
Sykesville, Md. 

Morse, Mary E., M. D., Assistant Pathologist State Hospital, Worcester, 
Mass. 

Murdock, J. M., M. D., Superintendent State Institution for Feeble- 
minded of Western Pennsylvania, Polk, Pa. 

NeflF, Irwin H., M. D., Superintendent Foxborough State Hospital, 
Foxborough, Mass. 

Nevin, Ethan A., M. D., Superintendent State Custodial Asylum, 
Newark, N. Y. 

Nevin, John, M. D., Consultant North Hudson Hospital, Jersey City. 

CHarrow, Marian, M. D., Assistant Physician Friends Asylum, Frank- 
ford, Philadelphia, Pa. 

O'Malley, Mary, M. D., Senior Assistant Physician Government Hos- 
pital for Insane, Washington, D. C 

Orton, Samuel T., M. D., Pathologist Pennsylvania Hospital for Insane, 
4401 Market St., PhiladeliAia, Pa. 

Packer, Flavins, M. D., Physician-in-Charge West Hill, Riverdale, New 
York City. 

Partlow, Wm. D., M. D., Assistant Superintendent Bryce Hospital, 
Tuscaloosa, Ala. 

Patterson, C. J., M. D., Physician-in-Charge Marshall Sanitarium, Troy, 
N. Y. 

Pajrne, Guy, M. D., Superintendent Essex County Hospital, Cedar 
Grove, N. J. 

Perry, Middleton L., M. D., Superintendent State Hospital for Epilep- 
tics, Parsons, Kans. 

Peterson, Jessie M., M. D., State Hospital for Insane, Norristown, Pa. 

Pierson, Clarence, M. D., Superintendent East Louisiana Hospital for 
Insane, Jackson, La. 

Poguc, Mary E, M. D., Physician-in-Charge Oak Leigh, Lake Geneva, 
Wis. 

Prout, Thomas P., M. D., Superintendent Fair Oaks Sanatorium, 
Summit, N. J. 

Purdum, H. D., M. D., Assistant Physician Springfield State Hospital, 
Sykesville, Md. 

Rhein, John H. W., M. D., 1732 Pine St, Philadelphia, Pa. 

Richards, Robert L., M. D., Superintendent Mendocino State Hospital, 
Taknage, Cal. 

Ridgway, R. F. L., M. D., First Assistant Physician Pennsylvania State 
Lunatic Hospital, Harrisburg, Pa. 

Salmon, Thomas W., M. D., National Committee for Mental Hygiene, 
50 Union Sq.. New York, N. Y. 

Sargent, George F., M. D., Assistant Physician Sheppard and Enoch 
Pratt Hospital, Towson, Md. 

8 



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114 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

Schlapp, Max G., M. D., Director Gearing House for Mental Defec- 
tives, 40 E. 4i8t St., New York, N. Y, 

Searl, W. A., M. D., Medical Director Fair Oaks Villa, Cuyahoga 
Falls, Ohio. 

Sheehan, R. F., M. D., Government Hospital for Insane, Washington, 
D. C. 

Sights, H. P., M. D., Superintendent Western State Hospital, Hop- 
kinsville, Ky. 

Slocum, C J., M. D., Resident Physician Dr. MacDonald's House, 
Central Valley, N. Y. 

Smart, L. Gibbons, M. D., Medical Director Creighton Sanitarium, 
Lutherville, Md. 

Smith, Samuel R, M. D., Medical Superintendent Eastern Indiana Hos- 
pital for Insane, Richmond, Ind. 

Somers, Elbert M., M. D., Superintendent Long Island State Hospital, 
Brooklyn, N. Y. 

Southard, E. E., M. D., Director Psychopathic Hospital, Boston, Mass. 

Spear, Irving J., M. D., 1810 Madison Ave., Baltimore, Md. 

Stack, S. S., M. D., St Mary's Hill, Milwaukee, Wis. 

Stedman, Henry R., M. D., Director Boumewood Hospital, BrookHne, 
Mass. 

Stick, H. Louis, M. D., Superintendent Worcester State Asylum, 
Worcester, Mass. 

Strecker, Edward A., M. D., Assistant Physician Pennsylvania Hospital 
for Insane, Philadelphia, Pa. 

Taylor, Isaac M., M. D., Resident Superintendent Broadoaks Sanato- 
rium, Morganton, N. C. 

Terflinger, Frederick W., M. D., Superintendent Northern Hospital 
for Insane, Logansport, Ind. 

Thompson, Charles R, M. D., Superintendent Gardner State Colony, 
Gardner, Mass. 

Thompson, W. N., M. D., Superintendent Hartford Retreat, Hartford, 
Conn. 

Truitt, Ralph P., M. D., First Assistant Resident Physician Phipps 
Qinic, Johns Hopkins Hospital, Baltimore, Md. 

Tyson, Forrest C, M. D., Superintendent Augusta State Hospital, 
Augusta, Me. 

Villeneuve, George, M. D., Superintendent St. Jean de Dieu Hospital, 
P. O. Box 2947, Montreal, Que., Canada. 

Wade, J. Percy, M. D., Superintendent Spring Grove State Hospital, 
Catonsville, Md. 

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

Wardner, Drew, M. D., Assistant Physician Essex County Hospital, 
Cedar Grove, N. J. 

White, Moses J., M. D., Supermtendent Milwaukee Hospital for the 
Insane, Wauwatosa, Wis. 



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PROCEEDINGS II5 

White, William A., M. D., Superintendent Government Hospital for 
the Insane, Washington, D. C. 

White, W. R., M. D., Superintendent Patapsco Manor Sanitarium, 
Ellicott aty, Md. 

Williams, G. H., M. D., Assistant Superintendent Columbus State 
Hospital, Columbus, O. 

Williams, Tom A., M. D., 1705 N St., Washington, D. C. 

Wilson, Wm. Tassie, M. D., Superintendent Hospital for Insane, 
Penetanguishene, Ont, Canada. 

Winterode, Robert P., M. D., Superintendent Crownsville State Hos- 
pital, Crownsville, Md. 

Woodbury, Frank, M. D., Secretary Committee on Lunacy of Pennsyl- 
vania, 717 Bulletin Building, Philadelphia, Pa. 

Wright, W. W., M. D., Assistant Physician Psychiatric Institute, Ward's 
Island, New York City. 

Yarbrough, Y. H., M. D., Assistant Physician Georgia State Sanitarium, 
Milledgeville, Ga. 

The following visitors and guests of the Association registered 
their names with the Secretary: 

Anderson, Albert, M. D., Superintendent State Hospital, Raleigh, N. C. 

Anderson, Paul V., M. D^ Resident Physician Westbrook Sanatorium, 
Richmond, Va. 

Bancroft, Mrs. Charles P., Concord, N. H. 

Beers, CliflFord W., Secretary National Committee for Mental Hygiene, 
50 Union Sq., New York, N. Y. 

Bennett, John, M. D., Phipps Psychiatric Qinic, Baltimore, Md. 

Bryson, Louise Fiske, M. D., Mt. Washington, Md. 

Campbell, C. Macfie, M. D., Phipps Psychiatric Qinic, Baltimore, Md. 

Curtiss, Dora, 1524 Park Ave., New York City. 

Dunlap, Charles B., M. D., Associate in Neuropathology, Psychiatric 
Institute, Ward's Island, New York City. 

Evans, Mrs. B. D., Greystone Park, N. J. 

Evans, Miss Louise, Greystone Park, N. J. 

Evans, Buckley, Greystone Park, N. J. 

Farrcll, Elizabeth E., 500 Park Ave., New York Gty. 

Fisher, Mrs. E. Moore, Greystone Park, N. J. 

Floumoy, Henri, M. D., House StaflF Phipps Clinic, Baltimore, Md. 

Fort, Samuel J., M. D., Medical Director Gelston Heights Sanitarium, 
Baltimore, Md. 

Francisco, H. M., M. D., Oeveland State Hospital, Qeveland, O. 

Gibbs, John S., President Board of Managers Spring Grove State 
Hospital, Baltimore, Md. 

Gillis, Andrew C, M. D., 914 N. Charles St., Baltimore, Md. 

Gundry, Wm. P., Member Board of Managers Crownsville State Hos- 
pital, Catonsville, Md. 



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Il6 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

Hall, R. W^ M. D., Phipps Qinic, Baltimore, Md. 

Hallowcll, Madeline A., Vineland, N. J. 

Heiskell, Dorothea BL, M. D., 1708 Madison Ave., Baltimore, Md. 

Hocking, George H., Maryland. 

Hyde, George E., M. D., Superintendent Idaho Insane Asylum, Black- 
foot, Idaho. 

Johnson, J. E., Cincinnati, O. 

Kelley, L. G., Member Utah State Board of Insanity, Salt Lake City. 

Lange, T. R, Rome State Custodial Asylum, Rome, N. Y. 

Libby, Elmer R., State Board of Insanity, Boston, Mass. 

McLean, W. S., State Asylum, Wemersville, Pa. 

Miller, Susan L., Allentown, Pa. 

Moneuse, E. D., Washington, D. C. 

Nevin, Mrs. John, Jersey City, N, J. 

Osper, J. B., Towson, Md. 

Parker, Miss Louise, Washington, D. C. 

Roche, Lily T., Norristown, Pa. 

SchauflHer, Wm. Gray, 400 Madison Ave., Lakewood, N. J. 

Smalley, Miss Evelyn, 50 Union Sq., New York, N. Y. 

Smith, Walter J., 43 Wooster St., New York, N. Y. 

Steele, S. M., M. D., Superintendent West Virginia Hospital for Insane, 
Weston, W. Va. 

Walling, Mrs. Stewart D., Colorado State Board of Charities. 

Taneyhill, G. Lane, M. D., 1103 Madison Ave., Baltimore, Md. 

Terflinger, Mrs. F. W., Logansport, Ind. 

Trefethen, H. A., Washington, D. C 

Van Nuys, W. C, M. D., Superintendent Indiana Village for Epileptics. 
New Castle, Ind. 

Williams, L. L., M. D., Surgeon United States Public Health Service, 
Ellis Island, New York City. 

Young, Ernest H., M. D., Assistant Superintendent Rockwood Hospital, 
Kingston, Ont. 

Zimmerman, Robert F., M. D., Assistant Physician Utica State Hos- 
pital, Utica, N. Y. 

The President. — The Association will please come to order. The next 
in order is the memorial notices of members who have died during the 
year. 

Dr. C. B. Burr. — I move that the memorial notices be received and 
published in full in the Transactions of the Association. 

Motion was duly seconded and carried. 

The following memorial notices were read by title : 

Dr. George Smith Adams, by H. O. Spalding, M. D.; Dr. Henry S. 
Upson, by H. C Eyman, M. D. ; Dr. E. H. Pomeroy, by Henry M. Hurd, 
M. D.; Dr. H. A. Tomlinson, by W. A, Jones, M. D.; Dr. S. Weir 



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PROCEEDINGS II7 

Mitchell, by Charles W. Burr, M. D. ; Dr. Ralph L. Parsons, by Theodore 
H. Kellogg, M. D.; Dr. Edward W. King, by F. W. Hatch, M. D.; Dr. 
Thomas J. Moher, by George C. Kidd, M. D. 

The PsEsnxBNT. — ^The next in order on the program is the President's 
address. 

Dr. Hancker. — In view of the small attendance at the present time, 
I would suggest that the address of the President be postponed and 
taken up as the first order of business this afternoon. 

On motion, the meeting adjourned. 

Afternoon Session. 

Dr. S. E. Smith (presiding).— The Association will please come to 
order. 

The program calls for the address of the President postponed from 
the morning session. 

The President of the Association, Dr. Carlos F. MacDonald, 
then read his address, which was greeted with applause. 

Dr. S. K Smith. — Members of the Association, you have listened to a 
very interesting address by our worthy President, and while custom 
decrees that the President's address is not a subject for discussion, the 
Chair will entertain a motion for a vote of thanks, which will give 
opportunity for some expression, if any member desires to do so, regard- 
ing the address at this time. 

Dr. Villeneuve. — ^I think it is proper to move a vote of thanks for 
the able address that has been delivered, and I would move that a vote 
of thanks be given Dr. MacDonald. 

This motion was duly seconded and carried. 

Dr. S. E. Smith. — Mr. President, the Association extends to you a 
vote of thanks for your very able and interesting address. It assures 
you also that it will give careful consideration to the resolutions you have 
submitted, at the morning session to-morrow. 

Dr. HERRiNa — Gentlemen: The symposium which is listed for this 
afternoon has been postponed until evening, first, for the reason that 
there is to be a lantern slide exhibition in connection with some of the 
papers, which we are unable to have in this room; and second, we have 
sent out invitations to the physicians in Baltimore to attend this session 
and we think they will be especially interested in hearing the symposium 
on General Paralysis. Therefore, if there is no objection, the program 
listed for to-night will be presented this afternoon so far as practicable. 



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Il8 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

The Pbesisbnt. — We will proceed this afternoon with the program that 
was arranged for to-night so far as it may be feasible to carry it out 
I do not know how many are present whose names appear on the program 
for this evening, but I will call for the papers in the order in which they 
are listed. The first paper on the program will be : " Report of a Case of 
Cerebellar Tumor, with Pathological Findings," by Dr. W. M. English, 
Hamilton, Ont 

The following papers were read : 

"Report of a Case of Cerebellar Tumor with Pathological 
Findings," by W. M. English, M. D., Hamilton, Ont. Dis- 
cussed by Dr. Wm. A. White. 

" Clinical and Anatomical Analysis of Eleven Cases of Mental 
Disease Arising in the Second Decade, with Special Reference 
to Cortical H)rperpigmentation in Manic-Depressive Insanity," 
by Earl D. Bond, M. D., Philadelphia, Pa., and E. E. Southard, 
M. D., Boston, Mass., read by Dr. Southard. 

"What is Paranoia?" by E. Stanley Abbot, M. D., Waverley, 
Mass. Discussed by Dr. C. B. Burr, and Dr. Abbot in closing. 

" Is There an Increase Among the Dementing Psychoses? " by 
Charles P. Bancroft, M. D., Concord, N. H. 

" Recidivation and Recommitments in Mental Troubles," by 
George Villeneuve, M. D., Montreal, Que. 

On motion the meeting adjourned. 

Evening Session, 
osler hall, medical library. 

The Presiisnt. — ^The time has arrived when we must commence the 
program for the evening, which will consist of a symposium on General 
Paralysis; the first paper in this symposium will be "General Paralysis 
as a Public Health Problem," by Dr. Salmon. 

The discussion of these contributions to the symposium will be deferred 
until we have heard from all, when there will be opportunity for general 
discussion of the subject. 

The following papers were read : 

" General Paralysis as a Public Health Problem," by Thomas 
W. Sabnon, M. D., New York, N. Y. 

" The Pathology of General Paralysis," by Charles B. Dtmlap, 
M. D., New York, N. Y. (Illustrated by lantern slides.) 

" The Diagnosis of General Paralysis," by Adolf Meyer, M. D., 
Baltimore, Md. 



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PROCEEDINGS II9 

"The Treatment of General Paralysis by Salvarsanized 
Serum," by Henry A. Cotton, M. D., Trenton, N. J. (Illustrated 
by lantern slides.) 

" A Report on Five Cases of Intra-cranial Injection of Auto- 
Sero-Salvarsan," by Drew M. Wardner, M. D., Cedar Grove, N. J. 

The President.— The discussion will be opened by Dr. H. W. Mitchell, 
of Warren, Pa, 

These papers were discussed by Drs. Mitchell, Swift, Williams 
and Gorst. 
Adjournment. 

Wednesday, May 2.T, 1914, 10 a. m. 
The meeting was called to order by the President. 

The President. — ^The first order of business is the report of the Council 

Report op the Council for May 27, 1914. 

The Council recommends the election of the following named physicians 
to associate membership: 

Edgar L. Brannlin, M. D., Dayton, O.; Morgan B. Hodskin, M. D., 
Palmer, Mass.; Eva Charlotte Reid, M. D., Talmage, CaL; N. P. Walker. 
M. D^ Milledgeville, Ga. 

The Council has received the following applications for active member- 
ship. In accordance with the constitution, final action will be deferred 
until next year: 

Paul V. Anderson, M. D,, Richmond, Va; J. Henry Qark, M. D., 
Newark, N. J.; D. W. Dcuschle, M. D., Columbus, O.; Andrew C. Gillis, 
M. D., Baltimore, Md. ; James K. Hall, M. D., Richmond, Va ; Ernest A 
Young, M. D., Kingston, Ont 

Respectfully submitted, 

Charles G. Wagner, Secretary, 

On motion, duly seconded, the report of the CotmcU was 
accepted and adopted. 

The President. — ^The next order of business is the election of members 
proposed yesterday. The Secretary will read their names. 

(This list is given in the first report of the Council.) 

Dr. Burgess. — ^I move that these members be elected and that the Sec- 
retary be instructed to cast the ballot of the Association electing these 
gentlemen to active and associate membership, and also that Dr. H. H. 
Young be elected to honorary membership. 

Which motion was duly seconded and carried. 

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I20 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

The Psesiixent.— The Secretary has cast the ballot of the Association as 
instructed and these physicians are elected members of the Association. 

The next in order is unfinished business; the Secretary will present a 
matter of business at this time. 

The Secretary. — The Council has recommended the adoption by the 
Association of the following preambles and resolutions submitted to it 
by the President: 

Whereas, It is universally conceded that feeble-minded persons are, by 
reason of their mental deficiency, unable to conform to the laws that 
govern normal people, and hold themselves to acceptable standards of 
work and morality; and 

Whereas, The inability of the feeble-minded to assume the responsi- 
bility for their own conduct renders them a burden to their families and 
a menace to the public, upon whom the burden of their maintenance, of 
their criminality, of their weakness and of their immorality ultimately 
falls; and 

Whereas, Many feeble-minded persons are susceptible to training and 
becoming self-supporting, useful individuals; and 

Whereas, It is the consensus of scientific belief that by the application 
of vigorous measures the conditions producing feeble-mindedness may 
be, in great measure, controlled and the number of such persons reduced 
to those arising from exogenous or accidental causes; therefore, be it 

Resolved, That it is the duty of every community to properly care and 
provide for all classes of idiots, feeble-minded persons and mental defec- 
tives, and that, in order to secure their greatest good and highest welfare, 
it is indispensable that institutions for their exclusive care and treatment, 
tmder competent medical supervision, and free from partisan influences, 
should be provided, and that it is improper, except from extreme neces- 
sity, as a temporary arrangement, to confine feeble-minded or mentally 
defective persons in jails, almshouses or other institutions not especially 
provided for their proper care and education. 

Resolved, That every state and country represented by this Association 
should enact adequate laws for the proper segregation of feeble-minded 
persons, and the prevention of propagation of their kind, by separating 
the sexes and precluding ill-advised contact with the world at large. 

Resolved, That these same states and countries should enact a marriage 
law which will require a clean bill of health and evidence of normal mind 
before a marriage license is issued. 

Dr. Smith. — I move the adoption of the resolutions. 

Motion seconded. 

The President. — It has been moved and seconded that these resolutions 
as read by the Secretary, be accepted and adopted; any remarks? 

Dr. Wm. a. White.— I think it is very ill-advised for this Association 
to go pn record as recommending the enactment of marriage laws in this 



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PROCEEDINGS 121 

blanket sort of way. These things have been tried elsewhere and have 
been shown to be hopeless failures, in many instances at least, and where 
there is effort made to restrict marriage under certain laws it has led to 
discouragement of marriage to a certain extent, and also naturally towards 
illegitimate sexual relations. Whereas, in an abstract way the thing is 
all right, I believe it would be unwise to recommend its adoption and by 
so doing tend to cause legislators to rush into ill-advised legislation. 
While I approve of the resolutions with that exception, I should disap- 
prove of them with that final paragraph. I think we should go into this 
matter carefully. I believe that such resolutions as these should be laid 
upon the table until we have discussed the "Eugenics" papers that are 
to be presented to-morrow. 

Dk. Busgess. — I do not quite agree with Dr. White. I do not think that 
the resolution proposed by the Chair can do any harm; it always has a 
deterring effect, and as I said before, it can do no harm. 

Dr. Tom A. Williams.— I would like to have the resolution read again 
so as to get the exact wording of the last paragraph. 

The Secretary re-read the last paragraph of the resolutions. 

The President. — Any further remarks? I think the Association under- 
stands the motion is to adopt these resolutions ; all in favor please signify 
by sajdng aye. Opposed, no. 

The President.— There seems to be a division; the Chair will call for 
a rising vote. 

A rising vote was taken, the Secretary counting. 

The President. — The Secretary informs me that the vote on the motion 
before the house is twenty in favor and fifty-two opposed. The motion 
is, therefore, lost. 

Dr. Brush. — Is a motion to reconsider the resolution in order? 

The President.— It is. 

Dr. Brush. — ^I move that the resolutions just rejected be reconsidered, 
with the objectionable clause in regard to the marriage law stricken out 

The President. — It has been moved and seconded that the last clause 
of the resolutions relating to marriage laws, be omitted; all in favor of 
this amendment, please signify by saying aye. 

Carried. 

The President. — The Chair will now entertain a motion to adopt the 
resolutions as amended, omitting the last clause in relation to marriage 
laws. 



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122 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

Dft. Brush. — ^I move the resolutions as amended be adopted. 

Which motion was duly seconded and carried. 

The Secretary, at the request of Dr. Hoch, called attention to 
a resolution adopted by the Association at its annual meeting held 
at Atlantic City in 1912, which provides for the co-operation of 
this Association and its members individually with the work of 
the National Committee for Mental Hygiene. 

Dr. Stedman. — I have been asked to present the following resolution, 
with which I am in hearty sympathy : 

Whereas, A bill has been introduced in Congress providing for the 
establishment of a Division of Mental Hygiene in the United States 
Public Health Service for the study and investigation of mental dis- 
orders and "their causes, care and prevention"; therefore, be it 

Resolved, That the American Medico-Psychological Association, now 
assembled in its Seventieth Annual Meeting, hereby records its hearty 
approval of this measure, which, we believe, if carried into effect, will be 
the most important step yet taken by this government to deal adequately 
with the great problem of the treatment and prevention of mental dis- 
eases; and be it further 

Resolved, That the Secretary of this Association be instructed to send 
a copy of diese resolutions to the President of the United States, to each 
member of the United States Senate and of the House of Representatives, 
and to the Surgeon-General of the United States Public Health Service. 

The Presii«nt.— The resolution offered by Dr. Stedman is before the 
Association, subject to a motion respecting its adoption. 

Dr. Burr. — I move the adoption of the resolution. 

Seconded. 

The President.— You have heard the resolution as read by Dr. Stedman, 
and the motion which is now before you; are there any remarks? 

Dr. WnxiAMS. — It might be proper to have this resolution referred 
to a committee for further consideration. 

Dr. Burgess. — ^I think the same resolution, or nearly the same was 
brought before the Council on Monday evening, and it was agreed that it 
should be left over, the idea being to make it international in character. 
I think the Council agreed to refer it to a committee of three, and to 
bring it before the Association for action at this session. 

Dr. Salmon. — ^I would like to say a few words about the purpose of 
the bill to which Dr. Stedman refers. Thus far the United States Gov- 
ernment has done practically nothing in the work of prevention of mental 
diseases, while everybody is familiar with what has been accomplished in 



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PROCEEDINGS 123 

the control of infectious diseases, especially those of a quarantinable 
nature. All the work done by the Public Health Service in the different 
states, except in a few instances where contagious disease threatened to 
extend across state boundaries and federal action was imperative, has 
been done upon the request of the local authorities. Although a recent 
act of Congress gives the Public Health Service authority to study any 
of the diseases of man, that service cannot go into a state and undertake 
active work for prevention unless it is invited by the local authorities to 
do so. This bill simply makes it possible for the Public Health Service 
to employ the same methods in the field of mental hygiene which it has 
used so successfully in other departments of preventive medicine. There 
is not the slightest possibility that the prerogatives of any state board of 
administration or of any institution will be invaded; on the other hand, 
help of the most useful kind will be available. 

When it was proposed a few years ago to unite all the medical activities 
of the government in a Department of Public Health, the patent medicine 
proprietors, the Christian Scientists and the " f ood-dopers " throughout 
the country said that this was only an attempt on the part of the federal 
government to enter the homes and treat the children of our citizens 
against their will. Of course this contention was absurd, but it is a 
special reason, it seems to me, why this Association ought to be careful 
not to show the faintest suspicion of a similar sort toward the establish- 
ment of a government agency for work in prevention and better care of 
mental diseases. 

This Association is dealing with some of the most difficult problems in 
medicine and sociology and we should welcome the strong aid of the 
federal government It has been withheld long enough. 

If one of the gentlemen here, who is a superintendent of a state hos- 
pital, had hog cholera break out among the animals on the farm of his 
institution, the federal government would not only give him advice as to 
how to manage the disease, disinfect the pens and treat the sick animals, 
but, in certain cases, it would send well-trained men to do it for him. 
In many other problems affecting his farm he would obtain similar 
advice from the United States Government; but if he decided to build a 
new reception hospital for the active treatment of acute cases of mental 
disease, to institute some new forms of diversion or occupation for his 
patients, to adopt a plan for collecting and interpreting the statistics of 
his institution, or to provide after-care for his paroled patients, there 
is not a single departmtot of the government to which he could turn for 
advice and aid at the present time. If this bill passes, the Division of 
Mental Hygiene in the Public Health Service will be able to work con- 
tinuously upon such problems, and to assemble the best trained men 
available for the work. I know from the experience of the National 
Committee for Mental Hygiene how great is the need for careful study 
of some of the problems of administration and treatment in the care 
of the insane. We have tried to deal with these matters as well as our 
resources permit, but the establishment of a division in an organization 



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124 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

like the Public Health Service would do far more than we could do in 
this direction, and would leave us free to devote our time to the social 
and humanitarian aspects of the care of the insane for which our type of 
organization seems best fitted. 

Ds. BiDDLE. — I would like to ask if there was a motion made for the 
adoption of this resolution preceding this last motion? 

The President. — As the Chair understands it, there is only one motion 
before the house — ^the motion for the adoption of the resolution offered 
by Dr. Stedman. If the Chair is in error, it would like to be corrected. 

Dk. Williams. — This Association is composed of men who are old in 
the practice of psychiatry, and it seems to me unwise to deprive them of 
the opportunity of mature deliberation of an important question. It 
seems to me the wiser course that this should be thrashed out elsewhere. 
In spite of Dr. Salmon's eloquence, I believe it is better that this should 
be taken under consideration by an appropriate committee and then 
presented to the Association. 

The President. — As the Chair understands it, there is a motion before 
the house for the adoption of Dr. Stedman's resolution; all in favor of 
that motion please signify by saying aye. Opposed, no. 

Carried. 

The President.— The next order of business is the report of the Nomi- 
nating Committee. 

Dr. Henry M. Hurd.— Your Nominating Committee reports as follows: 
For President, Dr. S. E. Smith, Richmond, Ind. 
For Vice-President, Dr. Edward N. Brush, Baltimore, Md. 
For Secretary-Treasurer, Dr. Charles G. Wagner, Binghamton, N. Y. 
For Councilors for three years: Dr. H. R. Stedman, Boston, Mass.; 
Dr. E. M. Green, Milledgeville, Ga.; Dr. W. M. English, Hamilton, Ont; 
Dr. C. F. Applegate, Mt Pleasant, la. 
For Auditor for three years. Dr. M. B. Heyman, Central Islip, N. Y. 

Respectfully submitted, 
Henry M. Hurd, 
William Mabon, 
C. B. Burr, 

Committee, 

The President.— The report of the Nominating Committee is before the 
Association; the Chair will entertain a motion respecting the disposition 
of this report 

Dr. a. W. Hurd.— I move the report be accepted and adopted. 

The Presii«nt. — I suppose it is in order to authorize the Secretary to 
cast the ballot of the Association for the election of these oflScers named. 



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PROCEEDINGS 12$ 

On motion, duly seconded, the Secretary was instructed to cast 
a single ballot for the election of the officers as nominated by the 
Nominating Committee. 

The PREsn)ENT. — ^The Chair would announce that the Secretary has cast 
the ballot in accordance with the instructions of the Association, and 
hereby declares these officers duly elected. 

We will now have the report of the Auditors. 

Dr. Somers. — I have examined the books and papers of the Association, 
including the bank-books, and found everything in good order, and accord- 
ing to the report of the Treasurer. The same is true of the report of the 
Editors of the American Journal of Insanity. 

Dr. Henry M. Hurd.— I move the report of the Auditors be accepted 
and adopted. 

Which motion was duly seconded and carried. 

The President. — The Chair will announce the Committee on Resolu- 
tions before the close of the session. 

The next order of business is amendments to the constitution; are 
there any to be offered? 

Dr. Henry M. Hurd. — In accordance with the written notice given at 
the 1913 meeting, at Niagara Falls, Ont., I move the following amendments 
to the constitution: 

Amendment to Article III. 

Article III to be amended to read as follows: 

"There shall be five classes of members: (i) Active members, who 
shall be physicians resident in the United States and British Americs^ 
especially interested in the treatment of insanity; (2) Associate members; 
(3) Life members; (4) Honorary members and (s) Corresponding 
members." 

Amendment to Article V. 
Add in line 4, after Active members, the following words : 
"Life members shall be such Active members as shall have been mem- 
bers of the Association for a consecutive period of thirty (30) years." 

Amendment to Article VI. 

Add the word " Life '* in line 2 of third paragraph, so that it may read : 

"Life, Honorary and Corresponding members shall be exempt from 
an payments to the Association." 

Dr. Henry M. Hurd. — I move that this amendment be now adopted. 



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126 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

Dr. Wagnes. — Before the Association acts upon these amendments I 
would like to call attention to one word in the amendment to Article VI, 
which provides that "Life, Honorary and Corresponding members shall 
be exempt from all payments to the Association." It occurs to me 
that possibly that might be a little too sweeping, as it might be interpreted 
as including subscription to the Journal of Insanity, the new index, 
payments for the volumes of the History, or any special matter that re- 
quired financial assistance in the future. I am not here to oppose it, but 
I thought it worthy of a little further consideration. 

Dr. Henry M. Hurd.— I think it is a little too broad. I intended to 
say "all payments for dues to the Association." I move, Mr. President, 
that the amendment to Article VI be amended by adding " all payments of 
annual dues to the Association," 

Dr. Kurd's motion, as amended, was duly seconded and carried. 

The President. — The next order of business, and the last before we 
proceed to the reading of papers, is the report of the Committee on 
Statistics, Dr. Thomas W. Salmon, Chairman. 

Dr. Salmon. — ^The committee has had several meetings during the year 
and has very carefully considered the matters outlined in the discussion 
at the meeting last year. In this we have had the very valuable advice 
and co-operation of Dr. Horatio M. Pollock, Statistician of the New York 
State Hospital Commission. Dr. Pollock has given a great deal of his 
time to the work and we feel deeply grateful to him for his interest and 
courtesy. Dr. August Hoch has very kindly given us the benefit of his 
knowledge in the consideration of some proposed tables on psychoses, 
and we wish to acknowledge our appreciation. 

The Census Bureau has been communicated with by this committee and 
an effort will be made to frame tables which can also be used by that 
bureau in the enumeration of the insane which is made every ten years. 

A number of tables have been considered and a series has been tenta- 
tively planned. It seems undesirable to present any tables until all have 
been completed, for it is desired to have all the tables bear a logical 
relation to each other. 

Therefore, this committee requests that the Association will continue 
it for another year, at the expiration of which time we will be able to 
render a full report for the consideration of the Association. 

Dr. C. B. Burr. — ^I move the contmittee be granted an extension of time. 

Motion duly seconded and carried. 

The President. — ^The first paper on the scientific program this morning 
is by Dr. Charles W. Burr, of Philadelphia, Pa., and Dr. Francis X, 
Dercum, of Philadelphia, will open the discussion, by invitation. 



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PROCEEDINGS 12/ 

Dr. Burr then read a paper entitled " A Criticism of Psycho- 
analysis." Discussed by Drs. Derctim (by invitation), Wm. A. 
White, Hoch, Williams and Burr in dosing. 

Dr. Hnx. — I want to make a motion that, as this subject has assumed a 
great deal of interest on account of its excellent presentations on both 
sides, it be made a part of our program in the form of a sjrmposium at our 
next meeting and that we invite Drs. Burr, Dercum and White and others 
to present different sides of the question at the meeting, when we can 
discuss it more deliberately, for I am sure we would like to have it more 
generally discussed. 

The President. — The Chair was about to suggest, when Dr. Hill made 
his motion, that inasmuch as we have only ten minutes more to devote to 
discussion of this subject, the discussion be suspended and taken up this 
afternoon on the boat, or at some future session of this meeting; if it 
goes over for a year the gentlemen who have presented it may not be 
here and we are likely to lose interest in the matter. 

Dr. Stedman. — ^I move the thanks of the Association be extended to 
our guest. Dr. Dercum, for his most able contribution to this important 
discussion. 

Which motion was duly seconded and carried. 

The Preshient. — ^The meeting is adjourned to meet on the boat for a 
trip down the bay at i p. m. 

Afternoon Session. 

At I p. m. the members of the Association and their friends 
enjoyed a trip down the Chesapeake Bay as guests of the Com- 
mittee of Arrangements, leaving the hotel in special cars which 
conveyed them to the wharf, where they boarded the city boat 
Latrobe, which had been placed at the disposal of the committee 
by the Mayor. A buflfet luncheon was served on board the boat, 
and the Physicians' Orchestra furnished delightful music during 
the trip. Many historical points of interest were passed en route ; 
one of the special features of the afternoon's entertainment was 
a demonstration by the fire-boat Deluge, shortly after leaving the 
wharf, A most enjoyable afternoon was spent, the party return- 
ing at 5.30 p. m., when special cars were waiting to convey them 
to the hotel, arriving there at 6 o'clock. 



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128 american medico-psychological association 

Evening Session. 

osler hall. 

The President. — ^The Association will please come to order. I want to 
say that we are very much honored to-night by the presence of a gentle- 
man who has kindly consented to deliver the annual address to the 
Association; a gentleman who is so well known not only to this Associa- 
tion, but throughout the length and breadth of the land, his reputation 
for his scientific and scholarly attainments being an international one, 
and his genial personality is so well known to all who have had the 
privilege of personal contact with, him, that no words of commfendation 
from me would add anything to our knowledge of and regard for the 
speaker who is to address us — indeed he needs no formal introduction. 
Dr. Lewellys F. Barker, Professor of Medicine Johns Hopkins University, 
and Physician-in-Chief Johns Hopkins Hospital, will deliver the annual 
address on the subject of "The Relation of Internal Medicine to 
Psychiatry." 

Dr. Barker then delivered his address, " The Relation of In- 
ternal Medicine to Psychiatry/' which was greeted with pro- 
longed applause. 

Dr. Wagner. — Mr. President, we have listened to this splendid address, 
full of food for thought, as an Association and as individuals, and we are 
under great obligations to the distinguished speaker who has addressed us, 
for taking the time necessary to prepare such an address, from the great 
work he is doing in a great university, and delivering it here for us 
to-night. I think it has never been my pleasure to listen to a better, 
stronger, abler address than Dr. Barker has given us on this occasion, 
and I believe that I voice the sentiments of every one here this evening 
when I move a vote of thanks to Dr. Barker. 

Dr. Brush. — It gives me very great pleasure to second that vote of 
thanks. Naturally when the custom was established in this Association 
to ask some one not connected with the organization to deliver the annual 
address it was intended that we should be brought in contact with what 
was being done in the broad field of science outside of our peculiar line 
of work; no man who has ever addressed us has brought us more 
thoroughly in contact with what are the relations between our work and 
the work of internal medicine, than has been done by Dr. Barker to- 
night I rise with peculiar interest to second this motion, because I 
congratulate myself both upon my good judgment and my temerity, 
especially my temerity; it may not be known to anybody except to Dr. 
Barker and myself, but some years ago I asked Dr. Barker to become 
my assistant. I think you will all commend my judgment, while possibly 
being surprised at my temerity. 



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PROCEEDINGS I29 

The President. — You have heard the motion made by Dr. Wagner 
and seconded by Dr. Brush. The Chair does not feel equal to saying 
anything that would add in any way to what Dr. Wagner has so well 
said in expressing the sentiments of this Association respecting our deep 
sense of obligation to Professor Barker for his able, interesting, instruc- 
tive and scholarly address. All in favor of this motion will please signify 
it by rising. 

Motion was unanimously carried. 
Adjournment. 

Thursday, May 28, 1914, 10 a. m. 

The President. — ^The Association will please come to order. 

The first order of business is the report of the Council on the time and 
place of next meeting. We are not prepared to report on the time and 
place of the next meeting, but we will do so at a later session to-day. 
We will listen to the report of the Council. 

Report of the Council May 2S, 1914. 

The Council recommends the election of the following named physicians 
to the associate class : 

W. Palmer, M. D., Logansport, Ind.; Ernest M. Poate, M. D., New 
York, N. Y. ; Robert F. Sheehan, M. D., Washington, D. C. 

The Council has received the application for active membership of 
John T. MacCurdy, M. D., New York, N. Y. According to the consti- 
tution, final consideration will be deferred until next year. 
Respectfully submitted, 

Charles G. Wagner, Secretary, 

On motion, duly seconded and carried, the report of the Council 
was accepted and adopted. 

The President. — ^The next in order is the election of members proposed 
yesterday. The Secretary will read the names. 

(This list is given in the report of the Council for Wednesday.) 

Dr. Hurd. — I move that the Secretary be instructed to cast the ballot 
of the Association for the election of the physicians whose names have 
been presented. 

Motion duly seconded and carried. 

The President.— The Secretary has cast the ballot of the Association 
as mstructed, and these physicians are duly elected to membership in the 
Association. 

The next order of business is the report of the Committee on Immigra- 
tion, Dr. Brush, Chairman. 



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130 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

ReFOKT of CoiilirmE on IlilllGRATION. 

To the American Medico-Psychological Association: The following 
report, it is due to Dr. Salmon to say, is written by him and not by the 
chairman of the committee, and is presented as showing the status of the 
proposed changes in the immigration law in a very concise manner : 

No federal immigration legislation has been enacted since the last meet- 
ing of this Association. A bill, which is very much similar in its important 
provisions to the one passed at the last session of Congress, but vetoed 
by President Taft, was passed in the House of Representatives and is 
now before the Senate. This bill includes nearly all the provisions 
recoounended by this Association, but as it also contains a clause exclud- 
ing illiterate aliens, the opposition to it has been very strong. 

Before this bill was reported by the Senate Committee on Immigration, 
several events occurred which had a very material influence upon the 
provisions in which we are interested. Dr. Spencer L. Dawes, who had 
been appointed by Governor Dix of New York in 1912 as Special Com- 
missioner on the Alien Insane, concluded his work in February and 
rendered a report to Governor Glynn. This report showed that the 
proportion of aliens in New York State institutions was far greater than 
had been before supposed. Dr. Dawes ascertained that of the 31,624 
patients in New York State hospitals, 13,728 were foreign-bom, and of the 
foreign-born, 9241 were aliens. He presented evidence to show that the 
cost of maintaining the alien patients amounted to more than $1,830,000 
a year. Dr. Dawes made recommendations which, in general, were similar 
to those adopted by this Association. Governor Glynn at once sent a 
special message on the subject to the New York State Legislature, making 
practically the same recommendations as those made by Dr. Dawes and 
urging the legislature to memoralize Congress for relief from the burden 
of caring for the alien insane. The legislature passed a resolution 
appointing a conunittee consisting of two state senators and Dr. Dawes to 
represent the State of New York before the various committees in 
Congress. 

At about the same time a report of the Special Committee on Inquiry 
into the Departments of Health, Charities and Bellevue and allied hos- 
pitals was rendered. Part of this report dealt with alien dependents at 
Bellevue and allied hospitals and in the institutions of the Department 
of Charities. It was shown that the maintenance of dependent aliens, 
many of whom were admitted to hospitals a short time after their arrival, 
cost the city of New York more than $1,000,000 annually. A great deal 
of publicity was given to the findings of these two commissions and so, 
when the Senate reported the bill it contained additional amendments 
serving to strengthen our defenses against the admission of insane or 
mentally defective aliens. 

The bill at present before the Senate (H. R. 6060) has the following 
important provisions relating to this subject which do not exist in the 
present immigration laws: 

I. Insanity is added to the conditions in immigrants for which a fine 
is imposed 



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PROCEEDINGS I3I 

2. This fine is increased to $200. 

3. Immigrants with constitutional psychopathic inferiority and with 
chronic alcoholism are added to the excludable classes. 

4. Chronic psychopathic inferiority and chronic alcoholism are also 
added to the finable conditions. 

5. Medical officers of the United States Public Health Service who 
have had especial training in the diagnosis of insanity and mental defect 
must be detailed for duty or employed at all ports of entry designated 
by the Secretary of Labor. 

6. Such medical officers must be provided with suitable facilities for 
the detention and examination of all arriving aliens in whom insanity 
or mental defect is suspected. 

7. Interpreters must be provided for this special service. 

8. The period in which aliens who become a public charge from 
causes prior to landing can be deported is increased to five years and 
such aliens may be deported at any time if they become a public charge 
within the five-year period. 

9. It is provided that it must be shown affirmatively that causes have 
arisen subsequent to landing to prevent deportation of such aliens being 
effected. 

la Suitable attendants must be provided to the final destinations of all 
deported aliens who are unable through mental or physical disease to 
care properly for themselves. 

A strong public sentiment has developed in favor of these provisions. 
Hon. Lathrop Brown, a member of the House of Representatives, has 
sent a circular letter to each member of the American Medical Associa- 
tion urging that amendments of this nature be supported by the medical 
profession and resolutions have been passed by a number of state medical 
societies endorsing the changes proposed in the law. 

There has been practically no opposition to the provisions in which 
this Association is interested, but opposition to the so-called illiteracy 
clause in the immigration bill has grown in volume rather than diminished. 
It is not likely that the proposed immigration bill will be defeated in the 
House or in the Senate, but there is said to be some possibility that any 
bill containing an illiteracy clause will be vetoed by the President. In 
case this occurs it will be highly desirable to have a bill containing only 
the provisions in which we are interested introduced in each house of 
Congress. Opposition to such legislation might come from those who 
are so much interested in passing the illiteracy clause that they would 
hesitate to have any other legislation advanced, but this is not likely. 

It is apparent that members of this Association can aid in the exclu- 
sion of the insane and mentally defective by urging their friends in 
Congress to stand for the amendments which have been mentioned, in 
whatever bill they may appear, and to see that they are not eliminated 
from any bills introduced in the future. 

A matter of much importance has been the greatly increased efficiency 
of the mental examination of immigrants at Ellis Island. Such members 



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132 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

of the Association as have visited Ellis Island lately cannot help being 
impressed by the earnest efforts which are being made there, in the face of 
the almost unsurmountable difficulties, to detect as many cases of insanity 
and mental deficiency as possible in the brief time which is allowed for 
the examination of each inunigrant. A number of communications re- 
garding this examination have appeared from time to time in medical 
journals and it is apparent that Ellis Island is becoming a great psycho- 
logical laboratory in which many problems in the examination of the 
feebleminded can be worked out 

It is suggested that the following resolutions, identical with those 
adopted by the American Genetic Association, be adopted by this Asso- 
ciation : 

Resolved, That the American Medico- Psychological Association respect- 
fully urges upon the Senate of the United States the importance of the 
passage, at the present session of Congress, of an immigration bill similar 
to that which passed the House of Representatives on February 4, 1914 (H. 
R. 6060), embodying provisions which, if enacted into law, would unques- 
tionably result in a more effective detection, exclusion and deportation of 
mentally and physically defective aliens, and in a general improvement 
in the character of our immigration. 

Resolved, That copies of these resolutions be sent to the President of 
the United States, and to the members of the Committee on Immigration 
of the Senate. 

Respectfully submitted, 

Edward N. Brush, Chairtnan, 

Dr. Brush.— I would move, Mr. President, that these resolutions, be 
adopted by this Association. 

The Preshncnt. — The report of the Committee on Immigration is before 
the Association for action, as is also the resolution just read. The Chair 
will entertain a motion for the adoption of the report, which shall include 
the resolution as read. 

On motion, duly seconded, the report of the Committee on 
Immigration was accepted and adopted. 

The President. — ^The Chair will appoint the following Committee on 
Resolutions: Dr. H. W. Mitchell, of Pennsylvania; Dr. Wm. A. White, 
of Washington, D. C, and Dr. B. D. Evans, of New Jersey. 

We are now prepared to proceed with the scientific part of the session. 
The first paper on the program is one which was left over from yesterday 
morning's session, entitled "Clinical Studies of Benign Psychoses," by 
Drs. August Hoch and George H. Kirby, of New York. 

Dr. Hoch then read his paper, which was discussed by Dr. Wm. 
A. White. 



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PROCEEDINGS I 33 

The President. — The next paper on the program is one by Surgeon 
L. L. Williams, Chief Medical Officer U. S. Immigration Station, Ellis 
Island, N. Y., by invitation. 

Dr. Williams then read a paper entitled " The Medical Exami- 
nation of Mentally Defective Aliens ; Its Scope and Limitations." 
Discussed by Drs. Bancroft, Briggs, Salmon and Williams in 
closing. 

Dr. Wm. a. White. — Dr. Williams has come here as the result of our 
invitation, to give us this paper, which explains so clearly the situation 
on Ellis Island, and I think the American Medico-Psychological Associa- 
tion is deeply indebted to him for this paper. I move, therefore, that the 
Association extend a vote of thanks to Dr. Williams for his highly 
instructive and valuable paper. 

The President. — ^The Chair is pleased to put this motion, which I am 
sure voices the sentiments of the entire Association. 

Motion was duly seconded and unanimously carried. 

The President. — Dr. Williams, the Association thanks you for your 
interesting and instructive paper. 

The next paper on the program is " Some Notes on Expert Testimony 
by Alienists and Neurologists," by Drs. Carlyle A. Porteous and Hedley 
V. Robinson, of Montreal, which will be read in abstract by Dr. T. J. W. 
Burgess. 

Dr. Burgess then read the above paper, which was discussed 
by Drs. Bancroft, Harrington, Evans, Briggs and MacDonald. 
Adjournment. 

Afternoon Session. 

henry phipps psychiatric clinic, johns hopkins hospital. 

At 1. 1 5 p. m., luncheon was served at The Johns Hopkins 
Hospital for the members of the Association and their friends. 
The Association was called to order by the President. 

The Pkesihent. — There were three papers on the program for this 
morning which were not read; two of them will be read by title and will 
appear in the Transactions; these are: "The Establishment of Training 
Schools for Attendants (now nurses) in Asylums (now hospitals) for 
the Insane at McLean Hospital and Buffalo State Hospital, 1882-1886," 
by Wm. D. Granger, M. D., New York, and "The Modern Treatn\ent 
of Inebriety," by Irwin H. Neff, M. D., of Foxborough, Mass. The third 
one, by Dr. Orton, will be postponed until the evening session, as it seems 



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134 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

desirable and proper to devote the session this afternoon to the work 
of the clinic here. 

The first order of business is the report of the Committee on Psy- 
chology in the Medical Schools, Dr. £. Stanley Abbot, Chairman. 

Report of the Committee on Psychology in the Medical Schools. 

To the American Medico-Psychological Association. Gentlemen,'^Tht 
Committee on Psychology in the Medical Schools has not been inactive, 
but is prepared to make only a preliminary report at the present time. 

For many unavoidable reasons the investigation of the results, present 
status and future possibilities of teaching psychology to medical students 
has not been carried far enough to warrant report this year. The impor- 
tance of such teaching has been brought to the attention of medical schools 
by the following methods : 

Dr. Franz, a member of this committee, as chainoan of a somewhat 
similar committee of the American Psychological Association, prepared 
a report to that Association very strongly recommending the introduc- 
tion of psychology into the medical curriculum. Reprints of that report 
were sent last November to each medical school in this country. In 
December, a reprint of Dr. Abbot's paper on the subject, with a leaflet 
calling attention to Dr. Franz's report, was sent to at least three members 
of the faculties of each of the Qass A + , Class A, and Qass B Medical 
Schools. In February a reprint of an address by Dr. Franz before the 
St Louis Medical Society, on " Psychological Factors in Medical Practice," 
was sent to each of the medical schools. There has been some response 
to this repeated attack. Committees on psychology in the nvedical sdiools 
were appointed by two other organizations— 4he American Psychological 
Association and the American Psychopathological Association— with 
which your committte has been co-operating. Your committee met in 
December and in April and discussed at length the content of a course 
in psychology for medical students, each member having been asked to 
submit a brief outline of what he thought should be included in such 
a course. Not all members could attend. As a result of the discussion 
your committee decided that it was more expedient, on account of the 
widely different men, view-points and facilities for teaching in the differ- 
ent schools, not to elaborate and recommend any specific outline at the 
present time. But your committee was strongly convinced that psychology 
should be taught in the medical schools; that in view of the fact that 
the medical curriculum is already well filled, the subject matter and the 
methods of presentation should be selected carefully, and solely with 
regard to their applicability to the problems of the physicians; that for 
this reason the course should be given not by a psychologist without 
medical experience, but preferably by a psychiatrist interested in psy- 
chology, or by a psychologist familiar with mental abnormalities and 
diseases, and interested chiefly in the higher mental activities; and that 
the course should be given under the direction of the department of 
psychiatry. 



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PROCEEDINGS I35 

^nce there is yet so much work to be done in carrying out the purpose 
of this committee, and since its objects cannot be acconiplished until 
the teachings of psychology become general, and since, until then, the 
subject will need frequent presentation and agitation, it is recommended 
that the same committee be continued, or a similar one appointed, with 
powers to co-operate with any other person, committee or association 
having similar objects in view. 

Respectfully submitted, 

£. Stanixy Abbot, Chairman. 

Thb PKESnffiNT.— The Chair would announce that the request of the 
committee that they be continued, with power to act, is ordered, believing 
that this will meet the views of the Association. 

We will now commence the regular program for the afternoon, which 
will be given by the members of the sta£f of the Phipps Psychiatric Clinic. 
The first item on the program is "Organization of the Work of the 
Clinic, with Special Reference to the First Year's Work," by Adolf 
Meyer, M. D., of Baltimore, Md. 

The following conununications were then read by members of 
the staflf of the Henry Phipps Psychiatric Qinic : 

" Organization of the Work of the Clinic, with Special Refer- 
ence to the First Year's Work," by Adolf Meyer, M. D. 

" A Review of the First Year's Work of the Dispensary of the 
Phipps Clinic," by Charles Macfie Campbell, M. D. 

"Korsakow's Psychosis Occurring During Pr^^nancy," by 
David K. Henderson, M. D. 

" The Colloidal-Gold Test," by Sydney R. Miller, M. D. 

"A Biological Interpretation of Conflict of Instincts and 
Emotions Applied to Some Problems in Htmian Behavior," by 
E. J. Kempf , M. D. 

" A Study of the Defectives of School Age," by R. C. Hall, 
M. D. 

" A Case of Obsessions," by Henri Floumoy, M. D. 

The Pkesident.— This concludes the scientific program of the afternoon. 

Dr. Richasd Dewby. — Mr. Chairman, I ask the privilege of o£fering 
the following resolution, and moving its adoption: 

The members of the American Medico-Psychologfical Association desire 
to express their appreciation of the privilege of inspection of the Henry 
Phipps Psychiatric Ginic; of listening to papers and demonstrations of 
high scientific value, and of partaking of a most enjoyable luncheon. 

They recognize that the equipment of the clinic in men and in apparatus 
places it in the first rank and forms a possession of inestimable value 



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136 AMERICAN MEDIC0-PSYCH0LCX5ICAL ASSOCIATION 

for education in psychiatry, and at the same time accomplishing a noble 
humanitarian work. 

The President. — ^You have heard the resolution, all who are in favor 
will please signify by saying aye. 

Carried. 

The President. — The Secretary will so record. 

I now declare this session adjourned to meet this evening at Osier HalL 

Evening Session. 

osler hall. 

The President.— The Association will please come to order. The first 
order of business is the report of the Council, which was deferred from 
the morning session. 

Report of Council May 2S, 1914. 

The Council has received the applications of the following named 
physicians for active membership. In accordance with the constitution, 
final consideration will be deferred until next year: 

Alfred O. Lewis, M. D., Philadelphia, Pa.; Charles E. Ross, M. D., 
Wichita, Kans. 

The Council makes the following recommendations: 

That the Association return to the former method of publishing the 
Transactions, viz,, that in use previous to 1913. 

That on and after June 15, 1914, the work of preparing the index to 
the American Journal of Insanity be suspended until further notice; 
that a letter be sent to each member of the Association by Dr. Brush, in 
order to determine the approximate number of volumes of the index that 
will be required when published, and to advise the Secretary thereof. 

That the Treasurer be authorized to pay the bill of the Committee on 
Diversional Occupation, on account of the exhibit, amounting to $125; 
also $30 for the use of Osier Hall. 

That the annual meeting of the Association in 191 5 be held at Old 
Point Comfort, Va., the date to be determined by the President and the 
Secretary later when it can be ascertained what dates can be assigned 
to the Association by the hotel management. 

Respectfully submitted, 

Charles G. Wagner, Secretary. 

Dr. Burgess. — ^I move the report of the Council, as read by the Sec- 
retary, be adopted. 

Which motion was duly seconded and carried. 

Thf President.— We will now proceed to the scientific part of the 
session this evening. The first item on the program is the symposium 



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PROCEEDINGS I37 

on Eugenics, of which Dr. Wm. Mabon, of New York, is the chairman; 
Dr. Mabon have you any report to make on the subject? 

Dk. Mabon. — If my recollection serves me right this committee was 
not expected to make a report. At the meeting at Niagara Falls last year 
a report was submitted by the chairman of the committee, Dr. Hubert 
Work. As a result of the discussion of the subject a committee was 
appointed to prepare a symposium on Eugenics. I believe that the report 
of the committee represents very largely the views of this Association 
and is of far-reaching importance. In the preparation of the program of 
the evening we asked Dr. Work to present a paper, but Dr. Work unfortu- 
nately is unable to be here and I have with me his communication, which 
I now beg to submit, with the approval of the President. 

The following papers were read, the first three of which com- 
posed the s)rmposium on " Eugenics ** : 

" Legislation in Reference to Sterilization," by Hubert Work, 
M. D., Pueblo, Colo. Read by Wm. Mabon, M. D., New York, 
N. Y. 

" Applied Eugenics," by Sanger Brown, M. D., Kenilworth, 111. 

" Some Aspects of the Problem of Mental Deficiency," by 
Max G. Schlapp, M. D., New York, N. Y. 

" Insanities in Children," by John H. W. Rhein, M. D., Phila- 
delphia, Pa. 

The PREsn)ENT. — ^This concludes the papers for the evening session and 
they are now before the Association for discussion; are there any 
remarks? The Chair realizes that owing to the lateness of the hour and 
the prolonged sessions we have had to-day there is not much incentive 
to prolong discussions of the subjects to-night. 

Dr. Bancroft. — Owing to the lateness of the hour I would like to 
suggest that, if it would be proper, we have the discussion on the subject 
of Eugenics to-morrow morning. 

The President. — ^The Chair would like very much to hear discussions 
on these papers, but it fears that it will not be feasible to take time for 
the purpose to-morrow morning; our meeting closes at noon and we 
have a number of papers on the program that should be read. I would 
suggest, therefore, in view of the number of papers we have to dispose of 
to-morrow morning, that we commence the session promptly at 10 o'clock. 

If there are no further remarks a motion to adjourn is in order. 

Adjournment. 



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138 american medico-psychological association 

Friday, May 29, 1914, 10 a. m. 
The meeting was called to order by the President. 

The President.— The first thing in order is the report of the G>uncil, 
which will be read by the Secretary. 

Report of the Council for May 29^ 1914. 

The Council has received the application for active membership of 
J. F. Wen Glesky, M. D., Milwaukee, Wis. According to the constitu- 
tion, final consideration will be deferred until next year. 

The Council makes the following recommendations: 

That the incoming President be authorized to appoint a Program 
Committee and a Committee of Arrangements for the next annual meeting. 

That the dues for the ensuing year be fixed at the usual rates, viz.: 
Five dollars for active members, and two dollars for associate members. 

That in future the Nominating Committee shall nominate as a member 
of the Council, for a term of three years, the retiring President. 
Respectfully submitted, 

Charles G. Wagner, Secretary, 

On motion, duly seconded, the report of the Council was 
accepted and adopted. 

The President.— The next order of business is the election to member- 
ship of the candidates proposed yesterday. The Secretary will read the 
names. 

(This list is given in the report of the Council read at the 
Thursday morning session.) 

On motion, duly seconded and carried, the Secretary was in- 
structed to cast the ballot of the Association electing these physi- 
cians to membership. 

The PREsroBNT.— The Secretary has cast the ballot of the Association 
and the candidates whose names were read are hereby declared elected. 

We will now hear the report of the Committee on Diversional Occu- 
pation of the Insane, Dr. Wm. Rush Dunton, Jr., Chairman. 

Report of the CbiiMiTiEE on Diversional Occupation. 

Mr. President and Gentlemen: Soon after its appointment your Com- 
mittee on Diversional Occupation formed plans for the exhibition and 
for a questionnaire similar to that used last year, but containing several 
additional questions. The former questions were again asked, as they 
had not been answered by a number of institutions, and it was hoped 
that improved conditions would make new answers necessary for those 
who had already replied. This questionnaire was sent January 2 to all 



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PROCEEDINGS I39 

of the institutions named in the secretary's list of members. These may 

be classified as follows: 

SUte 15s 

Comity 9 

City :.... 6 

Private fj 

Incorporated 16 

Epileptic 8 

Feebleminded 9 

Inebriate 2 

Tnberculosb i 

Undi£ferentiated 4 

It was requested that replies and applications for exhibition space be 
made by March 15. By May i replies had been received from but 
Ttj institutions and our hopes of making a complete report of occupa- 
tion in all institutions were dashed. 

Acting upon the suggestion of the chairman of last year's committee, 
the questionnairg was again sent to all the state institutions with an 
additional explanatory note printed on a different colored paper. This 
brought 39 more replies. We have had access to the replies to last 
year's questionnaire and find they number 107. Of these 42 answered 
this year, so that we have information from 131 of 287 institutions, 
or about 48 per cent It seemed useless to attempt to make several 
summaries, which had been planned, as the results would be too inaccurate. 
Our conclusions are therefore fewer than wotild have been the case if 
we had received replies from the majority of institutions. It seems 
necessary that there be some agreement as to what is meant by "diver- 
sional occupation." From the replies received it would appear that we 
are far from being unanimous on this point. Some restrict the term 
to "fancy work," others include all forms of work. 

Question 6 was as follows: 

" What is your opinion concerning the value of diversional occupation as 
a means for treating the unwilling workers, such as dementia praecox cases, 
acute cases that are not allowed the privilege of the grounds, and the senile 
cases who are not i^ysically able to perform routine work? " 

Of this year's 66 replies, nine did not understand the question, did not 
answer it, or for some reason were not qualified to speak, leaving 57, 
of whom all but four spoke with more or less enthusiasm of the benefits 
to be derived from occupation. The majority regard occupation as 
especially valuable in the treatment of dementia praecox and of less 
value in senile cases. 

The committee is quite aware that to answer their questionnaire requires 
some physical and mental effort, but it is not a very great one and is 
surely compensated by the "stock taking" and knowledge one gets of 
conditions in this respect We are grateful to all who have made this 



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140 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

eflfort and hope that those who have not yet answered the questionnaire 
will do so. For it is hoped that the information which has been received 
may yet be elaborated. 

It is believed that so far the affirmative side has been heard from and 
that those opposed have kept quiet. We hope that they will now speak up. 

It may be remembered that in the discussion following the presenta- 
tion of last year's report Eh-. White, of the Government Hospital, said 
that nothing had been said about the scientific aspect of the diversional 
occupations and raised the point "that in all of these hospitals that are 
doing this diversional occupation there are very few who are investi- 
gating the mechanisms of recoveries, and until we know what the 
mechanisms of recoveries are we cannot apply any therapeutic agency to 
bring about recovery, except by a hit-and-miss method.** 

Probably many will agree that we do not know the mechanism of 
recovery in all of our cases, but many of us know that occupation aids 
in all cases where it is helpful by replacement The patient's attention 
is necessarily focused on the task being performed and the depressive or 
other ideas are therefore less prominent. Gradually the patient takes an 
interest in the work, the ideas go still further into the background and 
finally disappear. In cases of dementia praecox we also have a replace- 
ment. The same applies to excited states where the purposeless restless- 
ness is replaced by purposeful movements. 

We believe that this criticism of Dr. White's is most helpful. He was 
one of the first to reply to this year's questionnaire and referred us to 
his reply of 1913. His reply to question 6 is as follows: 

" My opinion concerning the value of diversional occupation for treat- 
ing the unwilling workers is that we lack facts which will warrant any 
exact statement of the value of occupation for any class of the insane. 
The matter has been dealt with in an unscientific manner, and it is my 
belief that before we discuss it too much we need to make more observa- 
tions, or to publish the observations which we have made. General 
impressions do not take the place of exact observations, and we have 
tried in our laboratory here to begin the latter kind of work. At present 
we have not sufficient data to answer the question." 

We hope that the laboratory work above alluded to will give us more 
exact knowledge. 

EXHIBITION. 

With this year's exhibition is inaugurated several competitions. It was 
thought that these might stimulate more careful observation and conse- 
quent improvements in methods. 

The hospitals exhibiting are: 

Crownsville State Hospital. Taunton State Hospital. 

Spring Grove State Hospital. Kings Park State Hospital. 

Springfield State Hospital. New York State Hospitals. 

Raleigh State Hospital. Ohio State Hospitals. 

Boston State Hospital. Bloomingdale Hospital. 

Manhattan State Hospital. Sheppard and Enoch Pratt Hospital. 

Monson State Hospital. Mercer Sanitarium. 



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PROCEEDINGS I4I 

We believe that these exhibitions are helpful in stimulating interest in 
this work and that they should be continued. J. L. Hammett & Co., of 
Boston, were invited to exhibit the methods and materials for occupation. 

Your committee recommends that it be continued, with broader func- 
tions than it has had heretofore; that it be made a clearing-house or 
bureau of information, and that one of the committee be appointed 
secretary, to whom any one may write for information about the subject. 
We would suggest that a grant of $10 be made to meet the expenses 
of such service. 

Your committee also commends the Maryland Psychiatric Quarterly 
for its department of Occupation and Amusements. 

The committee desires to thank Miss Sarah Ireland, Miss Eleanor I. 
Sweringen and Miss Vemice Townsend Porter for acting as judges. 

Certificates have been awarded to those exhibiting, as follows: 

STATE HOSPITALS. 

Crownsville State Hospital for the best exhibit. 

Crownsville State Hospital for the best craft willow work, lathe turning, 
tied work, cross stitch embroidery, corn-husk work, oak splint baskets, 
rustic work and hand-made rugs. 

Taunton State Hospital for the best craft leather work, punched brass, 
burnt wood, brushes, loom-woven rugs, ash baskets and hooked rugs. 

Monson State Hospital for the best rake knitting. 

Kings Park State Hospital for the best raffia work. 

Kings Park State Hospital for the best photographs of work rooms. 

Spring Grove State Hospital for the best willow work (commercial), 
embroidery and crocheting. 

Willard State Hospital for the best shoes and leather work. 

Central Islip State Hospital for the best paper flowers. 

Manhattan State Hospital for the best schedule of handicraft classes. 

Manhattan State Hospital for the best schedule for an individual 
patient. 

Manhattan State Hospital for the best stencilling, illuminating and 
tatting. 

Springfield State Hospital for the best work of an individual patient 

Springfield State Hospital for the best reed work. 

INCORPORATED HOSPITALS. 

Bloomingdale Hospital for the best exhibit. 

Bloomingdale Hospital for the best weaving, raffia work, wood work, 
embroidery, crocheting and cement work. 

The Sheppard and Enoch Pratt Hospital for the best reed work, sten- 
cilling, block printing, wooden toys, bookbinding, leather work, paper 
work, printing and all (4) groups of metal work. 

The Sheppard and Enoch Pratt Hospital for the best schedule for an 
individual patient. 

The Sheppard and Enoch Pratt Hospital for the best schedule of handi- 
craft classes. 



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142 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

PBIVATE HOSPITALS. 

The Mercer Sanitarium for the best weaving and cement work. 

The Mercer Sanitarium for the best photograph of a work room. 
Respectfully submitted, 

W. R. DuNTON, Jr., Chairman. 
Chas. T. LaMoure, 
W. W. Richardson. 

The President. — You have heard the report of the Conunittee on 
Dxversional Occupation; what is your pleasure in regard to it? 

Dr. S. £. Smith. — I move that the report be accepted and that the 
committee be discharged. While it is not the idea to discontinue having 
a conunittee on diversional occupation, it would seem proper to have such 
a committee appointed by the Chair with reference to the place of meet- 
ing, and that the chairman of the committee shall reside in the immediate 
vicinity, as it requires a great deal of time and attention to arrange these 
exhibits, so the motion for the discharge of the present committee is not 
to be regarded as expressing any dissatisfaction with the committee, for 
it seems to me that this is the best exhibit we have ever had. 

The PRESioeNT. — In this connection perhaps it would be proper for the 
retiring President to suggest that we adopt a resolution providing, in sub- 
stance, that at the beginning of each annual meeting the President shall 
appoint a committee of three members on awards, who shall pass upon these 
exhibits; that this committee shall consist of persons who are not directly 
or indirectly interested in the exhibit, L e,, no member of the committee 
shall be a representative of a hospital having an exhibit, so that the com- 
mittee would be entirely free from bias or partiality in the awards which 
they might make. The Chair would be very glad to entertain a motion 
to that effect 

Dr. Dunton. — I would like to raise the point that every member who 
is sufficiently competent to judge on these things is likely to have an 
exhibit, and I do not know of any member of the Association who is as 
competent to act as a judge as some person who is directly or indirectly 
interested in handicraft. I think if it were possible to have that com- 
mittee consult with, or invite others to act as judges with them, it would 
be a good idea. I would make a resolution as you have suggested, giving 
that committee the power to call in any others they may desire to aid 
them in acting as judges. 

The President. — ^The Chair would state that such a committee would be 
entirely free to consult or advise with persons who were familiar with 
handicrafts. It would seem that a committee of the Association superin- 
tendents ought to be competent to pass upon these exhibits, and there 
would be nothing to prohibit their calling for advice from others. 



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PROCEEDINGS I43 

Dk. S. £. Smith. — I noticed this morning that certificates of award are 
placed about the exhibition room, bearing the seal of this Association, 
and signed by persons who are not members of the Association. Unless 
the Association has taken some action in this matter, I feel that I am 
obliged to raise a question in regard to using its seal in a matter of that 
kind without authority. I agree that awards for exhibits be made by a 
resolution, as has been suggested, but feel obliged to raise a question 
about the propriety of the action in this instance. 

The President.— The attention of the President and Secretary was 
called to that fact this morning, viz., that the awards bearing the seal 
and name of the Association and signed by a conunittee of several ladies 
who are not members of the Association, had been made, although not, 
I am sure, with any desire on Dr. Dunton's part to transcend his duties. 
It would seem to me that these awards, if made and certificates issued, 
should have the stamp of authority of a committee of the Association, 
authorized by the Association; it certainly would add very much to the 
value of the awards, at least I should so regard it if I had an exhibit 
While no criticism of the present commdttee is implied or intended, the 
Chair made the suggestion that a resolution be offered providing for this 
committee in the future, with the object of avoiding any such complica- 
tion in the future. 

You have heard the motion that the report of the Committee on Diver- 
sional Occupation be accepted and the committee discharged — all in favor 
say aye. 

Carried. 

The Presidbnt.— I would like to add, with the thanks of the Asso- 
ciation. 
We will now proceed with the scientific part of the program. 

The following papers were read: 

"The Present Status of the Application of the Abderhalden 
Dialysis Method in Psychiatry," by Samuel T. Orton, M. D., 
Philadelphia, Pa. 

"Insanity with Cerebral Disease," by H. P. Sights, M. D., 
Hopkinsville, Ky. 

" Epileptic Dementia," by Alfred Gordon, M. D., Philadelphia, 
Pa. 

"The Translation of Symptoms into Their Mechanism," by 
C. L. Carlisle, M. D., Kings Park, N. Y. 

" Some Remarks Upon the Methods and Results of Study of 
the Psychopathies of Children," by L. Pierce Clark, M. D., New 



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144 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

York. Discussed by Drs. Meyer, Schkpp, Williams, Miss 
Lathrop, Miss Farrell and Dr. Qark in closing. 

" The Prevention of Suicide, with Cases Illustrating Methods," 
by Tom A. Williams, M. D., Washington, D. C. 

The President. — ^The Chair is exceedingly sorry to curtail the reading 
of any paper or to cut off discussion, but owing to the lateness of the 
hour and the fact that our incoming President is obliged to take the 1.25 
p. m. train, we shall be obliged to do so at this time in order to install him 
in ofl&ce before his departure for home. 

Dr. Dunton. — I would like to offer the following resolution at this 
time: 

Resolved, That a committee of three be appointed by the President of 
the Association, to act as judges of any work which may be submitted 
in competition in the Diversional Occupation exhibit; these to be empow- 
ered to consult with any technical expert they may desire. 

Dr. Swift. — I move the adoption of this resolution. 

Dr. Engush. — Is this certificate to be an official one from the Asso- 
ciation? 

The President. — ^I understand that the Association contemplated in 
the resolution that the committee of three members of the Association 
shall have authority to issue a certificate or diploma, or whatever you 
are pleased to call it, to successful exhibitors. 

Motion duly seconded and carried. 

The President.— We will now hear from the Committee on Resolutions. 

Dr. H. W. Mitchell.— The committee offers the following resolution, 
accompanied by the verbal statement that this resolution in no sense 
expresses our grateful appreciation to those who have made our meeting 
this year so pleasant and profitable: 

Whereas, The arrangements for the Baltimore meeting of the American 
Medico- Psychological Association have been so elaborately devised and 
satisfactorily carried out by the Committee of Arrangements, who have 
given so generously in their efforts to promote the best interests of the 
meeting and the enjoyment of the members and their guests, as to make 
the 19 14 session one of the most instructive and enjoyable in the memory 
of those present; and 

Whereas, The medical profession, public officials, local institutions, 
citizens of Baltimore, and the Hotel Belvedere management have so 
effectively contributed in their several ways, to second the work of the 
committee ; therefore, be it 

Rtsolved, That the thanks of the Association, in no perfunctory sense, 
be extended to all the persons and organizations co-operating under the 



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PROCEEDINGS I45 

leadership of Dr. Wade and his committee aids, in making this meeting 
memorable both for its professional excellence and the exhibition of 
generosity and hospitality for which the region and people have been so 
justly famed. 

H. W. Mitchell, 
Wm. a. White, 
BwTTON D. Evans, 
Committee, 

Dr. Smith. — I move the adoption of the resolution. 

Which motion was duly seconded and carried. 

The President. — The time has now arrived for the induction of the 
President-elect. This to me is a particularly pleasing event, as it means 
my relief from official responsibilities and cares, while it is an added 
pleasure to be succeeded by Dr. Smith. Dr. Smith, will you kindly come 
to the ■ front (Applause.) The time has arrived when, in accordance 
with a time-honored custom, I must lay aside the mantle of authority 
with which the Association honored me last year, and in obedience to 
unanimous mandate, transfer the same to your shoulders, which I have 
much pleasure in doing, knowmg that you are fully qualified by training, 
experience and native equipment for the duties and responsibilities of the 
office of President, and I need not assure you that you are entering upon 
the office with the good will and best wishes of each and every member 
of the Association. I welcome you to the great office which you now 
asstmae, and salute you as President of the American Medico-Psycho- 
logical Association for the ensuing year, and I trust that the meeting of 
the Association next year, over whose destinies you will preside, may 
prove even more successful than the one which now closes with your 
induction into office. 

The Presidbnt-Elect. — I thank you for your gracious words of intro- 
duction. 

Members of the AssociaHon: You have conferred upon me a very great 
honor and placed me in a position of great responsibility, and I sincerely 
hope that you will believe me when I tell you that I appreciate both. No 
higher honor has ever come to me; to my mind this is the highest honor 
in the medical profession. This new responsibility means that I must 
devote some time and attention to the welfare of the Association and in 
the preparation of the business for the next session, which will be held 
at Old Point Comfort; to this I shall devote my best efforts, and with 
the assistance of our very able and efficient Secretary, Dr. Wagner, I 
sincerely hope that we may at least place the next meeting in the class 
with this one. It has reached such a standard of excellence under Dr. 
MacDonald, Dr. Wagner and our able Committee of Arrangements, 
that I cannot hope to see it excelled. I can only ask you, then, to accept 



10 



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146 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 

the simple word of thanks, indicating a heart full of gratefulness for 
the honor you have conferred upon me. 

I hope to meet you all in Old Point Comfort next year, and I trust that 
the meeting may be one of much interest and profit to us all (Applause.) 

Dr. Smith. — Is there any further business to come before the meeting? 

Dr. MacDonald. — I desire to move a special vote of thanks to our 
Secretary, Dr. Wagner, for the very valuable services he has rendered 
to the Association in the past and especially during this meeting, and to 
say that he is entitled to a large measure of credit for the success of the 
same. I would also include in the motion the thanks of the Association 
to Miss Bloxham, the Secretary's accomplished assistant. 

Motion duly seconded and carried. 

DsL Smith. — ^If there is no further business to come before the Asso 
ciation, I declare the Seventieth Meeting of this Association adjourned 
without date. 

Charles G. Wagner, Secretary. 



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PRESIDENTIAL ADDRESS 
By CARLOS F. MacDONALD, M.D. 

Afr. Vice-President, Fellow Members of the American Medico- 
Psychological Association, Ladies and Gentlemen : The fact that 
so many of my predecessors have prefaced their presidential 
addresses by referring to the difficulty of finding a pertinent sub- 
ject which had not already been traversed on like occasions, 
affords me at least the sanction of precedent for referring to the 
difficulty I have encountered in casting about for a subject, or 
subjects, upon which to address you on this occasion, in con- 
formity with time-honored custom and in obedience to a consti- 
tutional mandate which requires your president to " prepare an 
inaugural address to be delivered at the opening session of the 
meeting." 

With a realizing sense of their imperfections, I venture to 
offer a few cursory generalizations on topics which, it seemed 
to me, might prove of interest, even though they may be some- 
what trite and possibly threadbare. 

The fact that this is the seventieth anniversary of the organiza- 
tion of our association would seem to warrant the indulgence in 
a brief reminiscence respecting its organization and progress, 
even at the risk of suggesting to your minds the idea that the 
reminiscent-age and dotage are synon3rmous terms. 

Originally organized in 1844, under the somewhat elongated 
and not over-euphonious title of Association of Medical Super- 
intendents of American Institutions for the Insane, and subse- 
quently, in 1892, rechristened The American Medico-Psycholog- 
ical Association, thus wisely widening its scope and purpose, and 
opening its portals of membership to all medical officers of 
institutions for the insane in the United States and British 
America, and to other specialists in psychiatry and neurology, 
it stands to-day the oldest society on the western hemisphere 
devoted to the interests and welfare of the insane, and to the 
scientific study of psychiatry and allied subjects. 

The association, whether tmder its original or present title, has 
always been a progressive body and has attained a prominence 



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148 PRESIDENTIAL ADDRESS 

both in point of numbers and in the character of its scientific 
work, second to none in the world. 

Its roll of membership, both past and present, is a long and 
honorable one to which we may point with pardonable pride, 
embracing as it does the captains of psychiatry of the United 
States and Canada, not to mention its list of distinguished and 
eminent honorary members in Great Britain and continental 
Europe. 

Seventy years ago the medical men in the United States and 
Canada who were practically familiar with the subject of psy- 
chiatry, as it was then understood, numbered less than a score; 
that is, men with definite ideas of and practical experience in the 
care and treatment of the insane — ideas and experiences which 
can only be acquired by daily personal contact with patients in 
institutions for the insane. At that time the field of American 
psychiatry was a terra incognita — an unexplored wilderness, so to 
speak — through which the votaries of mental medicine had as 
yet scarcely blazed a trail. All honor then, to the original 13 
pioneer founders of our association, who met on that memorable 
occasion, three score and ten years ago, and inaugurated a move- 
ment which practically consummated the birth of the specialty 
of American psychiatry — this at a time, too, when medical prac- 
titioners were wont to look askance at all specialties. 

The organization of this association marked a distinct epoch 
in the progress of psychological medicine, the force and increas- 
ing influence of which have been felt throughout the civilized 
world. As a tree is known by its fruit, so are the labors of 
those 13 broadminded, far-sighted, philanthropic men who, as 
superintendents of hospitals for the insane, or " lunatic asylums " 
as they were then called, met in the city of Philadelphia on 
October 16, 1844, ^^d organized the Association of Medical 
Superintendents of American Institutions for the Insane, better 
appreciated and understood in the light of the scientific work 
that has been done and is being done under the fostering aegis 
of the American Medico-Psychological Association. 

It is well that we should pause and take note of the work of 
those earnest, and in many instances brilliant, men whose rare 
genius and devotion did so much to advance the cause to which 
their years of usefulness were dedicated, and that we should 
realize the far-reaching influence for good which has resulted 



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CARLOS F. MACDONALD I49 

from their unselfish efforts in behalf of our mentally afflicted 
fellow-men. May a knowledge of their labors engender in us, 
and in our successors, an increasing desire to uphold the stand- 
ards and measure up to the high ideals which they established. 

Of these revered nestors of our specialty, it may truly be said, 
"They builded better than they knew." They laid a firm and 
deep foundation upon which their successors have erected a 
permanent superstructure of psychiatry which shall stand, let us 
hope, despite the visionary eflforts and phantasmagoric distinc- 
tions of a small coterie of followers of the new-thought psychi- 
atry, which, happily, is already beginning to wane, and the 
essence of which is dream misinterpretations based on the unten- 
able theory of repressed memories of sexual tratunas in infancy 
or in intrauterine life. 

We, the members of this association, in this, our seventieth 
natal year, may point with pardonable pride to its traditions and 
to the rich legacies bequeathed to us by such men as Isaac Ray, 
Thomas S. Kirkbride, Luther Bell, C. H. Stedman, John S. 
Butler, Amariah Brigham, Pliny Earle, William M. Awl, Francis 
T. Stribling, John M. Gait, Nehemiah Cutter, Samuel B. Wood- 
ward, Samuel White, and a host of other distinguished men who 
came after them and who have left an indelible imprint of their 
greatness upon the annals of our association. 

Prominent among the galaxy of conspicuous names of members 
who have since passed on, may be mentioned John E. Tyler, John 
P. Bancroft, Charles H. Nichols, Edward Jarvis, Andrew McFar- 
land, John Curwen, John P. Gray (whose tmtimely death was 
indirectly caused 'by a madman's bullet), Richard Gundry, 
Orpheus Everts, Joseph Workman, John W. Sawyer, Peter 
Bryce, John H. Callender, Judson B. Andrews, Alexander E. 
Macdonald, and many others, who, by their contributions to psy- 
chiatry, have attained rank and fame in our specialty. 

When we recall the beneficent deeds of these departed members 
it is borne in upon us that they did not live in vain, and that the 
world, especially the mentally afflicted part of it, is better for 
their having lived and labored in it. 

The late Dr. Curwen, in his presidental address to the associa- 
tion on its fiftieth anniversary, referring to its founders, 
prophetically said : " Actuated by motives and principles of the 
highest philanthropy they initiated movements which have stead- 



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ISO PRESIDENTIAL ADDRESS 

ily advanced and are still advancing with a force and momentum 
which will gradually overcome all obstacles^ and give a consist- 
ence and permanence to all matters pertaining to the care of the 
insane, which will eventually issue in the most enduring and 
beneficent modes of relief." 

Among the more important of the numerous questions per- 
taining to the care and treatment of the insane and the manage- 
ment of institutions therefor which have received the attention 
of the association since its organization may be mentioned : 

The construction, organization and government of hospitals 
for the insane ; the statistics, classification and medical and moral 
treatment of the insane, including nursing, occupations and diver- 
sions ; support of the dependent insane ; provision for the criminal 
insane; provision for colored insane; the causes and prevention 
of insanity; comparative advantages of treatment in hospitals 
and private practice; the establishment of schools for certain 
classes of patients ; the use of mechanical restraints ; the corre- 
spondence of patients ; the care of patients at night ; the open-door 
system; the cottage system for hospitals; the pathology of 
insanity; the establishment of psychopathic buildings for acute 
cases ; nurses' homes ; the admission of visitors to the wards of 
hospitals ; the examination and commitment of the insane ; parole 
of patients; state care of the insane; asylums for idiots; the 
nature and treatment of alcoholic insanity; the evils of political 
control of institutions for the insane; fire protection; dietetics; 
warming and ventilation of institutions; the medico-legal rela- 
tions of the insane; medical expert testimony; teaching of 
psychiatry in medical schools; qualifications of officers of 
hospitals for the insane ; dual heads for hospitals for the insane, 
etc. These are but a few of the practical questions which have 
received the serious consideration of the association, many of 
which have been backed up by the adoption and promulgation of 
resolutions defining its attitude respecting them. Finally, during 
its existence practically every subject relating to lunacy adminis- 
tration, modem psychiatry and allied subjects have been brought 
before the association in original papers and committee reports 
contributed and discussed by its members. 

I have endeavored in these somewhat discursive remarks to 
outline briefly the good work accomplished by our early psychia- 



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CARLOS F. MACDONALD I5I 

trists in establishing the association which for 70 years has stood 
for all that is best in mental medicine and in .the care and treat- 
ment of the insane. 

The Mental Defective Probusm. 

Among the many live questions confronting the body politic 
to-day, there probably is none that rivals in importance, or none 
the solution of which promises greater benefit to the human race, 
whether viewed from a sociologic, philanthropic, or economic 
standpoint, than that of determining and rendering effective, the 
best method of dr3ring up the streams that produce the defective 
and delinquent classes now so prevalent in every state and coun- 
try. Nor is there any public problem that calls for more serious 
consideration and co-operation of the scientist, the political 
economist, the legislator, the taxpayer, and the humanitarian, 
than that of the custodial care and control of that vast army of 
mental defectives, large numbers of whom are to be found in 
every community, many of them unrecognized, where they are 
not only a disturbing element in the social fabric, but a menace 
to the public peace and safety, not to speak of the enormous 
pecuniary burden which their existence imposes upon the com- 
monwealth. And while the problem of the feeble-minded — ^the 
mental sub-normals — ^may never be solved in its entirety, it is the 
consensus of scientific opinion that it is first in importance of all 
public questions of the day, and that interest in the mental status 
and welfare of children is steadily widening, while the need of 
trained experts to determine the causes and methods of preven- 
tion of their mental and moral deficiencies is becoming more and 
more apparent. 

Owing to the fact that no really accurate census of the feeble- 
minded has been taken by the United States Government, or by 
any state, it is possible to determine the ntunber of mental defec- 
tives in this country only approximately ; the nearest approach to 
accuracy that can be made respecting the relative proportion of 
the feeble-minded to the whole population, as suggested in a 
report recently made to the State Charities Aid Association of 
New York,* is to base such estimate upon a comparatively pains- 

♦Thc feeble-minded in New York, by Anne Moore, Ph.D., 191 1. 



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152 PRESIDENTIAL ADDRESS 

taking investigation recently made by the English Royal Commis- 
sion. This commission estimated that "in Scotland there was 
one mentally defective person to every 400 inhabitants ; in Eng- 
land, one to every 217; and in Ireland, one in every 175." Dr. 
H. H. Goddard, of the Training School for Mental Defectives, at 
Vineland, New Jersey, avers that it is reasonable to assume that 
there is at least one mental defective to every 300 of the popula- 
tion of that state. 

It is estimated that in the United States, with a population of 
more than 90,000,000, the number of mentally defective persons 
is approximately 300,000. Of this number, according to the most 
conservative estimate, there are in the United States to-day 150,- 
000 to 200,000 incurable defectives who are unfit for social life 
or for the propagation of their kind. 

Of this vast multitude of defectives, an estimated number of 10 
per cent are in public and private institutions, the remaining 90 
per cent being at large, and practically unrestricted, some being 
in the public schools, where they are always mis-fits, and some 
at work, while the remainder comprise largely the idlers, the 
tramps, the vagabonds, the prostitutes, the inebriates and the 
criminals. 

Recent investigations had in the state of New York have 
shown that there are in that state approximately 30,000 feeble- 
minded or mentally defective persons, or one in about every 300 
of the population. Of these, in round numbers, less than 5000 
are in institutions established for their care; 7000 are confined 
in institutions not intended for their care; and the remainder, 
about 18,000, are at large, and free to reproduce their kind, thus 
perpetuating the race-menace of increasing fpeble-mindedness, 
and liable to commit murderous assault, arson, and crimes of 
sexual perversion, etc. It is estimated that there are in that state, 
at least 10,000 feeble-minded women and girls of child-bearing 
age, of whom more than 5000 are at large in the community, 
many of them leading immoral lives. 

Within the past two years a clearing house for mental defec- 
tives has been established by the commissioner of charities of 
New York, under the direction of Dr. Max G. Schlapp, assisted 
by a staff of psychiatrists and psychologists, as an accessory of 
the Department of Public Charities, for the purpose of determin- 
ing the final disposition of mental defectives and endeavoring to 



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CARLOS F. MACDONALD 1 53 

solve the problem of the classification, segregation, and the proper 
care and control of that constantly increasing class of our popu- 
lation — a purpose the importance of which could scarcely be 
overestimated. 

The clearing house, although still in its infancy, and maintained 
largely by voluntary contributions, has already rendered a great 
public service in registering and disposing of thousands of the 
city's mentally unfit, according to their several needs. This 
institution, the operations of which I have personally observed, 
is a veritable hive of scientific industry. Patients are referred to 
it from the schools, from the children's courts and from various 
charitable and philanthropic societies, while many of them are 
brought there by their relatives or friends. At present there are 
147 charitable and other institutions, exclusive of the children's 
court, hospitals and public schools, that send patients to the 
clearing house for examination and report. These patients are 
subjected to most careful scientific, mental and physical tests. 
The mental or psychological test — ^that is, the test to determine 
the patient's mental age or intelligence, as compared with his 
chronolc^c age — ^is made by the Binet-Simons method. This 
method enables the examiner to determine with reasonable cer- 
tainty the mental status of the subject, that is, the degree of his 
mental development, and to classify him accordingly. At the 
same time the family history is inquired into, with reference to 
the existence in the ancestry of a neuropathic or psychopathic 
taint, such as insanity, epilepsy, feeble-mindedness, alcoholism, 
criminality, moral obliquity or other prenatal influence. Inquiry is 
also made in respect to the personal history of the patients from in- 
fancy, especially with reference to their mental peculiarities, schol- 
arship, occupations, environment, etc., all of which are carefully 
recorded. These patients are also examined with reference to the 
existence of physical disorders or defects of a medical or surgical 
nature, the removal of which might effect an arrest of the mental 
retardation which is often mistaken by public school teachers for 
psychopathic mental defect. Subsequently they are seen at their 
homes, if they have any, by intelligent visiting nurses, and if it 
is found that that they cannot be properly cared for at home, as 
is frequently the case, they are sent to The Randall's Island 
Hospital for Atypical Children or to state institutions for that 
class. 



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154 PRESIDENTIAL ADDRESS 

Owing to the crowded state of the public institutions for the 
various classes of mental defectives in the state of New York, 
all of which have a constantly lengthening waiting list of s^li- 
cants, there remain thousands of uncounted and unrecognized 
mental defectives who ought to be segregated in proper colonies, 
but who, under existing conditions, remain at large, receiving 
no training whatever, and what is still worse, availing themselves 
of every opportunity to propagate their kind. 

It is clearly the duty of the state to protect itself from these 
growing evils by establishing colonies where those who are 
known to be mentally defective or subnormal can be segregated, 
and steps taken for the adoption of measures to prevent them 
from propagating their species. This duty can best be fulfilled 
by establishing such colonies under competent management which 
shall be entirely free from partisan influence and control. 

These colonies should be located in rural districts where lands 
are abtmdant and cheap, and where their inmates may be trained 
in ag^cultural and other industrial occupations, and where they 
will not have opportunity to commit crimes or to reproduce their 
kind. 

It is not to be expected that such colonies will ever become 
self-sustaining, although the products of their industries should 
materially lessen the cost of their maintenance. The cost to tax- 
payers, however, for the support of these institutions, would be 
a mere bagatelle in comparison with the enormous saving through 
eflfectual arrest of the propagation of the mentally defective 
classes. 

As bearing upon the question of cost, I quote the following 
illuminating paragraph from the report to the New York State 
Charities Aid Association, already referred to : 

That the segregation of defectives costs money is remembered; that it 
saves money is often forgotten. The initial cost of segregation would be 
great but the saving effected by correcting our present lax methods would 
be greater. As tax bills are not itemized, the ordinary citizen does not 
realize that he is at present paying for the unrestrained presence of the 
feeble-minded. An added tax for their segregation would be an apparent 
rather than a real increase, for through segregation of defectives, the num- 
ber of criminals, the number of prisoners, the cost of trials, the demand upon 
public and private charity would be materially decreased ; and as control of 
hereditary conditions resulted in decrease in the number of defectives, and 
training rendered many of them self-supporting, the expenditure necessary 



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CARLOS F. MACDONALD 1 55 

for their maintenance would from year to year grow less. The feeble- 
minded at large are as dangerous, if not more dangerous, than persons suf- 
fering from contagious disease. No consideration of cost, of parental affec- 
tion and responsibility, or of personal liberty should be allowed to weigh 
against public safety. 

Respecting the question of prophylaxis in connection with the 
problem of mental defectives, it may be said that there is no 
other form of disease or defect, mental or physical, with the 
possible exception of smallpox, that could be so readily and so 
surely stamped out, given the proper legal machinery for its 
control. This should embrace, first, the segregation of every 
dependent, feeble-minded person, and, second, the sterilization 
by vasectomy on the male and oophorectomy on the female, of 
every such person. 

That a radical cure of the evils incident to the dependent 
mentally defective classes would be eflfected if every feeble- 
minded person, every incurably insane or epileptic person, every 
imbecile, every habitual crimnial, every manifestly weak-minded 
person, and every confirmed inebriate were sterilized, is a self- 
evident proposition. By this means we could practically, if not 
absolutely, arrest, in a decade or two, the reproduction of men- 
tally defective persons, as surely as we could stamp out smallpox 
absolutely if every person in the world could be successfully 
vaccinated. 

The real object of dealing with mental defectives, as with 
crime, is the protection of society. This being true, there is no 
valid reason why society should not still further protect itself by 
making statutory provision for the prevention of child-bearing 
among the so-called unfit, that is, the mental defective and the 
hereditary criminal, and I believe that the time is not far distant 
when the necessity for such provision will be recognized and the 
means for its fulfilment adopted in every civilized community. 
Surely we should not hesitate to apply the same principles to the 
criminal and degenerate classes that we apply to vicious or other- 
wise unfit domestic animals, if by so doing it would, as we may 
reasonably suppose, result in materially lessening the vast amount 
of misery, crime and distress which are now so prevalent in 
every community, not to speak of the economic aspect of the 
question. 



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156 PRESIDENTIAL ADDRESS 

As regards the unsexing of criminals, feeble-minded, and other 
so-called tmfit individuals by surgical procedure, I am aware 
that strenuous objections to it have been raised in certain quar- 
ters. But these objections, I believe, are based largely on unrea- 
soning sentiment, prudery or ignorance of the nature and effects 
of the operation in question. 

The most of my hearers are doubtless familiar with the reports 
of Dr. H. C. Sharpe, of the Jeflfersonville Indiana State Reforma- 
tory, respecting the simple operation of vasectomy which he 
performed under legal sanction upon more than 500 of the 
inmates of that institution, without anaesthesia and without any 
tmtoward results. On the contrary, the operation was followed, 
in substantially every case, by improvement in the general char- 
acter and disposition of the individual, a lessening of nervous 
fatigue and irritability, and a decided increase in energy and 
sense of well-being. There was no atrophy of the genital organs 
nor impairment of sexual desire or of its gratification. These 
facts would seem to warrant the sanction of the operation as 
applied to mental defectives, chronic epileptics, confirmed crim- 
inals, habitual drunkards, etc., provided it be done under proper 
legal restrictions. 

Realizing that the subject of mental defectives is a trite one 
to most of my fellow members, I have aimed to discuss it here 
only in the most elementary way, and largely for the purpose of 
suggesting that it is a matter which may properly and profitably 
engage the attention of the association, and to that end I have 
prepared the following preambles and resolutions which, while 
disclaiming any pride of authorship or originality in them, I shall 
offer to the association at an opportune time during its present 
meeting for consideration and for such action thereon as it may 
deem best : 

Whereas, It is universally conceded that feeble-minded persons are, by 
reason of their mental deficiency, unable to conform to the laws that govern 
normal people, and hold themselves to acceptable standards of work and 
morality, and 

Whereas, The inability of the feeble-minded to assume the responsibility 
for their own conduct renders them a burden to their families and a menace 
to the public, upon whom the burden of their maintenance, of their crimi- 
nality, of their weakness and of their immorality ultimately falls, and 

Whereas, Many feeble-minded persons are susceptible to training and 
becoming self-supporting, useful individuals, and 



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CARLOS F. MACDONALD I57 

Whebeas, It is the consensus of scientific opinion that by the application 
of vigorous measures the conditions producing f eeble-mindedness may be, 
in great measure, controlled and the number of such persons reduced to 
those arising from exogenous or accidental causes, therefore be it 

Resolved, That it is the duty of every community properly to care and 
provide for all classes of idiots, feeble-minded persons and mental defec- 
tives, and that, in order to secure their greatest good and highest welfare, 
it is indispensable that institutions for their exclusive care and treatment, 
under competent medical supervision, and free from partisan influences, 
should be provided, and that it is improper except from extreme necessity 
as a temporary arrangement, to confine feeble-minded or mentally defective 
persons in jails, penitentiaries, hospitals for the insane, almshouses or other 
institutions not especially provided for their proper care and education. 

Resolved, That every state and country represented by this association 
should enact adequate laws for the proper segregation of feeble-minded 
persons, and the prevention of propagation of their kind, by separating 
the sexes and precluding ill-advised contact with the world at large. 

Resolved, That these same states and countries should enact a marriage 
law which will require a clean bill of health and evidence of normal mind 
before a marriage license is issued. 

In conclusion I congratulate the association upon the large 
attendance of representative members at this meeting; upon the 
excellence of the program offered; upon the prosperous and 
flourishing state of our affairs generally, and especially upon the 
number and quality of our present membership, which according 
to the secretary's records now numbers more than 800. 

I also congratulate you upon the spirit of fraternity which 
now pervades our ranks, and the comparative freedom from so- 
called " medical politics " and the cliques so often foimd in large 
organizations like ours, which meet but once a year, by reason 
of which there is an ever present tendency of its government to 
drift into the hands of a few, who, guided by precedent, often 
block the way of progress. 

And finally, I beg to thank the association for the high honor 
you have conferred upon me in choosing me to preside over your 
deliberations for the current year; and also for the uniform 
courtesy and indulgence extended to me by my associate officers, 
by the council, and especially by our accomplished and zealous 
committee of arrangements. 



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THE RELATIONS OF INTERNAL MEDICINE 

TO PSYCHIATRY. 

By LEWELLYS F. BARKER, M.D., 

Professor of Medicine in the Johns Hopkins University and Physician- 
in-Chief to the Johns Hopkins Hospital, Baltimore, Md. 

The subject which I have chosen for my remarks is the rela- 
tion of internal medicine to psychiatry. Workers in internal 
medicine who are not psychiatrists will, as a group, look at such 
a topic from a view-point somewhat different from that of a group 
of psychiatric workers. Moreover, no two members of either 
group can be expected to hold identical views, owing to in- 
equalities in innate tendencies and in opportunities for acquiring 
knowledge. You will not expect me, therefore, with the preju- 
dices of my group and with the bias peculiar to myself, to give 
expression to opinions wholly satisfactory either to psychiatrists 
or to other internists. As fellow workers in allied fields of natural 
science, however, your way of looking and mine are sufficiently 
alike to permit, I hope, of a similarity of view consistent with 
sympathy and with conditional approval. It is desirable that from 
time to time various internists and various psychiatrists shall give 
expression to their ideas regarding the mutual relations of their 
respective subjects, for the fruits of such discussion should grow 
in value with the number sharing in it. 

Satisfactorily to deal with my topic, the province of each of 
the two subjects should be defined ; but as with every two sciences 
which overlap or border on one another, there is likely to be some 
doubt as to the exact territory of each. As generally understood, 
internal medicine has to deal with the science and art concerned 
with the restoration and preservation of health by means other 
than those employed by the surgeon and the obstetrician, while 
psychiatry has to deal with the study and treatment of diseases of 
the " soul " or " mind," the word '* psychiatry " being derived from 
the Greek psukhe, meaning breath, life, soul, and iatros, meaning 



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physician. Thus, out of the larger subject, medicine, dealing 
with all disease other than that dealt with by surgery and by ob- 
stetrics, and including diseases affecting both what has been 
called the mind (psukhi) and what has been called the body 
(soma), there has developed a special branch known as psychiatry, 
in which, according to general assumption, special attention is paid 
to the diseases which affect particularly the mind. 

The actual establishment of psychiatry as a subdivision of 
internal medicine is of comparatively recent development, scarcely 
more than a htmdred years old. In the medicine of antiquity, it 
is true, disturbances of the " soul " were thought to be associated 
with bodily disturbances, especially with fever and with changes 
in the humors of the body, but this medical view of "mental 
disease " did not obtain during the middle ages. " Mental dis- 
turbances " for the scholars and the priests of that time were not 
looked upon as evidences of disease but rather as due to demo- 
niacal possession or divine punishment, occasionally to divine 
ecstasy or rapture. Medical men up to a century ago busied 
themselves but little with the study and treatment of those who 
were grossly disturbed " mentally." The treatment these unfortu- 
nates received varied with the disturbance. Some of them were 
lucky enough to be revered and worshipped as saints, but more of 
them had the misfortune to be regarded as sinners whose only 
hope lay in a priest who could exorcise evil spirits ; all too often, 
as witches or wizards, practitioners of sorcery, they were made 
to feel the tortures of the rack or to suffer at the stake.* The 
interest of medical men had become reawakened in mental disease 
a long time before it became generally recognized that mental 
disturbances are best studied and treated by physicians, and it 
was only after the insane began to be treated in a humane manner 
in hospitals under the care of physicians that the scientific study 
of " mental disease " could be begun.' 

Pinel and Elsquirol in France; Reil, Nasse and Jacobi in Ger- 
many; Gardner Hill, Tukc and G)nnelly in Great Britain were 
the pioneers in ameliorating the conditions by providing medical 

*Kraepclin, E.: Psychiatric. V. Aufl.. Leipz., 1896. 
* Cf. Ziehen (T.) : Die Entwicklungsstadicn dcr Psychiatric, Bcrl. klin. 
Wchnschr., 1904, XU, m-'fio. 



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LEWELLYS F. BARKER l6l 

treatment.' In America asylums for the insane began to be 
established in the first quarter of the last century; the propa- 
gandism of Miss Dorothea Dix, in the middle of the century, led 
to great reforms in care, and with the opening of the Utica State 
Hospital in 1843 began "the era of awakening/'* A demand 
for psychiatric clinics, for the scientific study of "mental dis- 
eases," was made by Griesinger in 1868, since when such clinics 
have been established in Germany in nearly all the university 
centers. We have begun to follow Germany's example in Amer- 
ica; a psychiatric clinic has existed for several years in Ann 
Arbor ; Boston has a psychopathic hospital ' which serves a similar 
purpose, and now Baltimore has the Phipps Psychiatric Clinic. 
During the past twenty-five years psychiatry, in spite of the ob- 
stacles in its way, has developed with surprising rapidity, attaining 
to general recognition as an important medical specialty. The 
study of patients by clinical methods has led to the recognition of 
certain types of abnormal behavior, disorders with characteristic 
symptoms, course and termination. Psychiatrists, calling to their 
aid the methods, and utilizing the results, of certain of the more 
fundamental sciences (anatomy, physiology and embryology of the 
nervous system, normal psychology, pathological anatomy, ex- 
perimental pathology, pharmacology, general medicine), have been 
gradually accumulating data for a foundation upon which a true 
science of psychiatry may later be built, a science which will 
reveal the nature and causes of what are now called "mental 
disorders " and which will permit man to cure or to prevent them. 
When we inquire why it is that psychiatry has been marked off 
as a special province of internal medicine, to be cultivated for its 
own sake by a selected group of men known as psychiatrists, 
rather than by the general practitioners of internal medicine who 
deal with diseases of the respiratory, circulatory, digestive, uro- 
genital, nervous and other systems of the body, we find the 

•Garrison (F. H.) : An introduction to the history of medicine. Phila. 
and Lond., 1913; also, Meyer (A.) : A few trends in modem psychiatry. 
Psychol. Bull, 1904, I, 217-240. 

*Hurd (H. M.) : Three-Quarters of a Century of Institutional Care of 
the Insane in the United States. Am. J. Insan., Jan., 1913. 

■C/. Southard (E. E.) : Contributions from the psychopathic hospital, 
Boston, Massachusetts: Introductory note. Bost. M. and S. J., 1913. 
CLXIX, 109-116. 
II 



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reasons (i) partly in the historical development above referred to, 
(2) partly in the fact that, for obvious reasons, the markedly dis- 
turbed patients with whom psychiatrists first dealt could not be 
cared for properly except under conditions differing somewhat 
from those which obtain in people's homes and in the ordinary 
wards of hospitals, and (3) partly in the recognition that abnormal 
mental states and the pathological behavior which accompanies 
them require for their investigation a training and an experience 
both in normal psychology and in psycho-pathology which have, 
hitherto, not been available to the ordinary graduates of medical 
schools. 

It was, then, chiefly an urgent practical need, that of caring for 
patients whose extraordinary behavior was such as to preclude 
medical attention at home and in ordinary hospitals, which led 
to the development of psychiatry as a special branch of medicine. 
It is well that this should be emphasized, for as knowledge of 
psychiatry and of medicine increases, it becomes ever dearer that 
there is no fundamental difference between the pathological states 
studied by the psychiatrist and those studied by the general 
internist. The patients who ultimately fall into the hands of the 
psychiatrists are usually observed in the earlier periods of their 
illness for a longer or shorter time by internists, and many patients 
who remain in the general internist's care throughout the whole 
of their illness exhibit behavior which would be recognized at 
once by those skilled in psychiatry as the accompaniment of ab- 
normal mental states. 

Some seem to believe that the domain of abnormal "mental 
states " is identical with that of psychiatry, belonging exclusively 
to it, while the domain of abnormal '' bodily states " is identical 
with that of internal medicine, belonging exclusively, in turn, to 
it. Without entering further at present upon what is meant by 
"mental states" and "bodily states" respectively, it is obvious 
that to define the provinces of internal medicine and psychiatry 
in the way mentioned will be satisfactory neither to the psychi- 
atrist nor to the general internist. For a large part of the work 
of psychiatrists to-day consists in the study of the " bodily states " 
of their patients ante mortem and post mortem, and no small 
part of the work of internists consists in securing from their 



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UEWELLYS F. BARKER I63 

patients reports of modifications of their '* mental states/' known 
ordinarily as the " symptoms *^ of which the patients complain. 

In the study of every patient, an internist begins with listening 
to a '' complaint." If a patient complain of a pain in the abdomen, 
of a cough, of a feeling of palpitation, of shortness of breath, of 
diarrhoea, of dimness of vision, of sleeplessness, of disinclination 
for exertion, of loss of appetite, of numbness in his left foot, in 
each instance he reports a modification of his " consciousness '' 
which has led him to assume that his body is diseased, perhaps, in 
the part of it which feels abnormal to him. This assumption of 
the patient may or may not be correct ; the internist often finds 
that the patient's '' ideas " of the nature and localization of his 
" bodily disturbance " are erroneous. The physician uses, how- 
ever, the psychic (anamnestic) clues as guides to his search for 
pathological-physiological processes ; he hunts for physical, chem- 
ical, or biological changes, first in the parts to which the patient 
has referred him, and also elsewhere in the patient's body; very 
often he gives but little more thought to the "mind" of the 
patient who has reported one or several modifications of his 
consciousness. Now there would seem to be easy transitions from 
these slighter modifications of "consciousness" which we call 
the " symptoms " of ordinary " somatic " disease, to the out- 
spoken and complex " mental " s}mdromes with flag^rant maladjust- 
ment to surroundings with which the psychiatrist has ordinarily 
to deal. It is the internist's experience with the pain of gall-stone 
colic, with the deliritun of typhoid fever, with the mental con- 
fusion of uraemic intoxications, with the hallucinations which ac- 
company enforced abstinence after alcoholic excess, with the de- 
pression which accompanies mucous colitis, with the optimism of 
the consumptive, with the aphasic, apraxic and agnostic phenomena 
in cerebral atherosclerosis, with the post-paroxysmal homicidal 
act of a man who has epilepsy, with the delusions of grandeur in 
general paresis, with the moral and intellectual defects often seen 
after disease of the brain in infancy, with the dulness, slow- 
wittedness and drowsiness of myxoedema, and with the anxiety, 
apprehension, fear, restlessness and irritability characteristic of 
exophthalmic goitre, which makes him think of the importance of 
studjring " somatic " alterations when the " mind " or " psyche " 
is disturbed, and of observing the " behavior " of the patient and 



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of inquiring as to changes in his "mental" states when the 
" body " or " soma " is obviously diseased. 

We might further attempt to express the relation which obtains 
between internal medicine and psychiatry by applying in patho- 
logical domains a modern conception of the relation of physiology 
to psychology,* and say that internal medicine (exclusive of 
psychiatry) investigates the processes (under diseased conditions) 
of the parts, or organs, of which any organism is composed, while 
psychiatry investigates the activities (in abnormal states) of the 
organism as a whole, that is, those activities in which it operates 
as a whole or unit. But from what has been said of the work now 
actually carried on by psychiatrists on one side and by general 
internists on the other, it is plain that these definitions are not 
entirely satisfactory, though they approach the goal and are 
doubtless akin to the considerations in which psychiatry is defined 
as " the science which deals with disorders of adaptation or ad- 
justment of the person to the ' situations ' in which he finds him- 
self." If we modify this last definition of psychiatry so as to 
include only the cases in which there is conspicuously abnormal 
behavior of the person as a whole, we shall come closer to the 
actual work of the psychiatry of our time. It is not worth while, 
perhaps, to strive too hard for precision. Even if we could satis- 
factorily delimit the provinces under discussion to-day, the bound- 
aries would have to be changed a little later on. We must, there- 
fore, forego any attempt at final and rigid mapping, be content 
with outlining the areas provisionally, and be prepared to change 
the outlines as the sciences develop, as their methods of study 
change, or as the needs of practice dictate. Our difficulties would 
only be increased if we tried sharply to mark out the field of 
neurology; this doubtless explains why, in some universities, 
neurology has an independent place, in others is combined with 
psychiatry, and in still others is kept in the department of internal 
medicine. 

It would certainly not be wise to limit the psychiatrist's studies 
to what are ordinarily known as the " insanities " or " lunacies," 
to the patients whose " unsoundness of mind " is, for example, 
symptomatologically designated as mania, melancholia, dementia, 

•McDougall (W.): Psychology, N. Y. (Home Univ. Library), 1913- 



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LEWELLYS F. BARKER l6S 

hallucinatory confusion, paranoia, hebephrenia or catatonia, S3m- 
dromes one or more of which may be met with in the several 
pathological states known as the manic-depressive psychoses, the 
idiocies and imbecilities, the toxic and infectious processes, de- 
mentia paralytica, the senile dementias, or the psychoses of 
adolescence (dementia praecox). While the practical side of his 
work may compel him to give the major part of his time to the 
study and care of such patients, it is mandatory for the advance 
of his science that he shall have opportunity to study also (i) 
some of the patients ordinarily described as " nervous " or " psy- 
choneurotic," rather than "insane," I mean, for instance, the 
"neurasthenic," the "hysterical," the "psychasthenic," or the 
" hypochondriacal," and (2) some of the patients, presenting the 
phenomena known as aphasia, agnosia, and apraxia, due to local 
lesions in the brain. There is no dearth of such material ; every 
community supplies it in amounts adequate to provide for the in- 
vestigative needs of the psychiatrists, as well as for those of the 
general internists and the neurologists. It will be all the better 
if the psychiatrist can add still further to his objects of study and 
include a certain number of those individuals who are thought 
not to be actually diseased but only to be psychologically " un- 
usual," for instance, (i) geniuses, (2) those who have undergone 
or are reported to have undergone peculiar experiences (hypnotic, 
mystical, psychotherapeutic, telepathic, etc.), and (3) those who 
manifest so-called anti-social tendencies (e. g., vagrants, prosti- 
tutes, criminals) . 

Indeed, to build up a general psychopathology, whether it have 
an associational basis, as in the attempt of Ziehen, or a clinical 
pathological basis, as in the effort of Wernicke,* or be more 
eclectic, as exemplified by the recent works of Lugaro' and of 
Jaspers,* a large and varied clinical and pathological experience is 
desirable. The general psycho-pathologist can, however, in his 
constructions, make good use of the results of intensive studies 
made in more circumscribed fields. He must know how to value 
in the first place researches dealing with the subjective phenomena 

' Wernicke (C.) : Grundriss der Psychiatrie. 2 Aufl., Leipz., 1906. 
'Lugaro (E.) : Modem problems in psychiatry, Eng. Transl. by D. 
Orr and R. G. Rows, Manchester, 1909. 
•Jaspers (K.) : Allgemeine Psychopathologie, Berlin, 1913. 



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of mental disease (phenomenology), whether these are reported 
by patients as referring to external objects, to persons other than 
themselves, or to their own bodies, and including not only cognitive 
states but also feelings and emotions (affective states), and con- 
sciousness of effort or striving (conative states) . He must under- 
stand also how to estimate the objective symptoms of "mental 
disease," the objectively demonstrable disturbances of perception, 
comprehension, orientation, association, memory, motility, speech, 
the bodily expressions of mental states (physiognomy, writing, 
work, behavior). He will pay attention especially to reports of 
investigations undertaken from the experimental side " Besides 
utilizing these studies bearing upon the subjective and objective 
elements, he has further to determine the worth of researches 
which deal with the connections which exist among the subjective 
phenomena, that is, with the way in which systems and disposi- 
tions develop in the mind in disease and with the manifestations 
of the abnormal " structure of the mind " in the so-called " patho- 
logical reactions,"" in "pathological suggestibility," in "patho- 
logical after-effects of earlier experiences," or in the splitting off 
of smaller or larger systems and dispositions from the mind as 
a whole ("dissociation of personality"). In this domain come 
also the observations upon the attitude of the patient toward his 
own disease, whether it be one of total "perplexity," or one in 
which he more or less critically observes his own mental state and 
decides that it is either normal or abnormal (absence or presence 
of so-called " disease-insight "). 

The worth of investigations of the connections existing among 
the elements on the objective side have also to be weighed and 
judged by the all-round psychopathologist. These connections 
appeal especially to the worker who has been trained in biology, 
physics and chemistry, for it is in them that he believes that causal 
explanations are to be sought. Regarding the structure and func- 
tions of a living organism as the resultant of the interactions 
between factors of heredity and factors of environment, he will 
enter upon the Herculean task of analyzing, in an individual case, 

**C/. Hoch (A.) : A review of psychological and physiological experi- 
ments done in connection with the study of mental diseases. PsychoL 
Bull, 1904, I, 241-357. 

** Meyer (A.): The problems of mental reaction-types, mental causes, 
and diseases. Psychol. Bull., 1908, V, 245-261. 



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LEWELLYS F. BARKER iSj 

the reciprocal influences of exogenous forces and the innate 
tendencies derived from the patient's progenitors. Here all the 
methods of internal medicine — ^physical, chemical and biological — 
have to be employed. It is only on a basis of studies such as I have 
referred to that we can hope in the future for a satisfactory gen- 
eral psychopathology, one adequate for application to the clinical 
syndromes which we meet every day either as psychiatrists or as 
general internists. And as our knowledge of general psycho- 
pathology grows, our classification of the psychoses and psy- 
choneuroses will gradually change. Qinical S3mdromes will be 
multiplied or reduced as further knowledge permits of greater dis- 
crimination on the one hand or of better s)mtheses on the other. 
Psychological classifications will arise on the subjective side, 
while on the objective side pathological-histological, chemical, 
physical, and biological classifications will be established; and, 
most important of all, we shall ultimately arrive at the groupings 
which are so important for prevention, namely the etiological. 

I have spoken of " consciousness " " as though there were no 
doubt that it occurs. But we live in iconoclastic times, and there 
are people who deny the existence of " consciousness " as they do 
that of " ideas " and the possibility of " introspection." " Now 
medical men, as a rule, have had but little training in psychology 
or in psychophysics. They have had an education in natural 
science (physics, chemistry and biology), and in the laboratory 
and clinical branches of medical science. They take it for granted 
that they are conscious organisms themselves, that other htunan 
beings and perhaps animals are conscious, and that consciousness 
if experienced by lower animals, by plants, or by inanimate ob- 
jects in the external world must be very unlike their own. They 
are familiar with different grades of consciousness in themselves 
from the full awareness of alert states through the lessened aware- 
ness of dreams to the "unconsciousness" of deep sleep or of 
ether-anaesthesia. This consciousness occurs in the same living 
body which they study in other ways ; " they do not think of it 

^Cf, Marshall (H. R.) : G)nsciousness. N. Y., 1909, 1-685. 

"See the interesting discussion of this subject by Lovejoy (A. 0.)» On 
the existence of ideas. Johns Hopkins Univ. Giro., n. s., 1914* 17B-235. 

^Kraus (F.) : Die Abhangigkeitsbeziehungen zwischen Seele und Korper 
in Fragen der inneren Medizin. Ergebn. d. inn. Med. n. Kinderheilk., 
Bcrl, 1908, I, 1-46. 



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as anything separable from the living body ; it disappears some- 
times while the body is alive ; they think that human and animal 
consciousness ceases to exist, as such, at death and often at a 
considerable period before death when this is preceded by coma." 
Familiar with the conceptions of development and of adaptation, 
they think of the gradual evolution of consciousness in each 
human individual as well as in the animal series ; they think of 
it as having its origin in lower forms of mentality, for they do 
not think of attributing to the amoeba any awareness comparable 
to their own; since, however, they see a graded series of living 
organisms extending all the way from the protozoa to man, it is 
not hard for them to think of similar gradations in the " mental " 
or " psychic " all the way up to the " mind " of man from the 
" protoaesthesia " of the amceba. Indeed some medical men, as 
did Paracelsus and Jerome Cardan centuries ago, can go further 
and conceive of a " psychic " side to the inorganic world (as in 
the doctrines of hylozoism and panpsychism) ." On account of 
their training in biology and in evolution, physicians think of the 
mind as developing parallel with the increasing complexity of the 
mechanisms of regulation and association, that is, with the ad- 
vancing intricacy of the nervous system, in organisms struggling 
for their own existence and that of their species. They find 
it natural, therefore, to look upon "consciousness" and upon 
" inf raconscious mind " as in some way indissolubly connected, in 
human beings and in the higher animals, with the physiological 
processes going on in the nervous system and the sense organs. 
They are s)mipathetic with the doctrine of various levels of 
reflexes in the nervous system ; they recognize that the activities 
of the lower levels may not be associated with consciousness but 
think it possible, with Knight Dunlap," that no consciousness 
occurs without complete arc-reflexes involving the higher levels. 
In examining the writings of workers in psychology, physicians 
sometimes find it diflicult to understand all that is said in the dis- 

" I am, of course, not referring here, in any sense, to the ultimate problem 
of the " immortality of the soul." 

"See articles on these subjects in Eisler (R.), Worterbuch der philo- 
sophischen Begriffe. 2 Aufi., Berlin, 1904. 

"Dunlap (K.) : A system of psychology, N. Y., 1912; also, Images and 
ideas. J. H. Univ. Circ, 1914, 161-177. 



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LEWELLYS F. BARKER 169 

cussions regarding (i) the difference between "consciousness" 
and its " content " and (2) the subject-object relationship ! Med- 
ical men are, however, conscious of " knowing " and " feeling " 
and " striving " themselves, and they note that these processes 
occur in cycles which tend naturally to end in feelings of " satis- 
faction." Observing other people's behavior, they conclude that 
these others also " know " and " feel " and " strive." They realize 
that they can be conscious not only of content which is '* present " 
(intuition) but also of content "not present" (imagination). 
They can recall the past (recollection) ; learning, too, that what 
they are conscious of at any given moment has its " meaning " 
because of earlier experiences, they speak of " memory " and try 
to explain it by conceiving of some structural modification of the 
nervous system that endures, labelling the record a " mental dis- 
position" or an "engram." They see that, as minds develop, 
these " mental dispositions " become exceedingly numerous and 
are systematically arranged in smaller groups, larger groups and 
finally in one vast system ; on the cognitive side, the total acctmiula- 
tion constitutes, abstractly considered, the " knowledge " possessed 
by the mind, while on the affective and conative side the total 
accumulation, abstractly considered constitutes the "character" 
of the individual." 

Especially interesting to physicians and psychiatrists are the 
systems of mental dispositions which pertain to the body of the 
individual in contrast with those which pertain to the " world " 
external to that body. In all conscious states the background is 
formed by somatopsychic constituents, that is by elements refer- 
able to the body itself, including the kinaesthetic and visceral sen- 
sations, the innervation-feelings, the appetites, and the aversions, 
and the various so-called affective or emotional states. Our 
bodies are always "with us"; they are being continually ex- 
perienced in our conscious states ; the " content " corresponding 
to these bodies is relatively constant as compared with the infinite 
variation of the " content " corresponding to the external world. 
No wonder that this "content" pertaining to the body seems 
to be peculiarly our own ; it is " private " content in contrast with 
that content which (in a sense, but only in a sense) can be publicly 
shared. No wonder that we speak therefore of the " self," and 

"C/. McDougall (W.) : loc. cit 

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define introspection in the narrower sense as " observation of the 
self," remembering, however, that in the wider sense introspection 
may refer to examination of the total content. Nor is it sur- 
prising that many find it desirable to designate the " observer " as 
the " I " or " Ego," the " subjective correlator of experience " in 
contrast with " what is observed," i. e., with the content (" self " 
and " not self ") ." In this connection it is well to keep in mind 
the fact that the body is an agglomerate of organs and that the 
conditions dealt with by the physician often involve gross altera- 
tions in the elements of this organ-agglomerate. It is surely not 
surprising, that somatic disease is often accompanied by altera- 
tions in the " self " which have a peculiar tendency to persist and 
to be characterized by negative feeling tones. 

Medical men are not likely to give up the study of consciousness 
or to refuse to use the reports given by patients of their " sub- 
jective " experiences." Such a policy would seem to them absurd. 
But wedded as they are to the method of investigation of the 
natural sciences, they welcome objective methods of study when- 
ever these are feasible. This predilection, together with the 
naturalist's tendency to resort when possible to comparative** 
and genetic methods, accotmts for the physicians' sympathy with 
the " behavior psychology " of our time. The study of animal 
behavior by men like Loeb " and Jennings " has given us entirely 
new conceptions of instinct and of intelligence, of the nature of 
so-called "purposive activities," of the bases of human nature, 
and of the evolution of mind in the animal series up to man. 
Recently a number of psychologists — ^the so-called behaviorists — 
have tried to eliminate introspective methods in psychology and to 
describe the whole mental life of man in terms of " expression " 
or " behavior." Starting with the conception of the neuropsychic 
reflexes (inherited nervous mechanisms modified by past indi- 
te/. Dunlap (K.): he, cit, 

^Cf, Angell (J. R.) : PsychoL Rev., 1913, XX, 255-270. 
**C/. Herrick (C. J.) : Some reflections on the origin and significance of 
the cerebral cortex. J. Animal Behavior, 1913, III, 236. 

"Loeb (J.): Comparative physiology of the brain and comparative 
psychology, N. Y., 1900, 1-309; also. The mechanistic conception of life, 
Chicago, 1912, 1-232. 

"Jcnnmgs (H.) : Behavior of the lower organisms. N. Y., 1906, 
Macmillan Co. 380 p. S"". 



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LEWELLYS F. BARKER I7I 

vidual experience) they study the responses to external stimuli 
(reflex responses) and to internal stimuli (automatic responses) 
as manifest in movements, vasomotor activity, or gland secretion. 
In this country, Watson ** and Meyer " are well-known advocates 
of behavioristic studies. Recently the Russian neurologist, v. 
Bechterew," in a book entitled " Objective Psychology *' has made 
a consistent and fairly successful attempt to view human psy- 
chology from this standpoint. The "conditional reflexes*' (in- 
volving associative memory) can be studied in several ways. 
Pawlow taught us the use of the " salivary method " in the dog; 
Weber, in Kraus's clinic in Berlin, worked with the vasomotor 
method; Bechterew uses a special method, that of motor asso- 
ciation reflexes. In studying the more specialized forms of com- 
plex responses, Bechterew describes the "concentration-reflex" 
(the behavior analogue of attention), the "s3rmbolic reflex" 
(analogue of language) , and the " personal reflex." As a program 
of study likely to be fruitful, behavior psychology would seem to 
be highly commendable ; but in its more dogmatic statements, its 
denial of the value of introspective methods, its total repudiation 
of " images," medical men are not likely wholly to concur. 

Internal medicine and psychiatry, confronted as they both are 
by the problems of the physical and the mental," must obviously 
be directly and deeply concerned with the nature and origin of 
knowledge (epistemology) and with the nature of reality (ont- 
ology) . Starting out, as every one must, with naive notions regard- 
ing the world of things we know and as to how we know it, 
physicians come gradually and more or less unconsciously to the 
adoption of certain epistemological and ontological theories. 
Though there is no unanimity in opinion among medical men, 
their special training and experience make them much more 
sympathetic with some tendencies than with others. First of all, 

•* Watson (J. B.) : Psychology as the behaviorist views it Psychol. 
Rev., 1913, XX, I5&-I77; also, Image and affection in behavior. J. Phil., 
PsychoL, etc, 1913, X, 421-428. 

" Meyer (M.) : Fundamental laws of human behavior. 1911. 

**v. Bechterew (W.) : Objective Psychologie. Leipz. and BerL, I9i3f 
1-468L Sec review by H. C. Warren in Science, N. Y., 1914, n. s., XXXIX, 
426-428. 

""Cf. Warren (H. C.) : The mental and the physical. Psychol. Rev., 
1914, XXI, 79-ioa 



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172 ANNUAL AIM>R£SS 

they desire to stick close to experience, lauding the empirical and 
deprecating the speculative ; but, despite this tendency, which on 
the whole is a good one, they often refuse to theorize when it 
would be helpful, and they are ever unconsciously transcending 
experience. In the second place, brought up in the school of the 
natural sciences, saturated with mechanistic explanations, the 
medical mind has a structure which predisposes it, at least at the 
beginning of its critical and philosophic interests, to what meta- 
physicists designate as materialism and realism, rather than to 
what they call idealism. 

On talking with a number of the more reflective among the 
medical men I know, and on reading opinions in the literature, 
it would seem that the critical medical mind of to-day is appealed 
to especially by the natural-science theory of knowledge" (W. K. 
Qifford, Karl Pearson, E. Mach, W. Ostwald, H. Poincare), but 
as regards theories of being it is less uniformly responsive. Many 
physicians lean toward a phenomenal idealism which is not far 
removed from realism {e, g., Immanent Philosophy of W. 
Schuppe; Empirio-criticism of Avenarius; Energetics of W. 
Ostwald and Lasswitz) ; others adopt a personal idealism (e. g,, 
Humanism of Schiller ; Pragmatism of W. James, J. Dewey, and 
H. Bergson) ; still others are captivated by some form of realism 
{e, g,, Intuitive Realism of the Scotch School; Synthetic Philoso- 
phy of H. Spencer ; the New Realism of Woodbridge, Montague, 
Holt, and S. Alexander) . Occasionally a physician adopts an out 
and out idealism {e, g,, Neo-Hegelian Rationalism or Absolutism 
of B. Bosanquet ; of J. Royce), and, here and there, one, reflecting 
upon the issues between the realists and the idealists, accepts a kind 
of synthesis of pragmatism and rationalism, trying to avoid the 
extremes of each (e. g., Theism of J. Ward; of E. H. Griffin"). 
A large number of medical men decline to let their pia mater be 
stretched by metaphysical considerations at all; many assume 
either an agnostic attitude, or at least one of suspended judgment." 

" For a good epitome of such views, see Kleinpeter (H.) : Die Erkennt- 
nistheorie der Naturforschung der Gegenwart. Leipz, 1905, 1-156. 

*C/. Griffin (E. H.) * Some present-day problems of philosophy. Johns 
Hopkins Univ. Ore, 1914, 140-160. 

■•For welcome summaries of current philosophical views, see (i) Perry: 
Present philosophical tendencies . . . . , and, Caldwell (W.) : Pragmatism 
and idealism. Lond., 1913, 1-265. 



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LEWELLYS F. BARKER 173 

Psychiatry, then, as I see it, is a large and very important 
chapter of Inner Medicine. Every internist should have at least 
some training in psychiatry, and every psychiatrist should be well- 
versed in the fundamental facts and methods of study of general 
medicine. Psychology — ^both introspective and behavioristic — is 
just as important as a preliminary study for the prospective med- 
ical student as physics, chemistry or biology. 

Considering the disadvantages under which psychiatry has 
worked in the past, the science is certainly to be congratulated 
upon the fine minds it has attracted and upon the results it has 
accomplished under difiiculties. Full of fascinating problems, 
psychiatry is in the near future, I venture to aver, likely to prove 
a formidable rival of all the other medical specialties for the 
aflFections of the better yoimg men now entering upon medical 
careers. We have only to think of the very important social re- 
lations of psychiatry to understand that this must be so. 

Contemporary psychiatry shows no timidity in the tasks it is 
assigning itself." On the contrary, it manifests an ardor and a 
courage typical of youth. It does not limit itself to the mere 
study of the insane or the manifestations of insanity. It desires 
to investigate the cerebral events underlying the abnormal mental 
states. It is not satisfied with normal psychology or with brain- 
anatomy and brain-physiology as they exist to-day, and insists, 
that at least some psychiatrists make contributions in these fields. 
It studies the pathological anatomy and histology of the brains 
of the mentally diseased, but it does not stop at the local changes 
in the brain; it studies also the changes in other organs of the 
body, seeking abnormal processes there which can account for 
abnormal brain processes. Then it tries to discover in a faulty 
heredity, or in environmental influences, explanations of these 
abnormal processes. Psychiatry studies also the evolution of mind 
in the individual and in the animal series, and tries to relate this 
evolution to studies in comparative anatomy and physiology. It 
does not try to escape from the borderlands of philosophy and 
metaphysics, but actually ventures into these neighboring terri- 
tories, taking part, as we have seen, in attempts to construct a 
theory of knowledge and theories as to the nature of reality. 

"C/. Lugaro (E.) : he. cit. 



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174 ANNUAL ADDRESS 

Psychiatry has, surely, no narrow conception of its plan of work " 
The technical knowledge demanded for a successful attack upon 
all its problems is enormous. The methods of a whole series of 
subsidiary sciences must be drawn upon. No single investigator, 
of course, can hope to be active in all parts of this large and 
varied field of inquiry. Not even the collective activities of the 
members of a single psychiatric clinic can cultivate more than a 
small portion of the field. The work is cut out for the aggregate 
of the world's psychiatrists for at least many generations ahead. 
The general internist can, perhaps, do most to help psychiatry 
progress by studying carefully the bodily " equivalents " of psychic 
phenomena, the contractions of striped and unstriped muscles, the 
activities of the glands of external and internal secretion, the 
respiratory and vasomotor changes, and the modifications of 
coenssthesia. Present-day studies of the abnormalities of the 
functions of the autonomic nervous system " on the one hand, and 
of the diseases of the ductless glands (endocrinopathies)** on the 
other, and their relations to the mind, are instances which illustrate 
the possible influence of Inner Medicine on a developing Psy- 
chiatry. We have far to go, but we are on the way. 

"C/. Meyer (A.) : A short sketch of the problems of psychiatry. Am. 
J. Insan., 1897, UII, S3»-S49. 

•C/. Barker (L. F.) and Sladen (F. J.) : The clinical analysis of some 
disturbances of the autonomic nervous system, etc Trans. Asso. Am. 
Phys., 1912, XXVII, 471-502; also, Barker (L. F.), the clinical significance 
of the autonomic nerves supplying the viscera, and their relations to the 
glands of internal secretion. Can. Med. Asso. J., Montreal, Aug., 1913. 

•• Biedl (A.) : Innere Sekrction. II Aufl., Wien, 1913. 



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GENERAL PARALYSIS AS A PUBLIC HEALTH 
PROBLEM. 

By THOMAS W. SALMON, M.D^ 

National Committee for Mental Hygiene; Passed Assistant Surgeon, 
U. S. Public Health Service. 

The object of this paper is simply to state the problem of general 
paralysis in the language of preventive medicine. We have to 
consider a disease so formidable that the mortality rate practically 
coincides with the morbidity rate. Let us attempt to answer some 
of the questions which we would ask if we were examining any 
other important cause of death from a public health view-point : 
What is the incidence of the disease? Do the mortality reports 
accurately show its prevalence? If not, in what mortality groups 
shall we be most likely to find it reported? What is there of 
practical sanitary interest in the age, sex, race, occupation and 
environment of the victims of the disease? By what means may 
it be controlled? 

The nation is the field in which an inquiry should be undertaken 
to answer these questions, but unfortunately there are two great 
obstacles to such a wide study. One is the fact that little more 
than 60 per cent of the people in the United States are bom and 
die in what is termed the " registration area " — ^that portion of 
the country in which satisfactory records of the causes of deaths 
are made. The other obstacle is the fact that the status of 
psychiatry in different parts of this country varies so greatly that 
the clinical reports of hospitals for the insane cannot be satis- 
factorily compared. It is necessary, therefore, to choose a nar- 
rower field and to sacrifice completeness for accuracy. New York 
State has an efficient law for the registration of births and deaths, 
and the insane are treated in hospitals making use of uniform 
methods of collecting scientific data. Moreover, statistical studies 
of the work of the hospitals are conducted, under a carefully 
devised general plan, by a competent medical statistician asso- 
ciated with the central supervising board. If our inquiry is made 
in New York, therefore, we shall be able to place much more 



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176 GENERAL PARALYSIS AS A PUBLIC HEALTH PROBLEM 

confidence in its results than if we undertook to make it in a larger 
territory. 

As general paralysis is practically a uniformly fatal disease, 
we may read the record of its incidence in the mortality rates. 
We find that in the year ending December 31, 1913, the New 
York State Department of Health reported 591 deaths from this 
disease. The fiscal year of the New York State hospitals ends 
September 30th. In the year ending on this date in 1913, 638 
cases of general paralysis died. The discrepancy is due to the 
fact that a considerable number of deaths in general paralysis 
are assigned to other causes. Of the 638 deaths in this disease 
which occurred last year in the New York State hospitals, only 
487, or yy per cent, were assigned to general paralysis. The 
others were assigned to a variety of other causes. In about one 
per cent of the paretics who died, the causes given are definitely 
associated with the lesions of the disease itself. Such causes are 
cerebral hemorrhage, meningitis and syphilis. There can be no 
question of the impropriety of ascribing deaths in general paraly- 
sis to these causes. It would be as logical to give " peritonitis " as 
a cause of death in cases of typhoid fever in which perforation 
occurs or to give " hemorrhage " as a cause of death in pulmonary 
tuberculosis. About ten per cent of deaths in general paralysis 
in New York State hospitals were assigned to causes which are 
really terminal conditions in the disease or accidents dependent 
upon its existence. Among these may be mentioned decubitus, 
purulent infections, septicemia, bronchopneumonia and edema 
of the lungs. There may be some doubt as to whether it is proper 
to give these as primary causes of death in a disease like general 
paralysis in which the pathological process is well understood 
and the relation of the lesions in the brain to the general bodily 
disintegration is definitely known. We do not give such causes 
in deaths from cancer and there seems no special reason for doing 
so in general paralysis. Personally, I think that it is most unde- 
sirable to term such conditions primary causes of death. They 
are distinctly secondary causes and this fact should be indicated 
in death certificates. 

In about six per cent of all deaths in general paralysis in the 
series under consideration the causes assigned bear little relation 
to the disease itself. Among such causes may be mentioned 



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THOMAS W. SALMON I77 

tuberculosis, t3rphoid fever, cancer, hernia and organic diseases 
of the heart and of the kidneys. 

So in our state hospitals, where very few cases of general 
paralysis die without a diagnosis of the disease being made, 
general paralysis is given as the cause in only yj percent of 
deaths. If this is true of deaths from this disease in the com- 
munity at large, 768 deaths must have occurred in the State of 
New York from recognized general paralysis during the year 
ending December 31, 1913, instead of 591 as reported. But it is 
undoubtedly true that a very much larger proportion of deaths 
in this disease occurring in the community are reported under 
some complicating physical condition, even though the existence 
of general paralysis is recognized, than in institutions where the 
disease itself is so well understood. 

It is a strong statement to make, but I believe that general 
paralysis is practically unrecognized outside of institutions for 
the insane and that the small excess in the number of deaths in 
recognized general paralysis reported in the state at large over 
those reported in institutions for the insane can be accounted for 
almost wholly by deaths among patients with general paralysis 
who have been discharged. Few persons, even those engaged in 
institution work, realize how many cases of general paralysis are 
discharged from our public institutions and are never readmitted. 
During 191 1, 1912 and 1913, practically one-fifth of the men and 
one-fourth of the women who were admitted to New York state 
hospitals with general paralysis were discharged and of this num- 
ber less than one-half were ever subsequently readmitted. The 
other half died in their homes, and, as the diagnosis was usually 
made known by the hospital authorities to the friends and relatives 
as well as to the family physicians, I believe it is among these 
persons, almost exclusively, that the deaths from recognized 
general paralysis in the community are reported. 

Thus far, we have made little progress in determining the total 
death-rate from general paralysis. We must examine other 
mortality groups for information as to the number of deaths from 
general paralysis in the community. Under what conditions shall 
we be most likely to find them reported? Obviously, a large 
number will be found reported under the names of those diseases 
which really constitute terminal conditions in general paralysis. 

12 



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178 GENERAL PARALYSIS AS A PUBLIC HEALTH PROBLEM 

I am afraid that those reported in thi^e groups are so deeply 
hidden that it is impossible to devise a practical means of inquity 
which will disclose them. There must be many cases of geheral 
pai^lysis dying at home, however, in which the mental atid nervous 
symptotns are too prominent to be igtiorcd in death certificates. 
Somie causes reported in New York state, in 1913, Which tnight 
arouse suspicion that general paralysis iS the real disease are " soft- 
ening of the brain ** (I50 deaths) and " paralysis without specified 
Cause." (716 deaths). We know the zgt period in which general 
paralysis is most f tequent and 1 think it would be entit^ly feasible 
to ascertain from the State Health Department the ftames and 
residences of persons dying within this age-period from the twb 
causes mentioned, and then to obtain from the ph)rsicians who 
signed the death certificates information as to whether mental 
Symptoms had exited before death and as to the dilation of the 
disease. Such an inquiry Would give us valuable clues regatding 
the frequency of unrecbghized general patalyisis. Dealing as we 
aine with a disease every case of which must ultimately come tb 
the iattention of public health offidals thtough a death certificate, 
the mortality lists aifotd ttre ttiost promising field of study. 

Another meiahs by which it might be thougfht we can estiin^tfe 
the incidence of unrecognized general pial^lysis is to proceed 
forward ft-bm infection with syphilis instead bf backward from 
the death tertificate. Until recently no one knew, even appiioici- 
mately. What proportibn t)f cases of syphilis terminated in generad 
paralysis. Many esthtiates have been made, most of them upon 
very slender evidence, but the first extensive istudy was that made 
ki 1912 by Pilcz and Mattauschek. They examined the records 
of 4,134 officers of the Atrstrian army who had cdnti-acted isyphilis 
between 1880 and 1890, and they ascertained that about 4^ per 
cent had developed general paralysis by 191^. If this propbrtion 
exists in other groups oi population, and if we had reliable 
information as to the number of persons with syphilis in the 
tbmmunity, it would be possible to predict with sbme degfee of 
accuracy the number oiE cases of general paralysis which will 
occur annually. Unfortunately neither of these asstimptions is 
cblf e<A. We know that many conditions of i-ace, personal sus- 
ceptibility, possibly heredity and other f actots have marked iwflti- 
cnce in determining whether syphilis invades the central netvous 



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THOMAS W. SALMON I79 

system or not and, if it does, in what form its manifestations will 
appear. Estimates of the number of cases of syphilis existing in 
the community vary so enormously that it is apparent that they 
are mere guesses. Therefore we must abandon this approach to 
our problem. 

A more practical plan is to attempt to discover the nimiber of 
paretics in groups of dependent people in such institutions as 
almshouses, work houses and hospitals for the treatment of 
chronic diseases. Here it is possible to obtain some interesting 
evidence, although very little careful study has been made of 
such conditions. Dr. A. J. Rosanoff once examined the necropsy 
records in a large general hospital and, although I do not know 
of any formal paper in which he has made his results known, he 
has told me that he found not a few cases in which the anatomical 
findings left no doubt that general paralysis existed, although this 
had not been suspected during life and, in some cases, it was not 
assigned as the cause of death even after the anatomical findings 
were made. It is a matter of common knowledge that a number 
of paretics of a simple dementing type are to be found in our 
almshouses and workhouses. I have frequently seen them in in- 
spections of almshouses. They are often unrecognized in general 
hospitals. During four years, ii cases of general paralysis were 
admitted to the United States Marine hospital at Boston among 
about 3,000 sailors admitted for all causes. Only five of these 
cases, as far as I have been able to learn, have been committed to 
institutions for the insane. The others died in the hospital or 
remained under treatment in the general wards, occasioning 
little more trouble than other chronic cases. It would be a most 
interesting experiment to have a census of the paretics in the 
almshouses and county hospitals of New York made by a com- 
petent psychiatrist. Such a study would only require about six 
months and would cost only a few thousand dollars. 

It seems strange that so little has been done in this field, but I 
think it is due principally to the fact that the psychiatric interest 
in general paralysis has over-shadowed all others. I believe that 
much can be expected from a general awakening to its public 
health aspects. Until such investigations as these have been 
made we must give up the attempt to estimate the number of cases 
of lumecognized general paralysis and return to the consideration 
of known cases. 



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l8o GENERAL PARALYSIS AS A PUBLIC HEALTH PROBLEM 

With the information in our possession at the present time, 
we are able to state that not fewer than i,ooo persons in whom 
general paralysis is recognized die in New York State every year. 
Let us compare this with the lives lost from some other important 
preventable diseases. It means that one in nine of the 6,909 men 
who died between the ages of 40 and 60 in New York last year 
died from recognized general paralysis and that one in 30 of the 
5,299 women who died in the same age-period died irotn this 
disease. 

The number of deaths from general paralysis in New York 
State last year about equalled the number of deaths from t3rphoid 
fever. The following table gives the number of deaths due to the 
ten most important specific infectious diseases. Of course, deaths 
in measles, typhoid fever and scarlet fever will be foimd also 
under the names of some of the complications of these diseases, 
but it should be remembered that these primary diseases are not 
invariably fatal as general paralysis is. Many of the patients 
with measles who died from bronchopneumonia would have 
recovered but for this complication, while the paretics with 
bronchopneumonia would have died even if this complication had 
not arisen. No attempt is being made to compare the prevalence 
of general paralysis with that of other diseases — ^we are tr)ring 
only to estimate its share in the mortality. 

1. Tuberculosis (all forms) 16,133 

2. Pneumonia 9,302 

3. Bronchopneumonia 7,217 

4. Diphtheria and croup 1,854 

5. Influenza 1,381 

6. Measles 1,071 

7. Typhoid fever 1,018 

General Paralysis — Recognised 1,000 

8. Scarlet fever 837 

9. Whooping cough 818 

10. Syphilis 782 

It may be interesting to compare the number of deaths from 
these causes with the number from some other causes which 
exact a heavy toll of human life. All forms of meningitis were 
responsible for 842 deaths, cancer of the breast for 809, and the 
total number of deaths due to injury by vehicles was 478. We 
hear a great deal about the appalling number of homicides in this 



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THOMAS W. SALMON l8l 

country. There were 459 deaths from this cause in 191 3, less 
than one-half the number due to general paralysis. Locomotor 
ataxia is of particular interest to us in this connection. There 
were 238 deaths from this cause. As the duration of this disease 
is about five times that of general paralysis, there must be about 
the same number of persons with each of these diseases living at 
the same time in the community. 

Thus we have seen that general paralysis constitutes a public 
health problem of the first magnitude. What can be done to 
control it ? The relation of general paralysis to syphilis needs no 
discussion in this connection and so we can turn to a very brief 
consideration of the means at our command for doing the only 
two things which can lessen the number of cases of general 
paralysis. The first of these is preventing well persons from being 
infected with s)rphilis; the second is preventing syphilitics from 
having general paralysis. 

The first problem belongs to venereal prophylaxis, a field of 
preventive medicine in which a few definite lines of attack have 
been established and in which many agencies are at work. Theo- 
retically this is as hopeful a field as any in the prevention of 
disease. Practically it presents apparently insurmoimtable diffi- 
culties. The prevalence of syphilis depends upon prostitution 
more than upon any other cause, and this great problem is so 
woven into every phase of civilized life that one wonders if it 
is within the power of the race to cope with it. If the prevention 
of syphilis is not an encouraging field for sanitation, recent work 
in the army and navy has shown us that it is a most promising 
one for hygiene. The success of personal prophylaxis is the 
bright spot in a gloomy picture. 

The most interesting contribution which we have to make from 
psychiatry is information regarding the amazing prevalence of 
a result of venereal disease which has thus far escaped adequate 
attention, even on the part of those especially interested in 
venereal prophylaxis. This may not be the most important con- 
tribution, however, for the impression is gaining ground that the 
facts which psychiatry is gleaning regarding the springs of 
human conduct may serve the high purpose of enabling us to deal 
better with the problems of personal life. The deeply-rooted 
institution of prostitution depends for its continued existence 



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l82 GENERAL PARALYSIS AS A PUBUC HEALTH PROBLEM 

most upon our failure to meet sexual questions frankly and 
courageously. Perhaps when certain mechanisms which clinical 
studies in psychiatry are defining become fully understood, clearer 
vision and the liberation of powerful new resources may enable 
mankind to deal with prostitution as it is dealing with religious 
intolerance, political inequality and some of the diseases which 
menace htrnian life and happiness. 

Preventing persons with syphilis from developing general 
paralysis belongs partly to our own work. It is possible that 
moderation in the use of alcohol, avoidance of mental stress and 
attention to many factors in personal hygiene may help in pre- 
venting a person who has syphilis from having general paralysis. 
We do not know. There is urgent need for research in these 
matters. Our text-*books are filled with ancient references, most 
of which have never been sufficiently verified or scientifically 
studied. Whatever information future studies may give us 
regarding the exact influence of such factors, it can be said at 
the present time that early, continued and effective treatment of 
syphilis constitutes the only means of prevention which is plainly 
indicated. Foumier tells us that only five per cent of paretics 
have gone through an adequate course of treatment for syphilis. 
On the other hand we are told of many instances in which general 
paralysis has followed the most efficient and intensive treatment. 
All references to this subject in the literature relate to events 
which happened before salvarsan had been added to our resources 
in the treatment of syphilis. The period which has elapsed 
between the general introduction of this remedy and the present 
time is shorter than the average period between infection with 
syphilis and the development of general paralysis. We are able 
now to judge of the efficiency of treatment by serological findings. 
With such resources at our command, we should be trifling with 
prevention in general paralysis if we failed to enter upon a 
vigorous campaign for treatment of all cases of syphilis. 

The first step in such a program is greatly to extend our means 
of detecting syphilis. A " Wassermann survey " is planned for 
a large group of applicants for enlistment in the United States 
Army. We should make such a survey at once in the groups of 
the civil population which receive public support. It is absurd 
to record cranial measurements of men and boys in our prisons and 



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T9QMAS W. SM-MON iS^ 

r^f Ofm^tpries and not to ascertain Uy this sipaple means whether 
or not they have syphilis. Children should nat be " placed out " 
until a negative Was§ernwm tjest h^ been obtained- The Sealtji 
Department qf New YQxk City now furnishes outfits for collect- 
ing blood and p^forms the test free, Tbe State Deps^tpxent of 
l^e^th should m^e this means, qf diagnosis available in eyery 
hamlet. 

These are matters in which w^ ^re interested qnly a§ physicians 
a^d good citizens. There ^re^ however, per^n? in the cpmni^mity 
with whom xnembers qf this, assotciatiou h^ve especial conti^ct. 
Th^se are the relatives qf the paretics in our public institutions. 
In at least three state hospitals the practice ha? been adqpted of 
S^nd^ng for the wives or husbands ^nd childrcm of patients with 
general paralysis, explaining the nature of the disease to them 
and having Wassermsa^n tes^ performed without cost. The 
result has been thei dctftction of a striking ntunber of cases of 
syphilis. The superintendent of one hospital has made arrange^ 
ments with a general hospital in the city so that such patients can 
bie immediately treated. The practically tinanimoiu willingness 
pi the rela^ves of patio^ts to have this test performed is not sur- 
prising, because it is| a common occurrence when a person dies 
frpn^ tuberculosis for tbe relatives^ although in perf^ health, 
to request to have tests made to determine if they, too, are afOicted 
with the disease* 

The chief obstacle tq the treatment of known cases of syphilid 
ia its cost. I know from personal obaervation that cases with 
contagbua lesions of syphilis are turned away from one of the 
largest public hospitals in New York City if they are tmable to 
pay for the treatment. In many other hospitals a single injection 
of salvarsan will be given free, but the treatment discontinued 
if patients are unable to pay. It is difficult to conceive of a more 
short-sighted policy than this. One man in nine who die between 
the ages of 40 and 60 dies from general paralysis, and yet the 
only means we have of preventing a person with sjrphilis from 
having this disease is thus deliberately withheld. The health au- 
thorities would permit no other communicable disease to be dealt 
with in this way. If the prevalence of such a frequent and fatal ter- 
mination of syphilis as general paralysis were made generally 
known, a most important step would be taken toward changing this 



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184 GENERAL PARALYSIS AS A PUBLIC HEALTH PROBLEM 

practice. I believe, however, that the only way in which we will be 
able to deal effectively with the problem of the treatment of 
syphilis is to place it wholly in the hands of public health officials. 
I believe that the health departments of cities should take up this 
matter vigorously and require general hospitals to report all cases 
of syphilis applying for treatment, together with information 
as to whether treatment was given or refused. Providing 
hospital accommodations for indigent cases of syphilis, at least 
during the period of active treatment with salvarsan, is as distinct 
a duty of the health department as it is to provide for cases of 
tuberculosis who are cared for under surroundings which tend to 
extend the infection to others. 

The problem of general paralysis has been considered from 
the point of view of preventive medicine. I believe no more 
effectual way exists of dealing with it and the disease upon which 
it depends than to awaken the health officials of our cities and 
states to a responsibility which they have long neglected. One 
may search the publications of American state and city depart- 
ments of health in vain for any reference to the importance of 
general paralysis or to its relation to syphilis. Dissertations will 
be found upon pellagra (which caused no deaths in New York 
State during 1913), and upon leprosy (which caused one death). 
Pages are devoted to smallpox (which caused one death), and 
references will be found to the latest work in tropical diseases, 
but one will find nothing about the great enemy to human life 
which we have been considering. Is it not time for psychiatrists 
to bring this important public health problem to the attention of 
public health officials ? 



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THE PATHOLOGY OF GENERAL PARALYSIS. 

By CHARLES B. DUNLAP, M. D., 

Chief Associate in Neuropathology of the New York State Psychiatric 
Institute, Ward's Island, N Y. 

In discussing the pathology of general paralysis we shall regard 
it as a disease etiologically dependent on the spirochaete pallida, 
but justly to be kept separate from other forms of cerebral s)rphilis, 
for reasons which will appear later. 

General paralysis, according to the best evidence obtainable at 
the present day, is only about two hundred years old ; it depends 
absolutely upon previous sjrphilitic infection, and comes on after 
an interval of about five to twenty years. Sjrphilis, however, had 
been known in Europe for hundreds of years before anything re- 
sembling general paralysis was described. If our historical infor- 
mation is correct, syphilis was introduced into Spain in 1493 
by Columbus's sailors, who had become infected in the Island of 
Hayti, and the next year it spread as a very fatal epidemic to 
Italy and France. Even now among primitive races {e. g,, the 
natives of the North African provinces) where syphilis is ram- 
pant, general paralysis is practically unknown. As S3rphilis lost 
its severe epidemic qualities, and, in the course of centuries, 
became a milder disease, general paralysis became gradually more 
frequent. It, too, in some of the civilized races to-day, according 
to certain observers, is gradually changing its character ; it is said 
to be milder, with a rather longer course, fewer convulsions, and 
the demented forms are said to be more frequent; Spielmeyer 
even suggests that it may eventually disappear. 

Previous to 1904 the gross changes in the brain of general 
paralysis were well known, and many of the finer changes had 
been described, especially degeneration and loss of nerve cells, loss 
of nerve fibers, and increase of neuroglia; these finer changes, 
however, formed part of a rather vague and uncertain disease 
picture, until Alzheimer, in his classical monograph in 1904, estab- 



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l86 TH£ PATHOLOGY OF GENERAL PARALYSIS 

lished general paralysis on a firm anatomical basis. The facts 
then established have since been confirmed and amplified by others, 
and are now well known. In 1912 to 1913 a new impetus was 
added to investigation, and especially to treatment, through the 
demonstration by Noguchi and Moor^ of the spirocba^e pallida 
in the brains of general paralytics, thus proving this disease to be 
dependent, with hardly a doubt, on the presence of the same 
organism as that found in syphilis. 

In addition to the degenerative changes previously established, 
AJzheinaer showed everywhere, not only ifl the gr^y, hut qJsQ in 
the white matter of the brain and ^>inal cord, a chronic inflam- 
nwitory process, with ^ perivascular ejcudate con3isting^ raainJy ol 
lymphocytes and plasma cells. The central nervous system is 
shot tbxougb and through by thi$ inflaronatory process; 00 part 
of it is spared, but the intensity of course may vary greatly in 
different parts. The frontal l.obe$ are regularly the parts most 
affected, but other regions may be as much involved, or even more 
so, and at times in such a circumscribed way ^^ to cause perfectly 
distinct focal atrophies. A peculiarity of the exudate in genejaj 
paralysis is that, within the nervous tissues it is strictly confined 
to the sheaths of the blood vessels, usually ^oing even into the 
smallest branches; in the pia mater, however, there is no such 
restriction of the exudate to the vessel sheaths. 

It is on this characteristic distribution of the exudate (i. e^ its 
restriction to the vessel sheaths throughout the whole central 
nervous system) more than on any other one thing, that the 
diagnosis of g^eneral paralysis rests to-day, and not principally on 
the character of the cells in the exudate itself ; the nervous tissues 
have only a limited ntunber of responses to irritants of whatever 
kind, and lymphocytes and plasma cells may be found in many otfier 
diseases of the brain or cord, and, as such, are in no way char- 
acteristic, unless characteristically distributed. 

This pattern of general paralysis applies generally to perhaps 
ninety-five out of one hundred cases, but pathology has shown an 
almost bewildering variety of minor changes and subvarieties com- 
ing under this general paradigm ; such, for example, are differences 
in the localization, or in the intensity of the inflammatory reaction, 
which may be extremely mild or very intense; differences ia the 
position, or in the extent of the degenerations in the nervous tis- 



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CHARLES B. PUNiLAP iSj 

sues of the brain, or of the spinal cord, or even in the nerves^ them- 
selves, especially the optic nerves; then there 13 the presence of un- 
usual degenerative products; for example, colloidal changes in the 
cortex or marrow ; occasional vascular narrowing or obliteration 
is also found in the form of typical Heubner's endarteritis^ with 
the necessary sequelae of focal softenings and focal ^ujptoms. 

The pathologist wonders, in the presence of these changes, so 
varied in positioii and in degree, that there can be sudi relative 
uniformity as usually exists in the clinical picttire of general 
paralysis, and lodes upon the cHmdan as an unreasonable sort of 
being, if tiie latter happtn^ to insist on an attempt at close cor- 
relation between the antemortem symptoms and the postmortem 
findings. Roughly we can aay, of course, that where destruction 
ol nervous tissue is widespread and great, mental deterioration is 
practically certain to be profound, but the memory defect, speedi 
defect, expansiveness, general deterionition, and even the physical 
signs, often appear to bear Kttte intimate relation to the amount 
of inflammatory or degenerative reaction, and we cannot correctly 
^tdkt beforehand whether we shall find anatomically a tremen* 
dous generalized reaction, or a slight one, or a spotty one. One 
would be rash indeed in attempting, at the present stage of our 
knowledge, to correlate, for instance, a disturbance of function, 
such as speech defect, in a disease of this character, where no part, 
from the cortex to the end organs of speech production, cam be 
counted on to be strictly normal-^how can we put our finger on 
a certain spot, or series of spots, and say '* this is responsible for 
the speech defect,'^ especially as we are far from knowing the 
cellular mechanisms of normal speech, and their connections one 
with another? 

The Relation of General Paralysis to Cerebral Syphilis. 

leaving out for the moment the etiological factors, the above 
brief description of general paralysis as a subacute or chronic 
inflammatory and degenerative process, which goes through and 
through the great central nervous organs, is correct for most 
cases. The varieties of cerebral syphilis on the other hand, for 
the most part^ play aroimd the surface of the central nervous 
^stem, instead of going all through it ; that is, the lesions, or ex- 



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l88 THE PATHOLOGY OF GENERAL PARALYSIS 

udates, which characterize these varieties are confined largely to 
the meninges, and to the blood vessels within the meninges, and 
there is rarely much, if any, essential exudate in the underlying 
nervous tissues. 

We hardly need to recall the main types of cerebral syphilis, 
the gummatous, the meningeal, and the vascular forms and their 
combinations, except to state, that in the so-called meningeal type 
there are cases, and they are not rare, the symptoms of which come 
on many years after the primary infection, just as in general par- 
alysis. In most of these meningeal cases the lymphocyte and 
plasma cell exudate behaves as it is expected to do, and is limited 
to the meninges, but sometimes, especially in certain regions 
(gyrus rectus or temporal lobes), a slight exudate is also seen in 
the depths of the nervous tissues, sometimes as a plain extension 
inwards from the meninges, but at times no evidence of such 
extension can be seen ; we thus, in rare cases of cerebral sypyhilis, 
have patches in the cortex that look just like general paralysis, 
especially like general paralysis of long duration, where regularly 
only a slight exudate is present. So the boundaries of general 
paralysis, usually sharp are not always so, and occasionally it is 
almost impossible to say whether we have under the microscope 
mild general paralysis, or the meningeal form of late cerebral 
syphilis. 

Clinically the same difficulties of differentiation in the two 
groups are met with; the Wassermann reaction often fails to 
settle the question, and the results of specific treatment have been 
of but little help, as they are about the same in both cases. The 
question, viewed from the larger aspect, is hardly worth settling, 
for general paralysis and the form of cerebral syphilis under dis- 
cussion should be looked upon as varieties of the same funda- 
mental process, with the same etiology, with much in common 
clinically and pathologically, and with no clear border-line. More- 
over, we still classify as general paralysis a set of cases in which 
the inflammatory reaction, although typical in form, and ubiqui- 
tous in the central nervous organs, is chiefly situated around the 
larger and longer blood vessels, the smaller vessels being nearly 
clear; some of these cases (evidently near relatives of cerebral 
syphilis) give, like the latter, a positive Wassermann reaction in 
the blood, but a negative Wassermann reaction in the spinal fluid. 



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CHARLES B. DUNLAP 189 

Our concept of general paralysis therefore must be kept suffici- 
ently open to admit some of the conditions formerly regarded as 
syphilitic ; and our concept of cerebral syphilis, on the other hand, 
will probably not suflFer by extending it to admit a wider range of 
what looks like general paralysis. 

We next turn to the meaning of the various reactions in gen- 
eral paralysis. That both the inflammation and the degeneration 
are a response to the presence of the spirochaete pallida, or to its 
toxin, spread widely through the nervous system, we can hardly 
doubt ; but owing to the difficulty of demonstrating this organism 
extremely little is positively known of its regional distribution. 
It is most disheartening to imbed section after section in cases 
where areas of intense reaction alternate with nearly normal 
portions, and to find, as the end result of many hours or days of 
endeavor, that none of the preparations have been successful on 
account of the capriciousness of the method. Noguchi has ex- 
amined material from niunerous cases, but from only a few areas 
of the brain in each instance; he found spirochetes in about 25 
per cent of the cases examined, mainly in the gray matter, occas- 
ionally in nerve cells, but as a rule not near the blood vessels. 

We might assume, in contrast to general paralysis, that in 
cerebral syphilis there is a restricted spread of the organism and 
that, like the exudate, the organism also is limited chiefly to the 
meninges or blood vessels; but although there are cases which 
support this view, positive proof is lacking. It seems, in general 
paralysis, that in those areas where the reaction is greatest spiro- 
chaetes are not necessarily present, or at least have not been 
found, and there is fair evidence to indicate that the reaction 
moves from place to place in an intermittent way, and that some 
areas may become quiescent, while in others there is advance. In 
some of the cases of long duration it looks as if this quiescent 
state had become general ; at any rate the process throughout the 
brain is extremely slight, so that a step further would mean re- 
covery ; and it is not certain (though as yet unproven) that rare 
cases of spontaneous recovery may not exist. We cannot demon- 
strate, then, that extreme local damage in the nervous tissue cor- 
responds to great local concentration of the spirochaete or its pro- 
ducts, and that slight diffuse damage means the reverse, though 
this seems highly probable. 



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190 THE PATHOLOGY OF GENfik^. PARALYSIS 

Cases have been observed in whidi, without the pre-existence 
of any obviotis psychosis, general paralysis was discovered after 
autopsy; moreover deaths in remission, where mentality was 
fairly weH restored, have also shown well-marked active general 
paralysis; besides, in cases of sudden onset, or of very short 
oonrse, we have strong reason to believe that the anatomical 
reaction was well advanced long before symptoms attracted at- 
tention. This occasional aiq>arent freedom from symptoms, in 
ttw presence of an active process of general paralysis, brings 
as to another one of the unsolved problems ; namely, as to what 
becomes of the spirochete in die free interval between the time of 
syphilkic infection and the outbreak of general paralysis. 

It is known that the body tissues do not always present a visible 
reaction to the presence of the spirochete pallida; the heait mus- 
cle, for example, may be flooded with the organism and show 
practically no response ; it therefore seems that this slowly grow- 
ing organism may live, for a time at least, in harmony with its 
host, with its capacity for harm latent, so to speak. We must 
assume, in our ignorance of the life history of the pallida, and of 
its biological cycles, if ^uch exist, that in general paralysis the or- 
ganisms are in some way downed and held in check for a number 
of years, to become obviously active when conditions are favor- 
able ; for that there are conditions which, in conjunction with the 
indispensable organism of syphilis, determine the develof^nent of 
gi^eral paralysis, seems beyond doubt ; what these conditions are 
forms another problem for the ftfture. 

We might put the profMem in this form: "What is needed 
besides syphilis to produce general paralysis? " We know from 
the studies of investigators, IBce Foumier, Mattauschdc and PilC2, 
and others, that it is those cases in whkh preceding syphilis has 
be^ very mffld that are especially prone to devetep general paraly- 
sis ; that is, it occurs more often in persons who have reacted only 
sdightly, or as some say, inadequately, and without a sufficient 
production of antibodies, to the original infection; among races 
and individuals where the reaction has been violent, general par- 
alysis is much less likely to appear. We cannot say whether it is 
a special strain of the spirochsete which is responsible for this mM 
syj^ilitic reaction, and 1^ later sequel of general paralysis, or 
whether it is a strain especially attracted to the nervous system, 



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CHAttLES B. DUNLA^ t^t 

a " fleurotf (t)pte " varifety, as some have supposed, or whether 
tertain biological changes wrought in the spirochaete by its so- 
journ in its host during the intervening years have rendered it 
more prone and fit to invade the nefvous tissues, which in their 
turn may have been tendered mote susceptible to attack. Nogu- 
thi tottird some experimental evidence for tfie existence of a 
special strain in the fact that the organisms, obtained from cases 
of general paralysis, had an unusually long inccfbation period. 

The same lack of acquaintance with the life history of the 
spirochaete, especially in human beings, clouds the question of 
successfully eradicating it from the nervous system by treatment. 
One difficulty here is certainly the relative inaccessibility of the 
central nervous system to drugs ; for an organism situated, as this 
is, in the depths of the nervous tissue, and producing lesions 
through its whole extent, is reached and attacked by drugs only 
with the greatest difficulty. Remedies introduced even through 
the blood, no matter how diflFusible they may be, hardly enter the 
tissues of the brain and cord at all, and while salvarsan seems a 
more powerful agent against the organisms in other parts of the 
body than any of the other specific drugs, and while the local use 
of salvarsanized serum through the cerebrospinal fluid seems 
most rational, it is yet too early to know whether the spirochaete 
is only retarded or rendered latent by this method, or whether it 
can be sufficiently gotten at to be completely eradicated. 

It seems fairly certain, from the standpoint of pathology, that 
prolonged and rigorous general treatment should be combined 
with local treatment, and that both should be pushed to the limit 
of safety ; for general paralysis is more than a local disease ; the 
spirochaetes have been demonstrated not only in the tissues of the 
central nervous system in general paralytics, but they have also 
been reported, by means of experimental inoculations, in the 
cerebrospinal fluid of such cases and, in a few instances, in the 
circulating blood of general paralytics ; besides this, inflammatory 
changes in the peripheral nerves similar to those seen in other 
parts of the nervous system in general paralysis have already been 
referred to. Much of the later work on the blood and spinal 
fluid needs control and checking by autopsy, in order to be sure 
that cases reported are unquestionable general paralysis, but it 
seems fairly safe to say to-day, that general paralysis is essenr 



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192 THE PATHOLOGY OF GENERAL PARALYSIS 

tially a generalised infection with the spirochete pallida, in which 
the central nervous system stands out more prominently than any 
other part. 

Any method of treatment which will arrest or cure this fatal 
disorder is most welcome, but on anatomical grounds I feel most 
strongly that in many cases by the time the diagnosis can be made 
much damage will have already been done. I look to prophy- 
laxis in syphilis itself as the great hope of the future. 



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DIFFERENTIAL DIAGNOSIS OF GENERAL PARESIS. 
By ADOLF MEYER. 

It IS not so very long since IClippel and Hyslop spoke of the 
general paralyses in the plural, evidently under the impression 
that there was more than one type of destructive brain disorder 
progressive if once started upon; perhaps subject to temporary 
arrests, but bound to progress to a fatal end, more or less directly 
referable to the brain condition. This h)rpothetical group would 
represent what Stanley Hall very brightly called "thanatic (or 
deadly) dementia." We do indeed know a number of such proc- 
esses. But when we speak to-day of general paralysis or paresis, 
we mean to exclude all the simple senile, focal organic and toxic 
and other diffuse progressive affections like arteriosclerosis, 
multiple sclerosis, progressive chorea, and Alzheimer's disease, 
which do not present the histological picture clearly accepted 
and marked off since Nissl's and Alzheimer's studies. The un- 
classified residuum is decreasing so that we do not care to give 
a whole group of cases a questionable all-embracing nimbus by 
naming the unknown. At the same time, we do well to respect 
the existence of this unclassified residuum and the occasional 
cropping out of the term pseudo-paresis. 

What we are concerned with is paresis with a practical and 
sufficiently decisive definition based on the cases studied to the 
end, f. e., studied with the inclusion of the best possible post- 
mortem technique. This condition might, of course, leave out, 
or make appear as very rare, those cases in which a transitory 
disorder diagnosed as general paresis either failed to be progres- 
sive or came to a practical recovery and away from neurological 
post-mortem services, so that few of these cases would be ex- 
amined by those experienced in the differential histology of these 
conditions, and few would appear in our discussion. It is quite 
probable, therefore, that we shall make our definition more and 
more clinical in a measure as our laboratory methods become 
safe and convincing. We shall indeed see that for practical 
working we come dose to accepting the Goldsol reaction as the 
starting point and central factor of definition. 

13 



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194 DIFFERENTIAL DIAGNOSIS OF GENERAL PARESIS 

The diagnosis of general paresis aims at the singling out of 
the cases of a diffuse progressive parenchymatous syphilis with 
preponderance of the loss of tangential fibers and other nervous 
structures, with neuroglia overgrowth, disorganization of the 
lamellation of the cortex, an infiltration of the sheaths of the small 
and medium vessels with plasma cells and lymphoid cells, and 
occasional local devastations. From a fairly noteworthy number 
of cases we may generalize that general paresis is an invasion of 
the brain by spirochaetes with a parenchymatous reaction, and 
a more or less incidental mesoblastic response (Weigert). 

When we speak of " diagnosis of dementia paralytica " we 
mean thereby the distinctive formulation of the facts which are 
clinched by the concept of progressive parenchymatous syphilis 
of the brain, in distinction from other progressive reductions of 
the brain and conditions resembling such a process, or in dis- 
tinction from processes which are not progressive and perhaps 
not even evidence of a distinctive brain damage. 

The diagnostic problem is most difficult where we deal with 
processes also on a luetic basis, but with a different type of 
lesion; the diffuse luetic meningitis and gummatous processes; 
the luetic vascular affection of tfie smaller vessels ; and the tabetic 
conditions with non-paralytic psychoses. It does also create con- 
siderable perplexity when we deal with a patient with evidences 
of syphilis, and symptoms of neurasthenia, arteriosclerosis, se- 
nility, epilepsy, alcoholism, multiple sclerosis or functional psy- 
choses, such as manic-depressive cycles or excitement and toxic 
psychoses. The question in these latter cases and in simple tabes 
is: What functional states give weight to the suspicion of or 
certainty of the existence of general paresis ? To which we may 
reply: Evidently the characteristic disorganization of the per- 
sonality and the cardinal findings in the cerebro-spinal fluid. 

The best evidences of a parenchymatous syphilis are : 

(i) The findings in the cerebro-spinal fluid. Historically the 
points of importance are : 

(a) The platinum-chloride reaction of Mott and Halliburton. 

(b) The demonstration of a pleocytosis (with plasma cells). 

(c) The demonstration of globulin. 

(d) The complement fixation according to Wassermann. 

(e) The colloidal gold chloride or Goldsol reaction. 



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ADOLF MEYER I9S 

In importance these rank as follows: 

(a) Complement fixation with various antigens. 

(b) The gold chloride reaction, if it involves the total dis- 
coloration of the first five dilutions, and relative discoloration of 
the dilutions 6, 7 and 8. 

(c) The presence of globulin either in the form of the first 
phase of Nonne-Apelt or with Noguchi's butyric acid test or the 
Ross- Jones test. 

(d) The presence of more than 10 or 12 cells per cmm., 
especially when there are plasma cells, and no leucocytes. 

Of all these, it would seem to-day that the colloidal gold 
reaction would offer the most distinctive findings. A slight 
pleocytosis and traces of globulin may also occur in brain ttunor. 

(2) The findings from brain-puncture, first applied by 
Pfeiffer, too radical a measure and not sufficiently certain to 
furnish conclusive information, but possibly more worth consider- 
ing in connection with cerebral introduction of curative fluids. 

(3) The ' cerebral symptom-complex ' of general paresis is far 
from being conclusive except where diffuse cerebral s)rmptoms 
and certain eye-symptoms combine with the specific paraluetic 
signs. The eye-symptoms, irregular and sluggish and especially 
Argyll Robertson pupils, are most helpful, if present, and lead 
over to the tabetic symptom group. The typical cerebral dis- 
orders are : 

The speech disorder. 

The writing disorder. 

Tremor. 

Difficulty of coordination and of relaxation and overflow. 

Innervation. 

Exaggeration of tendon-reflexes occasionally with ankle clonus, 
but relatively rarely with Babinski sign ; at times with a combi- 
nation of exaggeration of reflexes and hypotonia. 

More or less typicaA cerebral attacks (see below). 

Most of these symptoms occur also in toxic states and among 
these I want to mention especially the bromide intoxications 
which can simulate general paralysis more closely than any other 
drug-induced affection. 

(4) The tabetic symptom-complex; especially the eye-symp- 
toms ; simple sluggishness of pupils and absence of the secondary 
reaction of Weil, and distinct irregularity or Argyll Robertson 



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196 



DIFFERENTIAL DIAGNOSIS OF GENERAL PARESIS 



pupil, while mydriatic palsy belongs to the type of mesoblastic 
syphilis and a spasm of the sphincter may occur in hysteria (ex- 
posed by cocaine) and inequality of the pupil is omnipresent. 
With all this, we expect : 

(5) Evidence in the mental functions; progressive loss of 
memory (occasionally slight when the lesions involve mainly the 
right hemisphere), change of the personality, indiflFerence to the 
discrepancies of dates and memory, lapses of behavior, variable 
emotionality and suggestibility, euphoria and certain superim- 
posed reactions of predilection, such as the exalted polypraxia 
or the absurd hypochondriacal states. It is specially important 
to realize that there is no symptom-complex from neurasthenia, 
hysteria, delirium to manic-depressive and paranoic reactions 
which would as such exclude the possibility of a paresis. On the 
other hand, a number of these can be complicated by signs of 
nervous instability which might simulate general paralysis. 

(6) Combined mental (or psychobiological) and neurogenic 
attacks of the character of apoplectiform or epileptoid reactions, 
usually appearing in the form of a status, with prolonged coma 
and with varjring, but usually not lasting, Jacksonian or focal 
symptoms; occasionally epileptoid states of bewilderment and 
amnesia or fugues; rarely clean-cut epileptic attacks (which is 
more frequent in ostitis gummosa and the like). 

The most difficult issue is presented by tabes. A frank seg- 
mental tabes with the classical symptoms is relatively rare in 
the cases which succumb to the cerebral parenchymatous syphilis. 
The following contrasts are worthy of attention : 

TABO-PARESIS. 

The initial symptoms often missing; 
often unheeded; on the other 
hand, at times simulated by " dis- 
traction analgesis." 

Rarer. 

Rarely typical. 



TABES. 
The initial symptoms plain: shoot- 
ing pains, frequent girdle sensa- 
tion and numbness. 

Transitory ocular palsies. 

Typical ataxic gait and Romberg 
symptoms. 

Argyll Robertson pupil. 

Absence, or difference of tendon re- 
flexes with hypotonia. 

Radicular zones of anaesthesia. 

Trophic disorders (Charcot joints, 
pemphigus, etc.). 

Optic atrophy. 



Equally frequent 



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ADOLF MEYER I97 

While tabes does not imply immunity against general paresis, 
there remains the fact that only a small percentage of the cases 
with frank tabes develop general paralysis. Hence the initial 
symptoms of tabes are not of especially bad omen, unless they 
occur together with cerebral symptoms, such as transitory 
aphasia, or transitory palsies, or development of irregular tremor 
of face, tongue and hands, speech disorder, writing disorder; 
difficulties in limited innervation and relaxation, and the mental 
symptoms. 

In tabes with non-paralytic psychoses Henderson emphasizes 
the absence of any memory defect, and the absence of speech and 
writing defect and of facial tremor. 

Braifirsyphilis, in the sense of mesoblastic syphilis, vascular, 
meningeal or gummatous, in a remarkable percentage of cases 
fails to give the typical reaction of the cerebro-spinal fluid. 
According to the excellent study of Dr. Henderson, cerebral 
syphilis is rarely a late sequel of infection. The neurological 
symptoms are multiple-focal and not diffuse. The Argyll 
Robertson pupil belongs to the parenchymatous syphilis. The 
mental symptoms are those of all organic disorders (memory and 
retention defects, states of confusion and hallucinations), but 
with relatively little unaccountable and fundamental change of 
character and dilapidation of the personality. Euphoria and 
expansiveness may occur in mesoblastic syphilis as well as in the 
parenchymatous type. 

The formerly much-dreaded confusion with neurasthenia is 
no longer an issue except where the examination is insufficient. 

Alcoholism is apt to simulate the cerebral symptom complex 
of tremor, speech defect and even sluggishness of the pupil. 

Bromide and other toxic states are apt to simulate paresis very 
closely, but do not imply a spinal fluid finding. It is especially 
important to know that in bromide delirium the exaggeration 
of reflexes and weakness or numbness is by no means necessarily 
symmetrical. 

Frontal lobe and other tumors may lead to some difficulty, 
owing to the euphoria and non-appreciation of the seriousness 
of the condition, and the growing inattention to the sphincters. 
A slight pleocytosis and slight globulin reaction may occur. On 
the other hand, focal paresis may simulate brain tumor, owing 



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198 DIFFERENTIAL DIAGNOSIS OF GENERAL PARESIS 

to its progressive character, especially where the affection is in 
the right hemisphere and the memory-disorder is correspond- 
ingly slight. 

The examination of the blood is to-day an almost obligatory 
measure. The examination of the cerebrospinal fluid implies 
rest in bed for at least 24 hours and enough inconvenience to 
call for special indications. Experience with at least one recent 
failure of diagnosis in a patient who, by the way, had refused 
lumbar puncture, but has since been examined elsewhere under 
commitment, makes me inclined to consider an examination of 
the cerebro-spinal fluid mandatory wherever there is the slightest 
indication of suspicion or uncertainty, and a wise precaution 
where there is any doubt. A negative blood reaction does not 
make unnecessary a study of the cerebro-spinal fluid. 

It is, I think, necessary to emphasize that the diagnosis of the 
parenchymatous process is but the beginning of the diagnostic 
discrimination. Beyond this initial fact, there are many very 
important points to be settled. 

(i) The character and recoverability of any incidental dis- 
orders or complications; in other words, the chance that one or 
the other feature is not paretic, but a coincident independent 
event. 

(2) The chances for remissions. 

(3) The localization of the process if it is at all localizable. 

In this connection we meet the decided difficulty concerning 
the question when a case should be considered recovered or free 
of general paralysis. 

Fr. Schultze observed a case of tabo-paresis in a man of 49, 
who was discharged from the institution after ij4 years. He 
died of cancer of the pancreas 14J4 years later, without any 
further paretic symptoms or progress of his tabes. Alzheimer 
found the infiltrations too slight and the damage to the nerve 
elements too great for general paresis, but similar to the so-called 
stationary paresis. 

The diagnosis of stationary paresis would most probably de- 
pend on the findings in the cerebro-spinal fluid, the persistence 
of which would almost inevitably indicate a progressive process, 
to judge at least by the observations in stationary tabes. 



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ADOLF MEYER I99 

Considering the occurrence of mixtures of the parenchymatous 
and mesoblastic syphilis, there will always be a certain percentage 
of cases in which only the results of treatment or the anatomical 
study will bring certainty. It may, however, be possible that 
a better knowledge of strains of spirochcpta will give us some 
help in diagnosing the relative liability of any case with syph- 
ilitic infection being among the 4j4 per cent of the cases of 
syphilis that develop general paralysis. The light forms of 
primary and secondary reactions certainly preponderate in our 
records, more than would be accounted for by forgetfulness and 
defective history-taking. 

Spiller and Dana, who, no doubt as neurologists, see a larger 
number of cases in whom the graver mental symptoms are not 
preponderant, have for years voiced their feeling that general 
paresis and cerebral syphilis cannot seriously be separated. They 
probably would not even make the modem distinction of meso- 
blastic and parenchymatous syphilis or consider it clinically or 
histologically practicable. Spiller is influenced by histological 
considerations in which I believe the discrimination of detail of 
the methods employed by Nissl and Alzheimer is not sufficiently 
used, so that the margin of histological uncertainty is exagger- 
ated. Dana stands on the ground of therapeutic optimism with- 
out histological control. Hence his repeated appeal for recog- 
nition of the recovery of early " preparetic " cases with or without 
antiluetic treatment of the older methods and ijiith statistical 
results which the advocates of the Swift-Ellis or the cranio- 
spinal flushings do well to bear in mind. Since I h^ve seen more 
cases outside of hospital practice, I certainly have come across 
a small number of cases in which the neurological aad serological 
status left no doubt, but in which the behavior aspect did not 
make it easy to say whether the moment of cert^fiability had 
arrived and legal steps could be enforced, especially Where family 
conflicts existed. It seems, however, that to-day most judges and 
lawyers have become familiar with the disastrous results of 
general paresis. They are willing to proclaim their " non-compos 
mentis " because they assume that the brain-cells are disorgan- 
ized in this disease, as a lawyer recently put it. It is certainly 
wisest that every patient with positive colloidal gold chloride 
reaction and other warnings should be induced to put himself 



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200 DIFFERENTIAL DIAGNOSIS OF GENERAL PARESIS 

on the safe ground of an equivalent of guardianship by putting 
his business interests in trust or into the hands of l^^y super- 
vised friends, and it would seem wise to create a public sentiment 
in favor of such a practice. This practical question should be put 
far above mere academic hesitation and dispute. The step can never 
hurt, except possibly crooked interests ; and its wider acceptance 
will do much to soften the notions about the meaning of what 
now figures as declaration of insanity. 



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A REPORT OF FIVE CASES OF THE INTRACRANIAL 
INJECTION OF AUTO-SERO-SALVARSAN. 
By drew M. WARDNER, M.D., Cedar Gbove, N. J. 

It is generally conceded that the so-called parasyphilitic dis- 
ease, general paralysis, although due, as has been recently shown 
by Noguchi and others, to specific infection of the central nervous 
system with the treponema pallidum, is seldom, if ever, capable 
of being influenced through the medium of the blood by any of 
the antisyphilitic drugs at our disposal. 

The reasons for this have been adequately demonstrated in the 
preceding papers. That these drugs cannot be injected into any 
part of the central nervous system without the possibility of dan- 
gerous results has also been shown. That one of these drugs, 
viz. : salvarsan, can be so modified as to permit of its injection into 
the central nervous system has been established by Swift and 
Ellis of the Rockefeller Institute. Whether such a modification of 
salvarsan when introduced directly into some portion of the cen- 
tral nervous system is capable of influencing in any way the 
course of general paresis, it is in part the purpose of this sympo- 
sium to show. It is unnecessary to describe here the preparation 
of the Swift-Ellis serum, with which all our cases have been 
treated. 

It is at once apparent that, in a general way, two different 
methods of applying the serum are open to us. That is to say, it 
may be introduced by lumbar puncture into the subarachnoid 
space of the spinal cord, or through a trephine hole in the cranium 
into some portion of the brain or its meninges. 

The intraspinous method has been too well described by Dr. 
Cotton to need any further elaboration here. Dr. Cotton's results 
seem to be excellent and distinctly encouraging. At the same 
time this method in other hands has not always met with such 
pronounced success. Hough sums up the work of Swift and 
Ellis of the Rockefeller Institute; Myerson of the Psychopathic 
Hospital, Boston, Mass., and Asper of Baltimore, as follows: 



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202 INTRACRANIAL INJECTION OF AUTO-SERO-SALVARSAN 

There has been marked improvement in the syphilitic inflammatory 
processes and in many cases the patients with tabes especially, have 
shown pronounced clinical improvement. Drs. J. A. Cutting and 
C. W. Mack, of the Agnew State Hospital, California, summarize 
the result of the treatment of nine cases of general paresis as fol- 
lows : The most striking result of treatment is the reduction of 
the cell count, while a review of the mental symptoms is not very 
encouraging. Dr. Martland and Dr. Beling, of the City Hospital, 
Newark, have treated six cases of general paresis and cannot re- 
port improvement in their condition. We have treated five cases 
at our hospital by the intraspinous method without improvement 
in any case. Dr. Edward Mapother and Dr. Thomas Beaton of 
London have treated four cases without much change in the 
mental condition. 

In view of these rather discouraging reports, and bearing in 
mind the fact that the disease was incurable, we believed that a 
more radical procedure was justifiable. That is to say, we be- 
lieved it was justifiable to inject the remedy into the brain or its 
meninges. As for the theoretical advantage of intracranial proce- 
dures in general the following statement in the British Medical 
Journal by Dr. Harry Campbell is of interest. He says : 

The problem, therefore, which confronts us in the treatment of par 
enchymatous syphilis is how to get the spirilHcidal antibodies to enter 
the perineuronic lymph stream. This end can be gained by intrathecal 
injections of salvarsanized serum. Whether or not we accept the view of 
Mott— that the cerebrospinal fluid constitutes the lymph of the central 
nervous system— certain it is that substances introduced into the subarach- 
noid space do actually penetrate the central nervous system. If tripan blue 
be injected through a trephine hole into the cranial subarachnoid space 
above the tentorium ccrebelli, not only the cortex cerebri but the entire 
cerebrospinal axis is found, post mortem, to be stained. If on the other 
hand the pigment be injected into the spinal subarachnoid space by means 
of lumbar puncture the cortex cerebri remains unstained, the staining in 
these cases being confined to the spinal cord and brain stem. It would 
appear that the cerebrospinal fluid flows from the cranium spinalwards, 
probably in meager current, and also that some slight ebb or flow takes place 
between the fluid in the subarachnoid space at the base of the cranium and 
the spinal subarachnoid space in accordance with the variations in the 
quantity of intracranial blood. 

It will thus be seen that intrathecal spinal injections afford a ready 
means of bringing remedial agents into immediate relations with the 
neurons of the spinal cord and brain stem. While it is probable that the 



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DREW M. WARDNER 2O3 

neurons of the cortex cerebri may in some degree be reached in this 
T¥ay, a far more effectual way of reaching them would undoubtedly be by 
injecting the cranial subarachnoid space through a trephine hole. 

Furthermore, post-mortem injections of carbolfuchsin into 
spinal subarachnoid space have been made both by us and Dr. 
Martland of the Newark City Hospital. In no case, however, 
even with the body placed with head down and in an almost erect 
position has any staining of the structures beyond the posterior 
fossa been observed. 

Having decided, then, to imdertake the intracranial injection of 
the salvarsanized sertun, it was only necessary to cast about for 
a modus operandi. 

Four different procedures were open to us: (i) Nisser and 
Pollac's method of injecting the remedy by means of a small 
drill introduced beneath the dura through a small area of frozen 
scalp. (2) Into the subarachnoid space through the orbit, as 
shown by Beriel, of Lyons. (3) By means of callosal puncture 
as used by Foerster in Germany and by Dr. Harry Campbell and 
Mr. Balance in London. (4) The introduction of the remedy 
subdurally through a trephine hole in the skull, which pro- 
cedure seems to have been first reported upon by Levaditi, 
Marie and Martel in December, 191 3. It seemed to us that until 
the value of intracranial injections of salvarsanized serum could 
be put upon a firm basis that the safest of these procedures, that 
is to say, the one that was less likely to cause damage to the brain 
structures, was the one to be experimented with. The first three 
were set aside as being difficult of application and decidedly risky. 
The requirement of safety seemed to be best fulfilled by the fourth 
of these methods, that is to say, by the injection of the senun 
through a trephine hole in the skull. Accordingly, in conjunction 
with Dr. Martland, Dr. Eagleton and Dr. Beling, of Newark, we 
evolved the following operative procedure : 

The preparation of the senun is carried out in accordance with 
the Swift and Ellis technique, viz. : On the day previous to the 
operation the patient is given an intravenous injection of neo- 
salvarsan .9 gm. ; one hour later about 6 oz. of blood are drawn 
from the median basilic vein. This blood is set aside to clot at 
room temperature for about three hours, and is then put in the 
ice box at a temperature approximating io®C. until the following 



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204 INTRACRANIAL INJECTION OF AUTO-SERO-SALVARSAN 

day. The clear supernatant serum is then poured off, centrif uged 
and mixed with its own bulk of normal saline solution. It is then 
heated to 56^ C. for half an hour and is again placed in the ice box 
until ready for use. The patient is prepared for operation and 
given an ether anaesthetic. The trephine hole is bored as nearly 
as possible over the precentral gyrus. As soon as the dura is 
exposed a lumbar puncture is performed and about 20 cc of spinal 
fluid drawn off. The dura is, as a rule, found rather tense and 
enough fluid is abstracted to relieve the tension and allow the 
respiratory fluctuations of the membrane to be plainly seen. When 
this effect is accomplished the needle is inserted through the dura 
and about 30 cc. of the previously prepared mixture allowed to 
flow in by gravity. The apparatus used is an all-glass, 30 cc Luer 
syringe, with about 18 inches of rubber tubing attached and an 
ordinary small caliber salvarsan needle bent upon itself at about 
a quarter of an inch from the point. After some experience with 
the cadaver and living subject we find that an opening not less 
than 2 cm. in diameter is sufficient for the safe introduction of 
the needle. If the above conditions are complied with the fluid, 
as far as our experience goes, invariably flows in readily by 
gravity. 

Case i.— Male; white; 33; married; Pole; tinsmith. Admitted to the 
hospital June ^ 1912. At this time liis wife stated that during the past 
six months the patient had become nervous, irritable and depressed. He 
was easily fatigued and had been obliged to give up work. His memory 
had become so bad that he invariably forgot the errands upon which he 
was sent. He was exceedingly gluttonous and ate and drank everything 
he could lay his hands on. He seemed to have lost all interest in his former 
pursuits and even his affection for his family. Past History: Negative. 
Venereal : Denied. Habits : To have been good. Physical Examination : 
Showed a well-developed, somewhat emaciated man. Facial expression 
vacant Pupils equal, round, centrally placed and react sluggishly to direct 
illumination. The facial muscles and the fingers showed a well-marked 
tremor; the tongue on protrusion a trombone movement. The upper lip 
was raised with difficulty. Knee jerks were greatly exaggerated. No 
Babinski, no Oppenheim, no clonus. The gait was shuffling. The co- 
ordination tests were poorly performed and he had a slight Romberg. 
Speech showed a marked defect. Otherwise the physical examination was 
negative. Mentally: He was disoriented as to time, place and person; 
depressed, forgetful and untidy about his person. No delusions or hallu- 
cinations were brought out The spinal fluid showed excess of globulin 
and increase of cells. The Wassermann was plus, both in spinal fluid and 



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DREW M. WARDNER 20$ 

blood He rapidly became more helpless and demented, and on December 
12, 1912, he became permanently confined to bed. Examination January 
29, 1914 : Pupils are equal and regular ; do not react to direct or consensual 
light Knee jerks are exaggerated, especially on ris^t side. Ankle clonus 
present; no Babinski. Has well marked apraxia and dysphagia. Cannot 
walk or stand, or help himself in any way. Is incontinent of urine and 
faeces. The diet consists entirely of fluids. Apparently understands nothing 
that is said to him and has not spoken for Ave or six months. During 
this interval has had two or three epileptiform convulsions, commencing 
in the right leg and spreading to the arm and face of the same side. The 
spinal fluid shows Wassermann 4 plus, 30 cells per cm., and excessive 
globulin. In the blood the Wassermann is 2 plus. On February i, 1914, 
patient received treatment and made an uninterrupted recovery from the 
operation. On February 5 he was much brighter and made a few purposeful 
movements. On February 6 he recognized and talked with his wife and 
answered simple questions as to his physical needs by nods of the head. 
To date he is still bedridden and incontinent The apraxia and dysphagia 
have, to a great extent, disappeared. He talks a little. He is given solid 
food and feeds himself. The facial expression is much brighter. He 
can sit up by himself and walk a little with help. On March 12 patient was 
again treated. On coming out of the anaesthetic the patient had a series 
of right-sided convulsive seizures similar to those he had had before the 
first operation. The seizures ceased at the end of 48 hours, leaving the 
patient with apraxia, aphasia and dysphagia— in short, he was in a condi- 
tion similar to his status before operation. In a few days these symptoms 
began to clear up, and by March 29 he spoke occasionally and made pur- 
poseful movements. It was decided, nevertheless, to turn back an osteo- 
plastic flap over the cite of the second operation. This was accordingly 
done on April i and a small, organized subdural clot was f otmd immediately 
under the old trephine hole. Following this, the patient improved a 
little more and at present he sits up, speaks occasionally and feeds himself. 
Case 2. — White; male; 45; married; laundryman; German. Admitted 
here January 30, 1914. Family History: Negative. Past History: Dis- 
eases of childhood, not known. Has never had any severe acute illnesses. 
Patient was always of a somewhat stolid disposition and had few friends. 
Was inclined to be irritable and sullen with his wife, but was a good 
provider. Married at 23. Seventeen years in this country. Both wife and 
son have syphilis. No history of miscarriages. Habits : Alcohol at times 
to excess. Venereal : Syphilis at 22. Present Illness : About May, 1913, 
his wife noticed a change in patient's character. From being rather sullen 
and stolid he became jovial and expansive, forgetful and somewhat childish 
in his actions. He became noticeably lacking in judgment, and upon one 
occasion was arrested for stealing flowers in the cemetery. He finally 
developed ideas of great wealth and grandeur; could no longer attend to 
his business and was finally committed to this hospital Physical Examina- 
tion: Showed a well-developed, well-nourished man. Complexion muddy, 
with some Qranosis of hands, feet and middle portion of face. Respiratory 



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206 INTRACRANIAL INJECTION OF AUTO-SERD-SALVARSAN 

System: Normal. Circulatory System: Normal. Digestive System: 
Normal. Neuromuscular System : Pupils react sluggishly to direct illumi- 
nation. Consensual reflex absent on right side. Right pupil somewhat 
smaller than the left; no irregularity. Knee jerks much increased. No 
Babinski. Gait somewhat shuffling. No swaying with eyes closed. Co- 
ordination tests fair. Marked speech defect in ordinary conversation, and 
patient can't pronounce test phrases. Mental Examination : Oriented for 
time, place and person. His grasp of the situation and judgment are a 
good deal impaired. He knows this is a hospital, but thinks there are no 
insane people here. Says there is nothing the matter with him and seems 
quite indifferent to his surroundings, making no attempts to explain his 
presence here. Believes he can go home any time he so desires. Memory 
for past events is good. Memory for recent events is somewhat impaired. 
Patient has had a good education, apparently, but school knowledge is, to 
a great extent, lost. Delusions: He is quite exalted; has great wealth; 
can speak several languages well. Emotional Tone: He is indifferent to 
his surroundings, but happy and contented. Speaks of his family without 
emotion. He has no insight into his condition. Makes many glaring mis- 
takes in calculating figures and displays complete indifference to them when 
they are brought to his notice. Conduct : He is slovenly in his dress and 
somewhat untidy. 

On February 15, 1914, he received treatment. March 14 patient may be 
seen sitting about the ward, always occupied in some way. Reads the 
papers regularly and can quote news items of the day before. Facial 
expression much brighter. There is none of the indifferent, self-satisfied 
attitude toward his affairs. On the other hand, he discusses them inter- 
estedly and reasonably. Betrays a good deal of emotion when speaking 
of his family and tells, with pride, of his son's ability and ambitions. There 
is, however, no euphoria of grandiose ideas. He asks sensible questions 
about the institution. His speech defect is not so noticeable in ordinary 
conversation but test phrases are still poorly performed. Physical: The 
patient has put on weight. His complexion is better and the cyanosis is 
entirely cleared up. Other signs remain as before. On March 28 he again 
received treatment. For the last 15 cc. of the serum, slight pressure with 
the piston was found necessary. On coming out of the anaesthetic it was 
noticed that the patient was very incoherent and had great difficulty in 
articulation. This condition persisted for two or three dajrs and then began 
gradually to clear up. On May 6 an incision was made through the old 
scar of the left side and a small osteoplastic flap turned back. There was 
no sign of any hemorrhage. Forty cc. of serum flowed in readily by 
gravity. At present the patient's status is as follows: He is oriented as 
to time, place and person and has no delusions of grandeur or wealth. 
Patient does not understand the nature of his disease or that it is due to 
syphilis. Thinks, however, that since the operation his head feels clearer 
and that his memory is better than before. He takes a good deal of 
interest in his own affairs and wants to have the details of the operation 
and also of the Wassermann reaction explained to him. Seems to grasp 



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DREW M. WARDNER 20/ 

the outstanding points of the procedure fairly well. Wants to go home, 
but expresses a willingness to stay here as long as we think desirable. 
The egotism and feeling of exaltation have given place to stolidity without 
depression or childishness. There is no aphasia. There is still a marked 
articulatory disturbance. Other signs remain as before. 

February 15, 1914. — Wassermann in blood, 4 plus. Spinal fluid, Wasser- 
mann, 4 plus. Cells, 10 per cm. Globulin in excess. 

May I, 1914.— Wassermann in blood, i plus. Spinal fluid, Wassermann, 
4 plus. Cells, not counted. 

Case 3.— Male ; 35 ; white ; laborer (U. S.) ; married. Admitted February 
7, 1914, from Caldwell penitentiary, where he had spent one month of a three 
months' term, having previously been incarcerated for about two weeks in 
the Newark jail. The charges against him seem to have been petty thefts 
and intoxication. Family History: Negative. Past History: Ordinary 
diseases of childhood. No history of serious illness since. Moderately 
bright as a child Can read and write and add figures, but his education 
extends no further than this. Always a good workman. No previous 
mental abnormalities noted. Habits: Moderately alcoholic, occasionally 
drunk. Of late has drank to excess. Venereal : Gonorrhea denied. Syphilis 
probably eight years ago. Present Illness: About one year ago patient 
was noticed to be irritable and faultflnding, with both grandiose and per- 
secutory ideas. At times threatened to kill members of the family. Fre- 
quently drunk. Went away from home and lived with a woman whom he 
claimed as his wife, although there is no record of marriage. Came home 
after a while intoxicated, and stole a few small articles, for which his sister 
had him arrested, and he was given three months at Caldwell penitentiary. 
Summary of Condition at Caldwell Penitentiary: The patient was very 
restless in his cell and destructive, so that he had to be put in a padded 
cell He managed to And a loose spot in the padding and tore it away, 
doing much damage to the cell. When taken to the bath room for a bath 
he went at once under the spray with all his clothes on. Mental Condition : 
The patient is very destructive and excited ; uses alcohol to excess ; sleeps 
irregularly ; eats well. Said he intended to establish a printing office next 
week and would raise chickens and vegetables in conjunction with the 
business and thus make a large amount of money. Said he had never lost 
a position. He tore up his sheets and blankets to make handkerchiefs; 
claims he could make use of the pieces. Excited at first, but later laid down 
on a bare board with his cap for a pillow and said it was a very comfort- 
able position. On admission here he was excited and restless, tearing his 
bedding and climbing up on the window guards. Talking incoherently. 
Physical : Shows a well developed man, very much emaciated. Complexion 
sallow. Expression vacant Respiratory System: Normal. Circulatory 
System: Some cyanosis of extremities. No other abnormalities. Blood 
pressure, 120. Neuromuscular System: Eye movements normal. Pupils 
equal; react sluggishly to direct illumination. Do not hold well. Coarse 
tremor with hands extended. Coarse tremor of tongue. Knee jerks and 



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208 INTRACRANIAL INJECTION OF AUTO-SERO-SALVARSAN 

ankle jerks, increased No Babinski, no Oppenheim, no clonus. Gait 
somewhat shuffling. Station good. Patient performs the ordinary co- 
ordination tests rather poorly and is unable to button his coat Sensation : 
Patient is generally hypoesllietic Does not wince when lumbar puncture 
is performed. Taste and smell normal Speech low, monotonous and 
thick. He can't repeat test words. Cannot write his name and address. 
Mental Examination: Orientation; gives his name correctly. Does not 
know the name of this hospital, although he recognizes its general character. 
Gives several contradictory answers as to where he came from and why sent 
here. General Memory: Gives confused and contradictory answers as 
to his past life, members of family, etc. Is 35 years old (correct) ; was 
bom in 1465; school knowledge very poor; 8x9 are 34. California is 
in New Orleans. Can't give capital of country or state. Delusions are 
grandiose in character, very exalted. Has $60^000^ automobiles, horses and 
stores. Has lots of friends. Is very good-looking and well-built Much 
stronger than the average man. Can drink 50 glasses of whiskey a day. 
Insight: None. Is here because he has a pain over his kidneys. Is mentally 
sound. Is not at all affected when his numerous mistakes and shortcomings 
are brought to his notice. On March 6, 1914, patient received treatment 
March 16: Patient is working actively about the ward. Energetic and 
interested in his surroundings. Facial expression is greatly improved. Com* 
plexion ruddy and healthy in appearance. Other physical signs unchanged. 
Patient is oriented for time, place and person. He knows how long he has 
been here and gives a correct account of his experiences immediately pre- 
ceding his coming here. Still insists that he was married. He is somewhat 
exalted and slightly euphoric. Denies having any large amount of property 
now, but has no doubt of his ability to secure it and is full of plans for the 
future. He has $6000 in the bank and he is going to start a garage, also 
buy out his old employer in the printing business. This printing business 
is worth only about $2000, he says, and his ideas as to the garage are not 
exceedingly extravagant. There is a well-marked increase in cutaneous 
sensibility to touch and pain. March 24 patient again received treatment 
April 2, 1914 : Patient continues to gain physically and mentally. Delusions 
of grandeur entirely disappeared. Has no doubt as to his ability to take 
up his old work. Emotional reaction normal, and patient appears sane in 
every way. Remembers some of the things he said and thinks he must 
have been crazy to express such ideas. Gives a clear, connected account 
of his past life. His reaction toward his environment is normal His 
judgment is good, and although his education is not such as to allow his 
understanding the exact nature of his illness, he realizes that he has had 
some mental trouble, and is willing to continue treatment 

February 28» 1914 : Wassermann in blood, 4 plus. Spinal fluid, Wasser- 
mann, 4 plus. Cells, 109 per cm. Globulin in excess. 

May I, 1914: Wassermann in blood, 2 plus. Spinal fluid, Wassermann, 
4 plus. Cells, 33 per cm. Globulin unchanged. 

Case 4.— Male; white; 47; married (U. S.) ; proofreader. Family His- 
tory: Father died of apoplexy. Past History: Ordinary diseases of 



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DREW M. WARDNER 209 

childhood; no severe acute iUnesses. Always of a nervous disposition. 
A very hard worker, always working 12 to 14 hours a day. Held a very 
good position as head proofreader on Colliet^s Weekly. Habits : Alcohol 
to excess at times, but never lost a da/s work through intemperance. 
Venereal: Denied. Present History: He began to act peculiarly in 
August, 1912. Was somewhat incoherent in conversation ; would leave his 
work and go home before the specified time. Was sent to the country 
to recuperate, but did not improve. Was continually depressed. Walked 
about the house talking to himself and muttering words about his wife. 
Was extremely forgetful Had delusions of grandeur. Admitted to this 
hospital October 21, 1912. Physical Examination : Shows a well-developed 
poorly nourished man. Respiratory System: Negative. Circulatory Sys- 
tem: Negative. Digestive System: Negative. Neuromuscular System: 
Pupils react sluggishly. Knee jerks markedly exaggerated. Coarse tremor 
of tongue and fingers. Tremor of facial muscles. No Babinski. Sways 
slightly with eyes closed. Co-ordination tests poorly performed. Marked 
speech defect in ordinary conversation. Can't pronounce test phrases. 
Mental Examination: Is disoriented as to time and place. Memory for 
past events, fair. Memory for recent events, very much disturbed. Delu- 
sions : Imagines that all his organs are wealrened ; thinks his bowels never 
move. Thinks this is a hotel and that it belongs to him; that the whole 
world belongs to him; thinks he has millions of dollars, thousands of ele- 
phants, tigers and lions, and a harem full of giant wives. Emotional 
Tone: Is extremely irritable, unapproachable and easily enraged. Noisy 
and abusive. Restless and continually annoying the patients. Talks almost 
incessantly and frequently breaks out into fits of obscene fury. Tears up 
his clothing and beddothing. Smears urine and fceces about the room. 
May 29^ 1913: Patient had three convulsions. August 9^ 1913: Shouting 
continually. Is delusional, incoherent, has exalted ideas. February 11, 
1914: Is in a continuous noisy state; talks and sings all day long; is quite 
imapproachable; seem to have memory for recent events; thinks his mother 
is dead, although she visited him the day before. On March 7, 1914, 
patient received treatment Patient's condition remained about the same 
for about a week, continually talking, shouting and singing day and night 
At the end of this time he gradually began to grow quiet; slept well at 
night and during the day had fewer outbursts of rage. On March 27 he 
again received treatment. Following this operation, improvement was con- 
tinuous. At the present time he has taken on a good deal of wei^t, his 
complexion is ruddy and healthy in appearance. From being practically 
bedridden, he is able to take daily walks about the premises. His attitude 
has changed decidedly. Although not decidedly friendly, he is quite ap- 
proachable. He is never noisy except when purposely annoyed. He is 
not destructive and he is tidy about his person. The speech defect is not 
so noticeable. His memory for recent events is much improved. He is 
still disoriented and the delusions of grandeur persist 

November 10, 1913.— Wassermann in blood, 2 plus. Spinal fluid, Wasser- 
mann, 4 plus. Cells, 50 per cm. Globulin in excess. 

14 



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2IO INTRACRANIAL INJECTION OF AUTO-SERO-SALVARSAN 

April 14, 1914. — ^Wassermann in blood, minus. Spinal fluid, Wassermann, 
4 plus. Cells, 3.5 per cm. Globulin in excess. 

Cask 5.— Male; white; 35; married (U. S.) ; dentist. Admitted August 
28» 1913. Family History: Negative. Past History: Ordinary diseases 
of childhood, no severe acute illnesses. Said to have been one of the best 
dentists in Newark. No mental abnormalities noted until present illness. 
Habits : Moderate alcohol. Venereal : Syphilis 12 or 15 years ago. Present 
Illness: About four years ago patient's wife began to notice a change 
in her husband's character. He would buy and bring into the house all 
kinds of unnecessary articles, especially tools and instruments of various 
kinds. He also went into foolish real estate ventures. Finally it became 
necessary to have him committed. On admission here physical examina- 
tion showed a well-developed, well-nourished man. Respiratory System: 
Normal. Circulatory System: Normal Digestive System: Normal 
Neuromuscular System: Pupils normal and react fairly to light. Slight 
tremor of tongue and fingers. Knee jerks almost absent. Co-ordination 
tests fairly well performed. Walks straight line with some difficulty. No 
Romberg or Babinski. Somewhat hypoaesthetic Marked speech defect 
in ordinary conversation. Test phrases cannot be pronounced. Mental 
Examination: Oriented as to time, place and person. Memory for past 
events somewhat confused. Says he is 36 years of age and has been work- 
ing at dentistry for the past 22 years. Cannot do simple sums in arithmetic 
Cannot answer simple geographical or historical questions. Emotional 
Tone: He is happy and contented; somewhat exalted. Has no insight 
into his condition, and shows complete indifference when his numerous 
glaring mistakes are pointed out to him. Has no special delusions. On 
March 15 patient received treatment. There has been no special change in 
the patient's condition since he has been in this hospital, either before or 
since operation. 

March i, 1914. — ^Wassermann in blood, 2 plus. Spinal fluid, Wassermann, 
4 plus. Cells, 3.3 per cm. Globulin in excess. 

Case 6. — Male; white; 33 (U. S.) ; married; salesman. Admitted first. 
May 9, 1913. Family History: Mother and maternal aunt insane. Past 
History: Diseases of childhood, mumps and measles. He was bright in 
school; common school education, after which he went into the electrical 
supply business, where he proved himself a good salesman and drew good 
wages. Married at 20, and has four children, all alive and well except a 
baby, who died of measles three weeks before his coming here. Has never 
showed any mental abnormalities. Habits: Moderately alcoholic; never 
drunk. Venereal: Syphilis nine years ago. On his first commitment 
here he was said to have been acting in a peculiar manner for about six 
weeks. He was exalted, excited, with grandiose ideas; he was worth 
millions and had affairs of the utmost importance to attend to. Physical 
Examination : Showed a man in fair state of nutrition. Eyes, lateral and 
verticle nystagmus; right convergent strabismus. Pupils react sluggishly 
to direct and consensual light. Deep reflexes increased. Gait and station 



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DREW M. WARDNER 211 

good. Some tremor of fingers and tongue. No other abnormalities. The 
patient remained in the condition described for about three months, becom- 
ing much emaciated. At the end of this time be began gradually to improve 
mentally and physically, and on September ii, 1913, he was taken out 
against advice. He went back to his home and business and seems to have 
got along fairly well, although according to the statement of relatives 
he was not entirely normal mentally. 

On March 17, 1914, he was suddenly taken with convubive seizures, which 
lasted two days. He was removed to the City Hospital, where he became 
rapidly much deteriorated and helpless. On admission here on April 8, 
1914, he presented the following picture: Patient lies in bed with dull, 
expressionless facies. Conjunctiva glassy; eyes vacant; sordes on teeth 
and lips; tongue cracked, brown-coated and dry. Decubitus on left heel 
about the size of a silver dollar. Complexion sallow. Fairly well nourished. 
Circulatory System: Heart appears normal in size and position. No 
murmurs. Pulse rapid, small, not well-sustained. Hands and feet some- 
what cyanosed. Respiratory System: Normal. Abdomen: Normal. 
Neuromuscular System: Pupils equal in size; react sluggishly to direct 
illumination, the left more so than the right The left pupil does not react 
to indirect illumination; the right only slightly. Tongue shows coarse 
tremor. Tremor of fingers. Knee jerks exaggerated. No Oppenheim, 
no Babinski. Has some difficulty in distinguishing between the dull and 
sharp end of pin. Cannot stand or walk alone. Could not feed or help 
himself in any way. Would not turn himself over in bed. Mental Exami- 
nation: Patient's attention can be momentarily attracted by talking to 
him, and he gives his name. Is unable to give date, day, or name of 
hospital. Can answer no questions of any kind. On April 9 patient received 
treatment Grasp: Gives date. Remembered only in a very vague way 
that he was at the City Hospital, and that he was brought here and operated 
upon. Has a confused memory of sitting in a chair and having his head 
shaved ; of being given an anaesthetic and waking up with a bandage on his 
head. His recollection of this period and for several days after is very 
fleeting. The first event he remembers with distinctness, and from which 
accurate memory has continued, was being allowed to put on his clothes, 
which he was allowed to do on April 13. Understands in a general way 
the nature of his illness, and is anxious to continue treatment Says he 
feels in bad shape. Patient's speech is low and rather thick, but there is no 
elision of syllables, and test words are fairly well repeated. Patient has 
since received a second treatment and has continued to improve. He is 
completely oriented. Memory for past and recent events, excepting his 
stay at the City Hospital, is good. He has no delusions of any kind. His 
reaction to his environment is in every way normal, and he has good insight 
into his condition. Physically he is much improved. He takes extended 
walks about the place and has put on weight Test phrases still show 
speech defect, but in conversation there is none. 

April I, 1914.— Wassermann in blood, 4 plus. Spinal fluid, Wassermann, 
4 plus. Cells, 80 per cm. Globulin in excess. 



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212 INTRACRANIAL INJECTION OF AUTO-SERO-SALVARSAN 

May I, 1914. — Wassermann in blood, 3 plus. Spinal fluid, Wassermann, 
2 plus. Cells, 4.5 per cm. Globulin unchanged. 

From a clinical standpoint two cases, 3 and 6, have had complete 
remissions after two treatments. One has remained imchanged 
for two months and the other for one month. 

Case 3 has had three treatments, and clinically has a remission 
with slight impairment of apperception and judgment. 

Cases I and 4 have had three and two treatments respectively 
and have shown marked improvement, lasting in the first for 
three months and in the fourth for two months. 

Case 5 has had one treatment and has shown no change. Two 
other cases have been operated upon so recently as to preclude 
a report on their condition at present. 

The Wassermann reaction in the blood has, in all cases, been 
reduced in intensity and rendered negative in two cases. In only 
one case has it been reduced in the spinal fluid, where it was 
brought from 4 plus to 2 plus. The globulin reaction has re- 
mained unchanged. The cell count has been substantially reduced 
in all cases. 

The cases treated were not specially selected but were taken at 
random, the patients being in all stages of the disease. The best 
results were obtained in those cases in which the first manifesta- 
tions of the process have been noticed within a year or less, and 
in which the actual destruction of nerve tissue might reasonably 
be supposed to be comparatively slight. Conclusions as to the 
absolute and relative value of the treatment are as yet somewhat 
difficult to draw. The series of cases is still small and the period 
of observation short. We believe, however, that our results have 
been sufficiently striking to warrant further investigation along 
this line. We believe also, and we think special stress should be 
laid upon this point, that the treatment is in no sense heroic, and 
when properly undertaken is practically without danger. It con- 
sumes little time and is well borne by the patients in all our cases. 
We think it possible that an ideal treatment of general paresis 
may eventually be found to consist in a judicious combination of 
the intracranial and intraspinal methods. 



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DREW M. WARDNER 2I3 

DISCUSSION. 

Dr. H. W. Mitchell.— The papers presented this evening upon the sub- 
ject of paresis well illustrate the recently developed methods of obtaining 
relative accuracy in diagnosis, and the line of treatment outlined arouses 
the hope that some cases of this disease, hitherto considered a hopelessly 
fatal disorder, may be arrested if not cured. 

Our present knowledge of the disease may be said to have had its origin 
in 1857 when Esmarch and Jessen first reported cases which were sup- 
posed to have followed syphilitic infection. Then the para-syphilitic con- 
ception of Foumier was generally held until the discoveries of 3chaudinn, 
Wassermann, Noguchi and others have furnished means to prove the 
syphilitic nature of the process; to give accurate diagnostic measures and» 
upon this basis, to formulate the rational treatment suggested by Swift 
and Ellis. 

After reasonably prolonged observation, the older clinical methods of 
examination enabled observers to secure a high percentage of diagnostic 
accuracy, but with the general use of the Wassermann and globulin tests, 
cell counts, and the extremely delicate gold-chloride reaction, we can un- 
doubtedly make earlier positive diagnosis and also differentiate the ad- 
vanced cases that have not been accurately diagnosed by methods formerly 
available. Only by the routine use of these tests in newly admitted cases 
can we secure their full value in detecting early syphilitic involvement of 
the nervous system at a time when treatment offers the best hope of 
arresting the process, i, e., before irreparable damage has been done. 

Caution must be used in the interpretation of laboratory findings. The 
Wassermann serum test is occasionally negative in undoubted paretics 
and gives varied results at different times. In a series of repeated cell 
counts among untreated paretics at the Warren Hospital we found a very 
marked variation in the cell counts of the same patient, which could not 
be co-related with either clinical variations or stage of the disease. In these 
cases we found the globulin in reaction showing nearly as wide variation, 
while the Wassermann fluid test was much more constant The observa- 
tions on this series left the impression that one negative Wassermann test 
on blood and fluid, with negative globulin test and low cell count, did not 
eliminate paresis, and on the other hand, that repeated examinations would 
invariably yield positive results with some and, usually, all of the tests 
mentioned 

Anti-syphilitic treatment of paretics in the past has accomplished so 
little, that we turned eagerly to a trial of the method advanced by Swift- 
Ellis in the hope that a specific treatment may be at hand for use in 
cerebral syphilis. The results of this, or any treatment, must be most care- 
fully checked by careful observation of patients for a prolonged period 
before we can differentiate permanent improvement or arrest of the disease, 
from the frequent remissions observed by all. At the Warren Hospital 
we have a gradually increasing number of cases under observation, some 
of whom have been thus treated for over a year, and a year or two 



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214 INTRACRANIAL INJECTION OF AUTO-SERO-SALVARSAN 

later we shall be prepared to present the facts relating to this group. Such 
results as we have observed to date leave serious doubt concerning the 
possibility of arresting advanced cases of paresis. It is a logical supposi- 
tion that the earlier treatment can be instituted, following the onset of 
the paretic process, the greater expectation we may have of favorable 
results from treatment Unfortunately months and years often elapse after 
onset of clinical symptoms before the paretics are committed to a hospitaL 
Even if our efforts in such cases do not yield the desired results, they 
cannot fail to arouse a more general interest in the possibilities of treat- 
ment for cases of cerebro-spinal syphilis that will eventually result in a 
more careful observation of syphilitics and the application of best thera- 
peutic efforts in the earliest stages of this complication. From a study 
of the statistics presented by Nonne, Reumont, Hjdman, Matthes and 
others, it would appear that some form of cerebro-spinal syphilis occurs 
in about 5 per cent of syphilitics. The more constant and prolonged 
supervision of these patients at time of infection seems to offer our most 
promising means of preventing the late cerebral complications. 

Whether or not we materially modify the course of paresis in the ad- 
vanced stages, is a matter for future determination, but I consider it 
most fortunate that in our medical work we can have such a definite medical 
problem for solution, one which cannot fail to arouse the interest of the 
hospital physicians and give them the satisfaction of knowing that there is 
work at hand which demands their best efforts. The insane hospital service 
has a rich opportunity for the performance of work that will not only 
throw light upon the treatment of late syphilis, but also for the general 
diffusion of concrete information concerning the relation of syphilis to 
mental disorder. From such continued work a better prophylaxis, in its 
broadest sense, may be developed that shall ultimately reduce the incidence 
of syphilis, and its fatal complications. 

Dr. Swift. — I disagree with Dr. Dunlap that a multiplicity of names 
should still persist for numerous forms of the same infection. There are 
already precedents in medicine where several forms of disease have been 
unified under one head when a single infection for them all has been 
found. Take tuberculosis for example. We hear of miliary tuberculosis, 
tubercular joints, pulmonary tuberculosis, etc., for affections known by 
other names before the organism was discovered. And it has been the same 
with other diseases. This is authority enough for doing the same thing 
with syphilis, now that the organism is known. I, therefore, propose for 
all the lesions where the organism of syphilis has been found to be 
etiological, the single name spirochsetosis. 

Ds. Tom A. WnxiAMS.^Both on clinical and laboratory grounds the 
adequacy of intravenous injections of salvarsan followed by mercury intrav- 
enously, intramuscularly or even by inunction is maintained. Of the 
author's cases two especially striking are reported. 

A man tabetic for six years has been functionally well for two years, 
with a reduction of cell count from 38 to 9 after three courses of salvarsan 



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DREW M. WARDNER 215 

and mercury, totaling six intravenous injections in all. A woman who had 
been treated for six years for rheumatism at Clifton Springs and other 
places showed great loss of weight and strength, marked ataxia, almost 
complete loss of pain, vibration and attitude sense. She was recommended 
salvarsan and mercury against the opposition of several physicians. Seen 
only a few weeks ago this patient, although she has had only four periods 
of treatment of two salvarsans and from four to six weeks of mercurial 
injection in each, is at normal weight and perfectly well, save for the lost 
reflexes and a slight sensory loss in the tibial border of the feet, and can 
work with enjoyment again. As no arsenic is demonstrable in the serum 
used for intrathecal injection and arsenic is found in the serum after 
intravenous injection, and as no improvement has followed intrathecal 
injection unless intravenous injection is employed alone, it should be 
obvious enough that the intravenous injection is the more important pro- 
cedure. The clinical facts of Sachs and the author show this. The 
anatomical facts should leave one to infer it; for the disease process, 
although a meningitis, is deep in the membrane and is generally around 
the vessels, which are nourished not only from the cerebrospinal fluid, but 
from the blood. Any beneflt attributable to intrathecal injections must 
be due to their topical effect in causing hypersemia. These considerations 
show that the method is not specific, and, in view of the numerous re- 
lapses, its superiority is doubtful. 

Dr. Gorst. — ^Up to the first of October last, one of my assistants, with 
the aid of other members of the staff, had made the gold test in 120 cases. 
I speak of this especially for the reason that the general practitioner may 
make the gold test without having a very large laboratory and if he will, 
the state hospital will get the case much earlier, which should be bene- 
ficial to the patient; besides it will, perhaps, be a strong point in the way 
of education. With regard to syphilis in insanity, five of our cases have 
been treated both intravenously and intraspinously, and two have seemed 
to be arrested— one for nearly two years — ^the other three have not shown 
any change. We have had a number of cases under treatment, but they 
have not been tabulated. 



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REPORT OF A CASE OF CEREBELLAR TUMOR. 

By W. M. ENGUSH, iM. D^ C M., 
Supifintendent Hospital for Insane, Hamilton, Ont, 

The patient whose case I desire to present was a man 35 years 
of age, of English nativity; his father died at 68 as the result of 
an accident and his mother was living at the age of 78 years. 

He was the youngest of six children, the eldest being 50 years; 
there was no consanguinity between the parents, or history of 
alcoholism, syphilis or insanity in the connection. 

When 6 years of age he suffered from a severe attack of 
typhoid fever and was thereafter never robust, always being 
subject to gastric derangement and frequent attacks of vomiting. 

When 14 he fell and fractured his right clavicle. On leaving 
school at the age of 15 years he came to Canada and took up and 
followed the trade of a baker for two and one-half years and 
subsequently drifted into a barber shop and followed this business 
until May, 1912, when he was compelled to give up work owing 
to frequent attacks of vertigo, severe pains in the basilar region 
extending into the fundus of the right eye and eyeball and causing 
disorder of sight and inability to perform his duties. A physi- 
cian when consulted stated that he had right optic neuritis, proba- 
bly of specific origin, and prescribed potassium iodide in full doses. 

By September, 1912, he had sufficiently recovered to resume 
employment and took up work as collector for a railway company 
and pursued this with evident satisfaction to his employers — 
though occasionally he forgot to deliver accounts — ^until the time 
of his arrest for indecent behavior with a girl of 12 years of age 
whom he had invited to accompany him to a moving picture 
show. 

A mental examination being made, he was declared insane and 
irresponsible for his assault and committed to the Hospital for 
Insane, Hamilton, Ont., on April 23, 1913, and entered under the 
care of Dr. John Webster, to whom my thanks are due for able 
assistance in preparing this report. 



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2l8 REPORT OF A CASE OF CEREBELLAR TUMOR 

On admission he was evidently ill, though fairly well nourished 
and taking his food well and conversing freely and intelligently. 

He stated that during the 12 months previous to coming tmder 
our care he was subject to dizzy spells which would come on 
suddenly, the blood seeming to surge to the back of his neck when 
he would experience severe pain there which g^dually extended 
to his right eye and he would then become weak, especially upon 
his left side, and stagger if walking and he frequently had to stop 
on the street and support himself. This weakness would pass off 
in a few minutes and permit him to pursue his business, though 
he felt dull and stupid for two or three hours thereafter. 

He also noticed that his memory had failed considerably during 
the previous six months. He remembered taking the little g^rl, 
with whom he was not acquainted, to the picture show but had 
no recollection of the pictures exhibited or any misbehavior with 
the child. 

Sexual History. — In boyhood he practiced masturbation to 
some extent and later in life occasionally indulged in sexual inter- 
course, but not to excess as it caused him distress and he did not 
feel well after. 

He denied positively that he ever suffered from syphilitic or any 
other sores. Occasionally he handled his lady friends indecently 
and in so doing he experienced the sexual orgasm ; he thus handled 
the young child previous to his arrest. 

Physical Examination. — Face pale and pasty, skin of trunk and 
limbs mottled bluish red and showing many small angiomatous 
spots on trunk. No suspicious scars or eruptions. Body and 
limbs well formed and nourished ; there was a slight deformity at 
the site of the old fracture of the right clavicle. Heart and lungs 
normal. No arteriosclerosis. Dermatographie quite marked. 
Wassermann reaction positive. 

Neurological Examinationj— Pupils equal and normal in size, 
but responding very sluggishly to light and for accommodation — 
a hippie movement being quite noticeable. 

The tongue was protruded straight but there was a fine tremor, 
the right side of the face lacked tone and the nasolabial fold was 
almost obliterated ; the mouth was drawn slightly to the left side 
and he was unable to whistle. 



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W. M. ENGLISH 219 

The esthesiometer showed a marked lessening of sensibility 
of the right side of the face. 

The djmamometer recorded ^o in each hand. 

There was considerable ataxia of the left arm and leg, the 
finer movements of the arm and hand being uncertain. 

He fumbled in buttoning his clothes and his gait was unsteady 
and shuffling. Knee jerks were slightly exaggerated but other 
tendon and the skin reflexes were normal. 

Romberg's sign was present but Babinski's absent. Following 
one of the dizzy spells, these symptoms were all exaggerated. 

Mental Examination, — Hallucinations and illusions were not in 
evidence and were denied by him. 

He appeared befogged during and following his " dizzy spells " 
but at other times seemed quite clear and answered readily and 
intelligently questions asked. 

Course, — From the time of his admission to May 30, 1913, there 
was little change in his condition — ^though he frequently remained 
in bed for two or three days at a time — ^he was anaemic and had 
periodical attacks of vomiting, headache and giddiness, when 
the facial paralysis and staggering in gait would become more 
marked. 

Potassium iodide in doses of 45 grs. per day was g^ven with 
no good effect, and as the Wassermann test of the cerebro-spinal 
fluid proved positive it was decided to administer a course of 
salvarsan. 

On June 30, 1913, after a severe attack of vomiting, the initial 
dose of 0.6 gm. of salvarsan prepared in the following manner 
was administered intravenously — 0.6 gm. of salvarsan was dis- 
solved in 70 cc. of hot sterile distilled watef — ^this was made up 
to 100 cc. with sterile normal saline solution and then a 15 per cent 
solution of Na O. H. was added until the precipitate at first 
formed was cleared up and then the solution was made up to 
300 cc. and injected intravenously with the gravity apparatus, 
the time occupied in the process being 20 minutes. 

The dose was g^ven at 3.30 p. m. without any apparent discom- 
fort ; at 5 p. m. the patient vomited eight ounces of a watery fluid 
and, collapsing, became cyanosed and unconscious. 

A pinkish watery fluid was discharged about 7 p. m. from the 
mouth and nostrils and continued in considerable quantity up till 



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220 REPORT OF A CASE OF CEREBELLAR TUMOR 

death, which took place at 5.15 a. m. — i. e,, 13 J4 hours after the 
administration. 

Autopsy, — ^An autopsy made five hours thereafter disclosed the 
following : 

Heart: Valves normal. Ventricles showed some dilation. 
Muscle of good color and on section showed no evidence of 
degeneration. 

Lungs: Both organs were deep purple in color and mottled 
and extremely heavy. On removal they dripped fluid and on sec- 
tion the surface was deep red and dripped frothy red fluid. 
Mucous-like material could be squeezed from the bronchi. 

Spleen : Enlarged and rather tense. On section dripped bloody 
fluid and is deep purple in color. 

Liver: Seems somewhat enlarged and capsule felt tense. Was 
deep reddish purple in color and on section it showed indistinct 
lobulation and blood dripped from the surface. 

Kidneys: Were normal in size and capsule stripped easily, 
leaving a deep red surface. Striation was distinct in cortex. 
Glomeruli stood out as red pin points. 

Pancreas: Appeared somewhat injected but on section ap- 
peared normal. There was some increase in fluid in the peritoneal 
cavity. 

Intestinal Tract: Showed no abnormalities. 

Brain: On removing the skull-cap the dura protruded and 
seemed to be extremely tense and on incision thereof pinkish- 
colored fluid gushed forth. The blood vessels in the cortex were 
eversrwhere injected. 

On incision of the left tentorium cerebelli a slight bulging 
was noticed and on removing the membrane a tumor was re- 
vealed in the occipital fossa. On removing the brain the tumor 
appeared to be a hard white mass somewhat ovoid in form, about 
3 cm. in diameter. It was loosely attached to the cerebellar 
areolar tissue and shelled out easily. The only permanent attach- 
ment to the brain tissue proper was by a delicate nerve-like fila- 
ment to the middle lobe of the cerebellum. 

The tumor compressed deeply the left and middle cerebellar 
lobes, also the pons and to a slight extent the under surface of the 
tempero-sphenoidal lobes. The fourth ventricle showed no pres- 



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W. M. ENGLISH 221 

sure effects. Other than the results of compression, the cerebellar 
tissue showed nothing abnormal. 

Microscopically the specimen is diagnosed as a haemangio- 
endothelioma, in a disintegrating stage, that had commenced 
primarily in the blood vessels. 

A brief review of the recent literature regarding fatalities 
after the administration of salvarsan shows that : 

Alwkvist* in 191 1 reported a case where a single injection of 
0.5 gm. of salvarsan was administered and two days thereafter 
the patient complained of headache, slight shivering and the 
following morning had severe vomiting and in the evening — i. e,, 
70 hours after the injection — ^was found in bed imconscious and 
C3ranosed ; he partially recovered and then lapsed into a comatose 
state and died the following day. 

The post mortem disclosed hemorrhagic encephalitis. 

Kohrs,* in February, 1914, reported a case in which death oc- 
curred within three days after a single dose of 0.6 gr. administered 
following a Wassermann positive — ^the symptoms being those of 
arsenical poisoning and a post mortem verif}ring the diagnosis. 

Speaking of the risks of salvarsan, Dr. Van Stoker* at a recent 
meeting held in Munich said that, basing his conclusions on experi- 
ences of 2000 cases, he believed that fatalities were due to 
idiosyncrasy in r^;ard to arsenic, errors in technique, or the use 
of too large a primary dose, and that neither serious organic dis- 
ease nor lesions of the central nervous system were contra indi- 
cations. 

Speaking of the amount of the primary injection. Dr. Puvis 
Stewart,* in a paper read before the Medical Society, London, 
England, April 27, 1914, when referring to cerebro-spinal syphilis, 
expressed the belief that it is risky to g^ve salvarsan in the full 
intravenous dose of 0.6 gm., but that if given in one-half that 
amount and repeated at short intervals, acute arsenical s3rmptoms 
would be less likely to occur. 



REFERENCES. 

1. International Med. Annual, 1912. 

2. N. Y. Med. Record, pp. 5-39, March 2, 1914. 

3. Br. Med. JL, April 4, 1914, p. 778. 

4. Br. Med. JU May 2, 1914, p. 950. 



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222 REPORT OF A CASE OF CEREBELLAR TUMOR 

EXPLANATION OF PLATES. 

Fig. I. — Shows tumor " in situ " and the compression of the left posterior 
cerebellar lobe and compression and displacement of the pons. 

Fig. 2. — Makes more evident the effects of the pressure and shows the 
cavity left on the removal of the growth. 

Fig. 3. — Shows the tumor itself and its filamentous attachment. 

Fig. 4. — Illustrates under low power the presence of numerous sinuses* 
like blood spaces, some of which contain blood between which are fibrous 
trabeculae, undergoing degeneration in places. 

Fig. 5. — Illustrates the condition as seen in No. 4 but under higher power. 



DISCUSSION. 

Dr. Wm. a. White. — I merely rise to make the suggestion that the 
condition as found at autopsy — a disintegrating tumor — ^is precisely the 
sort of lesion that might cause a release of arsenic from this organic 
combination. There is a possible source of danger in giving salvarsan 
intravenously, and this is one of the sources that has always been 
recognized in giving salvarsan. 



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AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. PLATE I. 

W. M. ENGLISH. 



U, 



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AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. PLATE II. 

W. M. ENGLISH. 



Fin. 4. 



Fig. 5. 



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CLINICAL AND ANATOMICAL ANALYSIS OF ELEVEN 
CASES OF MENTAL DISEASE ARISING IN THE 
SECOND DECADE, WITH SPECIAL REFERENCE TO 
A CERTAIN TYPE OF CORTICAL HYPERPIGMEN- 
TATION IN MANIC-DEPRESSIVE INSANITY. 
By E. E. SOUTHARD, M.D., 

Pathologist to the State Board of Insanity of Massachusetts; Director of 

Psychopathic Hospital, Boston; and Bullard Professor of 

Neuropathology, Harvard Medical School, Boston, 

AND 

E. D. BOND, M.D., 
Clinical Director and Pathologist to the Danvers State Hospital, 
Hathome, Mass, 
(From the Laboratory of the Danvers State Hospital, Number 48 of Dan- 
vers State Hospital Series.) 

This paper is the third in a series which attacks the Danvers 
State Hospital material by decades. It concerns itself with those 
cases which first showed mental symptoms in the second decade, 
and is intended for comparison with similar analyses of the fifth,* 
sixth and seventh * already published, and papers in preparation 
for the remaining decades. 

The previous papers make an extended preface unnecessary. 
For our material we present abstracts of clinical histories followed 
by general autopsy findings, gross brain findings, and cursory 
notes of microscopical examination of the brain cortex with special 
reference to certain pigments best demonstrable by Heidenhain's 
iron-hematoxylin method. 

Nine himdred and thirty-eight consecutive autopsies, in several 
of which age at onset was unknown, gave 18 cases with first attack 
between the ages of 11 and 20. In 5 of these brain material had 
not been saved and in 2 histories were lacking. Eleven cases were 
left for study — 3 male and 8 female. 

* Southard and Bond : Clinical and Anatomical Analysis of Twenty-five 
Cases of Mental Disease Arising in the Fifth Decade. Am. J. Insan., 1914. 

'Southard and Mitchell: Clinical and Anat. Analysis of Twenty-three 
Cases of Insanity Arising in the Sixth and Seventh Decades. Am. J. Insan., 
Oct, 1908. 



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224 analysis of mental diseases in the second decade 

Case Material. 

Case i is that of a mulatto girl whose death followed the onset of her 
first mental illness in 20 days, at the age of 17. 

Family history is negative. She Uved on Island St Kitts mitil 18 months 
before admission ; since that time she worked hard at general housework. 
She had been strong and well and rather above the average in mental 
capacity. 

Twelve days before admission she seemed to her family rather depressed 
and confused, but the family noticed nothing peculiar and she went bade 
to her work for a few days. She fell fainting while at work and was sent 
home, where she moved about excitedly, laughed, sang, " rambled," gestic- 
ulated. Here she showed marked psychomotor activity, refused to eat 
food *' becatise it was poisoned " ; was good natured. She died suddenly on 
the eighth day. 

Autopsy discovered an acute fibrinous exudate on pharynx, tonsils and 
tongue; acute otitis and leptomeningitis; acute congestion of lungs, liver 
and spleen; subcutaneous emphysema of cervical and mediastinal tissues; 
small aorta; brain weight 134a (KL bacillus recovered from throat) 

Nissl, Pyronui and other stains showed " acute alteration " of the nerve 
cells, glial changes, infiltration by polynudear cells, lympho^es and a few 
plasma cells— all these changes most marked in the frontal region left 

There is little or no pigment in any region except the left superior frontal, 
where punctate small masses are found in moderate but singularly evenly 
distributed amounts. Almost every satellite and neuroglia cell has one or 
two small punctate masses, and some neuroglia cells in supragranular layers 
were noted, having a dozen or more granules, resembling the cells of cases 
much older (as examined in previous work). The question arises, whether 
the relatively severer acute and chronic inflammatory process whidi charac- 
terized this gyrus could have determined an alteration of cell metabolism 
such as we usually find in older cases. 

Case 2 is a girl who died nine months after entering the hospital at 17, 

Her father is insane (dementia prsecox). The patient was bom in 
Armenia and came to America when 5 years old. She was at work in the 
mills ; in the evenings attended night and sewing schools. 

Five days before entrance she expressed fears of the Catholics, of men, 
of negroes and devils and said that she had lived a lie for the last five 
years. In the hospital she at all times refused to answer questions, but 
would often talk and sing to hersdf— what she said seemed to have little 
connection if any. She was restless, her movements quick and tending to 
stereotypy; at the end of a month she had many mannerisms, was resistive, 
showed cerea flexibilitas and a little negativism. Her mood showed ap- 
parently neither depression nor elation. She was tube-fed. In six months 
tuberculosis devdoped, of which she died. 

Autopsy showed merely an extensive tubercular process in the left lung. 
Brain weight, 127a 



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E. E. SOUTHARD AND E. D. BOND 22$ 

This case is to be published more fully elsewhere with a description of 
microscopic findings; from the standpoint of this research, theHeidenhain 
staining pigments are absent or negligible in all areas so far studied. 

Case 3 is that of a married woman whose first attack occurred at 17, 
second at 31, third at 32, and who came to this hospital at 49- to die six 
weeks later. 

Father, mother and three brothers are living and well ; an aunt is insane. 
A strong child, developing normally and doing well at school. At 17, in 
private (high) school she studied hard and became depressed, weak, kept 
quiet and had no active interest. At 31, and after an unhappy marriage at 
32, she had similar attacks. In no attack did delusions appear. She made 
perfect recoveries. At 49 she came to this hospital in a typical manic 
attack which had lasted five months. She died of enterocolitis. 

Autopsy showed unequal pupils, dilated stomach, chronic pleuritis and 
endocarditis, infarst of spleen, chronic hepatitis and sclerosis of the aorta, 
with acute pyelonephritis and enteritis. 

The dura was thickened and adherent, the right ascending parietal artery 
enlarged and thrombosed. There was a softened hemorrhagic area i cm. in 
diameter, well defined, in right postcentral lobule, 2 cm. from superior 
surface. Brain weight, 12 10. 

Hddenhain preparations showed much pigment in the P3rramidal cells 
everywhere, varying most in amount in the frontal region; much glial 
pigment in all regions except frontal, where it was moderate ; much pigment 
in the perivascular spaces of calcarine and precentral regions, with little 
or none in temporal and frontal. 

Case 4 is that of a single woman whose first mental trouble was at 19, 
who came to the hospital at 20 and at 22, dying at 25 after an interrupted 
residence. 

An uncle had post-paralytic insanity ; an uncle had epilepsy ; grandmother 
paralytic ; father alcoholic. " Patient had ordinary mental capacity to 19." 
She finished a common school course and worked in a factory for $7 a week. 

She attempted suicide at 19 and at the Westboro State Hospital was found 
to be depressed and discharged recovered after several months. For 
several months at home she seemed well, then had a month's depression, 
after which she became very active and immoral. She was brought to this 
hospital, was at first only active and cheerful, but then went through a 
noisy, singing excitement, seeming almost well for a time, then growing 
depressed, then noisily excited, and then normal when she was discharged. 
An enlarged heart was noted on her entrance here. At home she got on 
well part of the time, but had spells of irritability and discouragement, 
and several times went off in the company of men. In a year she was re- 
turned to the hospital in a mild depression and after showing gradual im- 
provement for a year was allowed to go out on visit For a week she got 
on well and then resumed her immoral ways, being returned to the hospital 
two months later in a hyper-active condition, silly. Tuberculous infection 
of the Iting soon appeared, and in a yea.* she died ; during this time she 

15 

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226 ANALYSIS OF MENTAL DISEASES IN THE SECOND DECADE 

showed several attacks of excitement lasting for a day or two, and a few 
depressed spells. 

Autopsy showed tuberculosis of the lungs with cavitation and bron- 
chiectasis, tuberculosis of intestines, lymphnodes, miliary tubercles of liver 
and kidneys, amyloid reaction of spleen and liver, serous pericarditis and 
peritonitis, emaciation, decubitus, aortic sclerosis, chronic fibrous endo- 
and myocarditis, slight coronary sclerosis. 

The brain weighed 1310 g. Dura slightly adherent, with pia slightly 
milky over parietal sulci. The frontal convolutions on the left are smaller 
and more numerous than on the right Slight pial thickening over cord. 

The microscope shows fewer celb in the small pyramid layer of left 
superior frontal gyrus than of right The left occipital region seems poorer 
in cells in outer layers than the right Superficial gliosis in many regions 
(see Neurochemical Series, 1906-7) and some satellitosis. Under Heiden- 
hain a very slight pigmentation of nerve cells and gHa without local 
variation. 

Case 5 is that of a single woman whose first mental symptoms were 
noticed with the onset of convulsions at 13, who entered the hospital at 
55 to die four years later. 

There is a negative family history. The patient was well and bright as 
a girl ; she was making good progress when her school work was interrupted 
by fits at 13. All that is known of her ensuing history is that the convulsions 
increased in number and severity along with a gradual dementia. Here she 
showed severe dementia-animal-like behavior and athetoid movements of 
the arms and hands. Ten days before her death the right hand was 
infected. 

Autopsy showed a tuberculosis of the left apex, chronic interstitial 
nephritis, sclerosis of the aorta and coronaries, unequal pupils. Strepto- 
cocci were grown from the incised wound of the hand. 

The brain weight was loio g. The dura was adherent over small areas 
in each frontal region ; it was of normal thickness. 

A moderate amount of subpial edema. The right half of the brain ap- 
peared slightly larger than the left To the touch the motor areas gave the 
most resistance. The comua ammonis were smaller than usual; the ven- 
tricle walls finely sanded. 

Microscopically the glial cells were very much increased, with marked 
satellitosis. Under the Heidenhain stain the pigment was large in amount 
and evenly distributed over glia, nerve cells and perivascular spaces. 

Case 6.-— A single woman, whose first mental symptoms appeared at 20, 
who entered the hospital at 23 and died six years later. 

Family history negative. The patient was bom in Newfoundland. She 
developed normally. 

At 20 she began to be careless, at 22 had severe headaches with flushing 
of the face, and at 23, just before her entrance, she developed delusions 
about a man who she thought was following her. Here she was well 
oriented, showed considerable dulling of the finer sensibilities with loss of 



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£. E. SOUTHARD AND E. D. BOND 227 

affect, possible auditory hallucinations, cheerful and nonchalant manner, 
refused to occupy herself. In a year many mannerisms appeared, in three 
years outbursts of violent excitement After four years an epithelioma 
of the tonfi^ue was found; two years later she died with symptoms of 
pneumothorax. She was apathetic but never lost her orientation. 

Autopsy showed emaciation, pulmonary tuberculosis, empyema, chronic 
pleuritis, chronic lymphnoditis, chronic peritonitis, myo- and endocarditis, 
acute and chronic nephritis, cystic tube (right), epithelioma of tongue and 
sub-lingual glands, cancerous growth of pituitary. 

The brain weight was 1165 g. The dura was slightly thickened and ad- 
herent to the calvarium ; the pia was thickened over the vertex. There was 
a large amount of subpial edema. The convolutions were symmetrical and 
firm. 

With the Heidenhain stain pigment was found in extremely slight 
amounts in the glia and perivascular spaces of the right precentral lobe 
and was not found elsewhere. 

Case 7 is that of an immarried girl who came to this hospital in two 
attadcs, one at 17 (or 14), the other at 31 (or 28), and who died three weeks 
after her last admission. 

The paternal grandmother was insane, and the father and mother were 
both of very peculiar makeup. Home life was tmhappy. A social, mild, 
capable girl. She worked in factories and in housework. 

At 17 she felt very happy, restless, thought she was going to get married, 
was stage struck; throughout there seemed to be some indifference. This 
mood changed to a condition where she seemed depressed, indifferent, inac- 
tive. Both phases together lasted eight weeks. Her cervix and uterus 
appeared unusually large. She was well for 14 years. At 31, two months 
before admission, she became restless, laughed and talked incessantly at 
times, at other times cried, thought people were trying to injure her and 
that the food was poisoned. At the beginning of this attack her father 
and mother had separated. On second admission there was irregularity of 
heart action and a thrill was noticed over apex; tremor of arms and 
pectoral muscles. She talked dramatically, apparently tminfluenced by what 
went on about her ; at times flight is noticed, but often the connection be- 
tween sentences is not apparent " I am a widow instead of an old maid. 
They poisoned all but my insides and they can never poison that" Whether 
she was oriented could not be determined. Hallucinations are probable. 
After tube feeding she died of lobar pneumonia. 

Beside the pneumonia, right, the autopsy disclosed malnutrition, chronic 
atrophic dermatitis, chronic adhesions about gall bladder and appendix, 
right hydrosalpinx, chronic gastritis, acute colitis, dilatation of thoracic 
aorta. 

The brain weight was 1300 g. The dura is not adherent In a wedge 
shaped area including both first frontal convolutions, apex pointing back 
to the central fissure, there is considerable anemia in contrast to the rest 
of the brain. Section into the ventricles shows barely palpable granulations 
over the optic thalami. 



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228 ANALYSIS OF MENTAL DISEASES IN THE SECOND I^CADE 

'* Microscopically the Nissl sections would serve to give an example of 
normal cortex. The right frontal region shows slight superficial glioses, 
and the white matter of both frontal regions shows excess of neuroglia 
nuclei. About a vessel in cerebellum is a cell collection suggesting chrouic 
exudate. The cervical regions of the cord suggest posterior column 
gliosis." 

In the precentral region there was considerable pigment in the nerve 
cells, a less and more variable amount in the glia and perivascular spaces. 
In the frontal region the pigment was very slight and in the calcarine areas 
negligible. 

Case 8» a single woman, had a first attadc of mental trouble at 15 or 16, 
received hospital treatment first at 20 to 23, was taken home and first 
brought to the Danvers State Hospital at 26, where she remained 19 years 
till her death. 

Family history is negative. The patient was bright and was well ed- 
ucated. At 15 came a poorly described ** attack which left her demented to 
some extent" At 20 apparently she was worse, and then for some years 
was ''fairly reasonable." Then she began to have periods of depression 
and excitability, and several times attempted suicide. Menstruation was at 
times suppressed, at times painful. Brought here at 26; at first she seemed 
to enjoy it, then tried to escape and made a feeble attempt at suicide; 
became capricious, suddenly dropping her work or topic of conversation to 
switch off upon something else. Masturbation was noticed. At 30 she 
was boarded out for two months, being returned because of her rest- 
lessness. At 34 she was apathetic; at 41 her conversation loose and her 
voice unmodulated; at 43 tuberculosis was suspected; she showed nega- 
tivism. Without much further change she remained to her death at 45. 

The cause of death was pulmonary tuberculosis. The autopsy showed, 
in addition, emaciation, sclerosis of internal mammaries and aorta, hemor- 
rhagic endocarditis, fatty liver, chronic cholecystitis, cholelithiasis, chronic 
parenchymatous nephritis, uterine fibroid, hemorrhage and ulceration of 
stomach and intestine. 

The brain weight was 1385 g. The dura was not thickened and the pia 
showed only a slight clouding over vessels. The convolutions were well 
rounded and of normal consistency. The basal vessels were free of 
sclerosis. 

The pigment was negligible, being found only in an occasional satellite 
cell. 

Case 9 is that of a single man * whose first attack came at 12, who was 
admitted to this hospital at 19 and remained until his death at 32. 

The paternal grandfather was intemperate. The patient possessed ordi- 
nary mental capacity and did well at school. 

• This case has been published as Case XIV by Southard in his study of 
dementia praecox, 1910. 



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E. E. SOUTHARD AND E. D. BOND 229 

At 12 he had a two weeks' attack of confusion and more or less uncon- 
sciousness. For some years after he would at times complain of a pain in 
his back or head. At i8 he was observed to have laughing spells, which 
would perhaps lead to boisterous outbreaks ; he thought that someone was 
mesmerizing him. Then followed spells of elation and depression, in- 
somnia, threats of violence and suicide. On admission he was quiet and 
expressed most fantastic and absurd scientific theories. ''The moon is 
the blind eye of some animal." "I have the shoulders of an Egyptian, 
the head of Napoleon or an Italian and my limbs are French." " We arc 
an being continually acted upon by minerals .... and magnetism." 

The pigment under Heidenhain was negligible. 

Case io is that of a single man whose age at the onset of the first mental 
symptoms was 17, and who came to this hospital at 19 and at 22, dying 
7 weeks after his second admission. 

Family history seems good. The patient was born in Canada, learned 
to read but not to write, was a good boy, made no trouble, had to go to 
work in the mill at 12. He worked steadily for five years. 

At 17 he gave up work, and lay about the house smoking excessively. 
At 18 he had weak spells, which were explained by a doctor as due to 
tobacco heart. Until a month before entrance he was extremely dull, 
sleepy and inactive ; since that time he has been excitable, violent, claiming 
that his mother was the devil Admitted at 19, he showed a striking reaction 
to physical examination, twisting, turning, and suddenly allowing himself 
to be lifted as a dead weight, or stiffening and falling. No relevant an- 
swers could be obtained; there was much apparently disjointed production. 
For the next 14 months he was generally mute and resistive, but occasionally 
obeyed commands in an automatic manner. Transferred to another hos- 
pital, he was taken home after a month, where for a year he sat about and 
did nothing, during the next year having spells of a mild, peculiar excite- 
ment. Again committed to this hospital, at 22, his most prominent symp- 
toms were untidiness and apathy; after seven weeks he died of dysentery. 

Autopsy showed irregular pupils, apical scar, a limited aspiration pneumo- 
nia, injection of the mucosa of the gastro-intestinal tract with areas of 
denudation, acute nephritis, contracted bladder, enlarged mesenteric lymph- 
nodes, perforated drums in middle ears. 

The brain weighed 1335 g. Somewhat soft at occipital pols. Slight 
pigmentation of cerebrum; none of cerebellum. Pia and dura were 
thickened. 

Microscopical examination showed a considerable round cell infiltration. 
Everywhere there occurred a very slight but fairly regular nerve-cell pig- 
mentation, with only occasional traces of pigment in glia or perivascular 
spaces. 

Case ii is that of a married man whose mental illness began at 18 or 20 
and who came to this hospital at 58. After seven more admissions he died 
here at the age of 68. 



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230 ANALYSIS OF MENTAL DISEASES IN THE SECOND DBCADB 

Family history is negative. He was a cheerful, temperate man. There 
was a history of frequent attacks of depression from the age of 18 or 2a 
At 58 he was admitted in a depression from which he recovered in three 
weeks. At 59 he stayed five weeks in another depression, recovery being 
coincident with a follicular tonsilids. In the same year came another 
depression of two months; at this admission his heart was noticed to be 
enlarged. At 60 a depression lasted three months. At 62 he was manic one 
month, depressed one week, and then became normal. At 65 he returned 
incoherent and euphoric for four days, and then for three years to his 
death depressed, confused and elated episodes followed each other. 

At autopsy was found contracted kidneps, cardiac hypertrophy and dila- 
tation with general edema. The coronary arteries were atheromatous. 
Lobar pneumonia and a hemorrhagic infarct of the lung were found. 

The dura was adherent and the basal arteries moderately atheromatous. 
Brain weight, 1290. 

Under the Heidenhain stain there was much pigment in the nerve ceUs, 
less in the glia and least in the perivascular cells. 

Clinical Summary. 

SEX. 

We are dealing with a group of eight women and three men. 

HEREDITARY FACTORS. 

In six cases insanity in the family is denied; in five cases it 
appears ; in three cases it is prominent ; in Case 7 the father and 
mother were peculiar and the paternal grandmother insane; in 
Case 4 the father was alcoholic, an uncle epileptic, an uncle insane, 
a grandmother paralytic ; in Case 2 the father was insane. In Case 
3 an aunt was insane and in Case 9 the paternal grandfather 
alcoholic. 

Antecedent Factors. 

No antecedent factors appear which can reasonably be con- 
sidered causal. The first three cases worked hard, and cases 
3 and 7 had unhappy home lives. 

Hallucinations of any sort are doubtful; auditory ones arc 
probably present in cases 7 and 6. 

One case (3) showed no delusions; in another case (10) they 
were doubtfully expressed. The only case showing either delu- 
sions of influence or of somatic character was 9. Delusions of 
persecution characterized 4 cases (i, 2, 6, 7). 



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E. E. SOUTHARD AND E. D. BOND 



231 



GENERAL CLINICAL FEATURES. 

Case I showed confusion. Six cases (i, 3, 4, 7, 8, 11) at times 
showed depression, and five (i, 3, 4, 7, n) at times showed ex- 
hilaration. Four showed apathy (6, 7, 8, 10). Four showed ex- 
citements (4, 6, S, 10) ; negativism appeared in cases 2 and 6. 
Case 5 had convulsions and athetosis. Cases 9 and 10 were 
catatonic. 

Headache and vaso-motor disturbances characterized onset in 
Case 6. Menstrual disorders were noted in two women (7, 8), 
loose sexual habits in one (4), and self-abuse in another (8). 
Extreme weakness at onset is noted in one case (3). Cancer de- 
veloped in one case (6) ; heart disease in cases 4, 7, 11 ; body pain 
in Case 9. 

The general courses of the cases, and probable diagnoses, are 
summarized in the following table. 









TABLE I. 








Sex. 


Age at 


Duration of 


Diagnoses. 


Cmc 


OMet 


Subsequent Attacks. 


Death. 


Attacks. 


Life. 




F. 

F. 
F. 
F. 
F. 

F. 
F. 
F. 

M. 
M. 
M. 


17 

17 
17 
19 
13 

20 
17 
15 

12 

\l 




17 

17 
49 
25 
59 

29 
31 
45 

32 
22 
68 


20 d. 

9 m. 
2y.? 

Manyy. 

9y. 

5 m. 
30 y. 

15 y.? 
5y. 

20 y.? 


20 d. 
9 m. 

32 y. 

46 y. 

9y. 
My. 
30 y. 

20 y. 

5y. 
soy. 


Manic-depressive 
psychosis? 

Dementia praecox. 

Manic-depressive. 

Manic- depressive. 

Epileptic demen- 
tia. 

Dementia praecox. 

Manic-depressive. 

Dementia praecox. 

Dementia praecox. 
Dementia praecox. 
Manic-depressive. 


2 

3 
4 
5 

6 

i 

9 
10 
II 


.. 31,32^ 
Many attacks. 
Gradual demen- 
tia. 

31 
Many exacerba- 
tions. 
18 

Many attacks. 



Anatomical Analysis. 

Six of these cases showed severe tubercular lesions (4, 5, 6, 8, 
9, 2) and five were emaciated at death (4, 6, 7, 8, 9). Atheroma 
was found in five instances ; coronary alone in case 1 1 ; aorta alone 
in case 3 ; aorta and coronary in cases 5 and 4 (age 25) ; aorta and 
internal mammaries in case 8. Cardiac hypertrophy was found in 



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232 ANALYSIS OF MENTAL DISEASES IN THE SECOND DECADE 

case 1 1 ; endocarditis acute in 8 and chronic in 6, 4 and 3 ; 
myocarditis in 6 and 4. Acute nephritis in 3, 6, 9, 10 ; chronic in 
4, 6, 8, II. Lesions of the gastro-intestinal tract are recorded in 
six instances ; of the liver in two ; of spleen in one ; chronic peri- 
tonitis in three. Skin lesions appeared in cases 9 and 7. The first 
case had acute otitis media and the tenth perpration of the drum. 
A uterine fibroid was found in case 8, and hydrosalpinx in cases 
6 and 7. Diphtheria was the cause of death in case i, and pneu- 
monia in case 11, pyothorax appeared in case 6 and hydrothorax 
in 9. The first case had a small aorta. 

Brain weights with age at death are arranged in the following 
table: 

TABLE II. 



Brain Wt. 


Age at Death. 


Sex. 


Case Number. 


lOIO 


59 


F. 


5 


IIIO 


32 


M. 


9 


1 165 


29 


F. 


6 


I2I0 


49 


F. 


3 


1270 


^ 


F. 


2 


1290 


M. 


II 


1300 


31 


F. 


7 


I31O 


25 


F. 


4 


I33S 


22 


M. 


10 


lis 


17 

45 


F. 
F. 


I 
8 



Inflammation of the meninges we find in nine cases ; of the dura 
in cases 3, 4, 6, 10, 11 ; of the pia in cases i, 4, 5, 6, 8, 9, 10. In 
case 3 there was a chronic inflammatory exudate near the vessels 
of the frontal region. The only instance of basal atheroma oc- 
curred in case 11, 68 years old. Cases 5 and 7 showed granular 
ependymitis locally. Precentral gliosis was noted in case 5, and 
postcentral softening in case 3 ; increase of pigment (gross) in 10; 
local anemja in 7; variation in convolutions of the two sides in 
4 and 5; enlargement and thrombosis of the right ascending 
parietal artery in case 3, aged 49. 

The cord in case 10 was small, to correspond with the small 
brain. 

The distribution and amount of pigment was shown in the two 
following tables, the first arranged according to duration of life 



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E. E. SOUTHARD AND E. D. BOND 



233 



after onset, and the second according to the age at death. We 
have represented no pigment by o, slight by +, moderate by 
+ + , marked by + + +, and an extreme amount by + + + + . 

TABLE III. 
Pigment Distribution and Duration of Life after Onset. 



Case. 


Duration Life 
After;^Onset. 


Perivaacalar Cells. 


Glia Cells. 


Nerve Cells. 


II 


50 y. 


+ 


+ + 


+ + + 


5 


46 y. 


+ + + 


+ + + 


+ + + 


1 


32 y. 


+ -f + 


+ + + 


+ + -f 


30 y. 











9 


aoy. 











7 


My. 


to + + 


to + 


to + + • 


6 


9 y. 











4 


6y. 


+ 


+ 


+ 


10 


5 y. 


to -f 


to H- 


-f 


2 


9 m. 











I 


20 d. 












Case I. 
Case 3. 
Case 6. 
Case 7. 
spaces. 



More pigment in left superior frontal. Inflammation. 

Frontal pigment least. 

Precentral has slight pigment in glia and perivascular spaces. 

Precentral has moderate but variable pigment in pyramids and perivascular 



TABLE IV. 
Pigment Distribution and Age at Death. 



Case, 


Age at Death. 


Perivascular Cells. 


Glia Cells. 


Nerve Cells. 


II 


68 


+ 


+ + 


+ + + 


5 


59 


+ + + 


+ + + 


-f + + 


i 


49 


+ + + 


+ + + 


+ + + 


45 











9 


32 











7 


31 


to + + 


to H- 


oto + + 


6 


29 











4 


25 


+ 


+ 


+ 


10 


22 


to + 


to H- 


+ 


2 


17 











I 


17 












Conclusions. 

I. This work is another instahnent of work designed to throw 
light on the age-factor in the production of mental disease, and has 
the same features of random selection, employing only autopsied 



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234 ANALYSIS OF MENTAL DISEASES IN THE SECOND DECADE 

cases, from a long series, as did previous work from the Danvers 
State Hospital laboratory on cases having onset in the sixth and 
seventh decades (1908) and in the fifth decade (1913). 

2. There turned out to be surprisingly few cases for the an- 
alysis ; somewhat less than 2 per cent of a long series of autopsied 
cases ( 18 in 938) proved to be cases having onset of mental disease 
between 10 and 20 years. 

3. The age-distribution in the 11 cases which proved suitable 
for full clinical and anatomical correlations is striking ; of these 11, 
8 had onset between 17 and 20 years, and 5 (of these 8) at 17 ; the 
age-distribution, so far as it goes, suggests disorder at puberty as 
somehow related with the onset of the first attack. 

4. Omitting one female epileptic which demented, we find the 
cases equally distributed between manic-depressive insanity and 
dementia praecox. The manic-depressive five were composed of 4 
females (i of rather doubtful diagnosis) and i male. The de- 
mentia praecox five were composed of 3 females and 2 males. Four 
of the five dementia praecox cases were subject to tuberculosis ; one 
of the manic-depressives was tuberculous. 

5. The lipoid disorder, of which we attempted to get an index by 
a study of the distribution of certain substances stainable by the 
Heidenhain iron-hematoxylin method, was far more in evidence 
in the manic-depressive series than in the dementia pr&cox 
series. 

6. The three cases with most marked pigmentation (in this 
specialized sense) were : (a) the epileptic dement above mentioned, 
onset at 13, attacks till death at 59; (b) a manic-depressive, de- 
pressed at 17, 31 and 32, maniacal at 49, dead of intercurrent 
disease at 49 ; and (c) a manic-depressive, very numerous attacks 
of depression, first at 18-20, 7 known attacks between 58 and death 
at 68. Other three manic-depressive cases showed marked (al- 
though less marked) pigmentation focally in (d) the doubtful case 
above mentioned (in which indeed the pigment is rather an index 
of local metabolic disorder in an inflamed convolution) and (e, f ) 
cases dying at 25 and 31 respectively. 

7. The dementia praecox cases either showed no pigment as in 
(g) death at 17 after 9 months symptoms, (h) death at 45 after 
30 years of symptoms, (i) death at 32, 20 years after onset, or a 
slight amount, as in (j) death at 29 after 9 years of symptoms, 



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E. E. SOUTHARD AND E. D. BOND 235 

and (k) death at 22 after 5 years of symptoms (pigment in occa- 
sional pyramids) . 

8. If these findings should be taken at their face value, it might 
be inferred that manic-depressive insanity is more likely to prove 
a disease involving brain-cell metabolism than is dementia praecox. 
In dementia praecox there is more evidence that certain cells have 
been destroyed outright ; but cells which escape destruction are not 
likely to look in any respect abnormal. In manic-depressive in- 
sanity there is not such good evidence of cell-destruction ; on the 
other hand, these cases seem to show that overloading with a 
certain kind of pigment is more characteristic of the brain-cells 
of manic-depressives than of precocious dements. 

9. The manic-depressive cases of this series seem to have shown 
more depression than mania ; what the relation of this may be to 
the histology of these cases is doubtful ; but it would seem desir- 
able to examine cases of long-continued mania and long-continued 
depression with the same technique. 

10. Previous work from this laboratory on age-correlations with 
pigment-deposits has suggested that especially the neuroglia cells 
are likely to show progressively more and more pigment with 
advancing age ; the present work, regardless of the special entity 
correlations just discussed, seems to show that youthful cases do 
not show much neuroglia-cell pigment, and therefore this work 
is to that extent consistent with former results. 

11. As to the possible causes of the pigment deposits in various 
types of cell, perhaps nothing better than the mystic term " meta- 
bolic" can be risked. Still, there are two cases in which they 
were decidedly local accumulations of somewhat similar-looking 
substances due to or closely associated with acute inflammatory 
processes (see cases i and 10, dying at 17 and 22 years respect- 
ively). In these cases, to a large extent entirely free from pig- 
mentation, either the pressure or the toxines of the inflammation 
had producd the same appearances focally that are shown by other 
non-inflammatory cases diffusely. The deposits are, then, possibly 
favored by certain factors working ab extra with respect to the 
cells in question. 



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ANATOMICAL FINDINGS IN THE BRAINS OF MANIC- 
DEPRESSIVE SUBJECTS.* 
By E. E. southard, M. D., 

Pathologist, Massachusetts Board of Insanity; Bullard Professor of 

Neuropathology, Harvard Medical School, Boston, Mass.; 

and Director, Psychopathic Hospital, Boston, Mass. 

ABSTRACT. 

I. Introductory. 

Object of this work, to control the writer's dementia praecox 
work (1910). 

Symi>tomatological value of mild localized lesions. 

Microlocalization and macrolocalization. 

Brain consistences specially studied. 

Gliosis and brain consistence. 

Manic depressive insanity and dementia praecox. 

Prognosis and diagnosis. 

Autopsy findings uncertain in manic-depressive insanity 
(Kraepelin). 

Thalbitzer's suggestion. 

Significance of focal scleroses in silent brain areas. 

Paucity of brain material "normal" in all ways in manic- 
depressive insanity. 

Disintegration products in brains of catatonic excitement (Alz- 
heimer). 

The distribution of these should be studied. 

Orton's results in a study of satellitosis in manic-depressive 
insanity and otherdiseases. .t 

♦This paper is Number 36 (i9iS» 2). Contributions of the Massachu- 
setts Board of Insanity, and Number 54, Danvers State Hospital Con- 
tributions. Some of the concisions wec^' Pi'csented at the meeting 
of the New England Society of Psychiatry at Rutland, Mass., in September, 
igop. An abstract was presented at the seventieth annual meeting of the 
American Medico-Psychologic^ Association at Baltimore, May 26-29, I9i4* 
(Bibliographical Note, — The^ previous contribution (1915, i) by E. E. 
Southard and M: M. Canavan, entitled "A Study of Normal-looking 
Brains in Psychopathic Subjects: Third Note, Boston State Hospital," 
was published in the Boston Medical and Surgical Journal, Vol. CLXXII, 
No. 4. January 28, 1915, pages 124-131.) 



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238 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

II. Analysis of Case-Groups, with Special Reference to Excluded Cases, 
Cases with focal lesions (anomalies, scleroses, atrophies) espe- 
cially interesting in relation to dementia praecox. 
49 cases in the original random group. 

6 cases of involution-melancholia, excluded from prior consider- 
ation. 
4 cases excluded as containing focal arteriosclerotic lesions, 
rendering analysis of other focal lesions difficult 

1 case excluded as frank error of diagnosis. 

II of remaining 38 (29 per cent) show lesions recalling those of 
dementia praecox; but of these 11, 3 seem (post facto) actually 
to have been cases of dementia praecox. 

2 others are of very doubtful diagnosis and 2 more somewhat 

doubtful, leaving 4 focal-lesion cases in 31 cases of manic- 
depressive psychosis. 
13 per cent focal lesions (anomalies, scleroses, atrophies) in 
manic-depressive psychoses may be pitted against 86 per cent 
such arrived at by a similar analysis of dementia-praecox 
material. 

III. Analysis of Case Material, with Special Reference to Cases Showing 

Anomalies, Sclerosis and Atrophies, 
Involution-melancholia excluded (6 in 49). 
16 cases in 43 show gross lesions (4 of these arteriosclerotic 

lesions, leaving too complicated a picture for first analysis). 

3 in the focal (non-arteriosclerofic) list of 12 should be con- 

sidered cases of dementia praecox (analyses given). 
2 others probably best excluded as involution-melancholia and 
dementia praecox respectively (analyses given). 

IV. Notes from the Literature on " Organic " Cases of Manic-Depressvve 

Psychoses. 
Pilcz on periodic psychoses: emphasis on arteriosclerotic cases 

(excluded from the present analysis). 
Pilcz' hypothesis (1901) of faulty construction of nervous system 

not upheld by F. Hoppe, 1908. 
Other cases. 
The literature points to the great importance of heredity, and 

brings up questions as to the relation of arteriosclerosis and 

dementia. 
V. Special Questions. 

Tabulation of data. 

Example of a non-hereditary case (data not above reproach). 

Is not manic-depressive insanity essentially hereditary, in the 

sense that near relatives invariably show signs of insanity? 
This result probable, if involution melancholia, focal-lesion cases, 

and decidedly at3rpical cases be excluded. 
Dementia in manic-depressive insanity not yet proved to be due 

to arteriosclerosis. 
VI. Conclusions. 



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E. E. SOUTHARD 239 

I. Introductory. 

The first purpose of the present study was to effect a proper 
control of the writer's brain findings in dementia praecox (1910).* 
The intrinsic interest of findings in manic-depressive insanity, 
whether positive or negative, has prompted a more elaborate study 
than at first contemplated, and a photographic anatomical study 
is in preparation, following the lines of the writer's later study 
of dementia praecox (1914).' 

By and large, the study of brain anatomy in the insane, as dis- 
tinguished from cortex histology, has been much neglected of late 
years. While studying microscopic findings more or less inten- 
sively in these cases, I have relegated histology to the background 
so far as possible, both in the dementia praecox work already pub- 
lished and in the present work on manic-depressive insanity ; and I 
have sought to emphasize the possible symptomatological value of 
mild localised cortex lesions in a manner which will recall the 
methods of Hughlings Jackson and Theodor Meynert, rather than 
the more modem intentions of exactness displayed in several 
works. 

Meantime, I recognize that the task of future psychopathology 
will be tremendously cleared up by feats of microlocalization in 
the cortex, beside which the present efforts look small. What 
I seek is a rough orientation in this field, a kind of coarse macro- 
localization, which is an indispensable preliminary to more finished 
work. 

The suitability of my material for this study is enhanced by the 
fact that I had been for some time carrying on investigations of 
soft brains or brains with soft spots from a bacteriological point 
of view,**' and other investigations of hard brains or brains 
with hard spots, more particularly in connection with the study 
of gliosis in epilepsy. The consequence was that my protocols 
and those of my colleagues were filled with data concerning 
topical variations in brain consistence, coupled with observa- 
tions on visible atrophies, macrogyrias, or microgyrias, in a 
large group of cases. I am convinced that future brain anato- 
mists should carefully consider these tactile data in addition to the 
classical data afforded by the eye. Weigert used to insist in his 
laboratory that the neuroglia method would yield neurological 
results often superior to those afforded by the myeline-sheath 



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240 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

method. It seems to me that palpation of brains, revealing varie- 
ties of consistence due to differences in the framework of the 
tissues, is the natural preliminary of such neuroglia studies and 
teaches us where to spend our best microscopic effort. 

To the practical psychiatrist, manic-depressive insanity and 
dementia praecox are sister affections. Not merely is our knowl- 
edge of both diseases largely the product of Kraepelin's sjmthetic 
insight, but also in psychiatric practice these two affections, 
theoretically distinct, produce between them a perfect mare's-nest 
of diagnostic difficulty. 

Practically, the alienist is much concerned over this distinction 
because the prognosis is often assumed to hang upon the diagnosis, 
and because it is well known that the direction and intensity of 
our treatment hang very much upon prognosis. There is no doubt 
that many less strict diagnosticians, in America at least, proceed 
on the practical basis that manic-depressives may get well, but 
primary dements do not. Everyone knows somewhat successful 
practitioners who make up a prognosis in some cryptic, not to say 
feline, manner, and then proceed to label the case " M. D." or 
" D. P." according to the supposed favorable or unfavorable out- 
come. We are all acquainted, too, with eager psychiatric critics, 
who triumphantly demonstrate, months after some ardent staff 
controversy, that such a case was not " M. D." because it deterio- 
rated, or was not " D. P." because it recovered. I need scarcely 
recall that Kraepelin himself lays down no such hard-and-fast 
lines of prognosis. 

With respect to autopsy findings, Kraepelin himself dismisses 
the subject ( 1904) with these words (after the section on maniacal 
conditions) : " Von irgend gesicherten Leichenbefunden ist noch 
fiichts su berichten."* The same sentence stands in the 1913 
edition/ 

Thalbitzer has put forward claims for lesions in Helweg's 
triangle in the spinal cord in this disease.' A superficial review 
of available Danvers material by R. L. Van Wart of New Orleans, 
Louisiana, failed to show more alterations in available manic- 
depressive cases than in other conditions. A careful study of this 
region in many conditions is demanded; it is doubtful whether 
light will be thrown on manic-depressive insanity thereby. 



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£. £. SOUTHABD 24I 

» 

The somewhat surprising results of a recent analysis of our 
Danvers cases of dementia praecox, viz., 86 per cent of the cases 
demonstrating macroscopic or microscopic lesions, often of a sug- 
gestively focal character, gave point to a re-investigation of manic- 
depressive material from the same source. The presence or ab- 
sence of similar lesions, studied especially from the topographic 
point of view, would obviously offer one of the best possible con- 
trols for the dementia praecox work. 

The presence of focal atrophies, aplasias, or scleroses in silent 
areas of the brain, xvithout appropriate symptoms or without 
any symptoms, as I point out more fully dsewhere, would lead 
us to the old Meynert conception of " functionally unoccupied " 
areas, not yet filled or otherwise utilized by experience. This 
conception of Meynert's has been largely replaced to-day by the 
notion that these so-called silent areas really have a message for 
the right receiver. The pathologist feels bound to explain, as best 
he may, in some functional terms any "brain spots" he may 
discover. The " normal " brains of the general hospitals, prone 
as they are to show now and then massive cut-outs, such as cysts 
of softening, fail to show, as I shall shortly bring out by a de- 
tailed analysis now in preparation, the kind of thing I have 
described for dementia praecox. 

But grant, for the moment, that such things as normal brains 
exist and come to autopsy, how stand manic-depressive brains? 
Do they stand with the normal brains or with the dementia- 
praecox brains? 

A word concerning the intimate nature of the lesions in ques- 
tion: At the first symposium of the New England Society of 
Psychiatry dealing with manic-depressive insanity, I reported 
the surprising paucity of brain material " normal " in all ways in 
the series then available. Only one of 37 brains seemed normal 
in all macroscopic and microscopic respects. One critic jumped 
to the conclusion that the abnormalities discovered, various as 
they were, running all the way from sculptural anomalies to 
general cytopathological changes, were assumed by me to be 
correlated with the disease. Such i^as, of course, not my inten- 
tion, but merely to indicate how difficult is this region of analysis. 
Evidence of actual destruction of brain tissue, eventuating as a 
rule in macroscopically recognizable lesions, is the species of 

16 



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242 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

evidence of the greatest value at this juncture. I am far from 
discounting the scientific value of cytopathological changes per se 
or denying possible importance of, e, g., neurofibrillar changes. 

You are all aware, also, of the bold claim, recently made by 
Alzheimer,* that cases of catatonic excitement can be told from 
cases of maniacal excitement on the score of certain disintegra- 
tion products present in and between the cells of the catatonic 
brain. Similar disintegration products, Alzheimer states, may be 
found in the brains of cases showing severe visceral disease. Here 
lodges a tremendous difficulty; for precisely manic-depressive 
patients, dying in attacks, are often subject to severe visceral, 
apparently non-nervous, disease. To resolve that difficulty will 
require, I believe, the most careful inquiry into the distribution 
of these products, as well as of other cytopathological changes, 
in the different brain-parts, and much keen clinical correlation. 

It is true, too, that even such comparatively unequivocal evi- 
dence of nerve-cell injury as the development of satellitosis is 
often made to bear too heavy a burden of explanation. It was 
a very salutary thing that, at the second symposium of the New 
England Society of Psychiatry on manic-depressive insanity, S. 
T. Orton, of Worcester State Hospital, Mass., showed much 
evidence of satellitosis in manic-depressive material. Here, again, 
the important question, from the entity's standpoint, is the con- 
stancy, degree, and habitual regions of these destructive changes. 

An abstract of Orton's conclusions," based on his entirely inde- 
pendent data, studied without reference to my own woric, is as 
follows : 

ORTON's work on satellitosis IN THE PSYCHOSES. 

The analysis of the relative numerical occurrence of satellite cells in 
10 cases in each of five psychoses seems to warrant the conclusion that 
satellitosis cannot be considered in any sense indicative of the type of psy- 
choses, although it has in this series appeared with more consistent 
intensity in the manic-depressive cases and has been of very much less 
prominence in dementia praecox. 

The reaction elects the deeper cell layers both in regard to frequence 
of occurrence and degree of reaction. 

The cortices of the dome, precentral, postcentral and frontal, seem to 
show the reaction with greater intensity than do the temporal and 
occipital regions. 



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E. J£. SOUTHARD 243 

Age at the time of death seems to play some part in the occurrence of 
severe reactions, but cannot be considered the only factor. 

The duration of the psychosis bears no demonstrable relation to 
satellitosis. 

It is not the mere presence, then, of some kind of destructive 
changes somewhere in a brain which promises to solve these 
most difficult clinical problems. Decades of experience with etat 
cribli and cortical arteriosclerosis in general hospitals should alone 
dispose of so crude a hypothesis. 

The first question of our study is this : Do the brains of manic- 
depressive cases, studied by the same methods employed in work 
on dementia praecox, show anomalies or scleroses similar to those 
found in dementia pracoxt 

II. Analysis of Case-Groups, with Special Reference to 
Excluded Cases. 

Available for an orienting study were 49 cases of mental disease 
in which the diagnosis of manic-depressive insanity had been made 
on criteria, largely Kraepelinian, at Danvers Hospital. If some of 
these were really cases of dementia praecox, they might possibly 
stand out as such on the basis of lesions which they would prove 
to have. From prior consideration it seemed best to exclude 6 
cases of involution-melancholia (811, 821, 895, 1397, 1399, 1419), 
which happened to be all female. We remain with 43 cases, 
numerically a proper foil to the 37 cases of dementia praecox sup- 
posedly " non-organic " which we before studied (1910). 

Of these 43 cases, the following presented g^oss lesions of 
interest in this connection: 1067, 1097, 1156, 1170, 1173, 1277, 
1284, 1305, 1327, 1356, 1373, 142(6; *. e., 12 cases, or 28 per cent. 
These lesions include scleroses, atrophies and anomalies, wherever 
found, but do not include hemorrhages, cysts of softening, or 
other focal lesions, which occurred in 4 other cases. Should we 
exclude these 4 cases from our 43, we obtain as a percentage of 
manic-depressive cases having focal convolutional scleroses, atro- 
phies, or anomalies (12 in 39), 31 per cent. 

The above-detailed cases, it will be remembered, formed a group 
of 12 with lesions and anomalies more or less similar to those 
found in the dementia praecox study (1910). 



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244 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

1067 should be at once excluded both from numerator and 
denominator, leaving 11 in 38. 

NOTES OF THREE CASES REGARDED AS DEMENTIA PRiECOX. 

On the whole, I should myself be tempted to consider 1097, 
1305, and 1373 as more fitly placed in the dementia-praecox group, 
and should exclude these also from both parts of the fraction, 
leaving 8 focal lesion cases in 35. On account of the importance 
of not excluding any focal-lesion cases of manic-depressive cases 
by a post facto diagnosis of dementia praecox, I present condensed 
histories in these three cases. 

G. M., male, D. S. H. 12827, Path. Lab. 1097. 

The diagnosis of manic-depressive insanity, depressed phase, was made 
in this laborer of 29 years, largely on his general appearance and apparent 
depression. It is doubtful whether there was at any time in the single 
attack, which lasted in all less than one year from onset, any di£FerentiaI 
sign of manic-depressive insanity. 

The hereditary taint was strong: brother insane, dead at Worcester 
State Asylum at 29 years ; a second brother under treatment for nervous 
prostration; father alcoholic and a suicide at 50 years; father's brother 
insane, probably with dementia praecox; mother, one brother and a sister 
not insane so far as known. 

Patient left school at third grammar grade at 14, sustained a fall upon 
the head about that time, underwent ** t3rphoid-pneumonia " in the 
Spanish-American War, used little tobacco, some alcohol, had several 
attacks of gonorrhea and was unmarried. Tried to commit suicide 
with creolin on a drinking bout at 27 years. 

At onset (29 years), morose, loafing about house. Four weeks later 
stopped work and vanished, only to return with bundles of meat and a 
complaint of having been robbed of his money. Patient thought the 
family infested with vermin and combed a baby's hair for hours on that 
hypothesis. 

Signs of pulmonary tuberculosis on admission to D. S. H. December 2, 
1905. Tremors general, particularly of tongue and of extended fingers. 
Idea of vermin constant, possibly based on tactile hallucinations. Vermin 
also seen. Auditory hallucinations possible. A peculiar "sick" smell 
at times. Consciousness clear. Orientation for time and persons imperfect 
(indifference). Vague and shifting delusions (lice, poison, "Place will 
burn"). Refusal of food, weeping, wringing of hands, appearance of 
depression. 

May 24, 1906, about a dozen generalized convulsions. The lips twitch; 
eyelids tighten; mouth pulls to left; left arm, then left leg, stiffens; toes 
of both feet strongly flexed; mouth pulls to right; right eye shifts to 



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E. E. SOUTHABD 245 

right. Skin livid, breathing stertorous, groaning. Later, arms keep 
twitching; left side of face finely tremulous; gasping; grimacing, incon- 
tinence of urine. Pupils dilated, non-reactive to light Upward bend 
of all toes on plantar stimulation. Convulsions suspended by hyosdn. 

During the winter many boils and re-infections. Death after increasing 
weakness and ten days' symptoms of tuberculous enteritis, September 18, 
1906. 

A review of the case on clinical grounds alone would suggest a preferred 
diagnosis of dementia praecox. 

Anatomical Diagnosis. 

General muscular atrophy. 

Marked malnutrition. 

Sacral and trochanteric and left iliac decubitus. 

Tuberculosis, with cavitation of both upper lobes and right middle lobe 
of lungs. 

Infarct of left upper lobe (occlusion of vessel by caseous material). 

Tuberculous ulcers of jejunum and ileum, with peritoneal tubercles. 

Tuberculosis of mesenteric lymph-nodes and peribronchial nodes. 

Typhlitis and colitis. 

Chronic adhesive pleuritis of both upper lobes, right middle lobe and 
posterior part of right lower lobe. 

Chronic fibrous pericarditis. 

Chronic fibrous endocarditis. 

Slight mitral and aortic valvular sclerosis. 

Slight coronary arteriosclerosis. 

Chronic splenitis. 

Chronic perisplenitis, with adhesions. 

Chronic orchitis, right. 

Slight aortic sclerosis. 

Calvarium dense and lieavy. 

Chronic external adhesive pachymeningitis. 

Chronic fibrous leptomeningitis (right preccntral, left superior frontal, 
right third temporal, sulci, and about pineal body). 

Slight sulcal anomalies. 

Hypoplasia of left transverse sulcus of orbital region. 

Left gyrus rectus narrower than right. 

Prefrontal gliosis, especially left, 

Orebellar gliosis (?). 

Chronic inflammation of inferior halves of drtuns, especially right 

No gross lesions of spinal cord. 

Head Findings. 
Pia mater, in the main, normal ; thin and transparent, but thickened in a 
few fod, particularly about the arachnoidal villi, and especially in right 
precentral sulcus, in left superior frontal sulcus 4 cm. from frontal pole, 



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246 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

and in the right third temporal sulcus in a plane with uncus. The thicken- 
ings in the left frontal and right temporal regions amount to small frank 
scars, 4 mm. thick in the middle. The tissue of the velum interpositum 
also unusually dense about the pineal body; there is no especial thidcen- 
ing of the pia about the dsternse ; at the base, the vessels of the cranium 
show no gross signs of sclerosis. Pia mater strips readily in all parts. 

Brain weight 11 15 grams. 

Fissuration shows trifling anomalies on the two sides; the right trans- 
verse sulcus of the orbital region is well developed, the left almost absent. 
The substance shows a faintly darker color than usual. The left gyrus 
rectus is narrower than the right Consistence slightly reduced except 
in the two prefrontal regions, of which the left is firmer. The hippo- 
campal gyri are not unduly firm. 

On section, the left prefrontal region, the sulcal surfaces beneath the 
scar in left first frontal sulcus, and the external face of the left gyrus 
rectus are visibly atrophic, being narrower and of a lighter color than the 
adjacent cortex. The tissue beneath the scar in the right temporal sulcus 
is not visibly atrophic. 

Basal ganglia show no gross signs of lesion. 

Cerebellum of uniform consistence, which is slightly subnormaL The 
laminae look somewhat narrower than usuaL 

Olives and dentate nuclei of even and slightly reduced consistence. 

A. L., female, D. S. H. 8559, Path. Lab. 1305. 

Committed June 9, 1882, as suicidal and vagrant and classed under 
"chronic melancholia." Father died from some form of "paralysis.*' 
An aunt and cousin insane. Delusions of self-reproach and of perse- 
cution. 

Attacks said to have occurred at 35, at 45 (four months' duration), at 
47 (five months' duration). Discharged October 24, 1882. Recommitted 
March 30, 1893; discharged May 27, 1896; recommitted January 30, 1897. 
Despite these apparently separate attacks, the whole case presented the 
appearance of a long-standing dementia prsecox of paranoidal trend, with 
a certain variability of attitude. At times patient's delusions would 
retire into the background, and her attitude could be characterized as one 
of reticence on certain topics. The total picture showed now a quiet 
depression or a surly unresponsiveness or restlessness and quarrelsome- 
ness, or suicidal tendencies. March, 1902, an epileptiform seizure. 1905, 
amnesia prominent 1906, increasing feebleness, but maintenance of flesh. 
1908, disturbed, complaining, making suicidal threats, disoriented, amnestic, 
subject to involuntary urination. February 22, 1909, death after three days' 
acute illness. 

Anatomical Diagnosis. 

Bronchopnetmionia. 

Acute bronchitis. 

Peribronchial lymph-nodes enlarged. 



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E. E. SOUTHARD 247 

Injection of intestine. 

Congestion of ileum. 

Injection of trigone in bladder. 

Arteriosclerosis, basilar and of finer branches. 

Extreme calcification and atheromatous ulceration of aorta. 

Heart hypertrophied, weight 415 grams. 

Qironic valvular sclerosis, mitral, tricuspid, aortic, with calcification. 

Hydropericardium. 

Sclerosis of ventricular walls. 

Qoudy swelling heart muscle. 

Slight beginning cirrhosis of liver. 

Chronic interstitial nephritis, with cysts. 

Anomalous position of left adrenal. 

Chronic gastritis, with dilated stomach. 

Chronic perisplenitis. 

Calcification of terminal bronchi (?) in lungs. 

Chronic endocervicitis. 

Chronic cervicitis. 

Serous cysts of Fallopian tubes. 

Atrophy of ovaries. 

Eversion of left leg. 

Edema of lower eyelids. 

Unequal pupils. 

Teeth absent 

Calvarium dense. 

Chronic pachymeningitis. 

Slight chronic leptomeningitis. 

CerebrBl softening, fight precentral gyrus and right basal ganglia^ 

Narrow superior temporal gyri. 

Hypoplasia (?) of left superior temporal gyrus. 

Head Findings. 

Brain weight 1220 grams. 

Left hemisphere a trifle longer than right, which presents a blunted 
tip. Both frontal poles firm; otherwise the left side shows normal con- 
sistence, with exception of first temporal gyrus, which is narrow and of 
lessened consistency as compared with other gyri. In the parietal portion 
of the right cerebrum, the consistency is much b6low normal ; and the pre- 
central gyrus, 2 cm. from median line, has a softened area i cm. in 
diameter, witii loss of contour of gyrus. First temporal gyrus same as on 
left side. The right caudate nucleus shows a softened area with entire loss 
of internal capsule, the softened area being about 2 cm. in diameter. 

No other areas of softening found. 

Cord shows no gross lesion. 

J. M., male, D. S. H. 15368, Path. Lab. 1373. 

An English saw-maker. Father a suicide. Gonorrhea at 24, with 
attacks of inflammatory rheumatism at 24 and at 30. Since then attacks 



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248 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

of sciatica, lumbago, muscular rheumatism. Headaches began at 33 and 
lasted till three years before commitment, when a feeling of pressure at 
top of head replaced headaches. Wife had one miscarriage. Alcohol and 
tobacco moderate. Regular churchgoer. "Nervous prostration" at 47, 
depression, insomnia, restlessness, delusions of self-reproach, spells of 
praying, elated periods, visual hallucinations, ''shaking in the bowels." 
On commitment, December 6, 1909, orientation good, memory remarkably 
good, attention hard to secure, auditory hallucinations, persistent belief 
that "everyone has three doubles," untidiness, motor restlessness, flighty 
conversation. Death from dysentery, January 6, 1910. 

Anatomical Diagnosis. 

Bronchopneumonia. 

Acute ulcerative colitis. 

Mesenteric lymphnoditis, bronchial, retroperitoneal. 

Superficial abrasions. 

Coronary sclerosis. 

Slight basilar sclerosis. 

Ventricular endocarditis. 

Chronic fatty myocarditis. 

Slight hypertrophy of heart 

Fatty liver. 

Focal congestion (?) of liver. 

Chronic interstitial nephritis, with congestion. 

Hypertrophy of prostate. 

Distention of bladder. 

Chronic perisplenitis. 

Scar at apex of left lung. 

Thickening of mesentery. 

Hypernephroma of adrenaL 

Emaciation. 

Perforation of left and opacity of both ear-drums. 

Slight chronic internal adhesive pachymeningitis. 

Slight chronic leptomeningitis. 

Encephalomalacia (encephalitis ?) of temporal lobes. 

Superior parietal hypoplasia or atrophy. 

Frontal sclerosis (crowns of gyri). 

Head Findings. 

Brain weight 1450 grams. Pons and cerebellum weight 170 grams. 

Convolutions well rounded with exception of superior parietal gyri on 
either side. These are smaller than normal and depressed below the sur- 
face level. Brain firm throughout, resilient over superior aspect Comoa 
ammonis a trifle softer than usual. Ventricles smooth. Cxmsistence of 
temporal lobes softer than any other portion of brain. (Choroid plexus 
slightly cystic The frontal regions on section retract from under the 



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£. E. SOUTHARD 249 

knife, and the grey matter over the crowns of the gyri is china-white. 
White matter throtighout the brain shows many small bleeding points. 
Cord shows injection of pial vessels ; otherwise grossly negative. 

The outstanding eight possibly manic-depressive cases are : 

1 1 56: Probably high-grade imbecile, apparently never schizo- 
phrenic. 

1 1 70: Perhaps involution-melancholia, apparently never schizo- 
phrenic. 

1 173 : Attacks, hypochondriasis, apparently never schizophrenic. 

1277 : Hysterical reactions, perhaps schizophrenic. 

1284: Obscure, delusional, apparently never schizophrenic. 

1327 : Attacks, depressive, apparently never schizophrenic. 

1356: Attacks, depressive, apparently never schizophrenic. 

1426: Hallucinations, apparently never schizophrenic. 

If we exclude 1170 as involution-melancholia, leaving 7 in 34, 
we arrive at a group of cases of which only one (1277) yielded 
phenomena simulating, if not demonstrating, schizophrenia. 

NOTES OF TWO CASES EXCLUDED FROM THE MANIC-DEPRESSIVE 

GROUP. 

W. S., male, D. S. H. 13591. Path. Lab. 1170. 

Patient was a shoemaker, somewhat given to alcohol, a widower, 64 
years. A sister committed suicide at 56, another sister and a brother 
nervous. Mother nervous, but died at 91. Patient grew tired easily the 
winter of 1906-7 and began to worry over a strike. Working for a new 
company, he felt he was being thought a scab and finally stopped work, 
attempted to choke himself to death with a rope, and entertained 
delusions of poisoning. 

On commitment, April 11, 1907, the main features were delusions of 
poisoning, anxious depression, hallucinations of taste, smell, and hearing. 
Death occurred May 12, 1907, as a result of cellulitis of the arm. 

Whatever the nature of this case, it does not appear to be a classical 
instance of manic-depressive insanity. Possibly it belongs to the melan- 
cholia group. 

Anatomical Diagnosis. 

Infection of right arm. 
Acute nephritis. 

Hsrpostatic pneumonia, with acute fibrinous pleuritis of posterior third 
of both lower lobes. 



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250 BRAIN FINDINGS IN MANIC-D£PR£SSIVBS 

Abscess of muscles of left first intercostal space. 

Ecchymoses of scalp and of subcutaneous tissue of abdomen and 
around prostate and neck of bladder. 

Fatty myocarditis. 

Coronary, basal, and internal carotid sclerosis (a few foci). 

Fibrosis of apices of both lungs. 

Chronic adhesive pleuritis of right apex. 

Cervical and thoracic myelomalacia (autolytic process hastened post 
mortem?). 

Atrophy of both central regions best marked in post central gyri, and 
especially in the upper third of the left postcentral gyrus. 

Erosions of inner table of frontal bone. 

Chronic external adhesive pachymeningitis. 

Chronic fibrous, leptomeningitis of vertex of cerebello-medullary as- 
terns 

General encephalomalada (autolytic?). 

Gliosis of lumbar spinal £ord. 

Head Findings. 

Brain weight 1415 grams. 

Brain substance shows little variety of consistence and is almost uni- 
formly softer than normal The hippocampal gyri maintain their firm- • 
ness to some extent Upon stripping the pia mater, the convolutions show 
considerable visible atrophy (or hypoplasia) in the central regions (espe- 
cially of the left side), but no di£Ference in consistence can be detected with 
the finger between these convolutions and the rest of the brain. The con- 
volutions of the left central region show the maximal atrophy (or hypo- 
plasia) seen in this subject The sulci appear somewhat abnormally dis- 
tributed. The upper third of the left postcentral gyrus is reduced to a 
slender ridge, nowhere over i cm. in thickness and tapering somewhat 
sharply toward the crown. Right postcentral gyrus is also narrower than 
right precentral gyrus. Section of the central regions of both sides 
show that the white matter of the postcentral gyri retracts a trifle more 
from the surface of section than that of the precentral gyri. No similar 
alterations can be seen elsewhere in the brain. 

Weight of cerebellum, pons and bulb, 175 grams. Tissue in no way 
remarkable except for general reduction of consistence. 

Ventricles not remarkable. Basal ganglia normal. The cervical and 
thoracic regions of the spinal cord show a considerable reduction in con- 
sistence, with herniation of white substance from the surface section. 
The lumbar region, on the contrary, cuts firmly. 

L. W., female. D. S. H. 14469, Path. Lab. 1277. 

Patient died in the second attack of what may very well be manic- 
depressive insanity. The first attack was one of excitement at 45, two 



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B. B. SOUTHARD 2$! 

years after the menopause, occasioned apparently by reaction to a hoax 
played by her nephew (elaborate pretense of suicide). The second attack 
was at 58, regarded as a reaction to a quarrel with certain co-tenants over 
house matters. The interval was quite clear. 

Patient was youngest of five children. An older sister was peculiar and 
given to violent outbursts. The other three children lived to middle age 
without insanity. The patient's father was normal and temperate; 
death at 87. The patient's mother was normal till 85, when senile dementia 
set in; death at 86. The maternal grandmother was a notorious crank, 
thought to be insane. 

Patient was rather a delicate child, grew robust at 16, was subject to 
fits of bad temper and was a good scholar ; illegitimate child at 23. After 
marriage, several pregnancies, but only one survival to term, with death 
of child soon after. 

The first attack at 45 showed excitement and depression, with delusions 
of poisoning and two attempts at suicide. The diagnosis of acute mania 
was made at one time. Numerous details are available of both attacks; 
the second attack resembled the first, with auditory hallucinations added. 
On physical examination, August 11, 1908, there was some question of 
hysterical anesthesia or of a hysteroid reaction (patient lying flaccid in 
uncomfortable postures and not responding to pin-pncks, eyelids held 
tightly together). At first tube-fed, restless and untidy, patient later 
brightened somewhat and became well-oriented. Hypochondriacal ideas 
("numb and paralyzed all over,'' "cancer of mouth"). Stupor came on 
once more with same passive but less resistive attitude as before (eyelids 
kept dosed), albuminuria, rapid, irregular heart, puffy face and ankles. 
Death September 20, 1908. 

Anatomical Diagnosis. 

Acute diffuse nephritis. 

Chronic interstitial nephritis. 

Acute inflammation of ileocecal valve. 

Acute endometritis, with polypi. 

Atheromatous ulcers of aorta. 

Slight aortic-valve sclerosis. 

Sclerosis of ventricular walL 

Fatty myocarditis. 

Edema 

Obesity. 

Fat-replacement of pancreas. 

Fatty liver— passive congestion of liver. 

Cholecystitis. 

Focal adhesive pleuritis. 

Chronic bilateral hydrosalpinx. 

Contused wound of nose. 

Dilated pupils. 



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252 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

Calvaritim dense. 

Compensatory subpial edema. 

Cerebral atrophy, frontal and precentral. 

Head Findings. 

Brain weight 1205 grams. 

In the frontal and precentral regions of both hemispheres there is 
marked narrowing of convolutions and yawning of sulci. Posterior to 
Rolando and inferior to Sylvius, the convolutions are of about normal width. 
The vessels of the circle of Willis are soft, and free of demonstrable 
thickening except at the commencement of left posterior cerebral, at which 
point there is a minute yellowish plaque. On palpation the hemispheres 
are of uniform firmness. Ventricles contain a small amount of clear 
fluid. Ependyma smooth. Cut surface of brain not remarkable. Basal 
ganglia normal Weight of cerebellum and pons, 155 grams; not 
remarkable. 

Cord not remarkable. 

If one followed the Bleuler concept of dementia praecox as 
schizophrenia, there would thus remain 6 cases showing focal 
lesions or anomalies in a g^oup of 33 cases of manic-depressive 
insanity. Although I acknowledge that the diagnoses in these 
6 are not all trustworthy, yet we shall be overstating rather than 
understating the percentage of focal brain appeartinces in manic- 
depressive insanity if we state it on this basis, namely, 18 per cent 

Here is the gfroup : 

1 156, 12004: Female, onset at I9> attacks, death at 25; regarded as 
manic-depressive, but possibly as dementia praecox and probably as in any 
case somewhat feeble-minded. 

ii73> 13461 : Female, onset at 28, attacks (perhaps not well in intervals), 
death at 62; ''hypochondriasis on a psychasthenic basis, possibly manic- 
depressive" (son a Danvers patient). 

1284, 14583 : Male, onset at about 50, death 17 days from onset ; intensely 
hallucinated, hyperreligious, self -accusatory, following exile from Turkey 
(Armenian) and loss of property in Chelsea fire. The diagnosis must 
remain in doubt 

1327, 15061 : Female, onset at 50 (8 months), second attack at 73 (death 
after s weeks) ; strong hereditary taint, probably manic-depressive. 

1356, 1525 1 : Male, onset at 60 (suicidal, 6 months), second attack at 
65 (death after 7 weeks) ; very strong hereditary taint, probably manic- 
depressive. 

1426, 15724: Female, onset at 52, death after 5 or 6 months of symp- 
toms, possibly manic-depressive. 



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E. E. SOUTHARD 253 

I assume that 1156, 1173, ^3^7» and 1356 might be generally 
accepted as manic-depressive cases ; and removing 1284 ^^^ ^4^ 
as too fulminant for diagnosis, we should arrive at 4 focal cases 
in 31, or at least 13 per cent. 

EXCLUDED AS TOO FULMINANT FOR ACCURATE DIAGNOSIS. 

K. M., male, D. S. H. 14583, Path. Lab. 1284. 

Armenian, about 50 years old (grandfather a suicide), thought to 
have brooded over his exile from Turkey, overworked and exhausted. 
Lost furniture in the Chelsea fire. Two days before commitment, re- 
fused to go to work in shoe factory, confessed his sins to the priest, and 
told his son to pray. Visual hallucinations. Ideas of self-reproach 
(cause of the (Thelsea fire). Persistent beating his head and eyes. On 
commitment, October 3, 1908, beat his eyes and eventually blinded himself. 
Disorientation complete. Restlessness. Persistent talking about sins, 
Turks and the government Stuffed ears with rags (auditory halluci- 
nations?). Death October 18, 1908. 

Anatomical Diagnosis. 
Partial absorption and suppuration of both eyeballs. 
Extensive abrasions of face, neck and chest. 
Abrasions of both olecranons and of both feet 
Acute nephritis. 

Hypostatic pneumonia of right side. 
Acute fibrinous pleuritis. 
Edema and congestion of base of left lung. 
Enlargement of bronchial lymph-nodes of right side. 
Acute splenitis. 
(Congestion of pia mater. 
Enlargement of duodenal lymph-node. 
Chronic ventricular endocarditis. 

Sclerosis of mitral valve, aortic arch, coronary and basilar arteries. 
Fibrosis of border of liver. 
Slight cirrhosis of liver. 
Emaciation. 

Arachnoidal villi in excess. 
Prefrontal atrophy. 

Prefrontal, frontal, and occipital gliosis. 
Orebellum and cord soft 

Head Findings. 
Brain weight 1385 grams. 

The anterior and posterior poles are firmer than the central and ventral 
regions of the brain. The cortex, on section, is a trifle greyer in these 



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254 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

regions than elsewhere. The prefrontal region shows a slight narrowing 
of cortex. Gyri in general of a normal richness and appearance. The 
puncta cruenta of the interior do not seem unduly injected. No granular 
ependymitis was demonstrated. 

Cerebellum, weight with pons, ISS grams, soft 

Spinal cord not remarkable. 

D. P., female, D. S. H. 15724, Path. Lab. 1426. 

Normal until 52 years, when influenza kept patient in bed a week and 
left her weak, depressed, "nervous," delusive about neighbors, crying in 
spells. Later, auditory hallucinations, explained as delusions. Eventually, 
ideas of self-reproach and, four months after onset, attempt at suidde 
with razor. After recovery from this attempt, self-reproachful ideas per- 
sisted and deepened. Death after 5 days of dysentery, 26 days after 
commitment 

Anatomical Diagnosis. 
Acute hemorrhagic colitis. 
Localized fibrinous exudate over colon. 
Beginning bronchopneumonia. 
G)ngestion of lungs. 
Qoudy swelling of heart muscle. 
Atrophy of spleen. 

Qironic inflammation left internal laryngeal wall 
Chronic interstitial thyroiditis. 
Scar of neck. 

Sclerosis of coronary arteries, aorta^ left carotid and innominate 
arteries. 
Edema in legs. 
Anemic thoracic muscles. 
Chronic interstitial nephritis, with cysts. 
Chronic adhesive pleuritis. 
Scar at apex. 

Chronic focal perihepatitis. 
Cystic glands of cervix uteri. 
Cystic organ of Rosenmuller. 
Injection of Fallopian tubes. 
Slight splanchnoptosis. 
Asymmetry of face. 
Lueniae atrophica^. 
Calvarium dense and thick. 
Marked pigmentation of pia over medulla. 
Atrophy of left third frontal, left precentral and right postcentral gyri. 



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E. E. SOUTHARD 255 

Head Findings. 

Brain weight 1280 grams. 

Frontal lobulations plump. Considerable gaping of sulci around left 
third frontal convolution, with distinct depression at beginning of left 
Sylvian fissure. Left prefrontal convolutions much narrower than the 
ri^t while the left postcentral is slightly larger than its fellow on the 
right. No areas of softening. Slight increase in resilience in the right 
prefrontal region. The pia strips from brain easily. 

If we look more narrowly at the four remaining (viz., 1156, 
1173* I3^> 1356), having in mind anatomoclinical correlations, 
we are not astonished at some of the things found. Thus, the 
fact that 1 1 56, suspected of imbecility, should show small and 
ovemumerous convolutions in the left superior and middle frontal 
region (as well as microscopic changes) is not surprising ; but the 
findings may have little or nothing to do with the manic-depressive 
phenomena. 

1 173, again, shows frontal lesions, in the form of a bilateral 
atrophy; there was also a somewhat generalized gliosis as indi- 
cated by induration, involving both cerebrum (especially occipital 
regions) and cerebellum. There were various acute changes 
(including axonal reactions) in all parts of the central nervous 
system examined (death ascribed to chronic Bright's disease) . The 
correlation between the frontal emphasis of the lesion and the 
generally delusional nature of the symptoms is striking. Other- 
wise the whole nervous system may be said to have reacted with 
equal mildness to the degenerative process, whatever it was. 

1327 was another instance of frontal emphasis of lesions, here 
confined to the two prefrontal regions. The brain weight indi- 
cates a loss of perhaps 100 to no g^ams, with some internal 
hydrocephalus. There was also in this case a marked cerebral 
arteriosclerosis, together with an internal capsular cyst of some 
standing. 

1356 showed also a generalized mild induration of brain and 
cord, with a tendency to atrophy or aplasia of the left postcentral 
and right superior parietal regions. This case had considerable 
disorder of consciousness from time to time, terminating in periods 
of depression with delusions, and consequently regarded as due 
thereto. Perhaps the case belongs in one of Kraepelin's newer 
subgroups in dementia prsecox ( 1913) . 

I give, below, these : 



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256 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

FOUR CASES, WITH FOCAL BRAIN LESIONS, REGARDED AS POSSIBLY. 
BELONGING IN THE MANIC-DEPRESSIVE GROUP. 

K. T., female, D. S. H. 12004, Path. Lab. 1156. This case was termed 
one of manic-depressive insanity, depressed phase, hut dementia praecox 
was a diagnosis also entertained. A ** constitutional basis " was maintained. 
It is possible that patient should be regarded as an imbecile of high grade, 
with occasional suicidal and depressive attacks. 

The patient was an English girl (father intemperate, an uncle insane 
after stroke, another uncle epileptic) who came to the United States at 
8 years, finished school at 14, worked in mills till 19, 

August, 1901, patient grew despondent after menses ceased; October 
13, cut her throat with a carving-knife ; and was committed to Westboro 
State Hospital, November, 1901. Discharged recovered May i, 1902. 
Patient then began to lead an irregular and immoral life, and was com- 
mitted to Danvers State Hospital August 7> 1902, with insomnia, pains 
in head, and threats of violence. Patient became euphoric and amiable, 
but about October i, 1902, began to be depressed and to have crying spells, 
and to find fault Excitement, abusivd and profane lansfuage, and 
saudness followed. Discipline by transfer from one ward to another was 
usually successful in changing mood. Discharged on trial visit March 
25, 1903. 

Recommitted June 27, 1904, after spasmodic attempts to go to work 
and resumption of irregular life (gonorrhea). Discharged much im- 
proved on trial visit July 5, 1905, but was returned September 27, 1905, 
after another resumption of immorality, in a restless, euphoric state. 
Tubercle bacilli were demonstrated in the sputum in June, 1906. Moods 
were variable. There were some outbreaks of sharp excitement, other 
short periods of depressicm. Phthisis began early in 1907. Sacral bedsore. 
Ischio-rectal abscess. Death March 24, 1907. 

Anatomical Diagnosis. 

Tuberculosis of lungs, with cavitation and bronchiectasis. 

Tuberculosis of bronchial lymph-nodes. 

Tuberculous ulceration of jejunum, ileum and colon. 

Enlargement of mesenteric lymph-nodes. 

Miliary tubercles of liver. 

Miliary tubercles of kidneys. 

Amyloid reaction of liver and spleen. 

Emaciation and anemia. 

Sacral decubitus. 

Decubitus of heels. 

Aortic sclerosis. 

Chronic fibrous myocarditis, especially of left auricle. 

Chronic fibrous endocarditis, especially left ventricle and auricle. 

Slight mitral sclerosis. 



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E. E. SOUTHARD 257 

Slight coronary arteriosclerosis. 
Serous pericarditis and peritonitis. 
Chronic adhesive pleuritis. 
Chronic external adhesive pachymeningitis. 
Slight chronic leptomeningitis (parietal). 

Slight tendency to microgyria of left superior frontal and middle frontal 
convolutions. 
Calcified plaques in lumbar pia mater. 

Head Findings. 

Brain weight 13 10 grams. 

Consistence is not especially firm. Convolutions over the first and second 
frontal regions on the left are smaller and more numerous than the corre- 
sponding area on the right. On section the tissue is bloodless. The ven- 
tricles are free from granulations, no sclerosis in the basal vessels. 

Spinal cord: Pia over posterior surface of cord has numerous whitish 
thickenings ; otherwise not unusual. 

M. B., female, D. S. H. 13461, Path. Lab. 1173. 

** Hypochondriasis on a psychasthenic basis." ** The diagnosis of manic- 
depressive insanity can be stretched possibly to covfer this case." Always 
peculiar, patient had possibly nervous prostration at 28 years, after the 
birth of a second child. (This child, a son, was a patient in D. S. H., 
7654). Thereafter always ailing and taking patent medicines. Developed 
ideas of liver trouble and of slivers in food and on clothes. Committed 
at S3 to D. S. H., December 3, 1898, and discharged May i, 1899, much 
improved. Recommitted January 11, 1907, with delusions concerning liver 
disease, contamination by dust, and splinters in her clothes, the latter 
probably based on hallucinations. Death May 24, 1907, with chronic 
nephritis. 

Anatomical Diagnosis. 
Interstitial nephritis. 

Sclerosis of the aorta, common iliac, and left coronary arteries. 
Fibrous endocarditis. 
Emphysema of lungs. 
Chronic splenitis. 

Chronic passive congestion of liver. 
Chronic fibrous pleuritis of both sides. 
Dilation of the stomach, 
(jastroptosis. 
Slight emaciation. 
Degenerative myositis. 
Ecchymoses of the skin. 
Tumor of pituitary. 

General gliosis of brain, especially occipital. 
Frontal atrophy {or hypoplasia?). 
Cerebellar gliosis? 

17 



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258 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

Hkad Findings. 

Brain weight 1320 grams. 

There is increased consistence of the brain, greatest over the occipital 
poles, less in the frontal regions, with decreased consistence of the para- 
central regions. The frontal convolutions show a narrowing, with widely 
gaping sulci. On section, the brain substance is firm, and the grey matter 
shows no atrophy. 

Weight of cerebellum and pons 145 grams. Cerebellum firm, shows 
slight increase of consistence. 

Small tumor 3 mm. in diameter on anterior surface of pituitary body 

Spinal cord : No gross lesions. 

M. J., female, D. S. H. 15061, Path. Lab. 1327. 

A case with two attacks of mental disease, at 50 and 73 years. Both 
attacks were depressive, the first regarded as due to prostration attending 
a severe bum, the second without obvious reason. The first attack lasted 
eight months and was attended in hospital by a few feeble attempts at 
suicide, and showed apprehensiveness and depression, with some hypo- 
chondriacal and suspicious ideas. The second attack lasted five weeks and 
showed marked apprehensiveness, mild restlessness, slight emotional 
depression, ideas of self-reproach. There seemed every prospect of 
recovery from this attack, as there were no signs of cortical arterio- 
sclerosis and little or no impairment of memory. Death was due to 
an intercurrent cystitis, with hemorrhages from the bladder wall. 

Heredity: Mother twice insane at puerperium. Mother's sister died at 
72, a senile dement for 6 years. Patient's only brother alcoholic and only 
partially self-supporting. 

Anatomical Diagnosis. 

Acute diphtheritic and hemorrhagic cystitis. 

Distention of bladder. 

Retroperitoneal lymph-nodes enlarged. 

Acute proctitis. 

One ulcer in colon. 

Acute metritis. 

Acute cervicitis. 

Hemorrhagic infarction (?) of spleen. 

Chronic interstitial nephritis, arteriosclerotic type. 

Chronic hepatitis. 

Cholecystitis and cholelithiasis. 

Chronic interstitial pancreatitis. 

Chronic perisplenitis. 

Atrophy of spleen. 

Sclerosis of aorta, coronaries, and internal and common iliacs. 

Slight ventricular endocarditis. 

Hypertrophy of heart 



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E. a SOUTHARD 259 

Large amount of epicardial fat. 

Atrophy of stomach. 

Hemothorax. 

Chronic fibrous obliterative pleuritis. 

Chronic interstitial fibrosis of lung. 

Central softening of adrenals (postmortem?). 

Anomalous ureter (right). 

Unusual blood-supply of kidney (left). 

Mammary glands atrophic 

Teeth poor. 

Arrest of development in right hand. 

Scars on forearm. 

Dislocation of right wrist 

Inequality of length of legs. 

Unequal pupils. 

Heai) Findings. 

Brain weight 1195 grams. Weight of brain stem and cerebellum 145 
grams. 

Considerable atrophy and moderate sclerosis of the prefrontal region. 
Consistence of the remainder of brain about normal, except the temporal 
convolutions, which are rather soft. On section of brain, an area of 
white softening, about i cm. in its greatest diameter, is found in the 
anterior portion (also superior) of the left internal capsule. Lateral and 
third ventricles moderately dilated. No granulations in ependyma. Cere- 
bellum not notable. Cerebrospinal fluid increased in amount. 

A moderate subdural hemorrhage over the dorsal surface of the cord 
from the third cervical to the second dorsal segment The right lateral 
columns of the cord are somewhat lighter in color, in the region of the 
fifth and sixth cervical segments, than the left Some softening in sacral 
region of cord. Surface of section not notable, except that the anterior 
horn on the right side, in the midcervical region, is more red than the left 

W. B., male, D. S. H. 15251, Path. Lab. 1356. 

A physician, with two attacks of depression, the first at 60 years, after 
several suicidal attempts and lasting about 6 months, the second at 65, 
terminated by death after seven weeks (dysentery). The second attack 
(committed to D. S. H. September 24, 1909) showed some ideas of self- 
reproach and of a developing cancer, so that the case suggested involution 
melancholia. This i^ase of the disease was terminated (October 13, 1909) 
by restlessness and a screaming, trembling outbreak of almost hysterical 
character. Improvement was then rapid until November 4, when ideas 
of self-reproach of a sexual character emerged suddenly, followed by 
confusion, restlessness, anxious expression and general tremors. This 
condition deepened until no responses could be obtained. Restlessness in 
bed. A fall, with bruise of hip. Rapid loss of weight 



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260 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

Some hereditary data are available. The maternal grandmother bore 
to a second husband one daughter, who died at McLean Asylum. Patient's 
mother became insane after childbirth. Patient's oldest brother (J. B.) 
blind from "rheumatic iritis"; sister (M. B.) died of myxedema; brother 
(M. A. B.) a suicide in financial embarrassment; sister (S. B.) gloomy 
after husband left her, remarried for pique, diabetic; sister unmarried; 
sister (C B.) rheumatic, married, mentally normal; brother (A. B.) 
died of hemorrhage of lungs ; brother ( W. B.) living, normal. 

Anatomical Diagnosis. 

Bruises of skin over legs and thorax. 

Thrombus in aorta. 

Acute nephritis. 

Ulcerative duodenitis and proctitis. 

Injection left vocal cord and pharynx. 

Injection of pituitary. 

Icteric conjunctivae. 

Fatty myocarditis. 

Hypostatic congestion of lungs. 

Healed tuberculosis of right apex. 

Aortic sclerosis. 

Small spleen. 

Atrophy of liver. 

Slight fibrous endocarditis and fibrosis of aortic valve and ventricles. 

Unequal pupils. 

Hypertrophy of prostate. 

Skull thin. 

Chronic external adhesive pachymeningitis. 

Chronic fibrous leptomeningitis. 

General cerebral gliosis. 

Focal cerebral atrophy. 

Head Findings. 

Calvarium thin, with moderate amount of diploe. 

Dura mater very adherent, removed with the skull-cap. Pia mater 
irregularly thickened. 

Cbnvolutional pattern well preserved. The sulci in the right upper 
occipital and the left ascending parietal regions are markedly gaping; tissue 
in immediate vicinity softened. The cortex otherwise seems generally 
firmer than normal, as does the cord. 

Brain weight 1355 grams. Pons and cerebellum weight 175 grams. 

Basal vessels soft Ventricles smooth. Pituitary firm, shows much 
reddening at extremities. 



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E. E. SOUTHARD 26I 

III. Analysis of Case-Material, with Special Reference to 
Cases Showing Anomalies, Sclerosis and Atrophies. 

Accordingly, at the conclusion of the orienting analysis of all 
available manic-depressive material in a group of about 500 
autopsies, I found myself with a very small number showing 
lesions and anomalies of the type with which I had become familiar 
in dementia praecox. The findings may be tabulated as follows : 

Manic-<lepressive diagnosis (clinical) 49 

Exclude as dearly involution-melancholia 6 

43 
Exclude as complicated by hemorrhages, cysts, etc 4 

39 
Exclude as clearly an error of diagnosis i 

38 
Exclude as dementia prsecox 3 

35 
Exclude as of very doubtful diagnosis 2 

33 
Exclude as of somewhat doubtful diagnosis 2 

31 

II of the 38 cases (or 29 per cent) showed lesions of the tocal 
t3T)e. 3 of these (on evidence given above) seem to me to belong 
to the dementia-praecox group. 8 of 35 (or 23 per cent) remain 
of the focal-lesion group. I think the evidence above given would 
also go far to warrant the exclusion of two others (see 11 70 and 
1277) from the manic-depressive group. If we accordingly ex- 
clude these, we arrive at six focal-lesion cases in 33 (or 18 per 
cent), in two of which the diagnosis is surely not possible to 
establish. A residuum of 4 cases in 31 (or 13 per cent) remains. 

Of course, I do not mean that the problems presented by these 
excluded cases are solved by the mere process of exclusion. In- 
deed, we are heaping up a vast deal of trouble by so excluding 
them. But, in an orienting view of the manic-depressive problem, 
it is necessary to take cognizance of cases which belong to the 
classically accepted group. It seems to me that the above data 



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262 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

show that far more cases of manic-depressive insanity are free 
from focal lesions than are cases of dementia praecox examined 
by the same methods ( 1910) . 

It remains to be inquired how far a more careful analysis of a 
series of brains from the point of view of systematic photography 
will make or break this provisional hypothesis. We shall enter 
upon this photographic analysis feeling certain that we shall 
find no great number of focal-brain cases, but we shall perhaps 
be less sure of not finding cases of generalized mild atrophy. 
Inasmuch as certain cases of dementia prsecox also show gen- 
eralized mild atrophy, we should have to fall back on the hope of 
finding in the comparison of the two groups something diflFeren- 
tial microscopically. This hope is for the moment slim in view of 
Orton's study of satellitosis, which (see above) occurred in both 
dementia praecox and the manic-depressive psychosis. 

IV. Notes from the Literature on " Organic " Cases of 
Manic-Depressive Psychoses. 

Several writers have upheld the idea that those cases of manic- 
depressive insanity which issue in dementia exhibit organic brain 
changes. Pilcz, in 1900," collected some evidence in this direc- 
tion both from the literature and from v. Wagner's Vienna 
clinic. Recognizing possible hereditary factors, Pilcz lays stress 
on certain acquired factors, and particularly on injuries to the 
head. Head injuries may work indirectly by providing a locus 
minoris resistentuB for the hereditary factors, but they may also 
work directly by providing painful scars which might be con- 
ceived to act reflexly, creating mental disorder. Pilcz reminds 
us of Lasegue's " cerebral cases," " of Krafft-Ebing's concussion 
cases,"* and of v. Wagner's claim " that brain injury may be of 
such nature as to produce insanity directly, without recourse 
to the idea of hereditary taint. 

Over and above head injuries, Pilcz became especially interested 
in Herde of other causes, particularly those foci which are of 
embolic or arteriosclerotic origin, and draws the general conclusion 
that dementia in these periodic cases is always attended with 
focal brain lesions. " Der Sitz des cerebralen Herdes hat nichts 
characteristisches." WoUemer's case showed multiple cortical 
and thalamic foci of sclerosis." Schiile's showed circumscribed 



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E. E. SOUTHARD 263 

cortical " hyperplasias " and a tumor of the clivus ** (chordoma?). 
Kim's case showed cerebral and midbrain atrophy with cranial 
asynmietry." Worcester's case showed pontine and quadrigeminal 
cysts of softening" Savage's case showed scar of frontal lobe, 
pontine lesions." Charron's first case showed left frontal cyst." 
Charron's second case showed cysts of softening in right frontal 
region. Doutrebente's case showed circumscribed unilateral 
frontal meningoencephalitis.*^ Pilcz's first case showed sclerosis 
of the right dentate nucleus of cerebelltun. Pilcz's second case 
showed scars of right frontal, left frontal and orbital, left superior 
temporal, and left temporal pole. 

Pilcz therefore found lo cases with an assortment of focal 
brain lesions, all in dementing cases. He found eight cases 
sufficiently described so that he could state that they were anatomi- 
cally negative. Pilcz then introduces a hypothesis that such ana- 
tomically negative and intellectually intact cases will probably 
show, upon proper methods of examination, teratological changes, 
such as convolutional anomalies, developmental disorders, factors 
dependent upon " eine ab origine f ehlerhaf te Anlage des Central- 
nervensystems." 

In brief, Pilcz has reduced the focal lesions to the htunbler 
position of accounting for dementia, and will seek otherwise in the 
nervous system for sig^s of the constitutional or hereditary basis 
of the disease. He believes that certain hirncongestive Zustande 
are possibly accounted for by focal vascular lesions. 

Following Pilcz's work, appeared numerous publications deal- 
ing with the " organic " idea in periodic mental disease. In 1908, 
Hoppe published an analysis of 15 cases, autopsied during seven 
years at the AUenberg provincial asylimi of East Prussia (Dr. 
Dubbers' clinic)." Hoppe failed to find the congenital anomalies 
suspected to exist by Pilcz. Secondly, Hoppe refuses to agree 
with Pilcz that all dementing cases will be found to have brain 
scars, but concedes that the sig^s of chronic brain disease (loss of 
nerve elements, gliosis, atrophy, hydrocephalus, ependymitis, 
chronic leptomeningitis) are found in connection with dementia. 

On the other hand, Hoppe agrees with Pilcz in his claims that 
brain scars may serve as irritating factors in the production of 
mental symptoms of the sort found in the periodic mental diseases. 
The clinical picture deviates somewhat from that usually found. 



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264 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

The brain- focus cases give more the impression of twilight states 
such as occur in epilepsy. The excited states are not joyous and 
not attended by flight of ideas. The depressive phases of tliese 
cases may sometimes exhibit emotional dulling, peculiar attitudes, 
g^eat variation in the clinical picture, and even dementia ; in short, 
these cases may distinctly recall catatonia. 

Indeed, the question of catatonia is expressly raised by Hoppe 
for his thirteenth case, one of pial cyst at the base of the brain, 
possibly of congenital origin. This cyst occupied the site of the 
absent right hippocampal gyrus and had pushed to one side the 
temporal lobe, the pons, and the right cerebellar hemisphere. (A 
remarkable molding of the temporal lobe had taken place, re- 
calling the conditions of a case published by Ayer from the Dan- 
vers laboratory.") 

A somewhat similar case, in which the suspicion of catatonia 
has been legitimately raised, was published by Bonhoeffer** in 
1903 (depression of left parietal bone, catatonic in all general 
features, but periodic and given to epileptiform twilight states). 
An operation by Mikulicz, with lifting of bone into place, im- 
proved the mental condition, but true epileptic attacks of wide 
interval came in to supplant the twilight states. 

Taubert, 1910, has published an analysis of 42 cases'* from 
Siemens' clinic in Lauenburg, Pomerania. Six of these are fully 
described. Taubert is inclined to separate genetically the dement- 
ing factors from those that underlie periodicity in this group. 

Among factors which bring out the latent manic-depressive 
tendencies are cranial trauma, focal brain lesions, and chronic 
alcoholism. The cases which exhibit no obvious factors, except 
heredity, have a good prognosis as to dementia. But the dement- 
ing cases of manic-depressive insanity, according to Taubert, do 
not differ markedly from those that do not dement. Like Hoppe, 
Taubert fails to And the teratological signs in the brains which 
Pilcz thought would be found (three such cases in Taubert's 
series were imbeciles). About one-third of Taubert's cases 
showed wholly normal nervous systems (14 cases =8 normal -1-6 
with simple hyperemia). 

V. Special Questions. 
An excursion into the literature of the past decade concerning 
the periodic insanities yields the following problems : 



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B. B. SOUTHARD 



265 



1. What are the respective parts played by heredity, and by 
focal lesions of the nervous system (trauma and arteriosclerosis) ? 

2. Are there any evidences of hereditary taint of a visible and 
tangible sort in the shape of congenital anomalies of the nervous 
system? 

3. Is the dementia which affects some cases of manic-depres- 
sive insanity invariably due to arteriosclerotic or othe^ focal 
lesions ? 

4. Are the clinical features essentially modified by the inci- 
dence of focal lesions of the brain? 

The heredity problem admits no clear solution in cases which 
show, at autopsy, lesions of an obviously acquired nature. To 
disengage ourselves from an embarrassment of etiological riches, 
we must take up, if there be such, cases without such acquired 
lesions. From our own list we have laid aside 6 cases of involu- 
tion melancholia, whose title to inclusion in the group is sub 
judice^^^ and 12 cases complicated by focal lesions of a possi- 
bly mental-disease-producing character. We remain with 31 
cases whose brains, to a rough analysis, are free from disease- 
bearing factors and are therefore the proper theater for the play 
of " hereditary instability." 

These 31 cases have been thrown into six groups, according to 
their ages at death. With a few other data, I have set down the 
main hereditary factors. 





GROUP I. DEATH IN THIRD DECADE. 


Gate. 


Sex. 


Age. 


Duration. 


Dementia. 


Hereditary factors. 


HIS 13364 
I3S3 13069 


F. 
M. 


28 
26 


14 
4 


+ 



Parents peculiar ; father's 

mother insane. 
Heredity negative* 



GROUP II. DEATH IN FOURTH DECADK 



Case. 


Sex. 


Age. 


Duration. 


Dementia. 


Hereditary factors. 


942 12283 
956 12307 

X2I2 I395S 


F. 
F. 

F. 


32 
33 

^7 


5 
I 

5 








Mother tuberculous. 

Heredity unknown, post-surgi- 
cal. 

Mother's father hemiplegic ; 
father's father alcoholic; 
uncles alcoholic, insane; 
mother insane ; sister insane ; 
sister's three children insane. 



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266 



BRAIN FINDINGS IN MANIC-DEPRESSIVES 



GROUP III. DEATH IN FIFTH DECADE. 



Case. 



Sex. 



Age. 



Daration. 



Dementia. 



Hereditary factors. 



747 7763 

774 I I 131 

789 11252 

959 "657 

1201 13817 



F. 
F. 
F. 
M. 

F. 



2 

24 
I 

3 
32 



o 
o 

o 



Hereditary taint asserted. 

Father's father insane. 

Questionable. 

Negative (data doubtful). 

Paternal aunt mildly insane. 



* Amnesia. 



GROUP IV. DEATH IN SIXTH DECADE. 



Case. 



Sex. Ag:e. Duration. Dementia 



Hereditary factors. 



895 "913 

899 5840 

926 12250 

972 I 1857 

1005 1242I 

1041 12853 

1238 4457 

1348 14325 

1386 15221 

1425 14108 



F. 
F. 

F. 

M. 

M. 

F. 
M. 

F. 

M. 



13 

long 

I 

' I 

14 

20 

long 
12 

2 



+ 
o 

o 

o 

o 

+ 

o 
o 



Brother died apoplexy; mother 
nervous prostration. 

No data. 

Brother insane; father tuber- 
culous. 

Father weak-minded; mother 
insane. 

Father's mother insane; father's 
cousin insane. 

Father tuberculous; mother 
paralytic; cousins insane. 

No data. 

Questionable. 

Negative (but probably involu- 
tion type) . 

Mother died of apoplexy ; sister 
epileptic; mother's sister in- 
sane, suicide. 



GROUP V. DEATH IN SEVENTH DECADE. 



Case. 


Sex. 


Age. 


Duration. 


Dementia. 


HcrediUry factors. 


761 10004 


M. 


65 


43 





No data. 


821 II394 


F. 


63 


I 





Brother died after nervous 
prostration. 


864 11558 


M. 


68 


46 





Both grandfathers drunkards; 
brother melancholy ; two pa- 
ternal aunts insane; fatier 






















and sister and daughter easily 












depressed* 
No data. 


922 9306 


M. 


65 


44 





946 12317 


F. 


63 


41 





Mother demented ; two paternal 
relatives depressed. 


968 12040 


F. 


65 


13 




Questionable. 


978 12340 


F. 


69 


7 





Father's sister insane ; brother 
insane ; brother drunkard'. 


IIII 12564 


F. 


68 


18 


■ + 


Sister peculiar, probably in- 
sane. 


1 187 13361 


F. 


62 


37 





Brother insane. 


1306 714 


F. 


66 


40 


+ 


No data. 



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£. £. SOUTHARD 
GROUP VI. DEATH IN EIGHTH DECADE. 



267 



Case. 


Sex. 


Age. 


Duration. 


Dementia. 


Hereditary factors. 


732 3^53 


F. 


71 


18 





No data. 



A further investigation of the cases stated to be without 
heredity yields the following : 

Data concerning heredity are absent or extremely meager in 
II cases. The remaining cases yield a surprisingly rich array of 
hereditary evidence. Only two cases of this group fail to yield 
such evidence, though these two I am bound to say are pretty 
convincing. 

Thus 80 per cent of the manic-depressive insanities of this 
group, which do not show focal scleroses or anomalies of the 
nervous system, do give history of insanity in near relatives. 

One of the two cases might not be wholly acceptable to a strict 
critic as manic-depressive, since the case (1386) died in her first 
attack of depression 30 months after onset at 51 (previous history 
clear). Perhaps the case belongs rather with the involution 
melancholias. 

The other non-hereditary case deserves more attention. 1353 
(13069) was the third of six children, four of whom are well, 
and the fifth died at 5 years of a spinal injury. Father, Irish, 
living, always well. Mother, Irish, died at 39. Nothing known of 
grandparents. No mental or nervous trouble in near relatives. 

Patient left school at 14 in seventh grade (failed of propiotion 
once). Obedient, quiet, diffident, not interested in sports. 
Worked steadily four years in a mill (up to $9.00 per week), later 
in grocery store for about five years ($8.00 per week), and helped 
to support family. Smoked freely. Drank but moderately. 

Diseases: Measles and mumps as child. Tertian type of 
malaria at 16, with many chills despite treatment, and recurrence 
at 17. Grippe at about 19 (apparently a light attack) . " Pleurisy " 
at 21 (sick three to six weeks), but no evidence of this at autopsy. 

So far as a pretty adequate history informs us, there were no 
upsetting factors whatever. April i, 1906, patient forgot to de- 
liver his orders, became talkative, and grew restless. Patient 
developed an excessive appetite, complained of indigestion and 



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268 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

incapacity to work, once threatened to cure himself " in the river," 
and developed insomnia. An exacerbation of excitement led to 
commitment. The only known factor which could have led to the 
condition was worry over not securing a new position on a steam 
railway. 

The disease then followed a course of three years and seven 
months, terminated by bacillary dysentery. Death from bacillary 
dysentery at 26 years is a rare incident and is, I believe, in our 
hospital, unique, so that a peculiarly great loss of resistance must 
be argued in this case. There is evidence of a bilateral otitis 
media of unknown date, and there was an acute purulent process 
in one ear after an attack of tonsilitis in January, 1908. 

The disease was characterized by numerous short attacks of 
excitement, distractibility, playfulness (rarely threatening surly 
attitude), grimacing. Hallucinations were never thoroughly 
demonstrated, although auditory ones were suspected. There 
was an occasional suggestion of catatonic mutism and resist- 
iveism ; but on investigation these proved to be rather emotional 
reactions. In the intervals between excitements, patient was a 
quiet, good hospital worker. 

This case would seem to show that upon no hereditary basis, 
and without obvious external cause, a series of maniacal attacks 
can be produced. In patient's social stratum, perhaps alcoholism 
in parents and grandparents can scarcely be excluded. Otitis 
media may have some importance. There was a trifling degree 
of sclerosis in the lower abdominal aorta. 

My conclusion at this point is, therefore, that, whether focal 
brain lesions produce or essentially modify this disease or not, 
heredity is a very strong factor statistically (80 to 90 per cent) 
in a series especially studied. I present one case apparently 
against any absolute regularity in this respect. It is stringently 
desirable that cases be reported which fulfil these requirements : 

1. Classical or typical manic-depressive insanity. 

2. No gross lesions or anomalies of brain. 

3. No evidence of heredity (data to be above reproach). 

But, if manic-depressive insanity may be a heritable disease, 
may it also be acquired? The difficulty of resolving this question 
reminds one of cognate difficulties in the study of epilepsy. 



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E. E. SOUTHARD 269 

In this direction I have reviewed all the focal-lesion cases, with 
the surprising result that they practically all belong, to the best 
of my belief, in other groups of insanity or are remarkably atypi- 
cal cases. The evidence for this needs presentation in full. 

The answer to the question stated above (the existence of brain 
stigmata) therefore depends upon the attitude you adopt to the 
diagnoses of manic-depressive made in this group. 

The cases with cerebral anomalies, or with lesions which are 
interpretable as such, are virtually all cases in which you might 
readily refuse to grant the propriety of the diagnosis. 

And, just in so far as you grant the diagnosis to all these 
atypical cases, in so far are you botmd to admit that the lesions 
do modify the course of the disease. Personally, for the present, 
I prefer to set these unusual cases aside from the great group of 
manic-depressive insanity. I should be willing to accord them 
whatever degree of alliance with manic-depressive insanity you 
please ; but this alliance should not, I think, be taken to signify 
identity. 

As to the third question based on the literature (the correla- 
tion of dementia with arteriosclerotic or other focal lesions), we 
deal with 5 cases (or 6, if a case with merely amnesia be included) 
having dementia amongst the 31. All five were 60 years of age 
or older at death, except one ( 1 1 15) , who died at 28 after 14 years 
of s)rmptoms. All had symptoms for long periods. It must be 
remembered, however, that there were no coarse lesions of arterio- 
sclerotic type in the brains of these cases. The dementia, if 
arteriosclerotic in origin, must have been due to fine changes 
not readily observed with the naked eye. In point of fact I re- 
gard the hypothesis of an arteriosclerotic orig^ of dementia in 
manic-depressive psychosis as entirely arbitrary at the present 
stage of research. The problem should now be taken up on its 
merits from the histological point of view, on the basis of clini- 
cally unexceptionable cases which have demented — and I venture 
to think few will be found. I know that many alienists will point 
to cases with the history of attacks and eventual dementia; but 
we are beyond the phase of science in which purely clinical evi- 
dence is decisive on such a point as this. 

As to the fourth question (symptomatology possibly modified 
by focal lesions), I believe the evidence of the present paper goes 



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270 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

far toward pressing the focal-lesion cases out of the manic- 
depressive group. 

VI. Conclusions. 

1. Kraepelin states that the anatomy of manic-depressive sub- 
jects is negative. Various authors have described focal lesions 
with which to account for the occasional dementia which text- 
books mention. Evidence as to the existence of brain stigmata 
is equivocal. Orton has recently found satellitosis perhaps rather 
more in manic-depressive than in dementia-praecox subjects. 

2. The fundamental and even practically important question 
of brain-anatomy in manic-depressive subjects has been here 
taken up precisely with the same ideas and with similar material 
as in the writer's first study of dementia-praecox brains — namely, 
with the topographic idea far more prominent than it has been 
made by most workers in the field of what used to be called " func- 
tional psychoses." 

3. The first question which occurs to a critic of my 86 per cent 
of anomalies, scleroses, and atrophies in dementia praecox is: 
What percentage of similar conditions would " not-insane " sub- 
jects show, and what would be shown in the disease manic- 
depressive insanity? The present paper deals with the latter 
inquiry and throws indirect light upon the former. 

4. As ever, much depends upon what one terms manic-depres- 
sive psychosis. In the text I have given relatively full accounts 
of most cases excluded from my initial list, which comprised 
every case which had received the diagnosis (at times on de- 
cidedly insufficient grounds) in a certain period at Danvers Hos- 
pital. Many of my exclusions tend to swell the dementia-praecox 
group, and these cases may be studied with my dementia-praecox 
material of 1910. To avoid confusion I have excluded cases of 
involution-melancholia. 

5. As against my 86 per cent lesions in dementia praecox, I 
regard 13 per cent as a fair percentage for manic-depressive 
insanity (4 in 31). A little less rigorous clinical analysis would 
leave the percentage at 18 per cent (6 focal-lesion cases in 33). 
In a total random material (after certain obvious exclusions) of 
38 cases, it would not be possible, I believe, for the most ardent 
anatomist to find more than 11 cases of focal lesions (29 per 



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E. E. SOUTHARD 27 1 

cent) . But this last percentage is assuredly too high, since three 
cases in the group are pretty clearly cases of dementia praecox. 
Thus 8 in 35 (23 per cent) is a figure which some analysts might 
prefer, though personally I believe it too high. 

6. Roughly speaking, then, we may think of the manic-depres- 
sive group as exhibiting brain stigmata or focal lesions (not 
arteriosclerotic) in about one brain in every five, whereas 
dementia praecox brains show such conditions in about four out of 
every five brains. 

7. This finding must be of some significance, whatever the 
criteria, and whatever particular functional correlations one might 
infer. The finding does not prove or indicate that the manic- 
depressive brain is normal; but it does show that the cellular 
lesions, if any are to be found, must be of a peculiar and probably 
a reversible nature. And, whereas eager histological researches 
in the brain are much to the point, perhaps the canny observer 
will regard the non-nervous organs of the body, or those supplied 
by the autonomic system, as even more inviting to study in the 
manic-depressive group. 

8. No special histological study is here presented, although 
some orienting slides have been available in the great majority 
of cases, from which Orton's conclusions about satellitosis can 
be in a measure confirmed. Indications of a special line of attack 
have been presented by Bond in a paper with the writer," and some 
conclusions bearing on this point have been drawn in the writer's 
thalamus paper." 

9. A study of the literature yielded a few special questions 
which I have endeavored to answer, largely on the basis of the 
material without focal lesions, since I regard these four-fifths of 
my material as far less open to diagnostic suspicion than the one- 
fifth possessing lesions. 

ID. The question of the relation of certain instances of eventual 
dementia to arteriosclerotic brain lesions is provisionally answered 
in the negative ; but the question requires further study. 

II. Heredity does not show itself in most manic-depressives 
in the form of brain stigmata ; but the extremely high index of 
insane heredity in near relatives is remarkable. I am inclined pro- 
visionally to regard manic-depressive insanity as constantly or 
almost constantly hereditary — not in the sense of similar heredity 



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272 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

(this has not been adequately studied), but in the sense that 
some kind of insanity is almost always, if not always, to be found 
in near relatives. Without such evidence, I am clinically not now 
disposed to make the diagnosis " manic-depressive," although it 
is clear that the rule will not work in the other direction. For the 
moment, I am challenging my records to produce an unexception- 
able case of manic-depressive psychosis which does not show 
family taint of insanity. 

12. Upon these provisional hypotheses, are we to assume that 
the normal-looking brains of manic-depressives are really normal, 
i. e,, intrinsically," " " and merely purveying the impulses which 
a sick body is producing? Or shall we assume a chemical or 
physicochemical instability of the entire nervous system, such 
that, although the brain is intrinsically abnormal, the abnormality 
does not show as yet? Hereditary taint is consistent enough with 
either assumption, since the germ-plasm might with equal readi- 
ness mark the nervous and the non-nervous parts of the body 
with those invisible marks that produce " functional psychoses." 



REFERENCES. 

1. Southard: A Study of the Dementia-Praecox Group in the Light of 

Certain Cases Showing Anomalies or Scleroses in Particular Brain 
Regions. Am. Jour. Insanity and Boston Medical and Surgical 
Journal, 1910. 

2. Southard: On the Topographical Distribution of Cortex Lesions and 

Anomalies in Dementia Prsccox, with Some Account of Their 
Functional Significance. Am. Jour. Insanity; 1914. 

3. Southard and Hodskins: A Note on Cell Findings in Soft Brains. 

Am. Jour. Insanity, 1907. 

4. Gay and Southard: The Significance of Bacteria Cultivated from 

the Human Cadaver: A Study of 100 Cases of Mental Disease, 
with Blood and Cerebrospinal Fluid Cultures and Qinical and 
Histological Correlations. Centralbl. f. Bakteriologie, 1910. 

5. Canavan and Southard: The Significance of Bacteria Cultivated from 

the Human Cadaver: A Second Series of 100 Cases of Mental 
Disease, with Blood and Cerebrospinal Fluid Culttu-es and Qini- 
cal and Histological Correlations. Jour. Med. Research (ac- 
cepted for publication early in 1915} . 

6. Kraepelin: Psychiatric: Ein Lehrbuch fiir Studierende tmd Aerzte. 

Siebente Auflage. II. Bd. Klinische Psychiatric, S. 53a (The 
statement deals with the maniacal states.) 



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E. E. SOUTHARD 273 

7. Kraepelin: Psychiatric: Ein Lehrbuch fur Studierende und Artzte. 

Achte Auflage. III. Bd. KKnische Psychiatric, II. Tcil, S. 1353. 

8. Thalbitzer: Die Manio-depressive Psychose. Archiv f. Psychiatric, 

1908. 
g. Alzheimer: Beitragc zur Kcnntnis des pathologischcn Neurologic 
und ihrer Beziehungen zu den Abbauvorgangen in Nervcngewebc 
Nissl-Alzhcimer, Histologischc und Histopathologische Arbcitcn 
uber die Grosshimrindc, usw. III. Bd, IIL Heft, 191a 

10. Orton: A Study of Satellite Cells in 50 Selected Cases of Mental 

Disease. Brain, 1914. 

11. Pilcz: Aetiologie und pathologischcn Anatomic des pcriodischen 

Irrcseins. Monatsschr. f. Psychiat u. NeuroL, 8, 1900. 

12. Las^e : Les C6rebraux. Archives gen. d. M6d., 1880. 

13. KrafiFt-Ebing : Ueber die durch Gchimerschuttcrung hervorgerufencn 

psychischen Krankhciten, 1868. 

14. Wagner: Ueber Trauma, Epilcpsic, u. Gcistcsstorung Hahrb. f. Psy- 

chiat, 8, 1888. 

15. Wollcmer: Ein Fall von circularer Geistcskrankheit mit pathologish- 

anatomischen Bcfunde. Neurol. Zentralbl., 1887. 

16. Schtile: Sectionscrgebnissc bei Geistcskranken (Obs. XVIII), 1874. 

17. Kim : Die pcriodischen Psychosen, 1878. 

18. Worcester: Regeneration of Nerve Fibers in the Central Nervous 

System. Jour. Expcr. Med., 1898. 

19. Savage: Insanity and Allied Neuroses, Practical and Clinical, 1884. 
2a Charron : Foyers dc ramollisscmcnts c^^braux ct troubles psychiques. 

Archives dc neurologic, 1899. 

21. Doutrebente: Note sur la folic i double forme. Acces multiples. 

Annal. m6d. psychoL, 1882. 

22. Hoppc, F.: Zur pathologischcn Anatomic dcr pcriodischen Psychose. 

Archiv f. Psychiat, 1908. 

23. Ayer, J. B., Jr.: Cyst of Dura Mater Occupying the Left Middle 

Cranial Fossa, Associated with Anomalous Development of the 
Left Superior Temporal Gyrus. Am. Jour. Insanity, 1908. 

24. Bonhoc£Fcr: Ueber ein cigenartiges opcrativ bcscitigtes katatonischcs 

Zustandsbild. CentralbL f. Nervenk. u. Psychiat, 1903. 

25. Taubert: Zur Lehre von den pcriodischen Psychosen, insbesondcre 

Ausgang und Sektionsbefund. Archiv f. Psychiatric, 1910. 

26. Dreyfus: Die Melancholic ein Zustandsbild des manisch-deprcssiven 

Irecscins, Jena, 1907. 

27. Kraepelin: Sec reference I, Melancholic 

28. Southard and Bond: Clinical and Anatomical Aanalysis of Eleven 

Cases of Mental Disease Arising in the Second Decade, with 
Special Reference to a Certain Type of Cortical Hyperpigmenta- 
tion in Manic-Dcprcssive Insanity. Submitted to Am. Jour. 
Insanity. October, 1914. 
18 



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274 BRAIN FINDINGS IN MANIC-DEPRESSIVES 

29 Southard: On the Association of Various Hyperkinetic Symptoms 
with Partial Lesions of the Optic Thalamus. Jour. Nerv. Ment. 
Disease, October, 1914. 

30. Southard: A Series of Normal-looking Brains in Psychopathic Sub- 

jects. Am. Jour. Insanity, 1913. 

31. Southard and Canavan : Normal-looking Brains in Psychopathic Sub- 

jects: Second Note (Westborough State Hospital Material). 
Jour. Nerv. Ment. Disease, December, 1914. 

32. Southard: The Mind-Twist and Brain-Spot Hypotheses in Psycho- 

pathology and Neuropathology. Psychol. Bulletin, 1914. 



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WHAT IS PARANOIA? 

By E. STANLEY ABBOT, M.D^ 
Assistant Physician, McLean Hospital, Waverley, Mass, 

This is necessarily a very condensed presentation of the subject. 

The concepts that have been associated with the term paranoia 
have been narrowing ahnost to the vanishing point. Used by 
Hippocrates in the sense of " mad, delirious thinking " ; by Vogel 
in 1764 as a general term for insanity; and by Heinroth in 1802 
and later to signify intellectual confusion, the word was reintro- 
duced half a century ago as the name of a mental disorder char- 
acterized by " systematized " delusions, usually of a persecutory 
or grandiose nature, in a person otherwise fairly clear. It was 
then synon)anous with primare Verriicktheit, Wahnsinn, delire 
chronique a evolution systematizee, monomania, primary delu- 
sional insanity — ^terms which it has largely supplanted since Kahl- 
baum definitely used it in place of primare Verriicktheit in 1878. 

This broad s3rmptomatic concept included a relatively large 
number of cases, psychiatrists differing widely, however, on many 
points, such as the relative importance of degree of systematiza- 
tion, chronicity, recoverability, dementia, presence of hallucina- 
tions or other symptoms, and also as to whether it was primarily 
an intellectual or an emotional disorder. 

To discuss all these differences would be unprofitable, but 
certain ones are important, since there still persist certain funda- 
mentally differing view points. Thus Ziehen " on the one hand 
says : " The paranoias are those f tmctional psychoses whose chief 
S)anptoms are primary delusions or hallucinations"; he recog- 
nizes simple and hallucinatory, acute and chronic forms. Deliritun 
tremens, for example, is a pure type of the acute hallucinatory 
paranoia. Recoveries are frequent, especially among his acute 
forms. He includes in his paranoias cases which belong in widely 
different clinical groups. He therefore really uses the term 
symptomatically, not diagnostically ; and his conception is a sterile 
one as far as further advance in our understanding of the con- 
dition is concerned. 



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276 WHAT IS PARANOIA? 

On the other hand, ahnost all other writers limit the signifi- 
cance of the term much more, using it in a diagnostic sense to 
indicate a group of cases which they believe belong together on 
fundamental and not merely s3rmptomatic grounds. Kraepelin's 
conception as defined in 1904 * is as follows : " There is imdoubt- 
edly a group of cases in which delusions are the most prominent, 
if not the only, s3rmptoms of the disease. In these cases a chronic, 
stable system of delusions gradually develops without any dis- 
order of the train of thought, of will, or of action." The group 
thus defined is a small one — about i per cent of all cases. 

With the exception of Ziehen's followers, most of the writers 
on paranoia have based their discussions on cases which they 
regarded as conforming to the Kraepelinian conception. But 
tmtil the last two or three years even Kraepelin himself has not 
held rigidly to his own definition, and a close examination of the 
reported cases (Bleuler's, for example,) on which the discussions 
have been based shows a large majority to belong in other clinical 
groups — ^mild, slowly dementing or stationary dementia praecox, 
manic-depressive psychosis, chronic alcoholic delusional condi- 
tions, etc. Two years ago, Kraepelin,' ' after weeding out his 
non-conforming cases (which he grouped with some other para- 
noid conditions under a new heading, paraphrenias), found a 
small residuum of cases which he regarded as true paranoia. 
These cases insidiously develop, in persons with psychopathic 
predisposition, a coherent, stable, logically elaborated system of 
delusions of endogenous origin, without hallucinations, dissocia- 
tions, negativism, mannerisms, stereotypies, peculiarities of 
speech, neologisms, ideas of influence, emotional deterioration 
or dementia. The personality remains intact. Patients are capa- 
ble of continuing their usual occupations or at least of being 
self-supporting. Their behavior is abnormal only as the result 
of their delusions. The course is chronic. Recovery seldom or 
never occurs. 

Another line of cleavage in the paranoia-concept is that indi- 
cated on the one hand by Specht," Gadelius, Kleist* and others 
who maintain that the ftmdamental trouble is a disorder of the 
affect, and on the other by Krafft-Ebing,* Cramer, Berze,* 
Bleuler ' and others who claim that it is primarily an intelligence- 



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E. STANLEY ABBOT 277 

psychosis, or at least that the emotional disturbance is not the 
primary one. 

Owing to the prominence of the Freudian psychology, this 
last decade has seen the development of an interpretive as dis- 
tinguished from the older descriptive psychiatry. S)anptoms, 
symptom-pictures, even diseases and disease-processes, are being 
thrust into the background, while the mechanisms of the origin 
and development of the content of thinking and feeling, and the 
interpretation and explanation of symptoms, are coming more 
into the foreground. Make-up or personality and individual ex- 
periences assume increased value and importance. 

Kraepelin himself, the master of descriptive psychiatry, some- 
what 3rielding to this trend, two years ago wrote of paranoia as 
being not a disease-process, but a mental twist (psychische Miss- 
bildung), an abnormal development, occurring under the ordinary 
stress of life in a person psydiopathically predisposed by internal 
conflicts and by a mixture of egotism and suspiciousness — ^the 
" paranoid " constitution. 

Bleuler' (1906) and Hans Maier* (1913) believe paranoia to 
be a psychosis in which some complex or group of complexes 
has for the patient such strong associated feelings or emotions 
that the content of thinking in lines related to the complex is 
determined by these affects instead of by facts or logic (Bleuler's 
autistic thinking). Errors thus arise which the patient cannot 
correct. Hence, with persistence of the tendency to this affective 
response to the complex whenever anything in the individual or 
in the environment arouses associations leading to it, errors are 
perpetuated, new ones are made, and thus delusions are formed, 
persist and develop (Hans Maier's katathjrmic delusions). 
Wishes, fears, or internal conflicts are what give rise to such 
complexes. Only the thoughts and feelings connected with the 
complexes are abnormal; all the rest is normal. Hence the 
absence of dementia or other psychotic sjrmptoms. Autistic 
thinking and katath3miic delusions may occur in other psychoses 
and even in health (day dreaming; social or religious prejudices). 

Freud r^ards paranoia as the expression of a homosexual 
tendency, but the special case (Dr. Schreber) on which he based 
this interpretation is one of paranoid dementia, as he himself 
recognizes, and not one of paranoia in the very strict and narrow 
sense. 



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278 WHAT IS PARANOIA? 

A special predisposition, perhaps consisting in constitutional 
defect with bad heredity (Krafft-Ebing), a primary disposition 
to think with short associations (Friedmann), a special psycho- 
pathic constitution (Kleist, Bleuler and others), an egotistic and 
suspicious personality with internal conflicts (Kraepelin), or an 
imaginative personality with lively emotional reactions (Maier), 
may be the necessary soil for the development of paranoia. 

Practically all writers, except Ziehen and his followers, agree 
on the chronicity and incurability of paranoia, though a few 
recoveries have been reported. A critical examination of these 
cases, however, throws doubt upon the diagnosis of all except 
Bjerre's. 

Two of the characteristics of the condition — ^the psychopathic 
personality and the unfavorable outcome — seem to me not funda- 
mentally essential, however constant they may be in actual experi- 
ence, and however much unanimity on these points there may be 
among psychiatrists. 

That there are cases which conform rigidly to the narrow 
Kraepelinian description (except as to the type of personality and 
outcome) I propose to show. Since he has shown that other 
cases which have been called paranoia can, on rigid scrutiny, be 
classed with other recognized clinical groups, or excluded from 
this group by at least a mild dementia, we are justified in apply- 
ing the term paranoia to this group exclusively, especially as the 
cases seem to differ from the paraphrenias and other paranoid 
conditions in fundamental respects. 

The two following cases, of which one was reported in 1912 
by Bjerre,* and the other has been under my own observation, will 
be cited as briefly as possible. 

Bjerre's case is that of a Swedish woman bom in i860, of 
gifted, eccentric, neurotic, and dissolute as well as some normal 
heredity, who herself was gifted, capable, common-sense, level- 
headed, not subject to moods, a teacher and then a journalist. 
As a child, imaginative, the princess of her own day-dreams. 
On leaving school, helped her father, a journalist; at 23 com- 
pleted a three years' seminary course, then taught in schools and 
private families for 13 years. Didn't especially enjoy teaching 
and at 36 became journalist on a weekly for two years, traveling 
to England, France, and Germany, making many acquaintances. 



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E, STANLEY ABBOT 279 

becoming much interested in history, politics, literature, and 
especially women's work and rights. At seven was told that 
child-bearing was the curse of God on woman, so she was opposed 
to marrying — she and her next older sister, to whom she was 
deeply attached, would live together as two old maids. At 13 she 
resolved never to marry. At 18 she began an anonymous corre- 
spondence, kept up for 20 years, with a man whom she never 
saw till she was 38. She had idealized him, and in her 20's had 
met and, out of loyalty to her ideal, given up, after seven years' 
doubt and hesitation, a man whom she really loved. On meeting 
her correspondent, however, he proved to be very commonplace, 
and at once began to flirt with her sister. Thereafter she refused 
to see him, b^an to hate him and gjew bitter toward the whole 
world. This was in 1898. She gave up her position without 
cause and did various kinds of office work. In the winter of 
1898-99 she worked for a man in his hotel room, and allowed 
him to seduce her, justifying herself in it, declaring it was her 
right, and that she never regretted it. In April, 1899, she fol- 
lowed him to X in Germany to continue the relationship, 

remaining till November, keeping a Swedish maid in her employ. 
She dreaded conception, partly because of the troubles of a friend 
of hers who had been hounded and driven to suicide on account 
of extramarital pregnancy. 

Psychosis, — In spring of 1899, at 39, she hegsm to think others 
watched her, and insulted her. Some persons passing her on the 
street made peculiar movements of the tongue at her, similar to 
those she had seen men make at a demi-mondaine whom she met 

at X . On returning home in November, the hotel waiter 

made faces at her — he must have listened at the door. People 
b^an saying things about her behind her back, and to turn their 
backs on her; her friends grew cool towards her — ^the Swedish 
maid must have told about her. Retrospectively she thinks that 
in the Christmas ( 1899) number of Puck there was a caricature 
of her, and that in February, 1900, a scathing article about her 
appeared in another journal. Since then the papers contain hints 
and innuendoes, recognizable by everyone. She then knew that 
all these things were parts of a general persecution ; the waiters 
all knew about her ; through the press the whole country learned 
of her relations with the man ; society judged her and ostracized 



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28o WHAT IS PARANOIA? 

her. The conspiracy gradually spread all over Europe, even to 
America. A general sign language was developed, known every- 
where, to inform people about her. Wherever she went she saw 
evidences of it. In 1903 there was some let-up in the persecu- 
tion, but since 1906 it has grown worse, and especially since the 
removal of the uterus and left ovary for persistent metrorrhagia 
in 1908. More and more people joined the conspirators, so that 
after street-car conductors, shopkeepers, clerks, waiters, etc., had 
seen her once or twice, they began to make the signs with the 
tongue, or to scrape their feet. Wherever she went it was the 
same. Only at home with her mother was she relatively free 
from it. There she isolated herself more and more. The head 
of the conspiracy is a woman's alliance, which exercises inquisi- 
torial powers, and all its members are spies. They are hounding 
her to death, to make her commit suicide. It is getting unbear- 
able. The bookkeeper where she works (she has continued 
regularly employed in a publishing house) is a very devil; he 
stirs up the others and leads the persecution; he makes a sign 
every time he passes her door; even the chief puts his tongue 
out at her. 

Bjerre talked with her for an hour every other day, very 
tactfully, without ever contradicting her delusions or antagoniz- 
ing her, from December, 1909, to March, 1910, without apparently 
shaking the strength of her convictions in the least. Within the 
next month she b^^an to accept some, then others, of his alterna- 
tive explanations, and quickly came to complete correction of 
all her delusions, with full insight, and no trace of mental dis- 
order or enfeeblement. She remained so for the two years or 
more that had elapsed up to the time of reporting the case. 

We see here the complete integrity of the personality, the 
gradually growing, logically developed system of delusions, tena- 
ciously held for many years, and the ability to support herself at 
her accustomed work. We see also a not uncommon situation 
become the center of several persistent, strongly affective com- 
plexes, which give rise to and perpetuate errors of interpretation, 
which g^ow into spreading delusions. And we see an imaginative 
person with lively emotional reactions. 

The other case is that of an American man of remote Jewish 
ancestry, in which there has been talent, emotionalism, ^otism, 



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E. STANLEY ABBOT 28l 

and some psychopathy, as well as normal traits. Bom in the 
fall of 1873; now 40 years of age. Severe typhoid at six, 
hyperesthesia of nose and throat since 17, tremor of hands since 
childhood, varying in intensity; exophthalmos since 29, variable 
in degree ; slender till 26, then stout. A brilliant student, accom- 
plished in many directions, good at games, imaginative, witty, 
sociable but shy, gentle, law-abiding, wishing always to be fair- 
minded, set in his opinions. Graduated from Harvard and 
Massachusetts Institute of Technology before 24. Then worked 
as a chemist in a mill-town, where he boarded in the same house 
with two rich young men who dissipated. In the spring of 
1898 when he was 25, they brought a mill-girl to their room and 
then to his and tried to compromise him. They teased him about 
it and the whole household learned of it. 

Psychosis. — ^A few days later he thought his landlady's manner 
indicated that she wanted an intrigue with him. Then followed 
a series of incidents from which he inferred that the two young 
men, irritated at his refusal to join in the mill-girl affair, were 
tr}ring to implicate him in some scrape, in order to discredit him 
and hurt his reputation. Later in the year he interpreted two or 
three slight incidents to signify that these two men had got a 
mill-town physician to help them. He then taught chemistry for 
a year in a remote state without special incident. But at the 
seaside resort where he spent the summer of 1899 several thefts 
occurred and he saw a certain politician there. A series of 
biu-glaries occurred in his home town, where he spent the follow- 
ing winter and spring, happening to persons with whom he 
could trace some connection, though often by rather devious 
routes — similarity of names to those of friends of his, etc. The 
papers referred to the thefts as being done by an organized gang. 
The politician above mentioned was again at the seaside resort 
next summer (1900), and the patient began to think the two 
young men had enlisted a whole political gang to arrange these 
thefts and connect them with him to discredit him. He took up 
teaching and writing, which he did very acceptably to his em- 
ployers for the next five years. During this time thefts continued. 

One day someone asked over the telephone if Mr. , the 

chemist was there. As the patient was known as a chemist only 
in the mill-town and in the remote state, he thought this suspi- 



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282 WHAT IS PARANOIA? 

Clous. That night the office building was burned. This was the 
beginning of a series of fires with which the two men evidently 
sought to connect him. He found confirmation of his suspicions 
in various incidents, such as the cmiission or inclusion of his name 
in the press accounts of whist tournaments in which he took part 
coincidentally with accounts of incendiary fires. In 1905 he taught 
in a small New England college, where he began to think the 
professors' wives made illicit advances to him, which he repulsed. 
The following year he thought drugs were put into his food, and 
since then into that of his friends, at the instigation of these 
women. Students and professors, then the state governor and 
senators have tried to make him marry. In 1907, at the hospital, 
he firmly believed that the two men have organized this vast 
plot, to connect him with thefts, fires and immorality so that his 
friends won't want him around, but will want to destroy him. 
He was, and remains, perfectly clear, coherent and logical, with 
very accurate memory, with no evidences of hallucinations, 
autochthonous ideas, ideas of influence; no stereotjrpies or man- 
nerisms. Some of his closest friends had seen nothing abnormal 
about him up to the time of his admission to the hospital. In 
the seven years he has been under observation his delusions have 
grown somewhat. Women on the street-cars or elsewhere make 
improper advances to him ; the drugs may be introduced into the 
Metropolitan water system; the manner of the nurse indicates 
that he is forbidden to talk of the drugs ; he is at the mercy of 
any unfair official or machine that chooses to continue drugging 
him; the use of drugs seems merely a conspiracy to isolate 
and discredit him; they are beginning to drug members of his 
family, etc. Meanwhile, he has recently written articles for an 
authoritative cyclopaedia in a special field, and writes frequently 
at the request of publishers for standard publications. He could 
be at large but for his threats against store clerks and others 
whom he accuses of putting drugs into his food or drink. 

Here again is the gradually evolving coherent delusion with 
complete integrity of the personality and ordinary ability for 
work, without other s)anptoms. Here, too, is a not very startling 
situation involving strong, persistent affective reactions, which 
give rise to errors of interpretation evolving into delusions. We 
have also an imaginative person with rather intense emotional 
reactions. We have not enough data in this case to know why 



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E. STANLEY ABBOT 283 

the complexes associated with the mill-girl episode should have 
so strong a feeling-tone. 

A case has just been reported by Gaupp (Miinch. Med. 
Wchnschft., Vol. 6i, p. 633, March 24, 1914) of a school teacher 
of excellent standing in his community, of good judgment, of 
strong feelings and philosophical tendencies, imaginative in youth, 
who held slowly growing delusions of persecution (on account of 
sodomy) for twelve years. No one suspected that he held any 
delusions whatever until one night, in accordance with a plan 
which he had worked out and kept in mind for four years, he 
murdered his wife and four children and eight men. 

In these cases the psychical processes as processes are normal. 
What is abnormal in them is that some of the affects associated 
with the seduction-complex in the one case and with the personal- 
honor-complex in the other were so strong and so widely diffused 
as to determine the content of thinking in two chief directions : 
(i) of seeing connections between external events and these 
complexes, and (2) of being imable to see the force of contra- 
dictory or rectifying arguments or facts; and they were so 
persistent as to perpetuate this effect. In Bjerre's case we can 
see what some, though by no means all, of the experiences were 
which gave color, strength and persistency to the seduction-com- 
plex affects. In the other case we have no such data for the 
personal-honor-complex affects. 

The mechanism here is not unlike that of prejudice, in which 
an unreasonable judgment is made in disregard of some impor- 
tant and available facts or considerations, the perception of them 
or of their importance being inhibited by some strong affect 
which also fosters the formation of erroneous associations, both 
affective and conceptual. Thus errors of judgment and interpre- 
tation arise and are perpetuated by the influence of the affect. 
Religious, political, racial and other prejudices show this 
mechanism. 

Ordinary errors or mistakes without strong associated affects 
may persist, or even lead to further errors, but they are compar- 
atively easily correctable by sufficient evidence or demonstration 
— no strong affect (except that of amour propre) has to be 
changed or suppressed. 

Prejudices, however, persist ; they may expand a good deal — 
the antivivisectionist is apt to be an antivaccinationist also, and 



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284 WHAT IS PARANOIA? 

in theory at least to believe that all physicians love to torture 
animals. To correct or overcome prejudices, the affect must 
be suppressed or supplanted by a different and stronger one — 
we must overcome certain feelings, as we say. It requires effort, 
time and patience to do this, but it is sometimes done. 

The difference between prejudice and the delusions of paranoia 
is, so far as I can see, only this : that the complexes in the latter 
have to do with especially intimate personal affairs, while in 
prejudice — as, for example, the antivivisection or the negro- 
equality prejudice — ^the complexes have to do with more or less 
extraneous matters, or with matters of comparatively little 
moment to the individual. Other things being equal, the more 
importance the complexes have for the individual and the more 
intimately personal they are, the stronger and more persistent are 
their accompan3ring affects, the more difficult is it to uproot or 
suppress them, and perhaps the greater is their tendency to grow. 

For the formation and development of the affect-determined 
delusions of paranoia we do not need to posit an underlying 
disease process, but only some experiences and trends that make 
some precipitating event or series of events arouse unusually 
intense affects in connection with complexes closely related to 
what has been aptly called the inner shrine of the personality. 
Why it is not a more common psychosis, then, is hard to say. 
Perhaps there is an unbroken series of cases extending from 
simple prejudice easily overcome and not elaborated, through 
strongly held, ineradicable prejudices slightly elaborated, to such 
cases as those just cited. Every person has simple prejudices; 
the number of persons whom we meet in every-day life who have 
the very strong, slightly elaborated prejudices is not so very 
large; it would not be strange, then, if those with the most pro- 
nounced type, the paranoiacs, were rare. It may also be that we 
do not see many of the latter because their delusions are not 
such as to lead to asocial acts or attitudes, and they protect 
their sensitive inner shrine by not talking of their ideas — ^just 
as many of us avoid political and religious topics unless we are 
certain of the s)anpathy of our auditors. That a distinctly 
unusual combination of both internal and external factors is 
necessary is suggested by the fact that Bjerre's patient did not 
develop her psychosis, that is, her delusional interpretation, till 
she was nearly forty. 



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E. STANLEY ABBOT 285 

The delusions of paranoia tend to expand, and are almost 
never overcome, though Bjerre's case shows that with sufficient 
tact, patience, effort, skill and time it may not be impossible to 
correct even these if one can secure the cooperation of the patient. 
The reason more cases have not recovered is perhaps due to the 
extreme rarity of such a combination of favorable factors as 
occurred in that case. 

May we not then agree with Kraepelin's description of para- 
noia, except to say, not that it does not lead to dementia, but 
that it leads to its own form of dementia, *. e., a tendency to 
see in more and more trivial events a relationship to the main 
delusion and a growing incapacity to see events except in rela- 
tion to the system? And may we not agree in general with 
Bleuler and Maier as to the interpretation of paranoia, but add 
that the mechanism is like that of prejudice, rather than that of 
error, and that the basal complexes must be such as have an 
especially intimate personal significance for the individual, must 
reach to his inner shrine? It may be that an imaginative per- 
sonality with rather intense emotional reactions is necessary, as 
Maier thinks, but this has yet to be demonstrated. 

To sum up : Unless we use the word merely in a symptomatic 
or descriptive sense (in which case it is an unnecessary synonym 
for the old delusional insanity), paranoia is a psychosis, but not 
a disease-process. It is neither a pure affect-psychosis nor a pure 
ideation-psychosis, but rather a combined associational affect- 
ideation-psychosis. It is a continuous self-perpetuating faulty 
association of ideas and affects without disturbance of the think- 
ing or affective or conative processes as such. It is purely func- 
tional, but not related to the manic-depressive or dementia praecox 
psychoses, which are ordinarily, though to my mind wrongly, called 
functional. Hence it does not lead to depientia except in the 
sense above mentioned, which is merely in the line of its own 
evolution, and it does not necessarily have any of the symptoms 
of the other psychoses except delusions, which may occur in all 
of them. Its mechanism is that of prejudice, but the basal com^ 
plexes involved are very intimate and personal ones with corre- 
spondingly strong and durable affects. 

This conception gives us some therapeutic hope, realized in 
at least one case. 



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286 WHAT IS PARANOIA? 

REFERENCES. 

1. Berze: Ueber das Primarsymptom der Paranoia. Halle, 1903. 

2. Bjerre: Zur Radicalbehandlung der Chronischen Paranoia. Jhrb. f. 

Ps-an. u. Ps-path. Forsch., Vol. Ill (1912), pp. 795-^47. 

3. Bleuler : Affectivitat, Suggestibilitat, Paranoia. Halle, 1906. 

4. Kleist: Die Involutionsparanoia. Allg. Zft. f. Psychiat., Vol. 70 (1913), 

pp. 1-134. 

5. Kraepelin : Psychiatric, 7th Ed, 1904. 

6. Kraepelin: Psychiatrie, 8th Ed., VoL II, 1910; Vol. Ill, 1913. 

7. Kraepelin : Ueber Paranoide Erkrankungen. Zft f. d. g. Neur. u. Psy- 

chiat, Vol. XI, Orig. (1912), pp. 615-638. 
a KrafFt-Ebing: Text-book of Insanity (Tr. by Chaddock, 1904). 
9. Maier: Ueber Katathyme Wahnbildung und Paranoia. Zft f. d. g. 

Neur. u. Psychiat, VoL XIII, Orig. (1912), pp. 555-610. 

10. Specht: Ueber die Klinische Kardinalfrage der Paranoia. Qblt f. 

Nvhlknd. u. Psychiat, Vol. N. S. XIX (1908), pp. 817-833. 

11. Ziehen: Psychiatrie, 4th Ed., 191 1. 



DISCUSSION. 

Dr. C. B. Burr.— I should like to ask Dr. Abbot how important he re- 
gards the three distinct stages in the development of paranoia upon which 
Krafft Ebing in discussing primare Verriicktheit, a form of disease for 
which paranoia is but another name, lays very great stress. These stages 
are as follows: The first of apprehension, misgiving, suspicion — the so- 
called persecutory state. Second, the stage in which the individual dis- 
covers an explanation for the persecution to which he has been subjected— 
the stage of transformation. Third, the stage of exaltation, owing to the 
fact of this discovery. Comfortable delusions are related thereto. While 
ideas of persecution persist, they are in the main in abeyance and over- 
shadowed by those the contemplation of which results in self-complacency 
and self-appreciation. In neither of th^ cases which Dr. Abbot reported 
was there self-satisfaction or egotism. True paranoia is, to my mind, an 
evolution showing these three stages. Nothing else is paranoia to me. I 
believe the expression has been too loosely used and that discussion b 
important for clarifying the subject. 

Dr. Abbot. — Probably the cases showing the three states, exaltation, etc, 
do not really belong in the regular paranoia group, but on close examina- 
tion will be found to show very slight degrees of dementia; they show 
other psychotic symptoms than mere delusions ; I think they belong, there- 
fore, in another category — in the paranoid form of dementia praecox or 
of some other psychosis, and not to the real paranoia group. There are 
very few cases that have absolutely no other psychotic symptoms; where 
there are other symptoms than delusions I think we have to do with 
another underlying condition. Almost all the conceptions of paranoia 
have really been based on the study of very mildly demented cases that 
have remained partly or nearly normal. 



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IS THERE AN INCREASE AMONG THE DEMENTING 

PSYCHOSES? 

By CHARLES P. BANCROFT, M. D., 
Superintendent N. H. State Hospital, Concord, N, H. 

One dislikes to be a pessimist. The optimist finds greater 
favor in the world's opinion. The outlook of the pessimist is 
contracted and discouraging. The optimist is hopeful; he is 
more apt to have the open vision, and the majority of mankind 
listen more willingly to his prognostications. In the financial 
world the public sympathizes with the Bulls rather than the 
Bears, for the former preach the gospel of good times and en- 
courage belief in the substance of things hoped for. It is there- 
fore in no captious, C3mical frame of mind that the question of 
a possible increase among the dementing psychoses is raised. 
Genuine scientific interest to know the truth prompts the query 
rather than a pessimistic spirit that finds in modem psychiatry 
only a fatalistic trend. 

Eliminating the greater longevity of the insane, due to their 
better care ; disregarding the diminished popular prejudice against 
hospitals for the insane and the consequent accumulation of this 
class in institutions; making all due allowance for the better 
statistical recording of the insane now than in years past, still we 
are confronted with the assertion that insanity is increasing at 
a more rapid ratio than the population. In what variety of in- 
sanity does this inferred increase occur? Is any one t)rpe of 
insanity more prevalent than formerly? Has the character of 
mental disease changed, or have our methods of study and diag- 
nosis led to a different interpretation? Have a more intensive 
scientific research, a clearer conception of the psychogenetic 
causes of insanity operating through constitutionally predisposed 
or weakened nerve structure modified our conclusions? Under 
the same conditions as eighty years ago, and disregarding any 
increase in population, do we find an actual increase among the 
dementing psychoses, or did the alienist of the forties and fifties 
of the previous century fail to read aright the symptoms? Do 



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a88 IS DEMENTING PSYCHOSES INCREASING? 

we, observing identically the same symptoms as did our prede- 
cessors, interpret them differently? 

Our evaluation of the diagnostic importance of symptoms has 
unquestionably experienced a radical change. We no longer place 
any significance on excitement, exhilaration, dq>ression, confu- 
sion, stuporose states, and many other symptoms per se, for we 
know that all these manifestations may characterize any of the 
phases of mental disease. These phenomena appear and disap- 
pear in nearly every phase of insanity, and by themselves possess 
no great diagnostic value. We must look further than the mere 
superficial signs. We must dig down deep into the patient's 
mind, into the psychic life, not only of the patient, but of his 
antecedents, before pronouncing their true significance. We must 
discover why individuals react so differently to the same environ- 
ment — ^why one man breaks down mentally under stress and 
another passes through the same ordeal unscathed; why one 
man's mental int^^ty at ninety is unimpaired and another's 
mind gives way at fifty-five or sixty. If from some deq) hidden 
psychogenetic process one man has hallucinations of special sense, 
we must, if we can, ascertain why this special psychogenetic 
cause operates as it does in this particular case. Is it because 
of a certain inherited constitutional make-up, some acquired 
mental state due to environmental conditions, a toxaemia or other 
factor? Such investigation may lead to widely varying interpre- 
tations of symptoms, the significance of which will dq>end 
largely on the nature of the cause, the character of the subsequent 
morbid process, and more important than all else the inherited 
predisposition of the individual. 

The alienists of fifty years ago undoubtedly made more hope- 
ful prognoses than their successors of the present day. They laid 
more emphasis on the so-called exciting causes, and placed less 
importance on the predisposing factors. The tendency of the 
earlier psychiatrists was to exaggerate the significance of single 
symptoms. They were very apt to make a diagnosis or prognosis 
on one symptom, such as dq>ressioh or excitement, when really 
these emotional disturbances were only a part of a larger process 
and not therefore a symptom complex of a disease entity. They 
were especially narrow in their interpretation of causative influ- 
ences. Too much emphasis was placed on a single cause to the 



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CHARLES P. BANCROFT 289 

exclusion of other factors. This led to a somewhat circum- 
scribed conception of the case. By removal of an apparently 
conspicuous etiological factor the earlier alienists believed that 
the patient would recover. If the patient had been a too-ardent 
Millerite, spiritualist, if he had confined himself too closely to 
mental or physical work, by a simple withdrawal from these 
baneful activities it was felt that recovery would surely follow. In 
reading the reports of these earlier days one is led to the conclu- 
sion that not enough emphasis was laid on the constitutional 
element. One would like to know whether the patient would have 
had his mental disturbance at all if there had not existed some 
marked constitutional dyscrasia which predetermined the psycho- 
sis. Lugaro's statement that the healthy brain is the most resist- 
ive organ in the body; that it will endure more pressure and 
strain than any other tissue and still retain its recuperative 
vitality, is undoubtedly correct. Over strain is only likely to 
induce insanity in a brain predisposed by poor inheritance to 
feeble resistance. 

It would be interesting to know if these so-called recoveries 
were genuine recoveries; whether these same patients did not 
suffer relapses and finally become permanently insane. In these 
earlier days there were genuine recoveries as now, but the asylum 
reports of that time breathe a hopefulness that we of the present 
day cannot experience, much as we might desire. Unquestion- 
ably modem methods and a change in the psychopathological 
view point have resulted in classifying many cases among the 
dementing psychoses that in earlier days would have met with 
more hopeful consideration. 

The statistical tables of the earlier days were very simple 
affairs, and in reading them one almost envies the apparent ease 
with which they must have been made. Mania, melancholia, 
dementia, an occasional hypochondria and hysteria composed the 
diagnostic tables. Of these mania and melancholia constituted 
the larger number, while cases called dementia were in the 
minority. The query arises whether the physician of that day 
did not include among the manias and melancholias many cases 
that at the present time would be classified as dementing psycho- 
ses. Paresis never appeared in the diagnostic tables. This dis- 
ease, in the rural districts particularly, must have been extremely 

19 



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290 IS DEMENTING PSYCHOSES INCREASING? 

rare. Syphilis as an etiological factor in brain disease was rarely 
recognized. Indeed, it is very doubtful whether syphilis was as 
prevalent then as now. Even alcoholism did not appear as a 
prominent etiological factor. Arteriosclerosis was unknown, and 
therefore never mentioned. 

We must remember that state supervision did not exist at 
that period; that many of the insane, the epileptic and feeble- 
minded were cared for at home or allowed to roam at large and 
consequently were unrecorded. These facts may account for the 
smaller number of so-called dementias and incurable cases occur- 
ring in the earlier reports. But making due allowance for the 
fact that many cases were not committed to asylums, one cannot 
escape the conviction that the diagnostic methods of the earlier 
period lacked scientific precision and were far less accurate than 
those of the present day, and that for this reason the statistical 
tables recording diagnoses were to a certain extent misleading. 

It is true that the earlier psychiatrists may have frequently 
erred in their diagnoses and included many dementing psychoses 
among their manias and melancholias. Giving due credit for 
such errors in diagnosis, the large number of incurable and de- 
menting psychoses in the statistical tables of the present day is 
strong presumptive evidence that there is an actual and not a 
fancied increase among this class of mental diseases. The recov- 
erable and functional psychoses have practically become narrowed 
down to two groups: manic depressive insanity and infective 
psychoses. 

Among the dementing psychoses an apparent increase occurs 
in the following forms : paresias, dementia praecox, the various 
imbecilities, and the presenile and senile dementias. That there 
is an increase in paresis few will probably deny. Kraepelin says : 
*' A certain increase of paresis may be admitted as highly prob- 
able. The experience, especially of large cities, proves this. 
There the figures are so large and so continually growing, as 
for instance, the rate of Berlin and Munich, where the male 
paretics amount to 36 per cent, and in the Charite at Berlin 
where they reach 45 per cent, that the errors just mentioned are 
of little consequence. There are twice as many paretics in the 
city asylums as in those of the country districts. This fact, 
considering the rapid growth of the city population, makes an 
increase of paretic affections more probable." Kraepelin's sta- 



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CHARLES P. BANCROFT 29 1 

tistics are confirmed by those of this country, although possibly 
not to the same extent as in Germany. Recent serological and 
C3rtological findings positively connect syphilis with paresis. No 
longer can there be any etiological uncertainty concerning paresis. 
Kraepelin affirms : " We can, therefore, to-day with greatest cer- 
tainty declare that syphilitic infection is an essential for the 
later appearance of paresis." 

The increase of paresis in a general way must mean an in- 
creasing prevalence of syphilitic infection in the community. 
While the larger percentage of paresis occurs in the cities, there 
is a striking increase in rural districts. In New Hampshire, an 
agricultural state, whose largest insane population comes from 
the country, there has been in the state hospital a slow but steady 
increase of paresis among the commitments. In the Bangor 
State Hospital, which draws many of its insane from the coast 
communities, there is a striking prevalence and increase of 
paresis. In New York State the proportion of paresis to all 
other forms of insanity is one to eight; in Iowa one to fifteen, 
which is a marked increase above the proportion of former years. 
The spread of syphilitic infection becomes therefore a serious 
contributory factor in the causation of mental disease. Not that 
every luetic infection entails paresis, but such infection does, 
if not removed, certainly lower the resistive tone of nerve tissue 
and so lay the foundation for individual and family deterioration. 

Syphilis undoubtedly plays a prominent role among the obscurer 
causes of insanity. In paresis its influence represents the ten to 
fifteen-year invasion of the central nervous system after the orig- 
inal infection. Whether this increase of paresis is enhanced by 
a weakening of nerve structure through alcoholic excesses or 
the stress of civilization, may be a mooted point. That there is 
an increase of paresis among the most highly civilized races 
there can be no doubt. It is quite probable that with the spread 
of S3rphilis in the community this disease may be fast becoming 
one of the chief contributory factors in a variety of dementing 
psychoses, such as dementia praecox, imbecility, epilepsy, the 
senile and the presenile insanities. These psychoses occur in 
brains of feeble resistance and possibly demonstrable convolu- 
tional brain simplicity. That s)T)hilis may be one of the impor- 
tant causes of weakened durability of brain tissue in infected 
individuals and their descendants is extremely probable. 



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292 IS DEMENTING PSYCHOSES INCREASING? 

Misdirected sexual activity in youth may therefore become the 
initial cause of family brain deterioration in subsequent genera- 
tions. It is of course extremely difficult to demonstrate this 
statistically, but of the possibility there can be no doubt. Intelli- 
gent field work may render possible such demonstration, and 
disclose at what point family decline began in this or that genea- 
logical tree through the introduction of the syphilitic infection. 
Every psychiatrist is familiar with individual cases of this char- 
acter. Such cases may be more niunerous than we are aware. 

The increasing prevalence of syphilis is receiving deserved 
recognition in the medical journals of the day. The Boston 
Medical and Surgical Journal, in a timely editorial in the August 
31, 1913, issue quotes from a letter in the London Morning Post 
emanating from several eminent medical men condemning the 
" conspiracy of silence as regards venereal diseases " and recom- 
mending the appointment of a Royal Commission " to investigate 
the facts and to recommend what steps, prophylactic and thera- 
peutic, should be taken to cope with these diseases." The last 
report of the Massachusetts State Board of Insanity, under the 
section, " After Effects of Acute Diseases of the Nervous Sys- 
tem," makes the following interesting and pertinent statement : 

The correlation of Danvers material by Dr. H. I. Paine, of the Danvers 
staff, had previously shown that the routine of Essex County cases was run- 
ning over 20 per cent positive sera by the Wassermann test. Of course 
this percentage was far from showing that all the mental phenomena in 
these positive cases could be traced to syphilis. Moreover, the Danvers 
material included general paresis cases in which the relation to syphilis 
was already clear. It became desirable to learn what amount of residual 
syphilis could be traced in asylum (f. e,, technically, in Massachusetts chronic 
'* transfer ") cases. An extensive inquiry gave about 5 per cent positive sera 
in Worcester Asylum material, to which we had access by courtesy of 
Dr. H. L. Stick. The more general application of Wassermann tests on 
admission of our patients is indicated both by the Danvers and Worcester 
series, but also by the general Boston admissions which at times run as 
high as 30 per cent positive sera. Important therapeutic work is suggested 
by these results ; for, if the Wassermann positive serum indicates in some 
sense active syphilis, the condition would seem to demand therapeutic atten- 
tion for the possible amelioration, if not the cure, of certain mental sequels 
of syphilis. 

And again in the same report : 

Doubtless the percentage of syphilis demonstrable in asylum material may 
rarely run over 10 per cent, but the acute material of the active hospitals 



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CHARLES P. BANCROFT 293 

may yield a percentage somewhere between 20 and 30 under the present 
conditions of society. Certain leads in therapy are thereby indicated. 

We may conclude that paresis is a dementing psychosis which 
is exhibiting a marked increase at the present time; that the 
cause of paresis, syphilis, may be one of the prominent contri- 
butory factors in a large number of dementing psychoses that 
are apparently increasing more rapidly than the recoverable 
psychoses. 

While an increase in paresis is demonstrably certain, the same 
query as applied to dementia praecox presents a problem more 
difficult of solution. One chief reason for such difficulty lies in 
the fact that there is not a definite consensus of opinion as to 
the exact pathology of this disease. Some think that dementia 
praecox is of psychogenetic origin ; others that the psychosis has 
an organic basis ; still others that the name is a misnomer ; that 
the disease is not necessarily limited to the developmental period 
of life, but is merely a dementing process that may occur in 
predisposed individuals at almost any age period; and finally 
there is the supposition of Kraepelin that the disease is of toxic 
origin. Until there is greater unanimity of opinion as to what 
is actually meant by the term dementia praecox ; until the various 
theories of alienists shall have crystallized into a more permanent 
and universally accepted belief, it will be extremely difficult, if 
not impossible, to say definitely whether this psychosis is really 
increasing. Numerically dementia praecox has of late occupied 
an increasingly prominent place in statistical tables. There is 
fashion in diagnosis as in everything else. We are too near the 
advent of dementia praecox on the diagnostic horizon to sub- 
scribe unreservedly to the correctness of the diagnosis wherever 
made. The charge has been brought that this diagnosis offers 
an easy method of disposing of uncertain cases in the diagnostic 
tables toward the end of the hospital year. However this may 
all be, there is evidence tha.t greater caution is being exercised 
in making the diagnosis. Even Kraepelin has receded somewhat 
from the more positive position held by him when he first de- 
scribed the psychosis. Hospital reports during the next few years 
will doubtless show a decrease in the number of dementia praecox 
cases. 

The extension of the age limit at which this disease may occur 
discloses a modification of our original conception concerning it. 



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294 IS DEMENTING PSYCHOSES INCREASING? 

Formerly dementia praecox was identified with adolescence. At 
the present we are not surprised to meet with cases in the third 
decade presenting the characteristic symptoms of the disease 
which originally were limited to the periods of puberty and 
adolescence. Age limit is no longer regarded such an essential 
factor in the diagnosis. While theoretically retardation and neg- 
ativism may be pathognomonic of the depressed phase of manic 
depressive insanity and of dementia praecox respectively, yet 
practically they are oftentimes so nearly identical and merge into 
one another so easily that a positive diagnosis of either psychosis 
cannot be definitely made on these symptoms alone. Automatic 
negativism, following either a perversion or a paralysis of the 
will, may occur as readily in a functional melancholia as in a 
dementing psychosis with a presumable organic basis. In former 
days the diagnosis of stuporose melancholia with marked nega- 
tivism did not prevent the psychiatrist from venturing a hopeful 
prognosis. When dementia praecox became the fashion stuporose 
melancholia was relegated to the background, and a gloomy 
prognosis followed. The alienist of former days, his mind intent 
on a functional disease process, was not surprised at recovery 
after a year of stupor. During the last decade, however, the 
hospital physician, dominated by a name and feeling that the 
symptoms of dementia praecox rested on an organic basis, ren- 
dered an unfavorable prognosis. Not infrequently he has been 
chagrined and surprised to meet with a recovery in what he had 
supposed was an incurable psychosis. The meaning attached to 
a name may become an actual obsession ; in this way the generic 
word dementia leads frequently to the abandonment of a hopeful 
prognosis, and the specific title prcecox, by postulating an age 
period, prevents the making the diagnosis when it should be made. 
While the name may be unfortunate, in that it does not always 
meet all the facts, still the particular disease process which it 
connotes does exist and the demarcating the pathological symp- 
tomatology of dementia prcecox constitutes one of the most 
brilliant advances in mental science. It is evident that the diag- 
nosis of dementia praecox should not be made too hastily. 
Decision should be suspended in doubtful cases sufficiently long 
to convince the physician that the disease process is something 
more than a temporary disturbance of brain function. It is 



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CHARLES P. BANCROFT 295 

quite probable that when judgment is thus deferred dementia 
praecox will not appear as frequently in our diagnostic tables 
during the next ten as it has during the past ten years. 

The statistical tables of recent hospital reports disclose marked 
variation in the preponderance of dementia praecox in different 
institutions. So great is this variation that one questions the 
accuracy of the diagnosis, and wonders whether the mood of 
the diagnostician is not reflected in the result. In some hospitals 
dementia praecox and manic depressive insanity appear in nearly 
equal ratio, while in other hospitals the praecox cases are twice as 
numerous as the manic depressives. Thus : 

Hospital. Year. Aggregate ^^Mjnk ^ p,,,,,,. 

Westborough State Hospital, Mass... 1910 491 120 121 

Westborough State Hospital, Mass... 1912 494 115 124 

Worcester State Hospital, Mass 1910 568 72 194 

Worcester State Hospital, Mass 1912 486 T7 US 

Danvers State Hospital, Mass 1911 573 73 150 

Danvers State Hospital, Mass 1912 505 92 99 

Northampton State Hospital, Mass 1910 330 56 66 

Northampton State Hospital, Mass 1912 334 57 64 

Boston State Hospital, Mass 191 1 433 78 71 

Boston State Hospital, Mass 1912 651 108 97 

Taunton State Hospital, Mass 191 1 408 37 106 

Taunton State Hospital, .Mass 1912 520 48 172 

Bangor State Hospital, Me. 1912 183 23 28 

Augusta State Hospital, Me 1912 270 55 45 

New Hampshire State Hospital, N. H. 191 1 301 56 42 

New Hampshire State Hospital, N. H. 1912 327 65 52 

In New York State the per cent distribution of manic depres- 
sive insanity and dementia praecox in all hospitals was in 

191 1 manic depressive, 11.2; dementia praecox, 16.0 

1912 manic depressive, 11.5; dementia praecox, 16.0 

In the Boston, Augusta, and New Hampshire State hospitals 
there were fewer praecox cases; in all other hospitals cited the 
praecox cases exceeded the manic depressive, and in some cases 
the excess was over 30 per cent. The statistical variations are 
of such wide range as to render definite interpretation quite 
impossible. 

The very interesting psychogenetic studies of Meyer, Jung, 
and Bleuler on the one hand, and the proposed anatomical inve»- 



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296 IS DEMENTING PSYCHOSES INCREASING? 

tigations of Southard should prove most illtuninating, and ought 
to contribute materially to our understanding of this disease. 
In this connection the following statement by Southard in the 
last report of the Massachusetts State Board of Insanity is 
interesting : 

Work under way deals further with the dementia praecox problem in the 
endeavor to setde, from the convolutional standpoint, whether the victims 
of dementia pracox start with normally developed brains at birth. Publi- 
cations are in preparation which deal with this work. 

In a timely paper by Dr. George H. Kirby, entitled The 
Catatonic S)mdrome and Its Relation to Manic Depressive In- 
sanity, published in the Journal of Nervous and Mental Disease 
for November, 1913, the possibility of the occurrence of the 
catatonic s)mdrome in functional and recoverable mental disease 
has been ably and convincingly stated. Dr. Kirby logically draws 
the following conclusions : " From the point of view of formal 
symptomatology we find that very similar clinical pictures occur 
in deteriorating and non-deteriorating cases, and that in all cases 
the most reliable prognostic data are gained from a study of the 
personality and the mode of development of the psychoses." And 
again: "There can be little doubt that Kraepelin over-valued 
catatonic manifestations as evidence of a deteriorating psychosis, 
and that many of these cases have served to swell unduly the 
dementia praecox group." Dr. Kirby cites a number of cases in 
which stupor, catatonia, and negativism were prominent symptoms 
for long periods of time and eventually recovered, "in some 
instances after a duration of several years." 

Whether there has been an actual increase among the dement- 
ing psychoses of early and middle life is very uncertain. Statis- 
tics imply such increase. The conclusion is not necessarily 
proven. The fact that cases can be so readily transferred from 
the non-deteriorating to the deteriorating coltunn, according to 
the view point of the diagnostician, invalidates any opinion drawn 
from statistics. An actual increase of true dementia praecox 
throughout the country would mean a condition of serious import. 
True dementia praecox undoubtedly represents a weakening of 
the family stock. As such it may depend upon a variety of 
causes : alcoholism, constitutional diseases of various sorts in the 
antecedents, an)rthing, in fact, that lowers the resisting power 



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CHARLES P. BANCROFT 297 

of the nervous system. Dementia praecox is not consistent with 
a strong, virile family or racial stock. The writer inclines to the 
more hopeful conclusion that the larger statistical increase in 
dementia praecox is due rather to a change in the view point of 
the diagnostician than to any large numerical increase in the 
disease itself. Such conclusion should stimulate the psychiatrist 
to a more careful and hopeful study of all apparently dementing 
psychoses occurring in early life. Such dementing processes in 
adult periods are more serious and suggest impaired durability of 
brain tissue. That there is any real increase in this psychosis 
over what might be expected from the natural increase in popu- 
lation is doubtful. 

There is one fertile recruiting ground for dementia praecox 
demanding most thoughtful consideration, the ignoring of which 
may lead to disastrous results. Young immigrants, with poor 
hereditary and environmental antecedents, easily become victims 
to this psychosis. The adolescent recently arrived from south- 
eastern Europe, without education, with possibly an hereditary 
handicap, suddenly finds himself in a strange land, confronted 
with new customs, different food, and compelled to get a living 
out of unfamiliar and to him anomalous conditions. Most likely 
he is placed in an unsanitary city environment. His already 
weak mind readily succumbs under the strain. From the ranks 
of the predisposed immigrants will in all probability come a large 
increment of dementia praecox. In years past the Irish immi- 
grants have furnished the most noticeable recruiting ground for 
this psychosis. Their place has been taken by the French Cana- 
dian and the races of southeastern Europe. Prophylaxis should 
demand more rigid mental inspection of immigrants, preferably 
at their ports of embarcation. A large increase in dementia 
praecox during the next few years will in all probability pro- 
ceed from imported stock. The strong and mentally well- 
endowed immigrant, even though he be tmeducated, is welcomed 
and assimilated. The weaklings should be rigidly excluded, pre- 
ferably before they leave their native land. 

Whether the dementing psychoses are increasing in the fourth, 
fifth and sixth decades is largely problematical. Judging from 
statistical tables, diagnostic methods seem to be undergoing a 
transition. Involutional melancholia, presenile insanity, Alz- 



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298 IS DEMENTING PSYCHOSES INCREASING.^ 

heimer's disease, and senile insanity are terms that seem to 
connote varied phases of dementia occurring at any time after 
the beginning of the fourth decade. Cases may occur during 
this age period presenting manic depressive symptoms that do 
recover. The majority of these cases, it must be admitted, do 
not recover and the query arises whether the pathological etiology 
is not the same in all. An apparent increase in these dementias 
follows from the fact that persons becoming demented after 
fifty years of age are very apt to become permanent residents 
of institutions, and relatives are much more willing to commit 
family members who become incapacitated at this age than for- 
merly. A somewhat changed point of view has led to the placing 
of a larger number of cases occurring in the fourth, fifth, and 
sixth decades in the coltunn of the dementing psychoses. All 
these factors contribute toward an apparent increase among the 
dementing psychoses occurring after forty years of age. It is 
doubtful whether fundamental conditions have changed. Prob- 
ably the increase is more apparent than real, due to different 
pathological interpretation and diminished popular prejudice 
against institutional treatment. 

In this connection it is interesting to note that arteriosclerosis 
is given a less prominent part than formerly as a causative factor 
in the insanities of advancing years. Reduction in arterial cal- 
iber and consequent diminished brain cell nutrition are an easy 
explanation of senility and senile dementia. Recent studies, how- 
ever, do not support this contention. Dr. Southard and Dr. 
Mitchell, in the American Journal of Insanity, Vol. 65, October 
number, conclude that while arteriosclerosis may frequently 
accompany the insanities of the sixth and seventh decades, still 
" neither general nor cerebral arteriosclerosis bears an essentially 
causative relation" to mental attacks in these decades. Is it 
not more probable that all these insanities occurring in late 
middle life and old age are but the expression of tissue aging, 
of failing durability of cerebral cell structure, dependent on 
fundamental or inherited constitutional limitations? 

In a series of able articles in the Journal of Mental Science, 
Vols. 51, 52, 53, 54, Joseph Shaw Bolton presents a broad inclu- 
sive picture of all the dementing psychoses, attempting to bring 
them all under two groups, Amentia and Dementia. The attempt 



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CHARLES P. BANCROFT 299 

is made to trace back all the dementing psychoses, both con- 
genital and acquired, to a definite physical basis ; in other words, 
to simplify the nomenclature of mental diseases and unify the 
disease process by establishing a common pathological back- 
ground for a widely divergent symptomatology. The proposition 
is commendable and appeals to a logical mind. 

Briefly stated, Dr.Shaw's theory is that all epochal and degen- 
erative insanity has an organic basis. He employs "the term 
' dementia ' to connote in the widest sense the mental condition 
of patients who suffer from a permanent psychic disability due 
to neuronic degeneration following insufficient durability." By 
amentia he means those cases " suffering from deficient or sub- 
normally aberrant neuronic development." According to this 
theory all human beings at birth come under one of two classes : 

I. Those who are well endowed and have normal resistance ; and, 

II. Those who possess deficient durability of nerve tissue, or an 
actual defect — an incapacity in nerve structure to develop nor- 
mally. In either case there is a pathological handicap which 
sooner or later results in more or less permanent mental insta- 
bility. As Dr. White so well expresses it : " Every individual 
bom into the world has, if it could be determined, a definite 
potentiality for development." The durability of a man's nervous 
system is somewhat analogous to the tensile strength of iron. 
Just as the tensile strength of a steel plate varies with the molec- 
ular resistance of that particular plate, so each man's nervous 
system has its own durability beyond which it cannot be pressed 
without danger of disorganization. 

It is quite probable that the same histological and pathological 
processes underlie every form of tissue aging. Dr. Albert M. 
Barrett, in the 1913 June number of the Journal of Nervous and 
Mental Disease, reports an interesting case of Alzheimer's Disease 
occurring at an unusually early age. In this case the disease 
began at 33 years of age, and the patient died at 37. Dr. Barrett 
calls attention to the histological similarity between Alzheimer's 
Disease, usually considered a disease of the presenile period, and 
the brain changes in senile dementia, and raises the interesting 
query whether the limits of presenility may be extended forward 
to include this case as well as onward to the truly senile cases. 



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300 IS DEMENTING PSYCHOSES INCREASING? 

In the following language Dr. Barrett suggests histological and 
pathological identity underlying all these cases : 

The circumstance that there seems to be no difference in the character 
of the plaques and neurofibril alterations between these presenile and the 
truly senile cases, excepting in the intensity of the process, and that there 
also occur in each similar changes in the neuroglia of the marginal layer, and 
the accumulation of lipoid substances in the nerve cells, glia cells and blood 
vessels has led to the explanation that these early cases are prematurely 
senile, and that senility is not essentially a matter of years but of tissue 
aging. It has become difficult to limit disease processes by age periods, 
and Alzheimer comments that anatomical investigation has taught us that 
progressive paralysis may occur as late as the 70th year and the pathological 
process of senility as early as the 40th year. 

Speculation at the present time as to a probable increase in 
feeblemindedness is futile because accurate tabulation of this con- 
dition is very recent. In some states careful registration and 
study of imbecility have only begun. Comparatively a few years 
ago the feebleminded were ignored. They either roamed at will 
in their native communities, or when too great a nuisance were 
housed, not always permanently, at the town or county alms- 
houses. Within only a few years has segregation of these defec- 
tives been seriously advocated. An apparently large statistical 
increase may occur because feeblemindedness is better understood 
than formerly. The higher grades of imbecility were formerly 
ignored, but are now recognized and classified. In fact, the high 
grade imbecile is now regarded a far greater menace than the 
lower grades, for, with his larger intelligence, he moves about 
more freely in the community and propagates a numerous feeble- 
minded legitimate or illegitimate progeny. Statistical increase 
is therefore misleading. 

There are some valid reasons for inferring an actual increase. 
Present-day social conditions are widely different from those 
of fifty years ago. At that time feeblemindedness seemed more 
sporadic than now. Formerly imbecility was more restricted in 
its distribution and was confined within circumscribed localities 
in the state. Apparently there were centers of prevalence. The 
advent of easy transportation facilities by the extension of steam 
and electric roads has made possible a freer movement of all classes 
of the population. Isolated rural districts are more readily 
reached than formerly. The high grade imbecile finds little diffi- 



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CHARLES P. BANCROFT 3OI 

culty in changing his habitat, and presumably does not remain 
as permanent a resident as formerly in the native home locality. 
It must be admitted that social conditions favor a readier move- 
ment of these defectives from place to place and consequent 
propagation of their kind. The comparatively recent attempt 
at stricter segregation of all grades of imbecility, if persevered 
in, must eventually reduce any increase following freer move- 
ments of population, and should ultimately bring about an actual 
decrease among these defectives. Intelligent curtailment at the 
source must diminish their numbers. Statistical proof will not 
be available for a few years at least. 

In conclusion, the writer feels that while it is demonstrably 
certain that paresis has increased during the last twenty-five 
years, it is by no means equally certain that an actual increase 
in the other dementing psychoses has ocurred. Fundamental 
conditions are much the same now as they were fifty years ago. 
With the exception of paras)T)hilitic brain conditions the actual 
disparity between the functional diseases of the mind and the 
dementing psychoses is probably not much greater now than 
formerly, making due allowance for increase in population. 
Certain prophylactic endeavor is suggested by this cursory survey. 
Curtailment of the immigration of mental defectives at the source, 
restriction of alcoholic indulgence, prevention of syphilitic infec- 
tion, stricter segregation of the feebleminded, greater intelligence 
in entering upon the marriage relation, are some of the steps by 
which a decrease among the dementing psychoses may be attained. 



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A CRITICISM OF PSYCHANALYSIS. 

By CHARLES W. BURR, M. D., 

Professor of Mental Diseases, University of Pennsylvania, 
Philadelphia, Pa. 

Let me confess at the outset that my mental attitude, my bias, 
toward Freudian psychanalysis is not, at the present time and 
after study and investigation, sympathetic. I have tried to be 
fair, to listen to all the arguments with an open mind and with a 
desire to learn some new thing which is really true, but uncon- 
sciously as well as consciously, the habits of thought created by 
inheritance and by training along lines which make one expect 
to discover truth by the use of the senses, by the microscope and 
the test tube, and by the clinical study of people and on the facts 
gathered, basing an explanation by the use of reason, rather than 
of fancy, makes me tend to be sceptical about the value of the 
newer psychology. 

In order to understand what psychanalysis is, what it is based 
upon, the method of its application, and its therapeutic value, it 
is necessary to study the system of psychology of which Dr. Freud 
is the foremost advocate. I shall, therefore, briefly describe the 
theories of Dr. Freud and then discuss their therapeutic appli- 
cation. It is somewhat difficult to be brief, because Freud himself 
is not brief. He nowhere gives a short, clear cut statement of his 
opinions, and one must read many pages in several books and 
many papers in order to discover them. He sometimes uses words 
in an uncommon sense. He does not exhibit the clarity of expres- 
sion so charmingly manifest in almost all French and a great many 
English writers, so that sometimes his meaning is obscure. One 
is impressed by his obscurity, due perhaps to his careless literary 
style, rather than by the abstruseness of his matter, but his ideas 
are so unusual that they are well worth the trouble of discovering 
and the question of the causation and treatment of the psychoneu- 
roses is so important as to be worth a large amount of labor. A 
large literature has grown up about Freudism, most of which has 
been contributed by the not niunerous, but very enthusiastic, dis- 



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304 A CRITICISM OF PSYCHANALYSIS 

ciples of its originator. Its opponents have not indulged very 
largely in writing. Dr. A. A. Brill, of New York, is probably the 
American protagonist of the school of Freudian thought; at least 
he seems to be the American who has written most about it. Dr. 
Ernest Jones, of Toronto, has devoted much time to writing enter- 
taining, though to persons of a thoughtful cast of mind, the much- 
abused conservatives and reactionaries, somewhat startling papers. 
The entire pro-Freudian literary output is rather startling to 
readers who have been trained to expect evidence rather than 
assertion in papers discussing scientific problems. Dr. Bernard 
Hart, who does not write as a disciple, has given in " Brain " for 
January, 191 1, a very fair account, scientific in tone and free from 
bias, of the fundamental ideas of the newer psychology and I have 
quoted largely from him in the earlier part of this paper. My 
knowledge as to what constitutes the doctrines of Freudism is 
based not only on the writings of Freud, but also on those of his 
followers. There does not seem at the present time to be the 
unanimity of opinion among the apostles of the school that 
formerly existed, but there is not time to do more than give 
Freud's own views. I have tried to do this accurately. 

Freud's two fundamental ideas are, first, that mental processes, 
like all others, are ruled by law ; that nothing mental happens from 
chance ; and, second, that they can be explained by scientific laws 
involving psychological terms only. The second idea makes neces- 
sary the assumption of the existence of unconscious mental acts 
and processes, indeed of an unconscious mind. 

The next step in his theory is the doctrine of complexes. A 
complex is a combination of ideas having a certain emotional and 
conative trend and possessing energy which can only be dis- 
charged by reaching a definite end. The discharge of this energy 
leads to an end-state of satisfaction. A man may be altogether 
ignorant of his complexes. If two opposing complexes are 
actively present at the same time there is, not in a figurative sense, 
but actually, war between them ; in technical terms " a conflict " 
arises which causes emotional strain. The victim of such a con- 
flict may settle the matter by accepting one complex and disregard- 
ing the other, or he may alter both, but sometimes the solution is 
morbid and results in hysteria or some other psychoneurosis. A 
person may unconsciously suflFer from a conflict of complexes and 



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CHARLES W. BURR 305 

know nothing of what is going on in the unconscious mind, but 
only feel the misery of the results. If the person is conscious of 
" the conflict " he may avoid it, or try to avoid it, by putting one 
of the complexes out of his mind, tr3ring to forget or forgetting it. 
This is called " repression." A repressed complex does not cease 
to exist but becomes unconscious and may, though unconscious, 
prevent "satisfaction." There is an assumed active function,. 
" censor," which prevents a complex from coming into conscious- 
ness or drives it back into unconsciousness. A censored complex 
continues to influence consciousness, but indirectly and distortedly. 
The emotional and conative elements of the complex may sepa- 
rate from the ideas to which they belong, may exist independently, 
once having arisen, and the energy of the complex is also a sepa- 
rable thing which may be released from the idea to which it origi- 
nally belonged and attach itself to another. 

Conflicts among complexes cause much mental disorder, e, g., 
hysteria. In a conflict every endeavor is made to avoid the " cen- 
sor." This is done by: i, symbolization ; 2, condensation, by 
which is meant that one symptom may represent two or more in- 
dependent unconscious " wishes " ; 3, displacement, which means 
that the affect properly belonging to one constituent of the com- 
plex is attached to some element not under the ban of the " cen- 
isor " ; 4, representation of opposite, i. e,, certain elements of the 
symptom may portray the exact opposite of the corresponding 
element in the unconscious "wish"; 5, alterations in time 
sequence, f. e., the sequence of events may be reversed or altered 
in the hysteric attack. 

Conflicts have to do with a " repressed wish." The common 
" repressed wish " has to do with " libido " ; indeed it would seem 
from the reported dreams that almost all repressed wishes are of 
the same nature. The common reader would suppose that " libido " 
connotes sexual in the ordinary meaning of the word, but we are 
now told it means much more. The most recent American writer 
(C. C. Wholey, Joum. Amer. Med. Assoc, March 28, 1914, p. 
1036) says " it " (the meaning of sexual manifestations) " covers 
a broad and comprehensive field of experience and activity, 
whether bodily desires or mental longings. It embraces all desires, 
instincts, wishes, ambitions, like hunger, sex, acquisition, aspira- 

2Q 



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306 A CRITICISM OF PSYCHANALYSIS 

tions, the social sense, love of art etc." Some of us would like to 
know specifically what the " etc.," includes. 

In seeking the cause of psychoneuroses Freud has found the 
study of dreams of great value. He explains them as follows : 
They are the expression of repressed wishes. "The censor," 
active during waking life, is in sleep only strong enough to dis- 
tort and cause symbolism. As a result dreams have a " manifest 
content " apparent to consciousness and more or less remembered 
on waking (the dream as an ordinary man knows it), and a 
" latent," unconscious content. The latter, the ** latent content," 
is the really important part of the dream, while the ** manifest 
content " is of no value save as being symbolic. The unravelling 
of the symbolism explains what complexes are causing the con- 
flict. They are the repressed and unconscious, but real, wishes 
of the patient. Dreams also give the patient a chance to reach a 
wish fulfilment he cannot obtain in waking life. The dreams of 
everyone, even those who think they are entirely healthy, indeed 
are in good health, are to be interpreted in the same way and have 
the same cause. Inferentially one would conclude that the only 
useful study of dreams is of their symbolism ; that in no other way 
do they throw light on mental life, and that no other method of 
studying them is valuable. 

One writer at least (Hansell Crenshaw, New York Med. Jour- 
nal, April II, 1914, p. 733) regards dreams as a beneficient act of 
nature. He writes : " The dream is an effort on the part of nature 
to compensate and defend the mind. It is a protector instead of a 
disturber of sleep. Certain forms of insanity, wherein the persons 
imagine that they are kings, or even gods, are, like dreams, com- 
pensatory mechanisms for those whose burdens have been too 
galling and too hard to bear. Similarly the seeming fault of for- 
getting is generally a defense mechanism without which the 
average mortal would have to endure the tortures of the damned 
here on earth. Moreover, the day dream, or fantasy, is a wonder- 
ful compensation to many a soul." One expects to find in theo- 
logical treatises and in poetry the personification of nature, but 
scarcely in scientific papers. It is rather curious that one should 
be given, by nature, a compensatory mechanism to make him happy 
after he has had a chancre and in consequence gotten, say, paresis. 
A really good nature ought to reward the good and not sinners ; 



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CHARLES W. BURR 307 

that was the old teaching. The doctor is rather too rhetorical and 
quite too pessimistic about " the tortures of the damned " suffered 
by the average mortal. Even neurologists, who see a good bit of 
the painful side of life, are not as pessimistic as this. The paper, 
however, is interesting as showing the modem trend to mysticism. 

We come to psychanalysis proper. Its purpose is to discover 
repressed complexes. Formerly Freud hypnotized his patients 
before subjecting them to psychanalysis, but he has abandoned 
that method. Now he uses first " free association." The patient 
is ordered to talk freely about everything that comes into his mind. 
Especially must he tell the things that seem to him trival and of 
no importance, because it is the "censor" which makes them 
appear of no value to him ; they may be of vital importance. If 
he hesitates or refuses to tell something that comes in his mind 
that something is the clue to the trouble ; the ** censor " is trying 
to repress it. The patient having emptied himself of everything he 
can think of, the doctor proceeds to interpret what he has said. 

In addition to this method of " free association," complexes can 
often be discovered by the so-called association-experiments with 
words. A prepared list of words, say one hundred, is read to the 
patient and note made of the first word that comes into his mind 
after each is read. The time reaction is also noted. Too long 
time reaction means resistance. The word brought to mind after 
resistance is also a clue. One writer puts it this way : " Prolonged 
reaction time, a lack of or a faulty reaction, is a " complex indica- 
tor," that is, it indicates that the stimulus word has touched a 
complex and thus retarded or completely inhibited the reaction." 
In real life this procedure gives such varying results, dependent 
upon the differences in emotional makeup of different people, that 
I do not think it will ever become a usual method of reading the 
mind. It has been used a little in examining persons accused of 
crime, not, so far as I know, by district attorneys and such com- 
monplace people, but by learned amateur criminologists. Experi- 
ence has shown that the well-seasoned criminal answers well and 
rightly and quickly. The scared innocent convicts himself. 

Acts may be symbolic. Thus a woman patient of mine had con- 
vulsive tic with the explosive utterance of an obscene word ac- 
compained by spitting. A psychanalyst acquaintance of mine 
who knew nothing of the patient save what is stated above, and 



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308 A CRITICISM OF PSYCHANALYSIS 

what he could learn by looking at her, explained the spitting as 
symbolic of emptying the mouth after a certain act and further 
affirmed that the woman undoubtedly had indulged in this practice. 
I have every reason to believe, not from what the patient stated, 
because I saw no reason to discuss the matter with her, but from 
other sources of information, that the gentleman's conclusions 
were entirely erroneous. The case, however, illustrates the method 
of interpretation of acts as symbolic and shows its value. I was 
very much, and not altogether favorably, impressed by the cock- 
suredness with which the gentleman spoke and the positiveness 
with which he drew a conclusion from fanciful evidence. 

Finally the patient relates his or her dreams and they are also 
interpreted by symbolism. The method of interpretation is shown 
by the following examples. Freud relates this one: A woman 
dreamed she was having her menses. The meaning was the 
menses had stopped; she would have liked to have enjoyed her 
freedom longer before the discomforts of motherhood began. 
Another woman dreamed she saw milk stains on the bosom of her 
waist. It was an indication of pregnancy; the young mother 
wished to have more nourishment for the second than she had for 
the first child ; hence the dream. There is not much symbolism in 
either of these, but the first illustrates the theory that the " wish " 
may show itself in the dream either positively or negatively; in 
other words, the newest science confirms the truth of folklore in 
believing that dreams may go by contraries. Symbolism raised 
to the Nth. power is shown in the following dream recorded by 
Dr. A. A. Brill (*' Psychanalysis," p. 87) : A woman dreamed 
she walked on the street and a horse harnessed to a wagon was 
running toward her. She could not get out of the way ; the horse 
was almost upon her. She put out her hand to push it away, when 
it caught her hand in its mouth and bit her. Screaming, she awoke 
terrified. Such was the dream and it occurred just before or at 
the onset of an attack of anxiety hysteria, and as " dreams are 
always based on experiences or thoughts of the day preceding the 
dream," Dr. A. A. Brill asstuned that dream and attack had some 
relation. Further^ the doctor states that " the fear in the dream 
pointed to its being of a sexual nature and I suspected that the 
horse was simply a sexual symbol." On further examination she 
said that her first conscious sexual impression was from seeing 



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CHARLES W. BURR 309 

horses, though of course she was too young to know the real 
meaning of things and thought the horses were fighting. There 
was at this stage of the examination a sudden " blocking " and 
when asked to continue she recalled something which had nothing 
to do with horses. The evening before the dream some little an- 
imal ran out of the brick stove into the bed. Though usually not 
afraid of mice or rats, this time she was terribly frightened for 
hoiu-s. She hunted through the bed, found nothing, but was afraid 
to sleep in it. This recalled that the fright occurred a few hours 
after unsuccessfully trying to sell her feather beds. She again 
became silent and claimed her "stream of thought" was ex- 
hausted. The doctor suspected " her attack of fear was the man- 
ifestation of a mental conflict in a sexual abstainer." He asked 
her why the rat or mouse frightened her. She said she was not 
afraid of the real thing, but imagined they were apparitions ; that 
someone had tried to exert an evil influence over her by magic, 
but she no longer believed such nonsense. Asked who exerted 
the evil influence, she at first refused to answer, saying the whole 
thing was not worth talking about. Later she said it was the man 
who offered to buy the bed. She described the man (X) as a dis- 
agreeable, impudent fellow, who persisted in calling on her until 
she hid herself when he came. She suddenly broke off and became 
indignant, saying it was foolish to revive such things. The doctor 
told her he was sure she was concealing something and that he 
believed she had some affair with X. She denied it indignantly, 
but returned two days later and confessed. The horse symbolized 
X. Its being almost upon her, had a sexual significance. Is com- 
ment necessary? 

Dr. A. A. Brill (N. Y. Med. Joum., March 21, 1914) also 
relates the following dream : " A woman was at a menagerie with 
a little niece. The animals all came out of their cages. She was 
greatly frightened. She saw a stairway, which she went up with 
great trouble. All the doors at the top were locked." She awoke. 
He gives this analysis. The patient suffered from hysteria and 
had a terrible disgust for sex. The niece typified purity, innocence, 
maidenhood. The wild animals signified the animal passions that 
were pursuing her. The great effort to reach the top of the stairs 
signified the acceptance of normal sex without running away. 
" The whole act symbolizes coitus." *' The several closed doors 



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3IO A CRITICISM OF PSYCH ANALYSIS 

which she could not open signify the many opportunities to many 
which she let slip." This was published by a physician in the 
twentieth century and in America, not in the ages of witchcraft, 
nor in the heart of Africa. 

Dr. Hansel! Crenshaw (N. Y. Med. Joum., April ii, 1914) pub- 
lishes the following dream : " A vigorous young lady dreamt that a 
ferocious lion chased her up one side of a mountain and down the 
other." The doctor discovered, not from the dream, that " the 
lady was engaged to marry an elderly gentleman of considerable 
wealth. Her family encouraged the match, and while the young 
woman herself thought well of the alliance, nevertheless she post- 
poned it once or twice. Deep down in her heart she desired to be 
courted, pursued, by a more virile, more animal lover than the 
lamb-like old millionaire to whom she was betrothed. In a word 
she wished something more leonine." The doctor therefore in- 
terpreted the dream thus: "The lion personated the lacking 
attributes of her aged fiance. The mountain in this dream, too, 
had a sexual significance," the doctor continues, " if we are to 
believe with Freud that a wooded moxmtain is symbolic of the 
mons veneris and that climbing in dreams symbolizes sexual 
activity." Much more astounding than this, to my poor mind, 
is the doctor's reference to a young widow who had five possible 
chances of marriage and who dreamed of coming upon five snake- 
holes, from each of which protruded the head of a snake. Curi- 
ously enough, however, only one of the serpents came out and 
pursued the widow. What will the readers of the thirtieth century 
think of the writers of the twentieth? Fortunately wood pulp 
paper has no enduring qualities. 

The purpose of the psychanalysis of any given invalid is to 
discover some unpleasant, painful, or shameful event in the past 
history of the patient, because the event, or rather the memory 
of it in the unconscious mind, is the thing which is causing the 
conflict. When it is brought into conscious life and the patient is 
shown what really is the matter with him, then he, or more fre- 
quently she, is cured. It would seem to an outsider that this is a 
very complex way of doing a very simple thing. One does not 
need dreams, and free association, and blocking of word associa- 
tion to find out these matters. One does not need any such things 
at all. Honest confession is often good for the soul, and mistmder- 



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CHARLES W. BURR 3II 

standing and ignorance about the physiology of sex leads, espe- 
cially in adolescents, to much ill health, but there is not needed for 
its cure such performances as are described above and the trouble, 
when present, resides not in the unconscious mind, but in a very 
remembering and conscious mind. 

Freud's idea that mental processes are ruled by law will be 
accepted by many of us ; indeed it is no new thing, but came into 
the world as soon as the idea of natural law was first thought of 
and has been battled over ever since. When, however, he adds to 
that the idea that such laws of mental action can be explained by 
psychological terms only, there arises in the minds of some a feel- 
ing of resistance, of antipathy ; a feeling that he is getting into a 
very fanciful realm. Those of us who are inclined to the view 
that there is always a physical cause for a mental act, and a per- 
version of physical function whenever there is a perversion of men- 
tal acts, want proof before we will accept his opinions. Now, 
Freud nowhere gives any proof of his dogmas. He states that 
certain things are true, but he does not give any evidence of their 
truth, unless indeed there is the pragmatic sanction that, since 
patients are cured by his method, his psychology must be true. It 
may be true pragmatically, but the question is, is it true really? 
Again, it is claimed that the accuracy of the interpretation of 
dreams proves its verity, but of this I shall speak later. 

Freud emphasizes very much the importance of the unconscious 
mind. Now, no one doubts that the way to remember a forgotten 
word is to forget all about it ; no one doubts that it is well, to use 
a popular phrase, to sleep over a question requiring much thought 
before making a decision, though we do not all believe that an 
unconscious mind is wrestling with the problem; but Freud's 
unconscious mind is much more than, and very different from, 
this. An incident in childhood long forgotten and entirely out of 
conscious life is really there, according to him, and acting all the 
time, and may in mature life start a conflict among complexes 
which wrecks the mind. A woman without knowing it may be in 
love with a man whom she consciously knows she does not even 
fancy. Now, the feminine mind is mysterious to mere man, and is 
getting more so, and love and hate are in a sense not far apart, 
but it is rather difficult for some of us to accept Freud's notion of 
unconscious mind as correct. 



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312 A CRITICISM OF PSYCH ANALYSIS 

When we come to complexes and conflicts between them and a 
"censor" which controls them, we are getting into very deep 
waters. When we are told that these complexes have independent 
energy and that the discharge of this energy gives pleasure we are 
far over the heads of many people. To some it would seem that 
instead of being so far over our heads the writers were merely 
playing with words rather than attempting a real explanation; or 
it might be thought they were speaking figuratively. They say 
they are not. Of course it is true that a man's mental bias depends 
upon past experiences as well as upon his heredity and training. 
A man's type varies as these vary. In other words, the way a 
man will look at certain things, the way he will react under certain 
conditions, depends upon his bias, and bias is the unconscious 
eflfect of old memories, training, and inheritances ; but that certain 
ideas are grouped in complexes, that they themselves are ever 
present, and not only their results, is not proven or even rendered 
probable an)rwhere in the writings of Freud or anyone else. I 
cannot understand how a mental thing of which we are, by defini- 
tion, unconscious can influence conscious life. I can, e. g., under- 
stand how a boy can be in love without knowing what is the matter 
with him; most adolescents have the experience (it has a well- 
known underlying physical cause), but I cannot understand how 
a child's emotional feeling toward a grown person can, entirely 
unconsciously, be carried on into adult life and create a repressed 
wish, he not knowing he is repressing or wishing an)rthing, and 
hence lead to mental disorder. I cannot take seriously the state- 
ment that the affection of a little child for one of its own sex is 
really a manifestation of homosexual love, nor if such a thing be 
normal in children, as is claimed, can I see how or why a normal 
event should, years after, cause a sexual conflict and hence a 
sexual neuropsychosis. Normal things should not have patholog- 
ical results. I confess I am not willing to accept the symbolical 
interpretation of a dream as proof. 

As to dreams: According to Freud almost all dreams are 
sexual. In all there is a struggle to get satisfaction for a repressed 
wish. He proves this by interpreting all dreams symbolically and 
the sexual act is symbolized by almost everything, e. g., a bald 
head, a dagger, an umbrella, a toadstool, the toe, a fireplace 
(vagina), a horse, bulls, dogs, cats, chickens, a steeple, an aspar- 



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CHARLES W. BURR 3I3 

agus stalk, a wooded mountain, climbing, snakes, getting wet by 
rain, water, the lock and key, and finally any elongated object of 
any sort. Writers state: "All animals in dreams are usually 
sexual symbols " and fear also ; all of these things and more have 
a sexual significance. Now, if you start out with the premise 
that everything symbolizes some one thing, that one thing is going 
to be the meaning of every dream and it would be very difficult 
for anyone to have a dream in which one at least of the orthodox 
Freudian sexual symbols does not occur. I confess ignorance as 
to how it was discovered, in the first place, that the things cata- 
logued above are sexual symbols. One is inclined to suspect as 
much power of symbolizing in the interpreter of dreams as in the 
dreamer ; perhaps even a little more. 

What sort of diseases are suitable for psychanal)rtic treatment? 
Freud states its use is limited. The patient must have a certain 
degree of education and his character must be reliable. Only 
those who are prompted by their sufferings to seek treatment can 
be aided. Those who subject themselves to it by order of rela- 
tives are unfitted. Psychoses, confusional, and marked toxic de- 
pressions are unsuitable. Later it may be possible to disregard 
these contraindications, but not now. Persons near or over fifty 
are not psychically plastic enough — not educable. Youthful per- 
sons, even before puberty, make excellent subjects. Psychanalysis 
should not be attempted when it is a question of rapidly removing 
a threatening manifestation, such as hysteric anorexia. These are 
Freud's own statements. 

Dr. A. A. Brill always begins treatment with an investigation 
of the patient's dream life, but first he occupies two weeks with 
getting acquainted with the patient. He further states that it is 
not wise to " analyze relatives " (I do not think he tells us why) 
and advises ; " In private practice do not analyze any patient with- 
out receiving some compensation for it " (" Psychanalysis," p. 6). 
Surely the laborer is worthy of his hire. 

A word about the sexual element in psychanalysis : When any- 
one now accuses the disciples of the newer psychology of laying 
greater stress on sexual matters as a cause of mental trouble than 
they deserve, the word " libido " is claimed to be used sjmibolic- 
ally. But on reading the interpretation of the dreams reported 
in books and papers one finds ** libido " is used in its common, 



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314 A CRITICISM OF PSYCH ANALYSIS 

ordinary, everyday meaning. The words and phrases symbolic of 
" libido " quoted above, from printed dreams, were symbolic of 
the sexual act and desire and in no instance were they symbolic 
of social sense, love of art, hunger, or anything else. I refuse to 
make charges of bad faith, but I do not think the disciples of 
Freudism are altogether frank in their statements as to their use 
of the word. I think their enthusiasm has made them a little dis- 
ingenuous. The present explanation was not given till adverse 
criticism had been made. Almost all the dreams I have read have 
been interpreted by the writers of the books or papers in terms of 
ordinary sexual desire, sometimes normal, sometimes perverted. 

A very great objection to psychanal)rtic treatment is this stress 
laid on sexual matters. No good can come from keeping the mind 
of a patient wrought up on such things for months at a time and 
the treatment may, as we are told, need to be carried on over a 
period of two years. Dr. A. A. Brill seems to think that there may 
even be danger to the moral sense of the practitioner of the art. 
He writes : " Only those who are themselves free from all sexual 
resistance and who can discuss sex in a pure-minded manner 
should do psychanalytic work." Anyone who has studied hysteri- 
cal women will soon learn, unless he be obsessed, that so far from 
continually talking sex matters with them doing them good, it 
does them distinct harm. I have seen more than one young 
woman much injured by ideas put into her head as the result of 
the interpretation of dreams. I have seen more than one sensi- 
tive youth, who needed the wisest care and the most conservative 
handling, frightened into believing, or at least fearing, he was a 
congenital pervert. Further than this, the whole matter is of 
such a character that men of evil minds can use it for evil pur- 
poses much in the same way that pretence of hypnotism has been 
used by vicious men to mislead and lead into error, even into vice, 
psychoneurotic women. Of course it may be replied that on the 
same grounds poisons should not be used therapeutically, because 
men murder with them ; but poisons have a use. 

The danger is greatly increased by the fact that the treatment 
is no longer to be confined to physicians, and only recently a 
German has published a book the avowed purpose of which is to 
instruct teachers and clergjrmen how to practice the art. Need one 
ask if such a thing is wise? We have seen in recent years the 



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CHARLES W. BURR 3IS 

injury that has come from amateur treatment of mental diseases 
by religious systems. Can we expect good to come from psychan- 
alysis in the hands of the general public? Will it be wise for an 
interesting and spiritual-looking young curate to discuss the sexual 
symbolism of dreams with girls rather susceptible to human pas- 
sions? Would it not endanger his own welfare to do it with a 
woman who had reached the dangerous age? Might it not really 
lead to harm, the personal feeling becoming stronger than the 
scientific? 

The relation of will to memory is an important element in Freud- 
ism. Forgetting is, according to Freud, an act of the will. We 
forget, in his opinion, what is painful to us. We push it back into 
the unconscious, but it still acts. This is surely contrary to the 
experience of most people ; with most of us painful things are the 
very ones which stick in consciousness ; they obtrude themselves at 
the most inopportune times. 

Psychic insult is, according to Freud, the large cause of certain 
mental disorders. Much, however, can be said against the psychic 
origin of mental troubles, though of course stress and strain act 
as mere exciting causes. Certainly it is not the people who are 
subjected to the greatest mental and emotional strain who suc- 
cumb ; it is those who are inherently weak. Everyone who reaches 
middle life, and many even in childhood, suflfer many psychic 
strains and stresses, but very few become psychoneurotic. Clini- 
cians know that often the most protected, those who have suffered 
least, are the first to break. This is particularly true in insanity, 
and in all mental disorders many acts and thoughts popularly 
supposed to be the cause of disease are really symptoms of it. 
Thus the sexually perverted are not perverted because they do 
certain things ; they do certain things because they are perverted. 
It is not unusual for a patient's illness to be attributed to alcohol, 
when the excessive drinking was really a result of disease. In 
the minor mental diseases with which Freudism largely concerns 
itself, psychanalysis being confessedly of little or no value and im- 
possible to carry out in the true insanities, it is really, just as in 
insanity, the essential nature of the man, rather than the stresses 
and strains he has been subjected to, which is important. Thus it 
is common when a boy or girl breaks to say, out of kindness, that 
it was the stress of over-work at school or too much practicing of 



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3l6 A CRITICISM OF PSYCH ANALYSIS 

music that caused the mental trouble, but everyone who has inves- 
tigated the matter knows that public school work is carefully 
arranged so that a very ordinary boy or girl can accomplish it and 
that it is the weakness of the person and not the greatness of the 
stress which causes the breakdown. We are continually talking 
about the strenuousness of modem life. There is a great deal of 
humbug about this. The labor union worker is not, so far as work 
is concerned, under great stress with his eight-hour day and the 
strictly limited amount of work he is permitted to do. The savage 
man is under much greater stress ; he must get food or die. The 
modem is cared for if he is not able to take care of himself and he 
is rapidly realizing more and more that the state is his father and 
his mother and his wet nurse and that he need not worry. We 
hear much of family trouble as the cause of mental breakdown, but 
the people who marry the men or women who are going to cause 
trouble are very often themselves biologically degenerate. There 
is something in degenerates that attracts the affection of other de- 
generates and we often assume a person is strained by something 
because it would shock us. Not infrequently it is to them no 
strain. The normal person can and does withstand all the stress 
and strain of life without mental breakdown. Of course the 
strains and stresses I am speaking of are conscious, but the argu- 
ment holds for the unconscious. Really it would seem that more 
progress in discovering the cause of the psychoneuroses would 
result from a study of heredity and human chemistry and physi- 
ology and pathology than from the fanciful interpretation of 
hysterics' dreams. 

One trouble in bringing dreams into a system of philosophy, 
and we are told that Freudism has attained the dignity of being a 
philosophic school, that it has to do not only with disease, but with 
the explanation of folklore, and fairy tales, and education and 
questions of social policy and the rights and duties of man, is that 
we are entirely at the mercy of the veracity of the dreamer. I 
know of several instances in which impish, but brilliant, hysteric 
women have played with psychanalysts and made up dreams. One 
gentleman explained to me that that did not invalidate them. But 
it would seem that it would, inasmuch as real dreams happen only 
when the " censor " is not on duty and are the result of actions 
going on in the unconscious mind, and it would be rather difficult 



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CHARLES W. BURR 317 

even for an hysteric to fathom her unconscious mind and make up 
a proper dream. Not many centuries ago much harm came, even 
legal killing, from very good and, as they themselves thought, 
very intelligent people, believing the stories of lying children. Are 
we to accept the fanciful statements of imaginative hysterics, who 
by definition are devoid of any conception of truth, to help in 
building the edifice of a great philosophy? 

The frequent statement of the disciples of Freud, that those who 
oppose their teachings are men of no standing ; that they are " back 
numbers " and unprogressive and ignorant ; that they have never 
attained to the higher intellectual level; that they are mere des- 
cribers of symptoms and are not intelligent enough to understand 
such profound matters of philosophy, is not of importance save as 
indicating a rather egotistic state of mind. It is scarcely an argu- 
ment, because the question is not what one set of gentlemen think 
of another set, but whether particular dogmas as to the causation of 
certain pathologic states are true. If I were to maintain that the 
moon is made of cheese the correctness of my opinion would not be 
strengthened by calling gentlemen who doubted it names. It 
certainly does not require an intellect of a very high order to 
understand whether hypotheses ought to be accepted as proven 
facts ; whether the Freudian doctrine as to dreams is scientific ; 
whether you can learn much about the contents of a man's uncon- 
scious mind by listening to the unbridled babble of his tongue; 
whether the statements of hysterics are to be accepted as true 
without question and a system of philosophy be based thereon; 
whether it is wise to keep an already perturbed mind constantly 
attentive to sexual matters ; whether the test of word association 
is of much or little value, and whether, when a woman sees a fire- 
place in a dream, she is really the victim of unconscious " libido " 
and is symbolizing her own vagina. 

I remember an old and distinguished professor of medicine in 
Germany who, when some years ago I told him I had aspirations 
to become a neurologist and alienist, looked at me kindly and a 
little quizzically and then said : " Be careful, my young friend, 
alienists are all a little queer." The old gentleman had some justi- 
fication then, but what would he think now could he be told, what 
we are often told, that psychanalysis is one of the greatest con- 
tributions to therapeutic art ? 



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3l8 A CRITICISM OF PSYCHANALYSIS 

DISCUSSION. 

Dr. F. X. Dercum. — I need not say that I am heartily in accord with the 
emphasis which Dr. Burr has placed upon the causes of mental disease. 
I have only a short time ago in an address at the annual meeting of the 
Philadelphia Psychiatric Society laid emphasis upon the causes of mental 
disease inherent in the patient himself. There can be no doubt that these 
intrinsic causes, causes which are dependent upon arrests, deviations and 
other abnormalities of structure and function, whose origin is to be sought 
for not only in the very beginnings of the individual, but in his ancestry, 
far outweigh all other causes; the latter indeed must and can only with 
justice be regarded as adventitious and as far secondary in importance. 
It is a known fact that even such extrinsic causes as the infections, 
poisons and physical traumata are far more potent to bring about mental 
disturbance in individuals already inherently neuropathic than in those of 
a normal makeup. 

Psychogenic causes so-called must of course be included among the 
traumatic and it is a matter of every-day experience in the asylums that 
psychic factors play but a very limited role in the evolution of mental 
disease. As I have elsewhere pointed out, among such psychic factors 
the older writers used to give a prominent place to worry, care, sorrow, 
remorse, reverses, disappointments, misfortunes, but that as our knowl- 
edge of mental disease has increased, we have found that whole groups 
of affections, such as melancholia and mania, bear as little relation to 
psychic causes as does epilepsy. Manic-depressive insanity is now known 
to be a specific neuropathy, one almost exclusively hereditary, that bears 
no more relation to psychic traumata than it does to infection. The more 
we learn of the true nature of mental disease, the more have psychic causes 
retreated into the background and our ever widening knowledge has 
demonstrated that such factors can merely be incidental and at most would 
be of value only when there is a pre-existing neuropathy; and, finally, 
that this value is exceedingly limited. At most psychic factors give to the 
pre-existing morbid state a special coloring, give a special detail to a delu- 
sion or an obsession, act as an incidental support, a framework, a trellis, 
on which a delusional or obsessional feeling can secure a hold or by means 
of which it can find expression. 

As is well known, the Freudian sect, for the Freudians constitute a sect 
by themselves and should be treated as such, ascribe every known form of 
nervous and mental disease, with the sole exception of those affections the 
actual organic, toxic or infectious nature of which it is impossible to deny, 
to psychic causes sexual in nature. It is not necessary to review before this 
society the history of psychanalysis. It is not necessary to speak of 
Breuer's case of hysteria and of the recovery of the patient after her 
confession of masturbation, nor to repeat the specious theory of repressed 
complexes and the doctrine of displacement and conversion to which 
fears, obsessions, delusions, tics and what-not are claimed to be due. It 
is not necessary before this society to recall the views of Janet to which 
the psychanalysts have not deemed it necessary to give attention. Janet, 



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CHARLES W. BURR 319 

as is well known, long ago showed that the neurasthenic-neuropathic states 
which are characterized by fears, obsessions, states of anxiety, indecisions 
and like phenomena are but a manifestation of one neuropathy to which 
he applied the term psychasthenia. To this profound discovery of a great 
underlying scientific truth, to this brilliant generalization, he added the 
further observation that in this neuropathy, in many of the cases, various 
acts of the patient in the past, breaches of conduct, of the proprieties, 
peccadillos of various kinds of which the patient is subsequently ashamed 
and which he tries to forget, play an important role in the detailed evolution 
of the symptoms. Strange as it may seem, the Freudian sect did not even 
recognize the value or importance of Janet's observations ; indeed they seem 
to have been strangely ignorant of them. Certain it is that they added 
nothing to them. Instead, on such material as is furnished by the Breuer 
case of hysteria, and restricting all causes to sexual transgressions, they 
proceeded to erect a special and peculiar system of psychology, special first 
in that it deals exclusively with sexual factors and secondly peculiar in that 
it constitutes a system of psychology of the unconscious mind. Doubtful 
inferences, questionable hypotheses are dealt with by this sect as though 
they were established facts and this too in a field in which from the very 
nature of the case that which actually occurs is beyond the possibilities of 
human knowledge. I need not review the phantastic attire in which their 
ideas have been clothed, the weird verbiage by means of which their theory 
has been obscured, but simply recall to you that they deal with so-called 
** repressions, displacements, condensations, transference, introjection, pro- 
jection, introversion, conversion, sublimation, determinations, exteriori- 
zations" and what-not as though these terms represent actual, observed, 
concrete facts, instead of being mere metaphysical abstractions. 

Dr. Burr has already reviewed the subject of dreams. I need not retail 
to you again the secret non-communicable nature . of the dream, the 
desire suppressed, veiled or outspoken which constitutes, according to this 
cult, the important factor of the dream, nor need I dwell upon the 
critique or censor which Freud has found necessary to call into exist- 
ence, and to which supersuspended fragment of the ego he ascribes a 
watchful care over the proprieties so that the ugly facts of sexual trans- 
gressions and sexual perversions shall not be presented in the ordinary 
and vulgar language of the day but shall be modified or, as they express it, 
" S3rmbolized " ; nor will I take your time to discuss further the association 
test which the Freudian sect has added to its armamentarium save to say 
that the test by word association yields for the most part results which 
are essentially trivial and which are open to the same vagaries of inter- 
pretation as are the results of dream analysis. 

The analysis of the unrestrained recollections of the patient, of dreams, 
and of the association tests presupposes a repression of thoughts with an 
unpleasant emotional content That this view, however, is not in accord 
with universal experience must, I think, be unhesitatingly admitted, for it 
is impossible to forget a real worry, such as a crime, the death of a child, 
a financial disaster or some other great personal misfortune. The greater 



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320 A CRITICISM OF PSYCHANALYSIS 

the worry, the more insistently is it presented to the mind. Far from 
being forgotten, it recurs with a frequency in proportion to its seriousness 
and importance. How strange it is that the Freudian sect insist that all 
these detachable and movable memories and emotions have to do exclu- 
sively with sexual matters ! How significant it is that they seek cover under 
the subterfuge that the repressed ideas coming to the surface in dreams, 
in psychanalysis, in the association test, do not signify what they appear 
to signify, but are masked, disguised, are as they claim symbolized! 
Truly the art of the psychanalyst lies in the interpretation of these 
symbols. It is not necessary to point out that with such hypotheses 
as these the psychanalyst can find in a given patient anjrthing that 
he is looking for. The interpretation of the amnesias, of the dreams, 
of the association test, depends upon the imagination, the auto-sugges- 
tion of the analyst, upon the figments and fancies of his own brain. As 
I have elsewhere expressed it, as in hypnosis, the believing physician 
and the believing patient react upon each other; both are under the 
influence of the same suggestion. The patient knows just what is ex- 
pected of her and the physician finds just what he is expecting to find. 
In other words psychanalysis, in spite of the special technic which is 
claimed for it, is nothing more than suggestion in a new guise. The 
psychanalyst puts into the case exactly that which he takes out. The 
conclusion to be formed from an investigation of a case exists pre- 
formed in the psychanalyst's mind, namely, that there arc present in the 
patient repressed sexual memories. This preformed conclusion the analyst 
regards as an axiomatic truth. All else naturally follows. It is not 
necessary to detail here some of the lengths to which the psychanalysts 
have gone. They deal not only with the sexual traumata of childhood but 
actually invade the period of intra-uterine life to find support for their 
doctrines. I need not recall to your minds the theory of Freud's Hungarian 
disciple Ferenczi of the unconditioned omnipotence of the foetus in utero; 
I need not call to your minds the theory of Ferenczi of the fright from 
which the babe suffers in the act of being bom, that is the fear which it 
experiences in passing through the pelvis of its mother, and that this fear 
is the prototype of the attacks of fear from which patients suffer later 
in life, such attacks being only reproductions of this birth- fear. I need 
not call to your minds the theory of the eroticism of the child, nor 
Stekel's definition of the child as a polymorphic pervert and universal 
criminal whose first sexual tidal wave is reached at three or four years of 
age and whose determining factor is incestuous love. I need not remind 
you of other and equally weird assertions, e, g., that the sublimation of 
erotic and criminal tendencies gives rise to the surgeon ; that economy and 
love of order and obstinacy indicate anal eroticism; that luxurious water 
closets indicate homosexuality; and again, that the love for domesticated 
animals and the liking for sport are to be regarded as the outcome of the 
libido ; that the dream embraces not only the life of the child but also that 
of the savage and primitive man ; that the epileptic attack is a retrogression 
into the infantile period of wish fulfilment by means of incoordinate move- 



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CHARLES W. BURR 321 

ments; that the epileptic attack is the overpowering of the moral con- 
sciousness by the criminal unconsciousness and that it replaces the sinful 
sexual act We are told that melancholia and mania are the products of the 
repressions and displacements of the converted sexual desire, the trans- 
formed libido. We are told that paranoia has its origin in homosexual 
love, that it is due to an irritation of the anal erogenous zone. The 
symptoms of dementia praecox are conditioned by thoughts which because 
of their unpleasant character are repressed; the ludd ideas of the patient 
in this affection are merely " symbols of thought," the patient suffers from 
reminiscences of humanity, while his history embraces all mythology. The 
real underlying, the fundamental, the central phantasy of dementia prxcox 
is of course the incest, the Oedipus complex. Finally, the psychanalyst 
has not hesitated to invade other fields; he explains migraine and every 
form of headache that is not organic, asthma, angioneurotic cedema, hys- 
terical sneeezing, mucous colitis and other affections, as having a sexual 
origin. It is difficult to find words to characterize adequately such a system 
of psychology or of psychiatry. The views expressed savor themselves 
strongly of mental disease and yet they are dealt with by the psychanalsrtic 
sect as though they were profound discoveries, sublime revelations, self- 
evident facts, axiomatic truths. 

I have elsewhere pointed out that as a matter of asylum experience, 
sexual psychogenic factors are exceedingly infrequent The relations of 
the individual to the other members of the conununity are exceedingly close 
and the interchange of function unceasing. As a matter of fact disturb- 
ances of the complexes dealing with these relations are far more numerous 
than those dealing with self-preservation, or with sex; they are typified 
in the paranoid states. Similarly disturbances of the complexes dealing 
with self-preservation, namely, delusions dealing with food, digestion, the 
viscera, etc, are also found in great number in the asylums. The com- 
plexes dealing with sex are on the other hand very infrequent ; indeed they 
usually require to be unearthed. As a matter of fact they are found not so 
much in the asylum as in that great mass of cases met with outside of the 
asylums and which fall under the general caption of hysteria. That in 
hysteria everything can be found which is sought for is a truth which need 
hardly be called to your attention. 

In closing let me say that it should be a matter of keen humiliation and 
chagrin that at an epoch when psychiatry is beginning to unfold a prac- 
tically limitless field for actual scientific research, men should be found 
willing to devote themselves to a cult, to an ism, which like a salted mine 
returns to the investigator only that which he himself puts into it Blind 
pockets from which even the semblance of light is excluded, are his 
portion, nothing more. How much more inspiring it would be to know that 
he were at work upon the biochemical problems confronting him to-day 
at every step. I need not recall to your minds the modem problems of 
auto-intoxication, of the toxicity of the sera and secretions, the doctrine 
of the leucomaines, the problems of metabolism in the heboid-paranoid 
i^oup and in manic-depressive insanity and in epilepsy, the problems pre- 

21 



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322 A CRITICISM OF PSYCHANALYSIS 

sented by the biochemistry of the blood, of the cerebro-spinal fluid, the 
suggestive parallelism between auto-intoxication and recovery in the in- 
sane on the one hand and Ehrlich's theory of infection and immunity on 
the other, and further the whole world of serological problems now open- 
ing up, not to mention the ever-widening role of the internal secretions. 
Surely this is the direction of psychiatric progress. In actual material 
solution of the great biochemical problems of the day lies the hope of a real 
advance in psychiatry, not in doset-born theories and sterile speculations. 

Dr. Wm. a. White. — Of course it is entirely impossible to deal with 
these two papers in the few minutes at my disposal, but I think something 
should be said, even though I feel that I have been pretty well raked over 
the coals by the speakers, because I am in sympathy with psychoanalysis. 
Psychoanalysis, speaking very simply, pretends to do with the human mind 
what we learned to do with the human body hundreds of years ago; we 
had to learn to dissect the human body to find out what it was made of, 
just in the same way they have got to learn to dissect the human mind to 
find out what it is made of, and our efforts to do that dissection of the 
human mind must be made in the face of just about the same kind of 
arguments, the same kind of prejudices that hampered the efforts to dis- 
sect the human body years and years ago; every scientific advance, every 
step forward, every opening of a new door is made the same source of the 
same kind of resistances. I am entirely in harmony with Dr. Burr when he 
says that it does not make any difference about the type of the individual 
who stands for a certain doctrine; I have no feeling against the people 
who make this resistance; I consider them of value in the community. 
Galileo said he saw satellites about Jupiter and people said there was no 
such thing; there was nothing like that in the Bible. He said he had a 
telescope through which you could look and see these satellites ; they said 
it was a sin to look through a telescope, and even if you did look through 
it the telescope was made with the satellites in it 

Dr. Burr has presented certain cases, certain clinical records and dis- 
missed the subject by saying the whole thing was absurd; he did not 
bring forth any specific argument A society of this sort should be the 
proper arena where such things should be threshed out on scientific merits ; 
prejudices should not enter into the question at all. I am a psychoanalyst; 
I want the truth and I am willing to welcome any light that may be 
thrown upon the situation. I appreciate psychoanalysis for I have been 
confused by actual clinical contact with patients in regard to the under- 
lying principles and meanings involved and so I know there is an element 
of truth in the whole movement, which would be extremely unfortunate 
for us to discard at this point It is not the criticism of psychoanalysis that 
has been presented; I have no doubt that many hypotheses will be 
laughed at in years to come as being in fault, perhaps some of them ridicu- 
lous, but what we want is their correction at this point; we want more 
light; we want more truth; it does not do any good to call them absurd 
and let the matter go at that Why not when dealing with psychological 
things stick to them ; why must people go back of them to physical things- 



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CHARLES W. BURR 323 

until we are ready; while we are on the road let us deal frankly with the 
psychological subjects and not presume anything we do not know. Now, 
I anticipate for psychoanalysis an attitude of open-mindedness toward a 
movement which is endeavoring to help a certain type of sick individusds. 
It is not true that the psychoanalyst always seeks for certain repressed 
sexual features. The psychoanalyst deals with the patient in a difficulty; 
he tries to find out what the difficulty is and how to help the patient out of 
the difficulty, just as every other physician does, and he does not jump at 
a whole lot of make-believe things. It may be true of certain beginners 
who do not understand it We have to follow the patient and never lead 
him. We do not know when a dream is told to us what the translation 
means; we have no possible way of knowing. When the psychanalyst 
speaks himself of being cock sure, when he speaks with certain assurance 
before the other physician who does not understand such things, he is 
suffering from something which cannot be laid at the door of psychanaly- 
sis. Psychanalysis is a method and as a result of the method certain things 
have been uncovered, which are facts, whether they exist in the mind of 
the patient, the psychanalyst, or anywhere else, and those facts must re- 
ceive some interpretation; if our interpretation is wrong, there is a 
right interpretation, and I ask the people who criticise the movement to 
come forward and tell us what all these things mean. We offer our 
explanation; we are willing to withdraw if we are wrong. 

I trust this society will maintain an open attitude toward this subject. 
I will only say one word more : I think very largely the difficulty of under- 
standing the whole psychoanalytical movement is a lack of understanding 
of what is meant by the unconscious; that is an extremely difficult con- 
cept to get I have spent many months in getting a clear idea about it, 
and I would invite your attention especially to that feature. It is not 
strange that the psychanalyst should say that he has thrown a certain 
light on these things. We have, many years, been studying the human 
mind; we have gone deeper and deeper into the explanation of mental 
actions, and welcome any light that can be thrown on the human mind. 

What I have said is a simple statement of fact Now I believe there 
are others who also want to speak a few moments and so I will stop. 

Dr. Hoch. — In addition to what Dr. White has said so well, I should 
like to bring out only a point or two in regard to our experience with 
Freudian psychology in psychiatry. I think it must be admitted that the 
interpretation of dreams and of the material contained in the neuroses 
b difficult, and that every conscientious observer is bound to have a period 
of uncertainty which can be overcome only by painstaking work and the 
collection of a large amount of evidence. It is therefore fortunate that a 
careful study of the psychoses, more especially of the delusions and hallu- 
cinations in the constitutional disorders, gives any one who really desires 
to get at the facts, an easier and quicker way to obtain this knowledge. 
Whereas in the neuroses much is left to the difficult method of interpreta- 
tion, very little interpretation is often needed in the psychoses, because 
here the unconscious tendencies may be directly expressed in the delusions 



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324 A CRITICISM OF PSYCHANALYSIS 

of the patient. Now as a matter of fact, we find a good deal of what Freud 
has claimed directly corroborated by the study of psychoses; more espe- 
cially do we find the most fundamental facts of Freudian psychology con- 
firmed, namely, the existence of unconscious infantile motives, and it is 
certainly not accidental that these motives are identical with those which 
Freud inferred from his psychoanalytic studies of the neuroses. 

It always strikes me as a very unfortunate fact that discussions like this 
deal chiefly with denials of certain interpretations and not at all, in a 
constructive way, with fundamental principles. Dr. White has very 
correctly said that we see certain facts which require interpretation. If 
there are better interpretations available than those which we offer, we 
should certainly gladly accept them. 

Then another word in regard to the study of psychoses. The current 
theories of auto-intoxication, etc., although they are in harmony with the 
general tendency of medical thought, are, after all, often on a very flimsy 
basis. Therefore we feel that in our attempts at studying the development 
of psychoses from a dynamic psychological point of view (without deny- 
ing that there is another side to the problem), we are more conservative 
because we are willing to stick to the facts which we see, and to study the 
relationship of these facts among each other, rather than to make final 
premature theories which include the physical side at a time when there 
are not enough facts to warrant this. 

Dr. C. W. Buwl — Mr. President, it is rather late; we are very hungry. 
I have said all that I have to say ; nothing that I have heard has given me 
the slightest reason to change or alter my view-point. 



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THE MEDICAL EXAMINATION OF MENTALLY 

DEFECTIVE ALIENS: ITS SCOPE 

AND LIMITATIONS. 

By L. L. WILLIAMS, M.D., 

Surgeon, United States Public Health Service; Chief Medical OfUcer, 
Ellis Island, N. Y. 

In the paper which I am presenting through your courteous 
invitation, I shall not attempt to describe the diagnostic methods 
employed in determining the existence of mental defect among 
alien immigrants, but shall endeavor to present briefly the problem 
as viewed from the administrative standpoint, with some state- 
ment of what can be done and what cannot be done under present 
conditions, as well as an account of the progress which has been 
made and the results which have been accomplished. 

The intensive study of the feeble-minded during recent years, 
the propaganda for the early detection and proper care of defec- 
tives and the warning given the public as to the consequences to 
the state of the multiplication of persons of this type, have had, 
among other good results, a marked and beneficial effect upon 
the medical inspection of mentally defective aliens. To make my 
meaning plain, it will be necessary to explain briefly what the 
medical inspection of aliens consists of, and to contrast former 
conditions with those which obtain at the present time. 

Medical cheers of the United States Public Health Service 
are required by law to certify, for the information of the immi- 
gration officials, all physical or mental defects or diseases observed 
among aliens presented to them for examination. The law divides 
the persons who are subjects of medical certificate into three 
great classes : First, those who suffer from physical diseases and 
defects. The deportation of persons of this class is not mandatory, 
but they may be landed or deported in the discretion of the inmii- 
gration authorities. The medical certificate operates merely as 
a handicap in these cases and is considered by the immigration 
officials along with the rest of the evidence affecting the indi- 



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326 EXAMINATION OF MENTALLY DEFECTIVE ALIENS 

vidual's right to be landed. As a matter of fact most of the aliens 
in this category are landed. Aliens of this class who may be 
landed are of course liable to become a charge upon the public, 
but pecuniary loss is the worst that can happen. 

The second class comprises persons suffering from loathsome 
or dangerous contagious diseases, including such ailments as 
favus, trachoma and other chronic infectious diseases. In addi- 
tion to the economic burden, these persons are likely to spread 
the diseases from which they suffer; their exclusion is therefore 
mandatory under the law. 

The third class includes the insane, epileptics, idiots, imbeciles 
and feeble-minded persons. The insane and the low-grade idiot 
are of importance mainly on account of the financial burden 
involved. As the high-grade imbecile and feeble-minded, on the 
other hand, in addition to the financial loss they may occasion, 
are more disposed to delinquency and are especially likely to 
become the progenitors of an ever-increasing line of defective 
dependents and delinquents, they form the most dangerous class 
of immigrants seeking admission into the country. The exclusion 
of all these defectives is now mandatory under the law ; but this 
has not always been so. The law of 1891 required that idiots and 
insane persons be debarred. The act of 1903 included idiots, 
insane persons and epileptics. The immigration law of 1907 for 
the first time added imbeciles and the feeble-minded to the list of 
persons to be absolutely excluded. Prior to this date the feeble- 
minded, if made the subject of a medical certificate, were landed 
or deported at the discretion of the immigration officials. More- 
over, as most of the discretionary cases were landed, there was 
not much incentive to engage in the very laborious task of sifting 
out the feeble-minded. The addition to the law of the words 
" feeble-minded persons " and the placing of these persons in the 
category of those whose deportation is mandatory has been far- 
reaching in importance and has been the cause of a most radical 
change in the character of the medical inspection of immigrants at 
Ellis Island. This change in the law and the consequences that have 
followed it are directly due to the awakening of public interest 
in this question, and the education of public sentiment by the 
splendid work done in this department of medicine during recent 
years. Earnest work, whether done in the laboratory or in the 



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L. L. WILLIAMS 327 

fidd, eventually comes into its own, and this is only another 
conspicuous example of the practical fruits which the public even- 
tually reaps from scientific work which, at first sight, may appear 
to be only of academic interest In this particular instance an 
awakened public sentiment became crystallized into law and as the 
medical examination of aliens is conditioned by law and must, 
of necessity, proceed along channels which the law indicates, the 
beneficial results have become apparent. 

The problem presented to the medical staff is the necessity for 
examining daily, between the hours of 9.30 a. m. and 4.30 p. m., 
from 2000 to 5000 immigrants, without such undue detention as 
would result in blocking the work of the immigration officers 
and causing an indefensible congestion in the quarters for immi- 
grants detained over night. This examination is expected to 
weed out from a polyglot multitude all individuals suffering from 
physical and mental disabilities and to do this without the aids 
available to the physician under ordinary circumstances. No 
help is given by the alien and no previous history worthy the 
name is available. There is no indication upon which to base 
inquiry save the appearance, behavior and psychical reaction of 
the subject; speed is absolutely necessary; much of the work 
must be done through the medium of interpreters ; and the vary- 
ing characteristics and normal mental reaction of difiFerent races 
must be constantly borne in mind. 

In ordinary practice the suspected defective comes to the ob- 
server with a presumption against him; something in his past 
history has invited attention to him as a possible mental derelict, 
and he is brought to the physician by those responsible for him 
and who are usually actuated by a desire to learn the truth with 
a view to placing him in the best possible environment. The alien 
on the other hand appears before the medical examiner merely 
as a possible candidate for deportation. A positive diagnosis will 
not result in placing him in a favorable environment, but will be 
merely the signal for his exclusion. The medical examiner, there- 
fore, in any attempt to secure his previous history, will, as a 
rule, get none or else a false one. 

In dealing with! mental defectives the law confers broad powers 
upon the medical officers of the Public Health Service and in 
effect requires deportation upon a medical certificate. While 



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328 EXAMINATION OF MENTALLY DEFECTIVE ALIENS 

it would be a technical compliance with the law to cause a certif- 
icate to be issued by a single medical examiner, it is regarded as 
unwise to place so heavy a responsibility upon a single man. To 
safeguard the alien's interests, as well as those of the country, 
and to avoid as much as possible errors due to the personal 
equation, the procedure to be described has been adopted. 

As the immigrants pass through the primary inspection line 
each is inspected by two physicians, one of whom takes special 
note of any indication of mental defect or disorder and addresses 
to each alien a few questions in his own language. All who in 
appearance or behavior excite suspicion, or who give irrelevant 
or stupid replies, are set aside for further inquiry. The suspects 
thus turned aside are at once given a brief preliminary examination 
for the purpose of sifting out and discharging those among them 
who are obviously of sound mind. Of those who remain each 
one appears before a board of at least two medical cheers, who 
examine him by every available test which experience has proved 
to be useful and prepare a record of their findings. The record 
is carefully examined by a third officer, and should anyone of 
them disagree as to the diagnosis, further consultation is had and 
another examination given at a later date. In case of doubt or 
when the alien is emotionally disturbed he is sent to the hospital 
for observation. To still further guarantee him against unjust 
exclusion, moreover, he may be re-examined upon the request 
of the Commissioner of Inunigration, of any medical officer, of 
his relatives or his attorney ; in brief, upon the request of anyone 
having any legitimate connection with the case. In addition, his 
relatives or his attorney may have the privilege of causing him 
to be separately examined by a private physician of their own 
selection, and the report of such physician is given careful con- 
sideration. No such private physician, however, is permitted to 
participate in the official examination or to take part in the deliber- 
ations of a medical board. Much pressure has been brought to 
bear from various sources, including a federal court in at least 
one instance, to have the alien's physician participate in the 
official examination, but such pressure has been consistently re- 
sisted. What the law requires us to do we can neither shirk 
nor delegate to another. It will thus be seen that every reasonable 
precaution is taken to provide against an error which would be 



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L. L. WILLIAMS 329 

detrimental to the immigrant. Such precautions are just, because 
the execution of the law involves much personal hardship and 
this should not be increased through hasty action. These safe- 
guards thrown around the alien are often abused, however, 
and the demands for re-examination of cases which have already 
been exhaustively considered have at times been sufficiently 
numerous to seriously impede the day's work. 

Many efforts are made to invalidate the medical certificates 
in these cases. One of the principal methods adopted by the 
attorneys of aliens certified as feeble-minded is an appeal to the 
Department, the appeal being accompanied usually by a contradic- 
tory opinion from a private physician who has been permitted to 
examine the case ; and it may be stated here that, although some of 
these opinions are undoubtedly honest, unfortunately there are a 
few physicians who, while declaiming against the admission of 
defective aliens in the abstract, will in individual cases attempt 
to obstruct the operation of the law by opinions which are plainly 
disingenuous. The authority of the medical examiners, however, 
is so well guarded by the present statute that no serious danger 
is to be apprehended from this source, provided that the law is 
firmly and impartially administered. 

Another favorite method is by appeal to the federal courts. 
Heretofore it has been the practice of the courts to ascertain 
whether the alien has been accorded all the rights and privileges 
to which he is entitled under the Immigration Act and, if this 
is affirmatively proved, to dismiss the proceedings and return the 
alien to the custody of the inmiigration authorities for deportation. 
Of late there has been a tendency on the part of some members 
of the bench to reverse this practice and to bring into court and 
to question the validity of the technical procedures which arc 
undertaken under the Immigration Act, and to order the landing 
of persons who have been excluded. I am not qualified to discuss 
points of law, but the fact remains that if this tendency becomes a 
settled practice it will constitute the most serious menace to the 
elimination of unfit aliens through medical inspection. It may 
thus easily be seen that the pathway of the examining physician 
is beset by pitfalls and that he cannot proceed too cautiously in the 
performance of his duties. Keen attorneys, ever wakeful to 
find cause for appeal, scan his every act and are prcnnpt to take 



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330 EXAMINATION OF MENTALLY DEFECTIVE ALIENS 

advantage of any technical irregularity of procedure or unwary 
statement as a pretext for attacking his conclusions and attempting 
to destroy the value of his work. 

Under the law the medical mspection is an independent function, 
necessarily so, inasmuch as it deals only with questions of scien- 
tific fact. Herein lies its efficiency, and should it at any time 
become subordinated to considerations of expediency it will with- 
out doubt undergo deterioration. 

The progress which has been made in sifting out mentally 
defective persons from the mass of incoming immigrants is well 
shown in the official statistics for the past 22 years, covering the 
period during which the general government has exercised full 
control of immigration. During the 12 years from 1892 to 1903 in- 
clusive, from one to seven idiots were excluded annually from the 
United States, a negligible number ; from 1904 to 1907 the number 
deported varied from 16 to 92 annually. After the passage of the 
act of 1907 the number perceptibly increased, as shown in the 
following table, taken from the published reports of the Bureau 
of Immigration: 

DEPORTED FROM THE UNITED STATES. 



Fiscal Year. 


Idiots. 


Imbeciles. 


Feeble-minded. 


Total. 


1908 


20 


45 


121 


186 


1909 


18 


42 


121 


181 


I910 


16 


40 


125 


181 


191 1 


13 


26 


126 


164 


I912 


10 


44 


1 10 


164 


1913 


IS 


54 


483 


555 



For the first ten months of the current fiscal year, 776 mentally 
defective persons have been detected at the Ellis Island Station, 
indicating a probable total for the year of 930 at the port of New 
York. It will be seen therefore that the past two years have been 
especially productive of results. These figures do not include 
the insane and the epileptic. In 1912 18 defectives in 100,000 
were certified at Ellis Island. In 1913 the number increased to 
50 per 100,000. For the first ten months of the current year 91 
per 100,000 have been detected. In March, 1914, the rate rose 
to 148 per 100,000, and in April to 157 per 100,000. 



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L. L. WILLIAMS 331 

An examination of a large number of records shows that 
go per cent of these persons were illiterate. 

While these numbers are not large in comparison with the 
mass of population, they indicate that there have been stopped 
at one of the sources of supply a considerable number of indi- 
viduals, many of whom would not only have themselves become 
dependents, or worse, but who would have become in time the 
parents of an ever-increasing progeny of defectives to fill our 
almshouses, reformatories and jails. The increasing efficiency 
of this work, as indicated by the record, is most encouraging. 
The medical staff engaged in this laborious task includes a num- 
ber of men of large experience and long training, and a spirit of 
team work has been developed which has made these results 
possible and which is an earnest of better things in the future. 

The medical inspection of aliens, especially mentally defective 
aliens, is a highly specialized subdivision of practical medicine 
and requires of the examiner exceptional qualities. In order 
to succeed he must possess, in addition to a broad professional 
training, tact, good judgment, firmness, discrimination and the 
power of close observation ; he must be free from prejudice and 
the partisan spirit ; he must not strain after a record or be governed 
by statistical considerations, but should consider every case that 
comes before him as though it were the only one upon which he 
was required to pass judgment The attitude of the medical 
examiner toward these suspects must, above all, be a judicial one, 
for he is, in effect, a member of a jury to decide a g^ave question 
of fact, involving the heredity of many future citizens of this 
country. He should not permit himself to adopt the role of pros- 
ecuting attorney and must resist the tendency to develop the 
hunting spirit which would incite him to strain a point for the 
sake of a record. He represents the country at large and must 
protect it against invasion by the unfit; but in discharging this 
duty he must accord to the alien at least that measure of mercy 
which a court of justice would consider to be his right, and must 
give him the benefit of every reasonable doubt. To adopt a dif- 
ferent attitude and to issue a dictum which is not backed by 
recorded evidence sufficient to support it beyond question would 
savor of tyranny, and such a policy in the long run would defeat 
itself by running counter to the public conscience. 



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332 EXAMINATION OF MENTALLY DEFECTIVE AUENS 

All these considerations, all these difficulties which are bound 
up with this problem and are an essential part of it, militate against 
the official certification of the high-grade moron, although it is 
recognized that he may be a source of greater danger to the 
community than his more defective fellow. In approaching the 
problem of the detection of the high-grade defective, we are 
met at the very beginning of the inquiry by obstacles that are 
most discouraging. Among these may be mentioned the inability 
to obtain a history of his past life and activities, of his social and 
industrial habits, of his emotional stability, of the attitude of his 
companions toward him and especially of his moral development, 
or lack of it, as shown by his behavior in his home environment. 
In an inquiry along these lines the examiner runs against a blank 
wall. Then we must consider the difficulty in examining such a 
subject through the medium of an interpreter, and the practical 
impossibility of holding him for observation long enough to obtain 
evidence from his behavior. If such observation were possible 
it would be in an artificial and protected environment in which 
his habitual reactions would be unlikely to appear. The idiot, 
the imbecile, and the fairly well-defined grades of the feeble- 
minded are now the subjects of medical certificates. With increas- 
ing experience we may hope to approach the ideal more neariy 
and may reasonably expect to sift out most of the feeble-minds 
characterized by intellectual defect. Under existing immigration 
conditions, and for the reasons given, we cannot hope to detect 
any large percentage of high-grade feeble-minds whose defect 
appears mainly in emotional instability or moral obliquity. 

The law places a heavy responsibility upon the medical cheers 
who perform this work, a responsibility which should and does 
make for conservatism. Because of this conservative attitude 
the medical inspection of mentally defective aliens at Ellis Island 
has been criticised at times and the claim made that it does not 
go far enough, and that many persons are passed by our examiners 
who should be excluded. That the examination is still far from 
perfect is readily conceded ; we hopt to make it better. But much 
of the criticism thus far has been based upon the opinions of 
observers without medical knowledge; lay workers who have 
learned the usual tests employed in examining school children, 
or else upon the dicta of persons who may be otherwise qualified 



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L. L. WILLIAMS 333 

to express an opinion, but who have not taken into consideration 
either the practical difficulties which confront the medical exam- 
iner, or the gravity of a certificate of feeble-mindedness under 
the immigration law. We cannot aflford to make many mistakes 
in examining aliens. While failure to recognize a feeble-minded 
individual results in his admission into the country to the detri- 
ment of the state, on the other hand a certificate based on insuffi- 
cient grounds means unnecessary and painful separation of 
families and the sending back an alien to the ends of the earth 
regardless of the hardship involved. An error in the case of a 
child at school or in an institution merely means that he will be 
wrongly classified, an error easily corrected. An error which 
results in unjustly deporting an alien from New York to Eastern 
Europe is a grievous blunder and is without remedy. A rigfid 
formula which may be very useful in examining school children 
cannot unreservedly be applied in determining the mental con- 
dition of illiterate immigrants, and it becwnes necessary to make 
use of every available means of arriving at a just conclusion. 
As in all other diagnostic problems, rule-of-thumb methods are 
misleading and unscientific. In view of the serious consequences, 
as our findings are frequently combatted at Ellis Island, at 
Washington and in court, and as all of our work is thus done 
in an atmosphere of hostility, we cannot afford to depend upon 
any single test, no matter how valuable, or to adopt a mode of 
procedure which would result in mechanically grinding out a 
diagnosis. Nor can we certify as defective a number of individuals 
concerning whose mental status we may entertain strong doubts. 
The very word "certify" used in the law lays upon us this 
limitation. A strong probability will not suffice; we must be 
certain of our ground. For these reasons it is not surprising 
that we cannot concede the justice of criticisms based upon work 
in a widely different field, and which are made without a knowl- 
edge of the legal aspects of this work and the discouraging 
array of practical difficulties which surround it. 

'* The toad beneath the harrow knows 
Exactly where each tooth-point goes ; 
The butterfly upon the road 
Preaches contentment to that toad." 



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334 EXAMINATION OF MENTALLY DEFECTIVE ALIENS 

In shaping this work and bringing it to greater perfection the 
theorist, the faddist, the fanatic and the self-seeker have no 
proper place. The only rational method of attacking the problem 
is by close study of the actual conditions, by the application of the 
experimental method, and by laborious research carried on in 
connection with the practical work. The criticism of the judicious 
and the informed, any criticism that is constructive and helpful, 
will be welcomed. Mere fault-finding is unproductive, and can 
serve no useful purpose. 

Some original investigations are now being conducted at Ellis 
Island, and are being pushed as rapidly as the routine work will 
permit. A medical crfficer assigned to the special duty of exam- 
ining as large a number as possible of normal individuals 
belonging to various races and nationalities, has devised a carefully 
considered scheme of inquiry, and it is believed that much valu- 
able material will be obtained which may aid in standardizing 
the tests in use, and assist in establishing at least approximately 
a practical standard upon which certification may be based. The 
records of cases which have been held for examination and sub- 
sequently discharged, including many which may be regarded 
as borderland cases, are also being searched for data which may 
prove valuable. 

At present the point of maximum error in the examination 
is the primary inspection. If an alien is passed on this first 
inspection, there is no further opportunity to examine him, and 
it is here that most improvement may be had. To obtain such 
improvement and more closely sift out possible feeble-minds for 
further inquiry, this initial examination should be slightly pro- 
longed and more time given the examiner to pick out suspects 
by such interrogations as may throw light on their mental pecu- 
liarities. The additional time required in each case would not 
be great, but it is difficult to secure it without unduly slowing 
down the entire process. Two thousand immigrants are now 
handled at this primary inspection in two hours and a half by 
operating four inspection lines, the maximum number for which 
space is available. They pass through therefore at the rate of one 
every 4j4 seconds, but, as there are four lines, each alien is given 
on an average i8 seconds. This rate will vary according to the 
class of immigrants brought by particular ships and will also be 



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L. L. WILLIAMS 335 

affected by fatigue on the part of the medical staff. The most 
potent factor, however, in fixing the amount of time given each 
alien is the necessity for passing them fast enough to avoid 
blocking the work of the immigration officials. When immigrants 
are coming in at the rate of 4000 to 5000 daily and the detention 
space is limited, it will readily be seen that this practical factor 
becomes dominant; otherwise such congestion would speedily 
result that the entire process would come to a standstill. A few 
additional seconds devoted to each alien would be of great value, 
but, for the reasons given, these additional seconds can be secured 
only by a substantial increase in the medical personnel and a 
corresponding increase in the working space. The work which 
has been done by individuals and by scientific bodies, of which 
this Association is a type, has had its effect in shaping the law. 
But the spreading of a law upon the statute books is only half 
the battle ; it is equally essential that adequate means be provided 
for carrying that law into effect. While the work among mental 
defectives at Ellis Island is becoming more and more efficient, as 
shown by the record, the possibilities of the present law cannot 
be fully realized until a sufficient number of medical officers, a 
sufficient force of competent interpreters and an adequate work- 
ing space shall have been provided. 

The necessity for such additional provision has been brought 
to the attention of the national legfislature and the effort to secure 
a complete execution of the law in this regard should command 
the support of the medical profession, and especially of those 
members of it whose daily work has given them a clearer insight 
into the danger to the country from the introduction of persons 
with mental defect or psychopathic taint, and whose special train- 
ing entitles them to speak with authority. 

The elimination of mental defectives is only one of the phases, 
probably the most important one, of the great problem of the 
restriction of immigration by excluding the undesirable elements 
and many legislative schemes have been proposed. 

It is likely that there will be much empirical legislation in 
the future as in the past before this question is finally set at rest, 
but I believe that in the long run immigration will be restricted 
by a process of intensive selection based upon scientific grounds 
and resulting from scientific study of all of the conditions; 



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336 EXAMINATION OF MENTALLY DEFECTIVE ALIENS 

and it may not be too much to hope that the day is not far 
distant when the intending immigrant will be required to present 
a clean bill of health, physically and mentally, and a clean bill of 
character as well and, through agencies to be devised by the 
scientist and the statesman of the future, be compelled to prove his 
right to enjoy the benefits of American citizenship. 



DISCUSSION. 

Dr. Bancroft. — ^I have been greatly interested in this paper; it is very 
illuminating and presents problems which are particularly interesting: 
to the cities of our country, and I would like to ask if it would not be 
possible to submit the immigrant to some preliminary examination before 
he is allowed to embark? It would seem that it would be impossible for 
defectives to come into this cotmtry if a careful examination were made 
at the port of embarkation. I presume there may be difficulties, and I 
rise, therefore, to ask the question whether these difficulties cannot be 
solved, and whether it is not possible for the incoming immigrant to be 
submitted to intelligent examination before he leaves the port of embarka- 
tion? 

Dr. Briggs.— This question is a very live one in Massachusetts as in New 
York, and as a member of the Board of Insanity of the State of Massa- 
chusetts, I would say that we have 17,000 people in 27 institutions ; of those 
13,000 are certified as insane, and 40 per cent are aliens. I have been 
appointed commissioner of the alien insane in Massachusetts, 'and we are 
making a special study of that particular subject. What Dr. Williams says 
regarding the hurried examinations is not quite as bad in Massachusetts, 
but if those of us who examine defectives in a clinic think we are doing 
pretty well if we make examinations of 12 to 15 cases in a morning clinic, 
what would we think of the examinations at the immigration station, which 
number three or four a minute? It is a wonder we do not get many more 
in our institutions than we do. The difficulty is after they get into our 
institutions, to get them back again as the laws are to-day. They come into 
the institution and the superintendent notifies us that they are deportable; 
maybe one member or friend of the family will bring all the sympathies 
of the family to bear, especially if one member of a large family is sent 
back alone to Europe and the family thus hopelessly separated. If the 
pressure of sympathy fails the next thing often is that some relative or 
friend is paid to give a bond for the patient, to relieve the state of the charge, 
and after a few years that bond disappears, usually after the time limit 
has gone by for deporting that case. I do not see now, how, in the cursory 
examination that is made, the examiner can take in the facts of environ- 
ment and of the life of the inunigrant before he came over. It is most 
difficult in the mental clinic to size up a patient, see what the normal sur- 



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L. L. WILLIAMS 337 

roundings have been before making the examination, and what advantages 
the patient has had to enable him to stand up mider the many tests now 
given. 

There is another thing which I think we have got to meet and that is 
whether examinations shall include syphilis and alcoholism ; this is such an 
important factor in the production of insanity. We have a great many 
such cases among our immigrants and I believe the time is coming when we 
are bound to demand some sort of certificate or bill of health before we 
can admit these doubtful cases. 

Dr. L. L. Williams. — ^The question as to making a thorough medical 
examination before embarkation is one that has frequently come up, and 
there is no question that it should be done on the other side if practicable. 
It is possible that in time it may be done ; one foreign government at least 
may not be very much averse to such a procedure — I have in mind my 
conversation with some of its representatives — but in many other coun- 
tries it undoubtedly would be opposed. Such a procedure would save the 
inunigrant much hardship and relieve this country of much trouble. Of 
course a certain kind of examination is now made by the medical officers 
of the steamship lines ; they are required to make a report in regard to all 
cases of disease found on shipboard and a fine of $ioo can be assessed 
against the company if it can be shown that certain diseases found on 
board could have been detected by competent medical examination before 
embarkation. These fines are not infrequently imposed but in such in- 
stances a dear case must be made out against the steamship company. 

As far as the question of getting a " clean bill of character/' so to speak, 
is concerned, that of course would be very desirable, and it is something 
that we would all very much like to see brought about; it has been sug- 
gested that it might be done in the way of passports ; how much such pass- 
ports would be worth I am not prepared to say, but in some cases they 
might not be of much value, human nature being practically the same the 
world over. In my paper I have felt obliged to content myself by passing 
this problem on to a future generation. 



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SOME NOTES ON EXPERT TESTIMONY BY ALIENISTS 
AND NEUROLOGISTS. 

By dr. C a. PORTEOUS and DR. H. V. ROBINSON, 
Montreal^ Canada. 

I have been prompted to write this paper principally because it 
concerns a civil case of much prominence recently heard in the 
Montreal courts. Dr. T. J. W. Burgess and the writer were sum- 
moned, both being witnesses as to fact ; the plaintiffs father at 
the time was a patient at Verdun Hospital. 

Such a paper, it must be confessed, brought before this Society, 
smacks strongly of " Carrying coals to Newcastle," when one 
considers the many excellent monographs on this subject presented 
to you in the past few years. My apology must be that a dart, 
though feebly delivered at an evil, may strike its mark. The 
writer assumes there is no disagreement among the members of 
the profession with the assertion that there is room for improve- 
ment in the methods allowed and practised, on the one hand, re- 
garding the securing and hearing of expert testimony, and the 
gfiving of it, on the other, in the courts of the United States and 
Canada. This applies particularly to civil cases which hinge upon 
proof or non-proof of insanity, an example of which it is hoped to 
demonstrate in this paper; certainly, the contradictory character 
of the evidence submitted by the various experts in the case here 
dealt with, calls for some remedy. 

Thirteen physicians gave evidence in the case herewith sketched, 
eleven of whom have made a special study of psychiatry or neurol- 
ogy. The review of their statements, under oath, which forms the 
major part of this paper, furnishes one of the most instructive 
examples as to why expert testimony, by alienists especially, in 
Canada and the United States is to-day liable to be received with 
a damning smile of tolerance that can well be imagfined. The spec- 
tacle of reputable medical men (for be it understood that all con- 
cerned were, and are highly so) making depositions so bluntly 
opposed to each other, can but cast a shadow on the physician's 



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34t> EXPERT TESTIMONY BY AUENISTS AND NEUROLOGISTS 

reliability or knowledge, or both, when he is in the witness box — 
whatever he may be when outside of it. 

The fact might as well be squarely faced that a physician is but 
human, and notwithstanding the high ethical and professional 
standards to which he is bound, and in justice be it said, to which 
he faithfully adheres, the influences of partizanship, personal feel- 
ings, and the desire that his side shall win in the courtroom, have, 
in degree, an effect upon his testimony, as upon that of the non- 
professional and inexpert witness. A prominent and most able 
judge of Toronto, Can., not so long ago remarked to the writer 
that even in his official capacity, when hearing evidence, he felt 
that subconsciously he gave heed to the very expression of a wit- 
ness, his manner and his method of answering questions under 
cross-examination, and that while all these points were distinctly 
not pertinent to the evidence, they, to a limited extent, tended to 
bias his belief as to the value of the testimony adduced, either 
favorably or unfavorably. If a man, with a wealth of experience 
on the bench, will honestly make such a statement, it would be 
surprising indeed if the quasi-expert testator could prevent him- 
self from showing some trace of partiality, although he might in- 
tend and desire to preserve the aloofness and detachment that one 
totally disinterested as to the issue in a given case should manifest. 

The spirit in which this paper is written is not one of arraign- 
ment ; it is intended to point out, by a practical example, that the 
matter of experts and their selection, etc., deserves the most serious 
deliberation by legislator and physician alike. It is hardly possible 
in a paper of this scope to attempt suggestions as to how this may 
be best done. Some practical ideas by an eminent English judge, 
which bear upon the point of how more unanimity of opinion may 
be arrived at among medical witnesses, is worth reading, and I 
quote it with pleasure. In " A History of the Criminal Law of 
England," by Sir James Fitzjames Stephen, K. C. (Edition 1883, 
page 575) > he says: 

It is impossible to say what an expert is to be, if he is not to be a witness 
like other witnesses. If he is to decide upon medical or other scientific 
questions connected with the case so as to bind cither the judge or the 
jury, the inevitable result is a divided responsibility which would destroy 
the whole value of the trial. If the expert is to tell the jury what is 
the law — say, about madness — ^he supersedes the judge. If he is to 
decide whether, in fact, the prisoner is mad, he supersedes the jury. If 



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C. A. PORTEOUS AND H. V. ROBINSON 34I 

he is only to advise the court, is he or is he not to do so publicly, and to 
be liable to cross-examination? If yes, he is a witness like any other; 
if no, he will be placed in a position opposed to all principle. The judge 
and the jury alike are, and ought to be, instructed only by witnesses 
publicly testifying in open court on oath. 

It never would be, and never ought to be, endured for a moment that 
a judge should have irresponsible advisers protected against cross-exami- 
nation. 

And proceeding, he says : 

The truth is, that the demand for experts is simply a protest made 
by medical men against cross-examination. They are not accustomed 
to it and they do not like it, but I should say that no class of witnesses 
ought to be so carefully watched and so strictly cross-examined. 

There is one way in which medical men may altogether avoid the 
inconveniences of which they complain, and that is by knowing their 
business and giving their testimony with absolute candor and frankness. 
There have been, no doubt, and there still occasionally are, scenes be- 
tween medical witnesses and the counsel who cross-examine them which 
are not creditable, but the reason is that medical witnesses in such cases 
are not really witnesses, but cotmsel in disguise, who have come to sup- 
port the side by which they are called. The practice is, happily, rarer 
than it used to be, but when it occurs it can be met and exposed only 
by the most searching, and no doubt unpleasant, questioning. By proper 
means it may be wholly avoided. If medical men laid down for them- 
selves a positive rule that they would not give evidence, unless before 
doing so they met in consultation the medical men to be called on the 
other side and exchanged their views fully, so that the medical witnesses 
on the one side might know what was to be said by the medical witnesses 
on the other, they would be able to give a full and impartial account of 
the case, which would not provoke cross-examination. For many years 
this course has been invariably pursued by all the most eminent physi- 
cians and surgeons in Leeds, and the result is that, in trials at Leeds 
(where actions for injuries in railway accidents and the like are very 
common), the medical witnesses are hardly ever cross-examined at all, 
and it is by no means uncommon for them to be called on one side only. 
Such a practice, of course, implies a high standard of honor and pro- 
fessional knowledge on the part of the witnesses emplo3red to give 
evidence; but this is a matter for medical men. If they steadily refuse 
to act as counsel, and insist on knowing what is to be said on both sides 
before they testify, they need not fear cross-examination. 

I would also refer to the law in France regarding expert wit- 
nesses, from which we in Canada, as well as the United States, 
might glean much of profit to improve faults common to both 
countries. 



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342 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 

In " Precis de Medecine Legale," by L. Thoinot, professor of 
legal medicine of the Faculty of Medicine of Paris (Edition 191 3, 
Vol. I, pages 36-37), we learn that the nomination of medical 
experts in France is governed by a decree of November, 1892, 
Art. XIV, which states that " The duties of medical experts can 
only be filled by medical men holding French degrees." As to 
the appointment of medical experts by a decree of November, 1893, 
Art. I, we find the following : " At the commencement of each 
judicial year and in the month which follows its opening, the 
Courts of Appeal in Chambers, the Attorney-General being present, 
will designate upon their lists the doctors in medicine on whom they 
will confer the title of expert before the courts." Article II, 
amended by the decree of April, 1906, states : " The nominees of 
the court must be graduates of a French medical school residing 
within the jurisdiction of the court. They must have five years 
practice in their profession or have a diploma from the University 
of Paris bearing the special qualification of Medecine legale et 
Psychiatrie, or a similar diploma created by the other French 
universities." 

The French Republic, certainly not a backward nation in legal 
matters, deems medico-legal experts — ^and it follows their testi- 
mony — of sufficiently grave importance to officially designate who 
shall be deemed worthy of this title. These experts are appointed 
yearly, by one of the most powerful judicial bodies of France, 
and are invariably men fully qualified; they must reside in the 
judicial district in which the trial takes place, none being called 
from outside the " arrondissement " of the tribunal, ♦. e,, the dis- 
trict over which a particular court presides, and a special diploma 
is exacted in lieu of five years' practice. Such a system unques- 
tionably makes for a high standard in the personnel of the medical 
expert, and surely it cannot but place his testimony on a plane not 
easily assailed by even the most astute attorney, as well as armor 
it against cavil by the laity. 

Now as to the case at issue : First, the salient points regarding 
certain physical features and the character of the psychosis from 
which the patient suffered may well be presented. 

G. M., Montreal. Previous History: Admitted July 15, 1912, to Verdun 
Hospital, act 66; first attack manifested itself November, 1911, in in- 
somnia, irregularities in finance; at present shows visual hallucinations; 



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C. A. PORTEOUS AND H. V. ROBINSON 343 

stiiddal propensities; capricious appetite; insomnia; heavy drinker for 
thirty years; progressive muscular atrophy evident in wasting muscles 
of right thenar eminence ; has lost weight ; has arteriosclerosis ; emotion- 
ally depressed and states he contemplated suicide. 

On Admission: Depressed; speaks of suidde and claims to have at- 
tempted it; delusion that detectives are continually on his trade; says 
he lost several hundred thousand dollars in poor business deals and that 
he is finandally ruined; worrying greatly over his son, who is now 
seriously ill with typhoid; sleepless. 

Abstract of Physical Examination. — Pulse 68. Circulatory System: 
Arteriosderosis of radial and temporal arteries evident; blood pressure 
168, pulse pressure 65. Kidneys: Examination of urine; nothing abnor- 
mal Syncopal attacks several (five or six). 

Diagnosis. — Melancholia of involution type. 

The litigation in the case centers about these facts. The patient, 
G. M., was certified as insane in Jtdy, 1912, and committed to Ver- 
dun Hospital in that month. In the months of February and 
March, 1912, he had made over certain bonds and securities, worth 
some $70,000, to his nephew, W. M. The patient's son, R. M., 
claimed that this collateral was gfiven to the nephew without ad- 
equate consideration of any kind and that his father's mind was 
affected when he made the transaction. He, R. M., therefore 
brought suit against W. M. to recover the said securities, etc. 
The question to be decided resolved itself into, whether when 
G. M. transferred this valuable collateral to his nephew he was 
in a fit mental state to do so or not. Both sides called a number of 
expert witnesses, and the vital portion of their testimony is ap- 
pended in juxtaposition. Were any one of you who read this 
article called upon to be the judge, from the learned expert testi- 
mony presented, what would your decision be? You are not 
required to give your opinion on the value of expert evidence 
in the connection ; it were better left to the imagfination. I have 
totally disregarded in this paper what has been said by the lay 
witnesses. It has no particular place, as it is quite non-technical. 
Suffice it to say that it brings much to prove the man was abso- 
lutely insane and perfectly sane when he consummated the business 
deal out of which the suit arose. 

A brief hearing of the depositions of Dr. S. and Dr. T., the 
physicians who saw the patient in January and March, 1912, should 
first be considered. Neither affected alienism or neurology, both 
being general practitioners. Their declarations seem of especial 



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344 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 

value, owing to the symptoms which both observed, and the early 
dates, viz., January and March, 191 2, on which they saw the 
patient. 

Deposition of Dr. S., a witness produced and examined on 
behalf of the plaintiff in this matter. 

Examined by H. J. E., counsel for plaintiff. 

Q. Will you describe to us the condition in which you found the in- 
terdict, G. M., when you made your first examination in January, 19x2? 

A. A physical examination developed a condition of marked arterio- 
sclerosis, or hardening of the arteries, enlargement of the heart, and 
wasting of the muscles of the hand. The nervous symptoms at the time 
were insomnia, great agitation and inability to fix his mind on what I 
talked to him about 

By the Court : 

Q. Inability of concentration? 

A. Yes. A " stary " look when you talked to him for a while, and you 
had to recall him to himself in order to get him to answer questions 
correctly. He also had an idea that he had ruined his boy. 

Mr. £., continuing: 

Q. When was this? 

A. Early in January. I prescribed for him and the case went along. 
At times I heard from Mrs. M. that he was still walking the floor at 
night, and unable to sleep; that he was tadtum and would not talk. 
The next act of importance in his case was toward the end of February, 
when he had a revolver and thought he would do away with himself. 
Mrs. M. took the revolver from him. 

Q. From your examination of the patient up till that time, and from 
your practically constant observation of the man, what is your opinion, 
as a medical man, as to his mental condition at that time? 

A. I think he was mentally unfit at that time, and he was gradually 
getting worse. 

Q. What condition did you find him in prior to the 5th of March, when 
you advised his incarceration in a sanitarium? Was he sane or insane? 

A. Insane. 

By the Court: 

Q. And it goes without saying that he was insane in June when you 
came back? 

A. Yes. 

By Mr. £., continuing: 

Q. In your opinion, what would be the effect of such a condition on 
his capability to conduct business? 

A. I don't think he was fit, for the simple reason that he could not 
concentrate his mind on the business he had to perform. 



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C. A. PORTEOUS AND H. V. ROBINSON 345 

Deposition of Dr. T., a witness produced and examined on behalf 
of the plaintiff in this matter. 
Examined by Mr. S., counsel for plaintiff. 

Q. Do you know G. M., now a patient in the Verdun Asylum? 

A. Yes, I do. 

Q. How long have you known him? 

A. I have known him since the beginning of his son's illness. As far 
as I can remember, it may have been September or October, 191 1. It 
was the beginning of the autumn of the year he was taken ilL As far 
as I can remember the first time I saw Mr. G. M. professionally was 
some time in the first two weeks in March. I could not be quite precise 
about the date. 

Q. March, 1912? 

A. Yes. 

Q. Some time in the first two weeks of March? 

A. Yes, as near as I can remember. 

Q. What was his condition at that time? 

A. When I saw him I remember it was in the late afternoon. It was 
pretty dark in the room where he was. I saw him sitting in a chair 
looking very downcast I sat down and began to question him. I asked 
him what the matter was, and I told him that Mrs. M. was worried about 
him and had asked me to see him. At first I could not get any answers 
at all He simply sat there in a gloomy condition, and I had the greatest 
difficulty in getting any information at all from him. I asked him whether 
he felt ill himself, that is, whether he was physically ill, and he said, 
"No." I then asked him what was the matter, and he said, I cannot 
give you his exact words, because I cannot pretend to do so at this dis- 
tance, but he said, " It is terrible. I have ruined my family." That was 
really the first intimation I had that there was anything wrong with him. 

Q. What idea did you form, if any, as to the character of the mental 
trouble from which he was suflFering? 

A. Well, I came, first of all, to the immediate conclusion that he was 
profoundly melancholic Nobody could have seen that man in the 
attitude in which he was, and the way he answered questions, without 
coming to the conclusion that he was in the larger sense melancholic 

Q. Will you tell the court the opinion you formed as to whether he was 
rational or irrational? 

A. I may say, whenever I spoke to him, asking him what he felt like, or 
how he was, he would always come back upon this same idea that he 
had ruined his family. That was the invariable topic which he drifted 
back to, and that without my suggestion. If you asked him what was 
the matter with him he would answer, ** Oh, I have ruined my family. It 
is terrible." That was the usual way he spoke. 

Q. Did you tender any advice to the family concerning him during that 
period? 



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346 EXPERT TESTIMONY BY AUENISTS AND NEUROLOGISTS 



A. I did, yes. The advice was that, in the first place, I considered 
Mr. G. M. was not in his right mind, and that it was a question as to what 
should be done with him. 

None of the alienists or neurologfists whose evidence is subse- 
quently submitted examined the patient until after he had been 
committed to Verdun Hospital in July, 1912 ; they were unanimous 
in their opinion as to his condition when seen by them ; they all 
state that the man was a case of involution melancholia beyond 
doubt. It is in their deductions as to how long the disease had ex- 
isted before they saw the patient, that their amazing differences of 
interpretation are manifested. 



EXTRACTS FROM EXPERT 
TESTIMONY. AND CROSS- 
EXAMINATION THEREON, 
AS GIVEN FOR PLAINTIFF. 



Deposition op Dr. U. 



of 



Examined by Mr. C. H. S, 
counsel for plaintiff. 

Q. Dr. U., you are Superintend- 
ent of the Hospital for the 

Insane? 

A. Yes. 

Q. It is recognized by the Govern- 
ment of the Province of Quebec? 

A. Oh, yes. As a matter of fact, 
I am appointed as superintendent by 
the government 

Q. How long have you occupied 
the position of superintendent of 
this institution ? 

A. Twenty-three years. 

Q. Before that, were you in the 
same profession? 

A. I have been forty years in the 
same profession. 

Q. As a specialist in mental dis- 
eases? 

A. Yes. Very nearly forty years. 
Practically forty years. 

Q. Have you among the patients 
at the Hospital for the In- 
sane a person named G. M.? 

A. Yes. 



EXTRACTS FROM EXPERT 
TESTIMONY. AND CROSS- 
EXAMINATION THEREON, 
AS GIVEN FOR DEFENDANT. 

Deposition op Ds. E. 

Examined by Mr. S. L. D. H., of 
counsel for defendant 

Q. Are you a practising physi- 
cian and surgeon? 

A. Yes. 

Q. What is your position? 

A. I am superintendent of the 
Hospital for the Insane at 



Q. That is the public hospital for 
the insane? 

A. Yes. 

Q. Did you examine G. M., who 
has been referred to in this case? 

A. Yes. 

Q. What was the date of your 
examination? 

A. December 17. 

Q. December 17, 1913? 

A. Yes. Together with Dr. B. 

Q. In what condition did you find 
him? Was he suffering from any 
trouble? 

A. Yes. I found him suffering 
from melancholia. 

Q. In view of all the evidence 
which has been given at this trial, 



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C. A. PORTEOUS AND H. V. ROBINSON 



347 



Q. How long has he been incar- 
cerated there? 

A. I was absent in Europe at the 
time he came in, but according to 
our records he came in on the 15th 
of July, 1912. 

Q. You were absent at the time? 

A. Yes. I first saw him, I think, 
oii the 27th of August. 

Q. Did you examine him person- 
ally on your return? 

A. I did. Either the first or 
second day after my return. 

Q. Did you have a report with 
regard to him when you returned? 

A. I had the case book reports. 

Q. What was the condition of G. 
M. when you personally examined 
him? 

A. I found him suffering from 
melancholia. 

Q. Is that a technical expression ? 

A. It is the ordinary technical 
phrase for that form of mental 
disorder. Of course there are any 
number of subdivisions of that 
form. If I had to put it down be- 
fore a lot of medical men, I would 
say he was suffering from involu- 
tional melancholia. 

By the Court : 

Q. Does that mean melancholy 
against his will? 

A. No, sir. Evolutional is a grad- 
ual progress forward. Involutional 
is a progress backwards. 

By Mr. S., continuing: 

Q. Is that a form of mental 
disease? 

A. Decidedly. 

Q. Would you call it insanity? 

A. Certainly. 

Q. Will you describe to the court 
the characteristics and peculiarities 
of this form of mental disease? 

A. Melancholia, especially this 
form, is a disease of very slow 



and the documents which have been 
filed in this case, what is your con- 
clusion as to the sanity or insanity 
of G. M. during the months of 
December, 191 1, January, February, 
March, 1912? 

A. In December, 191 1, and Janu- 
ary, February, March, 1912, 1 do not 
consider he was insane at that 
time. 

Q. Do you consider he was sane? 

A. Yes. 

Q. On this evidence and on the 
documents filed, what in your opin- 
ion was the mental capacity of G. M. 
to appreciate the nature of the 
transactions referred to in this 
case? That is to say, on or about 
the 5th of March, 1912, and about 
the 2ist of February, 1912? 

A. I think he had the mental 
capacity to fully appreciate the 
nature and quality of lus act at that 
time. 

Q. You say you think — ^is that 
your opinion? 

A. I give that as my professional 
opinion. 

Q. Would you consider from the 
evidence made in this case, and 
from the documents filed, that Mr. 
G. M. was suffering from confirmed 
melancholia (which is a continuous 
and progressive disease) during the 
months of December, 191 1, January, 
February and March, 1912? 

A, No. 

Q. With regard to the evidence 
of Dr. S. and Dr. T., what have you 
to say? 

A, I have gone very carefully 
over the evidence of Dr. S. and Dr. 
T. and studied their descriptions as 
carefully as I possibly could. Dr. S. 
had first observed Mr. M.'s condi- 
tion in the beginning of the 3rear. 
He said he was agitated and that 



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348 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



growth, ordinarily speaking (I am 
speaking, of course, of cases that 
come into hospitals). The disease 
exists for months and months prior 
to the admission of the patient. The 
beginning of the disease is so in- 
sidious that very often the friends 
do not notice it in the early stages 
at all. After that it is gradually 
progressive. The disease in many 
cases (especially in involutional 
melancholia) is dependent upon a 
condition that we call arterioscler- 
osis — ^that is, hardening of the ar- 
teries — and that disease is progress- 
ive beyond a doubt At the begin- 
ning the symptoms are very insid- 
ious, and perhaps the friends do not 
notice it at all They gradually 
become worse and worse, and finally 
the man has to be taken in charge. 
After he is taken in charge he still 
continues to grow worse. Finally 
he winds up in a condition of what 
we would call dementia, which is 
followed by death. 

Q. Is there any going back, or re- 
covery? 

A. I think not Not in a case of 
arteriosclerosis. You cannot soften 
the arteries when they are once 
hardened up. 

By the Court : 

Q. Then, it is a result of a physi- 
cal condition? 

A. A physical condition, probably 
plus some worry as an exciting 
cause. The thing depends in the 
start upon a physical condition — 
a condition of the arteries. 

By Mr. S., continuing: 

Q. And that is what G. M. had 
and has? 

A. Yes ; he had and has. 

Q. Would you say that was the 
cause of his mental condition? 



he had insomnia. These are the 
two principal points he brings out 
He made no mental examination, 
and so he declares. He prescribed 
nothing for him except some bro- 
mide. Then, coming on toward the 
end of March (he had seen him 
during these months and had made 
no examination), I realize fully the 
statement he makes that he advised 
Mrs. M. to send him to a sanitarium 
and he stated that he took this ac- 
tion on the advice of Mrs. M. He 
is quite careful to state that in his 
evidence. 
By Mr. S., of counsel for plaindfiF : 
Q. Now coming to Dr. T.'s evi- 
dence? 

A. Dr. T. sees him in March, 
presumably the week of the 5th of 
March, or, say, during the first two 
weeks of March. He also states 
that he made no mental examina- 
tion. His examination was directed 
to Mr. M.'s physical condition rather 
than to his mental condition. He 
states that Mr. M. had an idea that 
he had lost his property and that he 
had ruined his son. I cannot quote 
the exact words, but this would be 
the substance of it Dr. T. states 
that he cannot tell whether this con- 
dition was permanent or transitory, 
but he makes the very significant 
statement later on that the case de- 
veloped during the months of May 
and June. Now these are the state- 
ments of Dr. S. and Dr. T., and 
these statements go to show that the 
man was depressed, suffering from 
worry, which is quite normal under 
the circumstances. I attribute this, 
of course, to the fact that his son 
was ill, and that the property of the 
son— quite large amounts as given 
by the evidence — ^was in a somewhat 



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C. A. PORTEOUS AND H. V. ROBINSON 



349 



A. I think so. As I say, that prob- 
ably plus some worry. I don't 
know what it would be at alL The 
condition of arteriosclerosis tends 
toward mental enf eeblement 

Q. Inevitably? 

A. Inevitably. 

Q. Insanity, I presume, has many 
different forms? 

A. Oh, many. 

Q. Are they classified at all? 

A. They are. Too much so, very 
often. 

Q. When you use the expression, 
"melancholia," that is one of the 
classifications? 

A. Yes, it is one. 

Q. It is the one into which you 
put this particular case? 

A. Yes. As I say, there are 
several forms. You might divide 
melancholia into a number of 
forms, but, ordinarily speaking, it 
is melancholia. 

Q. It is that form of insanity 
which is known among scientific 
men as melancholia? 

A. Yes. 

Q. How does it affect a patient 
with regard to his capacity for do- 
ing business? 

A. I should think it would affect 
him deleteriously. 

By the Court: 

Q. What do you mean by "del- 
eteriously?" 

A. That is giving a general 
opinion. I think any man suffering 
from melancholia could not make 
as fair a judgment as an average 
man. Of course, I cannot say any- 
thing at all positively as to Mr. M.'s 
judgment prior to my seeing him. 
I can only judge that this disease 
had made slow progress, and, in my 
opinion, must have existed for 



embarrassed condition. It is only 
normal that a man under these dr- 
cumstances should be in this con- 
dition of worry. 

Q. What conclusion do you draw 
from the evidence of Dr. S. and of 
Dr. T., presuming that all the facts 
they state are correct? 

A. The conclusion I draw from 
the evidence of Dr. S. and Dr. T., 
after giving every possible consider- 
ation to it, is that during the months 
of January, February and March, 
1912, Mr. M. was suffering from 
worry and anxiety, due to the con- 
dition of his son and his son's 
affairs, and that he was not insane. 

Q. Assuming that Mr. G. M. did 
make the statement on different 
occasions that his family was ruined, 
and his son was ruined, and that he 
was ruined, prior to the first week 
of March, 1912, does that, in your 
opinion, indicate that he was insane 
and incapable of appreciating any of 
these transactions with W. M.? 

A. No, I don't think so, because 
it is quite natural that at these 
times he would be suffering from 
extreme depression and anxiety 
with these facts in his mind. He 
might very well feel, and very nat- 
urally feel, very much depressed and 
would therefore probably give ex- 
pression to ratiber exaggerated 
ideas of depression. 

Q. Presuming that on one occa- 
sion, about the end of February, Mr. 
G. M. did make a statement to his 
wife that the best thing would be 
for the three of them to die to- 
gether, does that, in your opinion, 
indicate that he was suffering from 
continuous and progressive melan- 
cholia, and that he was unable to 
appreciate his actions? 



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350 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



months, or probably a 3rear or more, 
before he came into my care. Of 
course, that is only a supposition. 
I can only speak of the man as I 
found him. 

Q. Do you conclude from the con- 
dition in which you found him that 
that disease must have existed for 
a year? 

A. For months before. 

Q. Six months? 

A. I should think more. I do not 
think that that condition of arteri- 
osclerosis could have originated in 
six months. 

Q. During that time — six months 
— would that patient be in an or- 
dinary, normal condition to transact 
business? 

A. Ordinarily speaking, I should 
think not. In this special case, I 
cannot say. 

Q. What has been the conduct of 
the patient since your return — can 
you speak of that personally? 

A. He has been a case of melan- 
cholia, with all manner of delusions, 
to the effect that he was ruined, and 
his family was ruined; that he was 
to be arrested and put in prison, 
and that he was to be tortured in 
all sorts of ways. These were the 
original symptoms when I saw him 
first Prior to that, of course, there 
was a number of things of which 
other witnesses can speak. I am 
only speaking of my own personal 
knowledge. That was his condition 
when I first saw him, and that con- 
dition has continued, and continues 
to-day. 

Q. Does it get better or worse? 

A. If anything, worse. There is 
a tendency towards what we call 
" f eeble-mindedness." 

Q. According to your experience 
and observation, at the time you 



A. No. I would not say that. He 
might make that same statement if 
he was quite depressed, owing to 
the condition of his son. If he felt 
that his son was dying, he might 
make use of the expression that it 
was better for all three of them to 
die together. However, you must 
follow that by his actions subse- 
quently. He had plenty of oppor- 
tunity during the following month, 
if he was determined to suidde, to 
do so. That would be before he was 
interdicted, but he did not do so, as 
far as I can read the evidence. 

Q. What I want to know is, if a 
person suffering from the disease 
which you found G. M. suffering 
from, can at times or on certain 
subjects behave rationally and talk 
rationally? 

A. On certain subjects? Do you 
mean on certain subjects or ration- 
ally at all, at any time? 

Q. I mean can he conduct him- 
self rationally, eat, drink, and go to 
bed, and do all that kind of thing, 
like an ordinary person? 

A. If a man has a condition of 
melancholia, while he is ill with that 
disease, he does not conduct himself 
rationally on all subjects, no. 

Q. I did not say on all subjects. 
I said on any subject? 

A. Yes. My answer is that a man 
with melancholia may intelligently 
discuss many things. 

Q. Is it not a fact that patients 
suffering from melancholia and de- 
pression and delusions, as you have 
described it, might deceive an ordi- 
nary person as to their condition, or 
might dissimulate their condition, 
and deceive persons who are not ex- 
perts as to their delusions? 

A. You are quite contrary to 
the facts. They magnify enor- 



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C. A. PORTEOUS AND H. V. ROBINSON 



351 



first saw the patient, had the disease 
made marked progress? 

A. My conclusion, when I first 
saw the man, was that the disease 
must have existed for quite a 
lengthy period beforehand. I could 
not just say how long. Of course, 
I might be wrong, but that would be 
the conclusion I would draw from 
the condition of the man— that the 
disease must have existed over 
months and months previously. 
That is the conclusion I would draw 
as a medical man. 

Q. According to your observa- 
tion, for what length of time had 
the mental condition of the patient 
existed at the time you saw him ? 

A. It is impossible to say defi- 
nitely, but in my own opinion (al- 
though I cannot say definitely) he 
must have been insane for months 
before. In my opinion, I have no 
doubt of it. Of course, I cannot say 
positively. It is only an opinion. 

By the Court: 

Q. That is, months before 3rou 
saw him in the month of August? 

A. Months before I saw him in 
August Of course, I could not say 
any definite, fixed time. 

By Mr. S.: 

Q. Is that according to your ex- 
perience? 

A. That is according to my ex- 
perience. 

Q. I presume you have had ex- 
perience in many similar cases? 

A. Probably some thousands. 

Q. Is it according to your ex- 
perience that the disease with which 
G. M. is afflicted is continuous and 
without intermission? 

A. It is continuous and progress- 
ive—both according to my own ob- 
servations, and from the weight of 



mously their condition, and their 
hypochondriasis. They never hide 
their condition. They do not try to 
hide their case at alL They g^ive it 
away too much. 

By the Court : 

Q. At the present time, can this 
man converse with apparent good 
sense on some subjects? 

A. On some subjects. For in- 
stance, he talked to me over the 
early history of his life in N. B., and 
told me how he tramped the rivers 
from there, and he knew a great 
deal about the geography of it He 
told me, to my surprise, that his 
son, R. M., was a cadet at the K. 
Military College when he learned 
that I was from K. 



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352 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



all authorities I have read at dif- 
ferent times. It is contiiiuous and 
progressive. 

Q. How does arteriosclerosis 
affect the brain ? 

A. By the changes in the circula- 
tion. The smaller blood vessels be- 
come thickened and the larger ones 
become what we call caldform — ^that 
is, deposits such as lime come in the 
coats, and they get thickened, so 
that the circulation in the brain 
is markedly affected, and this in- 
creases all the time; finally, if the 
patient lives long enough, it leads 
to what we call dementia. 

In rebuttal: 

Q. Dr. U., jrou have already been 
examined in this case? 

A. Yes. 

Q. Were you present yesterday 
when the medical experts for the 
defense gave their evidence? 

A, Part of the time. I may say 
I have not read any of the evidence 
at all, thank the Lord. I did not 
have to. I heard part of the evi- 
dence yesterday. 

Q. The opinion was expressed 
yesterday by one of the medical ex- 
perts for the defense that it was not 
possible to discover by examina- 
tion of the patient whether he is 
suffering from cerebral arterio- 
sclerosis or not Do you agree with 
that? You understand, I do not 
mean any patient in particular ? 

A. I do not agree with that en- 
tirely. For instance, if I find a 
man with marked arteriosclerosis 
in the radial arteries, there is a 
strong suspicion in my mind that 
that arteriosclerosis extends more 
or less all over the body, including 
the brain. If I find, then, there is 
marked arteriosclerosis of the tem- 



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C. A. PORTEOUS AND H. V. ROBINSON 



353 



poral arteries, then I am still more 
confirmed in my belief. Then, if 
the man has attacks of dizziness — 
almost semi-paralytic attacks— I 
would not hesitate to diagnose cere- 
bral arteriosclerosis. I might be 
wrong, but that would be my opin- 
ion as a medical man. 

Q. Suppose cerebral arterioscler- 
osis does exist, does it constitute an 
organic lesion of the brain? 

A. Certainly. Not of the brain 
substance, but of the brain as a 
whole. 

Q. What is the effect of that? 

A. The effect is to weaken a man's 
intellect all through. 

Q. Would that be a curable con- 
dition or an incurable condition? 

A. Absolutely incurable. 

Q. There is no going bade? 

A. No going back. 

Q. It has been sworn to here, in 
the medical evidence for the de- 
fense, that the condition of a patient 
suffering from melancholia is at all 
times apparent, and that it is impos- 
sible for the patient to conceal it 
or dissimulate it Do you agree 
with that or not? 

A. I do not I could dte you a 
score of cases of marked melan- 
cholia confined in an asylum where 
I would defy anyone, for dasrs, to 
say it was a case of melancholia. 
I do not agree with that opinion at 
all 

Q. Are you speaking now from 
your personal experience in the 
asylum? 

A, That is my personal experi- 
ence, extending over forty years, 
and covering perhaps 8000 or 9000 
cases. 

Cross-examined by Mr. G. : 

Q. Do you suggest that this par- 
ticular roelandioliac G. M. dissimu- 
lates? 

as 



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354 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



A. No; I don't think so. 

Q. And that was the meamng of 
your answer to Mr. S.? 

A. That is the meaning of my 
answer to Mr. S. He might appear 
to be sane for a time, but no insane 
man can imitate sanity. If I may 
be allowed to say it, an insane man 
might pass muster for a time as a 
sane man. I can dte you dozens of 
cases. 

By the Court: 

Q. Could a man suffering from 
melancholia meet old friends, for 
example, and be able to converse 
with them about the affairs of his 
childhood, and of his former life, in 
apparently a perfectly rational way? 

A. It is quite possible. I have 
known a number of cases of the 
kind in my own experience. Of 
course, he could not do it for any 
extreme length of time, but I have 
known cases of melancholia go for 
a day or two, or perhaps a week, 
brightened up so that they would 
be apparently sane. However, at 
the same time they were insane. 

Q. With a roelancholiac there is 
usually some delusion or appre- 
hension? 

A. Usually. 

Q. When there is such a delusion, 
is it the tendency of the melancholiac 
to give vent to that delusion in 
speaking of his friends and com- 
panions? 

A. I think the tendency is that 
way. On the other hand, the mel- 
ancholiac sometimes has the power 
to restrain himself to a large ex- 
tent Probably his will power is 
not lost entirely. Of course, the 
tendency is to talk freely about his 
delusions, but, if something else 
comes to his mind, he has the 



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C. A. PORTEOUS AND H. V. ROBINSON 



3SS 



power to control himself to a cer- 
tain extent and not give expression 
to the delusions. I have seen scores 
of cases of that kind. As I say, I 
have probably had 8000 or 9000 or 
xo^ooo cases of insanity to deal with 
in my experience, and I know th^ 
can control themselves to a certain 
extent, and appear absolutely sane. 

DBFosmoNs OF Dm. V. and X. 

Db. V. 
Examined by Mr. H. J. E, of 
counsel for plaintiff: 

Q. How many years have you 
been practising medidne, Dr. V.? 

A. Since 1883, 30 years. 

Q. I understand you have made 
a specialty of mental diseases? 

A. I have. 

Q. How long have you been en- 
gaged in that special work? 

A, About twenty-six years. 

Q. You were connected with one 
of the hospitals for the insane here 
in Montreal? 

A. I am. 

Q. Which one? 

A. The HospitaL 

Q. Is that a large hospital? 

A, It is. 

Q. About how many patients 
would you have there under treat- 
ment at a time? 

A. I was looking up the records 
the other day, and we had alto- 
gether, public and private, about 
2300 cases. 

Q. Did you have occasion to visit 
and examine G. M., now confined in 
the Verdun Asylum? 

A, I did. 

Q. When did you examine him? 

A. A week ago kwt Sunday. No- 
vember 30^ I think it was. 



Deposition of Dk. D. 
Examined by Mr. S. L. D. H., of 
counsel for defendant: 
Q. What is your present position? 

A, Superintendent of the 

Sanitarium, , Ontario. 

Q. What has been your expe- 
rience with mental diseases? 

A. I graduated in Toronto in 
1890. I spent two years in general 
medidne, and from that time on I 
have been continuously in mental 
work. I spent ten or eleven years 

in Asylum, and the balance 

of the time at . 

Q. What sort of people do you 

treat at ? 

A. At the Asylum we 

treated all mental diseases. At the 

Sanitarium we have all 

classes of patients. 

Q. What is the size of the 

Asylum? 

A. The Asylum has about 

1000 or 1 100. In the Sani- 
tarium we have a capadty of about 
130. 

Q. I understand you examined G. 
M. a short time ago? 
A, December 11, 1913. 
Q. Did you find him suffering 
from any mental disease then? 

A. I found him suffering from 
melancholia, with delusions. 



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356 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



Q. Will you please describe to the 
court the condition in which you 
found him on your examination? 

A. I found him suffering from 
profound involutional melancholia. 
His depression was very, very 
marked. He was overcome by an 
intense idea of ruination. I found 
his memory very much affected. He 
could not tell me the date nor the 
year. He could not tell me how 
long he had been in the institution. 
He was under the impression that 
his wife was in an adjoining part 
of the institution and he had certain 
expressions that he made use of in 
the course of the conversation quite 
characteristic of melancholia of in- 
volution, such as ** My God " ! ** My 
God "I At times in all of these 
cases, even in the advanced stages, 
there is a certain amount of coher- 
ency of thought and they can an- 
swer questions and their answers 
taken by themselves are quite co- 
herent. 

Q. From your examination at 
that time, and from your examina- 
tion alone, were you able to form 
any opinion as to the date when this 
disease had its beginning? 

A. Taking his case, independent 
of any legal connection, but in the 
ordinary run of my experience, I 
should say from the enfeeblement 
I noticed in his memory I would 
naturally come to the conclusion, as 
I have in many other cases which I 
have observed, that the disease had 
an antecedent history of quite a 
duration of time. 

Q. Have you been present in court 
during the hearing of this trial? 

A. Yes. 

Q. Did you hear the evidence of 
Dr. W.? 



Q. You have, I understand, read 
all the evidence which has been 
given at the trial? 

A. Yes. I heard part of it and I 
read it alL 

Q. From the evidence and from 
the documents filed which you may 
have read are you able to form an 
opinion as to the sanity of Mr. G. 
M., the father of the plaintifl^ dur- 
ing the months of December, 191 1, 
and January, February, Mardi, 
1912? 

A. I consider he was sane. 

Q. During these months? 

A. During these months. 

Q. Basing yourself on the evi- 
dence and the documents filed, what 
in your opinion was the mental ca- 
padty of G. M. to s^redate die 
nature of his transactions with Mr. 
M. which are referred to in this 
case? 

A. He was mentally capable of 
doing it 

Q. That is your opinion? 

A. That is my opinion. 

Q. Do you mean that he was 
naturally capable of appreciating 
it? 

A. Yes. 

Q. Would you consider from the 
evidence you read and from the 
documents you read that G. M. was 
suffering from confirmed melan- 
cholia (which I understand is con- 
tinuous and progressive) during the 
months in question? 

A. No. 

Q. What are your reasons briefly 
for the opinions you have expressed 
regarding G. M.'s condition during 
these months of January, February 
and March? 

A. Well, as from the evidence as 
given by Mr. W., his solicitor, who 



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C. A. PORTEOUS AND H. V. ROBINSON 



357 



A. I did. 

Q. And Dr. S.? 

A. Yes. 

Q. And Dr. T.? 

A. Yes. 

Q. Assuming that the facts re- 
cited by these several witnesses are 
correct, have you in these facts a 
basis upon which to form an opinion, 
and if so, will you state to the 
court what that opinion is as to 
the date of the commencement of 
this disease in Mr. M.? 

A. Assuming these facts to be 
true. I am of the opinion that the 
man was insane for quite a period 
of time prior to his commitment to 
the Verdun Asylum. I would be of 
the opinion that the man was insane 
in the month of January or Feb- 
ruary positively. 

Q. 1912? 

A. 1912. 

Q. What is the character of this 
particular disease? By what name 
would you term it? 

A. In later years we have adopted 
for the time being only, as a quasi 
classification of insanity, the Ger- 
man classification, and such condi- 
tions as are observed in the case of 
Mr. M. we place in the category of 
melancholia of involution. This is 
a disease characterized by uniform 
depression, accompanied with fear. 
It is, however, accompanied by dis- 
tinct delusions, self -accusations, and 
self-depredation of a persecutory 
nature and of a hypochondriac 
nature, with disturbances In the 
train of thought, and in the vast 
majority of cases it ends up with 
deterioration of the brain. There 
is a certain percentage of cases 
which are considered to recover, but 
thor are very small. 



saw him frequently in these months 
— ^between December and March — 
and who transacted business for 
him. Mr. W. drew up certain docu- 
ments, and he states in his evidence 
that Mr. M. insisted on and directed 
certain changes in these documents, 
and that he was capable of under- 
standing them. Mr. W. also says 
that he did not notice ansrthing un- 
usual in the man at the time. That 
is one of my reasons. Another 
reason is that he performed certain 
business transactions during these 
months, as evidenced by the dep- 
osition of Mr. D., who told us 
what Mr. M. had done with refer- 
ence to the dredges. This is also 
evidenced by Mr. B., whom Mr. M. 
advised in regard to some farm 
lands, and by the evidence of Mr. 
P. in regard to the purchase of 
some real estate in Montreal I 
consider all this evidence is good 
evidence of the man's mental con- 
dition and capability of doing busi- 
ness at that time. He also met many 
witnesses upon the streets in Mon- 
treal, who knew him welL He met 
them in the different hotels, the 
Corona, the St Lawrence Hall, the 
Windsor Hotel, and so on. Th^r 
had conversations with him and they 
stated that they noticed nothing out 
of the way in his actions or speech. 
A little more important is the evi- 
dence of men like Mr. S. and Mr. J., 
both capable business men, who im- 
pressed me here m the witness box 
as being straightforward business 
men. They saw Mr. M. frequently 
during the same months and had 
conversations extending from ten 
minutes to an hour with him at dif- 
ferent times. They knew him in- 
timately and they stated that they 



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Q. From the history of this case, 
do you find any evidence of inter- 
mission in the disease, or was it 
continuous and progressive? 

A. In my humble opinion there 
was no intermission; simply a pro- 
gression of symptoms. 

Q. So that, assuming as a matter 
of fact that this disease existed in 
January (or certainly in February), 
in your opinion was the man insane 
from that time on? 

A. It is my opinion that from that 
time on he was insane. 

His Lordship: From what time 
on, Mr. E.? 

Mr. £. : From the month of Jan- 
uary, 1912, my Lord. 

By the Court: 

Q. Is tha.t what you mean, Dr. 
v.? Is it your opinion that he was 
insane from the month of January, 
1912? 

A. Yes, my Lord; from towards 
the close of the month of January. 

Cross-examined by Mr. H., of 
counsel for defendant: 

Q. Will you tell us exactly what 
you mean by " insane ? " 

A. I would say that the man was 
deprived of the power of exercis- 
ing his common sense. 

Q. You consider he was deprived 
of the power of exercising his com- 
mon sense since January? 

A. I would say that he was de- 
prived of the exercise of his com- 
mon sense. I might specify more 
clearly by saying in matters involv- 
ing the higher relations in his life. 

Q. What do you mean by the 
** higher relations?" 

A. Passing judgment upon mat- 
ters of importance to himself and 
those connected with him. 

Q. Will you tell us exactly what 
were the facts upon which you base 



saw nothing wrong with him in his 
actions or his reasoning power. 
They did not notice anything out of 
the way. Then, evidence is given 
of certain documents or letters that 
he wrote in reference to business 
matters during these months. 
These documents show fairly dear 
reasoning. We also have the evi- 
dence of Mr. S., an independent 
lawyer, who occupied adjoining 
offices to Mr. W. Mr. S. saw him 
frequently during the same months. 
He did not have any business trans- 
actions with him whatever. I think 
he was absolutely independent in his 
opinion. He stated he saw nothing 
wrong with Mr. M. during that time. 
In the converse we have the evi- 
dence of Dr. S. and Dr. T. and the 
sanitarium nurses, who saw him 
during the same period at certain 
intervals. They stated he was very 
much agitated, suffered from in- 
somnia and they noticed a number 
of conditions which I consider were^ 
at that time, the natural anxieties 
of a man suffering from stress and 
worry. That is my own evidence 
in regard to his condition. He was 
anxious and worried over his son's 
business and his own affairs at the 
time. 

Q. Assuming that on certain oc- 
casions prior to the first week of 
March, 1912, or about that time G. 
M. made statements to the effect 
that he was ruined or that his 
family was ruined or his son was 
ruined (as stated in the evidence), 
would that in your opinion indicate 
that he was insane and incapable of 
appreciating the nature of these 
transactions with Mr. M. and Mrs. 
M., referred to in this action? 

A. This man was under great 
stress and strain at the time, and. 



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C. A. PORTEOUS AND H. V. ROBINSON 



359 



the opinion that he was insane in 
January? 

A. In the first place, I base my- 
self upon the fact that in melan- 
cholia there is a delusional state 
which differs from the delusional 
states observed in other forms of 
insanity. That is to say, the delu- 
sional state of ruin or depression is 
of such a character and such an 
intensity that once it takes a hold 
of the individual attacked it domi- 
nates his whole psychic being, even 
without there bdng anything in his 
external appearance or in his con- 
versation to dte the fact in partic- 
ular. While I do not feel that any 
close observation, such as we ordi- 
narily make of a patient coming 
under observation, was made, still 
there was a sufficient examination 
made, and the description of the ex- 
amination as given by Dr. T. was a 
very classical presentation of a case 
of melancholia of that character, as 
it would appear in the wards of our 
asyluuL The manner in which Dr. 
T. described his interview with the 
patient, his downcast appearance, 
his state of torpor; when put a 
plain, ordinary, sensible question as 
to what was the matter with him 
he could not describe it except as 
that of a condition of ruin. The 
very words he used are typical of 
these cases— ** It is terrible." "It 
is terrible." These are the words 
that a melancholiac would use. It is 
a vague expression, if you will, of 
the profound disturbance of his 
mind. 

Dbposrion op Ds. X. 

Examined by Mr. L., of counsel 
for plaintiff: 

Q. For how many years have you 
been practising your profession? 



I believe, was in a fair way to lose 
a large amount of money. It ap- 
peared to the man, who had worked 
very hard in times gone by, that 
this looked as if the commencement 
of ruin was upon him, and that it 
might go on. He expressed these 
delusions especially when he was in 
the hospital, in contiguity to his son, 
who was very ilL I consider these 
were normal anxieties at that time. 

Q. In giving your opinion, do you 
bear in mind the statement he made 
on certain occasions as to ruin, or 
the statement made by Mrs. M. that 
on one occasion he said the best 
thing would be for the three of 
them to die together? 

A. I think in his normal mind he 
might give expression to a thought 
of that kind when they were suf- 
fering. At a certain time he might 
give expression to the idea that the 
best thing to do would be to die. 
I have known normal men give ex- 
pression to the thought that th^ 
wished to God they were out of 
the world, or wished th^ were 
dead, or something like that 

Q. You have borne these facts in 
mind in giving your opinion? 

A. I include them together with 
the fact that he met these intelligent 
people at different times on the 
street and never expressed these 
ideas to them at all, which, un- 
doubtedly, he would have done if 
the disease of melancholia were 
established at that time. 

Cross-examined by Mr. S., of 
counsel for plaintiff: 

Q. May a person be insane with 
that form of insanity known as 
melancholia and yet perform the 
usual acts of life in the usual way? 

A. It depends again upon the 
delusion that he may have. 



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360 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



A. Since iBSg. 

Q. Have you made a specialty of 
the study of certain diseases? 

A. Yes, sir. Since i8$^ I have 
been occupying the position of Med- 
ical Superintendent of the 

Hospital for the Insane. 

Q. How does that hospital com- 
pare with others in the Province of 
Quebec for importance? 

A. I think it is the largest asylum 
in the Province of Quebec, and I 
think about the second largest in 
Canada, if not the largest 

Q. You have been there since 
1894? 

A. Yes. 

Q. Did you ever examine Mr. 
G. M., who is in question in this 
case? 

A. Yes, sir. 

Q. Will you say on how many 
occasions? 

A. I examined Mr. M. on the 28th 
of February last, 1913. 

Q. At the request of whom? 

A. I examined him at the request 
of Dr. Y., who sought my opinion 
as to Mr. M.'s condition at the time, 
and as to whether I could form an 
opinion in regard to his condition 
for some time previous to that 

Q. Let us deal with the marks 
whereby you recognized this form 
of insanity which you call melan- 
cholia. What were these marks? 

A. At the time I found Mr. G. M. 
a patient in the Verdun Hospital for 
the Insane. He was in a great state 
of anxiety and was suffering from 
delusions of a depressing and terri- 
fying nature. He was also suffering 
from hallucinations of hearing, also 
of a depressing and terrifying 
nature. 

Q. Starting from what you found 
on the 28th of February, and adding 



Q. If we leave aside the question 
of the remissions and come back 
to the question I asked you, I would 
like you to inform the court 
whether persons recognized to be 
insane with that form of insanity 
known as melancholia may perform 
all the usual acts of life in the 
usual way? 

A. Again I must answer it de- 
pends upon the intensity. 

Q. I am not speaking of the in- 
tensity at alL I am speaking of per- 
sons who are recognized as being 
insane? 

A. I am speaking of the same 
people. 

Q. So that, according to you, per- 
sons recognized to be insane from 
melancholia may perform the usual 
acts of life in the usual way? 

A. Under certain circumstances. 

Q. I am speaking of any patient 
suffering from melancholia. I am 
not speaking of all patients. 

A. It depends on the intensity. 
In the remissions the disease still 
exists, but at these times they may, 
and do^ direct one in carrying on 
certain business, in ways which are 
perfectly justified and perfectly 
clear. 

Q. During these remissions, are 
they sane or insane? 

A. They are insane; the depres- 
sion still exists. 

Q. Is it not a fact, Dr. D^ Hat 
a patient so afflicted may converse 
for a considerable length of time 
without betraying his condition? 

A. Not in my experience. Thty 
worry the life and soul out of me 
every day. It is hard to get away 
from them. They will persist in 
talking about their delusions. 

Q. Is it not a fact that in an un- 
limited number of cases the patient 



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C. A. PORTEOUS AND H. V. ROBINSON 



361 



to your own findings those of Dr. 
S. and Dr. T., at the respective dates 
they have mentioned, and also the 
evidence of Dr. U. and Dr. W., 
would these findings and these facts 
constitute a previous history of the 
case sufficient to complete your con- 
clusions as to the duration of time 
during which this disease had pre- 
existed? 

A. Yes, sir. 

Q. Taking these findings and 
these facts in conjunction with your 
own observations on the 28th of 
February, what: conclusion have 
you reached as to the time during 
which this disease probably pre- 
existed? 

A. I would date it at least as 
far bade as December, xpii, and 
would say that it was continuous 
and progressive since that time. 

Q. When you say "progressive" 
I suppose in matters such as this 
it is merely a figure of speech, be- 
cause it is progressive die wrong 
way. It is an aggravation really? 

A. Yes. "Progressive" means 
aggravation. 

Q. Now, Dr. X., you are not a 
business man? 

A. No. I have no time for that. 

Q. But you have made contracts. 
Apart from the contract of mar- 
riage, of course? 

A. I never made a contract in my 
life. I never did anything but study 
medidne. 

Q. You know what a contract is? 

A. Yes; sure. 

Q. Would you believe that a man 
laboring under this disease of mel- 
ancholia, the presence of whidi was 
detected as far bade as December, 
19x1, and which became graver up 
to the month of March, 1912, would 



will converse for a certain length 
of time without referring to his 
delusions at all, unless his attention 
is called to them? That is to say, 
as long as you keep the patient on 
indifferent subjects he may be per- 
fectly sane, to all outward appear- 
ances, but as soon as you approach 
him on the subject of his delusions 
then he is persistent and the delu- 
sions become predominant and par- 
amount? 

A. My experience is, with friends 
constantly visiting the patients, they 
are always harping on their delu- 
sions. The friends are constantly 
telling me, "Well, So and So will 
persistently talk about his ruin," 
or whatever the delusion may be. 
My experience has not been with 
strangers, but with the friends of 
the patients. These people persist 
in talking to thdr friends about 
thdr delusions. 

Q. So that you would give it as 
your definite opinion that patients 
afflicted with melancholia must 
always betray thdr condition to 
persons with whom they are in con- 
versation? 

A. Particularly friends and rela- 
tives. 

Q. According to your experience, 
how long would the disease have 
existed in this man before he was 
committed on July 15? 

A. In May and June. I agree 
with Dr. S. and the evidence of Dr. 
T., and the fact that in that month 
he noticed a diange. 

Q. So that, in your opinion, he 
was insane as far back as May, 
1912? 

A. Yes; the end of May. 

Q. You will not go back any fur- 
ther than that? 



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362 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



be able to exercise his judgment 
and mental faculties for the pur- 
pose of transacting business, or en- 
tering into contracts? 

A. No; certainly not 

Cross-examined by Mr. G., of 
counsel for defendant: 

Q. Will you please specify to me 
the facts which you have seen in the 
evidence which have induced you to 
say that in December, January and 
February it was a case of confirmed 
melancholia ? 

A. I find there most of the symp- 
toms which I found myself in Feb- 
ruary, 1913, and which gave me 
the opinion then that it was a con- 
firmed stage of melancholia. 

Q. I am asking you to specify 
these symptoms, which, according 
to what you understood or read in 
the evidence, existed in December, 
191 1, and January and February, 
1912? 

A. We find the man to have been 
in a great state of moral pain, 
anxiety and anguish, and that he 
had delusions Uiat he had ruined 
himself and family. He was act- 
ing in a very excited manner and 
speaking incoherently, according to 
the evidence. This condition is 
stated to have existed in Decem- 
ber, 191 1. Then, we find these 
ideas repeated at frequent intervals 
by those who observed him in Jan- 
uary, February, March, April, June, 
July, and so on. 

Deposition of Dr. Z. 

Examined by Mr. S., of counsel 
for plaintiff : 

Q. You are a practising physician 
in the City of Montreal? 
A. Yes. 



A. I cannot find evidence that 
would commit the man further back 
than that 

Q. Is the disease of melancholia 
one of rapid development or of 
slow development? 

A. It depends on the case. Sud- 
den shock will bring a patient into 
melancholia in a short time. 

Q. He cannot be sane and insane 
at the same time of course? 

A. No; he cannot be water and 
oil. 



Deposition op Dr. A. 

Examined by Mr. S. L. D. H., of 
counsel for defendant: 

Q. You are practising your pro- 
fession in Montreal? 
A. Yes. 



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C. A. PORTEOUS AND H. V. ROBINSON 



363 



Q. Since how long? 

A. I graduated in 1901 in medi- 
cme and in 1897 in arts at McGilL 

Q. Have you been practising in 
Montreal ever since? 

A. No. I was two years at the 

as house surgeon; then I 

went to the Hospital in Balti- 
more for the better part of a year. 
Then I went to Europe and I had 
a year in Switzerland with Profes- 
sor Von Munerkof, working in his 
laboratory. Then I was in various 
parts of Germany, Berlin, and so 
on. After that I went to Paris. 
Then I spent a year in London, at 
the National Hospital for the Par- 
alyzed and Epileptics, where they 
make a specialty of diseases of the 
nervous system. 

Q. If I understand you rightly, 
you have made a specialty of nerv- 
ous diseases? 

A. Nervous and mental diseases; 
yes. 

Q. You visited Mr. M. at the 
asylum? 

A. Yes. 

Q. In what condition did you find 
him? 

A. I have a letter which I wrote 
to Dr. Y. I think if I were per- 
mitted to read that letter to the 
court it might save time and con- 
vey all to you that I could convey by 
my evidence. 

Q. Was the letter you are about 
to read written after your visit? 

A. Yes. I wrote it that same 
evening. 

The letter in question reads as 
follows : 

MoNTBEAL, May 3, 1913. 

My dear Dr. Y.: Re Mr. M., 
whom I examined in 3rour presence 
at the Protestant Hospital for the 



Q. Have you specialized in any 
particular branch of medicine? 

A. Nervous and mental diseases. 

Q. What is your experience in 
that regard? 

A. I am lecturer on nervous dis- 
eases at University. I am 

neurologist at the General 

Hospital I am consulting neurol- 
ogist at the Hospital for Insane, 
. I am professor of nervous 



and mental diseases. University of 

, and have been for over 

twelve years. I was associated for 

some time with the Hospital 

for the Insane. I am consultant for 
the Hospital of Mental Disease, 

, Vermont I was associated 

for some time with the Hospital 

for the Insane at , England. 

I have been employed by the 
United States Government for many 
years as an expert for the criminal 

insane in the State of and 

the State of » I am neurolo- 
gist for the Railroad. I am 

a member of the Neuro- 
logical Association. I am a member 

of the Association. I am a 

member of the ■ Institute for 

Criminal Law and Criminology. 

Q. How long have you been prac- 
tising 3rour profession? 

A. I graduated twenty-eight years 
ago. 

Q. From where did 3rou graduate? 

A. University, . 

Q, You say you are consulting 

physician at Asylum. Is 

that the ■ for Insane at 



-? 



A. Yes. 

Q. With which Dr. U. and Dr. 
W., examined here on behalf of the 
plaintiff, are connected? 

A. Yes. 



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364 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



Insane at Verdun, the 2d inst, I 
find that this patient is suffering 
from great mental depression, asso- 
ciated with delusions of a persecu- 
tory nature. Suicidal tendencies 
are evidently marked, also he has 
made more than one attempt on his 
life. He imagines that he has ruined 
his whole family hy giving away 
money and also some contract that 
his son had. He has, he thinks, 
committed the great sin — he is 
lost When asked why he gave away 
his son's money he answered that 
he did not know; he must simply 
have got a notion. He could not 
remember just when or where he 
had done it Instead of a shrewd 
business man, his mind is now full 
of indecisions. He practically 
never makes a positive statement, 
and seldom ever gives a positive 
answer to a question. He has in- 
sane delusions and imagines that 
people are saying things against him 
of a horrible nature. He stated that 
everything he said to us was over- 
heard because the room was wired 
and connected with telephones and 
all our remarks were noted down 
already somewhere. Examination 
showed paralysis of the movements, 
atrophy of the optic nerve, and 
blindness of the right eye, the re- 
sult of an attempt at suicide with a 
pair of scissors. He has all the evi- 
dence of marked arteriosclerosis. 
I am, therefore, of the opinion that 
this patient is suffering from men- 
tal disease of the nature of an in- 
volutional melancholia, associated 
with cerebral arteriosclerosis. In 
answer to the question as to whether 
this would have had bearing of an 
etiological nature on his peculiar 
action in giving away the money, 
one can only answer that it probably 



Q. You are consultant for men- 
tal diseases at that hospital? 

A. Yes. 

Q. In 3rour practise at the hospital 
and the different places you have 
described 3rou confine yourself to 
nervous and mental diseases ? 

A. Yes. 

By the Court: 

Q. Has your work as a specialist 
been running for many years? 

A. About eighteen years. 

By Mr. H., continuing: 

Q. I understand you have had 
occasion to examine G. M., the 
father of the plaintiff in this case? 

A. Yes. 

Q. At the Verdun Asylum? 

A. Yes. 

Q. On what date did you examine 
him, and what did you find him suf- 
fering from? 

A. I examined him on the nth 
of December, 1913. He was suf- 
fering from melancholia. 

Q. You have read through the 
evidence given on both sides of this 
case? 

A. I have. 

Q. You have also read the letters 
filed as exhibits from G. M. to W. 
M., the defendant, and from Mrs. 
M. to M., as well as the other writ- 
ings of G. M. filed in this case? 

A. I have. 

Q. Are you able to form any opin- 
ion, as a result of the evidence 
given and the documents filed as to 
the sanity or insanity of Mr. G. M. 
during the months of December, 
191 1, and January, February and 
March, 1912? 

A. I believe he was sane. 

Q. Is that your opinion as a med- 
ical man? 

A. That is my opinion as a med- 
ical man. 



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C. A. PORTEOUS AND H. V. ROBINSON 



365 



did, but one would need corrobora- 
tive evidence of some change in 
character, some peculiarity of ideas 
and actions present at the time. One 
of course recognized that the symp- 
toms of cerebral arteriosclerosis 
may often come on almost acutely, 
following some shock either mental 
or physical, or as a result of mental 
strain. I would, therefore, urge the 
necessity of searching for corrobo- 
rative evidence of the nature re- 
ferred to. 

'\A^th kind regards, I remain. 
Yours sincerely. 

Q. Did you or were you able to 
form an opinion as to how long the 
condition in which you found the 
patient had lasted? 

Witness: Do you mean at the 
time of that examination or since? 

Counsel: At the time you made 
the examination? 

A. I could form no opinion from 
what I saw, except that it nmst 
have been present for some time. 
One could not say more than that 

By the Court: 

Q. What would ** some time ** in- 
dicate? '^ Some time " is a general 
expression of course. As regards 
wedcs, months, or years, what 
would you want the court to under- 
stand? 

A. One could definitely say it had 
existed for some months I think; 
especially if one could take into 
account the history one got with the 
patient one could very positively 
say it had existed for some months. 

Q. From what you knew at the 
time you went there to examine 
him? 

A. From nay examination of Mr. 
M. at that time I would say that the 
condition might have lasted for a 



Q. And as a specialist? 

A. And as a specialist 

Q. Basing yourself on the same 
evidence and the same documents, 
what is your opinion as to the men- 
tal capacity of G. M. to appreciate 
the nature of the dispositions of his 
property in question in this case, 
about February 21, 1912? 

A. I think he was a sane man and 
perfectly capable of doing it 

Q. You consider he was capable 
of appreciating the nature of these 
transactions? 

A. I do. 

Q. Would you consider from the 
evidence and documents on record 
that Mr. G. M. was suffering from 
confirmed melancholia (which is a 
continuous and progressive disease) 
during and throughout these 
months? 

A. He was not 

Q. Will you give us briefly some 
of the reasons for the opinions you 
have expressed in regard to Mr. 
G. M.'s mental condition? 

A. To make it brief, I may say 
that I agree thoroughly with Dr. £. 
and Dr. C^ Dr. D. and Dr. B. I 
agree with what they have said in 
connection with the different wit- 
nesses who came up from Dalhousie 
and who were residing in the neigh* 
borhood of Montreal 

Q. Do you agree with the reasons 
they expressed with regard to thdi 
opinion as to the mental condition 
of G. M. during the time in ques- 
tion? 

A. Yes. I also agree with them 
in their opinion as regards the 
nurses in the sanitarium— that at no 
time was a delusion demonstrated 
or ever shown to be a fixed delu- 
sion. I think that, as the court 



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366 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



couple of years or it might have 
lasted for a less period. One could 
not make a statement, as I said in 
that letter, as to how long this had 
lasted. One could not judge from 
one's examination. 

Q. Did you hear the evidence 
which had been given in this case 
by other specialists and by those 
intimate with the patient? 

A. I heard Dr. W.'s evidence and 
I heard the evidence of Dr. U. I 
also heard the evidence of Dr. S. 
and Dr. T. 

Q. Does that enable you to form 
any more definite opinion with re- 
gard to the time this disease may 
have lasted? 

A. I think it does; yes. Dr. S. 
gave evidence that in January the 
man was suffering from insonmia, 
mental indecision, and that he was 
worrying and showed lack of con- 
centration. This was in January. 
Now, in February and March Dr. 
S. recommended that they should 
send him to a sanitarium for mental 
diseases. Evidently he had pro- 
gressed backwards a good deal. In 
June Dr. S. had to bring him home 
from the comer of Peel street. 
This man was then standing in the 
middle of the street in a state of 
mental confusion. On July 11 he 
had definite delusions. Then, as 
far as I know, he was a man quite 
well off, but at the same time he 
was going around asking everybody 
for ridiculous positions. I mean 
to say he was asking for positions 
that were ridiculous, taking into 
account his position and his age. 
Imagine a man of his age volunteer- 
ing or thinking of climbing tele- 
graph poles. He was a man who 
had managed big business affairs, 



stated yesterday, we may apparently 
be taking sides, and to offset this, I 
believe we should lay particular 
stress on that part of the evidence 
where no outside influence can be 
brought into play. That in partic- 
ular would be the letters written 
by Mr. M. during that period. Th^ 
speak for themselves. These letters 
relate to certain business transac- 
tions which have been shown to be 
carried out and which were, in my 
opinion, carried out in a very cor- 
rect manner. If G. M. was able to 
undertake journeys, considerable 
distances from Montreal and carry 
out business on these journeys — if 
he was able to go, in the spring of 
the 3rear, some hundreds of miles 
alone, down to Dalhousie and come 
bade again, to my mind this clearly 
demonstrates that the man used his 
will power and his judgment and 
nothing in his conduct in any way 
showed that he was suffering from 
an insane condition. Dr. S., who 
saw him in December and examined 
him for the first time in January, 
says that at that time he was suffer- 
ing from nervousness, agitation and 
depression. At that time Dr. S. did 
not see any symptoms of insanity. 
It was not until about the beginning 
of March, when his attention was 
drawn to Mr. M.'s condition by 
Mrs. M. and the statement was 
made with regard to the revolver, 
that he thought it was necessary to 
advise a sanitarium. Dr. T. saw him 
about that time and made an ex- 
amination. He states he paid par- 
ticular attention to M.'s physical 
condition. At the same time he 
mentions that M. did show some 
nervous states, but that he did not 
make a mental examination. I was 



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C. A. PORTEOUS AND H. V. ROBINSON 



367 



and he had made a success of things. 
I think any idea of this kind showed 
decided mental deterioration at that 
time. 

Q. What about his will power, Dr. 
Z.? 

Witness: What do you mean by 
"will power?" 

Q. There would be marked en- 
f eeblement of the power of the will, 
so as to act independently of others, 
or would he be subject to being in- 
fluenced by the will of others more 
than he would in his normal con- 
dition? 

A. He would be uncertain in un- 
dertaking new lines, but in regard to 
actions that were caused by his 
delusions, he might be very obsti- 
nate. He would, perhaps, be de- 
pendent upon the help of other 
people in undertaking new lines, 
and new thoughts, and new ideas, 
and new a£Fairs— he would feel his 
own enfeeblement 

Q. From the personal examina- 
tion you made of the patient at the 
time, could you say whether arte- 
riosclerosis that he had was known 
as cerebral arteriosclerosis or not? 

A. Oh, yes. He had definite evi- 
dences of cerebral arteriosclerosis 

Cross-examined by Mr. D. H., of 
counsel for defendant: 

Q. I suppose that before you ex- 
amined Mr. M. you were told some- 
thing of his case, were you not? 

A. Oh, yes, of his case. 

By the Court: 

Q. Do I understand you to say 
that very few people whose minds 
are affected are free from insomnia? 

A. No, my Lord; I did not say 
that I say there are very few 
people suffering from insomnia 
whose minds do not become affect- 
ed, more or less of course. 



not present during the examination 
of Dr. S. or the examination of Dr. 
T., but there is a feeling to the 
effect that they stated Mr. M. was 
insane. I cannot think it possible, 
seeing that he was allowed his 
full liberty, and allowed to journey 
down to Dalhousie, and allowed to 
go around the hotels just as he 
liked. Dr. T. is one of our leading 
men in the City of Montreal, and a 
case of insanity would be treated by 
him like a case of diphtheria— in a 
case of diphtheria we naturally take 
precaution to save the individual 
and to save the people at large. In 
insanity we do the same thing. So 
far as I am concerned I cannot 
think for a moment that Mr. M. 
was insane in the months of Jan- 
uary, February and March. True, 
he did speak about being ruined, or 
ruining his family. Dr. S. telb us 
about him being worried and stating 
repeatedly that he was ruined, yet 
he was known to give two thousand 
dollars to Mr. M. in April. He did 
not act like a man who had a delu- 
sion — ^a melancholiac He certainly 
had nervous sjrmptoms. He was 
agitated, depressed and emotional 
I might say he was peculiar, but all 
alienists know that peculiarity in 
character frequently is present in 
those cases of people who develop 
melancholia later on. For these 
reasons and others I conclude that 
Mr. M. was a sane man in the 
months of January, February and 
March, 1913. 

Q. Assuming that Mr. M. had 
beta suffering from melancholia 
during these two months what 
would you say as to the possibility 
of persons with whom he came in 
contact during that period noticing 
anything about his condition? 



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368 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



Q. It is one of the initial stages 
of mental trouble? 

A. It may be. It is not always. 

Q. A man may have insomnia for 
a few months, and then right him- 
self? 

A. Yes. 

Q. But if it be continuous? 

A. A man may have insomnia 
from worry or from pain. You 
have to take the whole case together. 
Here is a man suffering from ar- 
teriosclerosis, and a very definite 
worry, beginning to suffer from 
constant insomnia. That is a very 
different and very serious symptom. 

By Mr. H.: 

Q. A man suffering from mel- 
ancholia is not necessarily at all 
times incapable of appreciating 
what he is doing? 

A. A man suffering from melan- 
cholia with mental deterioration is 
at all times under the power of his 
delusions. 

Q. But there has to be mental de- 
terioration also? 

A. Well, even without mental de- 
terioration, a man who is suffering 
from melancholia would be influ- 
enced by his delusions. Of course 
there are melancholiacs and melan- 
choliacs. If we stick to the point as 
you know, this man was suffering 
from involutional melancholia. 

Q. That is when you saw him in 
May, 1913? 

A. Yes; I have no doubt in my 
mind, from the testimony I have 
heard here, that in January, 1912, 
he also had it I have no doubt he 
had it then. If we just stick to 
the point, I am perfectly certain 
that man was influenced by his de- 
lusions constantly from time to 
time, and he had mental deteriora- 
tion at that time. 



A. I think if a man is suffering 
from melancholia he could not meet 
his friends as Mr. M. did without 
displaying it He could not meet 
friends from day to day, sometimes 
twice a day, and not manifest the 
symptoms of the disease. 

Q. In giving your opinion do 
you bear in mind the facts (assum- 
ing them to be true) that Mr. M. 
did, on certain occasions, during 
these months make statements to 
the effect that he or his family or 
his son were ruined, or on one oc- 
casion he said the best thing would 
be for the three of them to die 
together? 

A. Yes, I have borne that in mind. 
I believe a sane man might make a 
statement like that if he was wor- 
ried as Mr. M. was by his son's con- 
dition and other things. He might 
very well do these things and not 
mean anything thereby, as the state- 
ments were not repeated time and 
time again. 

Q. Would you consider the fact 
that G. M. was addicted to the use 
of alcohol would have any bearing 
on his making a statement of this 
kind? 

A. I believe it would. 

Q. In what way? 

A. Well, he might be depressed 
from the effects of the alcohoL 

Q. Does that occur? 

A. Frequently. 

Q. What opinion can you give 
at regards Mr. M.'s will power and 
the liability of undue influence be- 
ing exerted over him these months? 

A. I think his will power was 
perfectly normal 

Q. In addition to reading the evi- 
dence of the different witnesses in 
the case I understand you were 
present in court every day? 



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369 



Q. What are the delusions to 
which you refer? 

A. He had delusions that he was 
ruined, and that he had ruined his 
family. He had delusions that he 
was being persecuted and that he 
was going to be put in jail. 

Re-examined by Mr. S., of counsel 
for plaintiff : 

Q. The opinion you have given 
us, Dr. Z,, is based on the ensemble 
of the facts which you have learned ; 
it is not based on any one particular 
fact? 

A. It is on the whole thing. 

Q. Taken together? 

A. Yes. 

By the Court: 

Q. The opinion you give is that 
this man was insane from the month 
of January, 1912? 

A. Yes. 

Q. And continuously insane from 
that time forward? 

A. Absolutely. 

His Lordship: The witness has 
taken notes and has given you cer- 
tain opinions based on these notes. 
He took notes of what he con- 
sidered important in the evidence 
of the different witnesses. He says 
these notes represent what to him 
was important, from his point of 
view, in the evidence of these dif- 
ferent witnesses, and that he used 
these notes to base his opinion on. 
The result of his examination of 
these notes is that he has no hesita- 
tion in stating that the man must 
have been insane in the month of 
January, and that he never recov- 
ered his sanity. Is that correct? 

Witness: Yes, my Lord; that is 
correct 



A. Every day with the exception 
of part of one day. 

Q. From the commencement? 

A. Yes. 

Q. So you have also practically 
heard all the evidence from the wit- 
nesses themselves? 

A. Yes. 

Q. In fact, you have read through 
all the evidence given in the case in 
addition to hearing it? 

A. I read it through quite a num- 
ber of times. 

Cross-examined by Mr. S., of 
counsel for plaintiff: 

Q. When did you see Mr. M. at 
the asylum? 

A. December 11, 1913. 

Q. At that time was he sane or 
insane? 

A. Insane. 

Q. How long had he been insane 

A. I could not say. 

Q. You heard the evidence of the 
other expert witnesses, Dr. E., Dr. 
C, Dr. D., and Dr. B., to the effect 
that this man had been insane, in 
their opinion, since the month of 
May of that year? 

A. From the evidence I had, it 
is likely. 

Q. You heard the evidence of the 
other expert witnesses, Dr. E., Dr. 
C, Dr. D. and Dr. B. to the effect 
that this man had been insane, in 
their opinion, since the month of 
May of that year? 

A. Well, I cannot say I did. I 
cannot recollect that. They may 
have said it or they may not. 

Q. Do you agree with that or not? 

A. Well, I don't know. They 
spoke about the condition of the 
patient developing in May or June. 
By that they may have meant that 
the disease started in May or June. 



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370 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



Q. Can you say whether in your 
opinion G. M. was sane or insane 
when he was confined to the asylum ? 

A. He was certainly insane. 

Q. How long had he been insane 
previous to the isth of July? 

A. Well, it is pretty hard to say. 
He showed symptoms, as brought 
out by the evidence, before that 
Dr. S. speaks about him losing him- 
self and other things. It looks as 
if in May and June the disease was 
present 

Q. So that you are not able to 
say whether or not he was insane in 
the month of May? 

A. I would not like to swear to it 

Q. But I would like to have your 
opinion and see whether you agree 
with these other gentlemen who 
were examined here and who said 
that in their opinion M. was insane 
about the middle of May? 

A. I would not like to give a 
date. 

Q. Have you any doubt at all 
that he was insane previous to July? 

A. He certainly was insane be- 
fore July. 

Q. Before the 15th of July? 

A. Yes. 

Q. I think you have said that a 
person suffering from melancholia 
cannot hide his condition or dis- 
simulate his condition for any 
length of time so as to deceive 
others. Is that right? 

A. That is what I said. 

Q. Then, how do you account for 
the fact that one of the principal 
witnesses for the defendant saw him 
on an average of fifteen times out of 
every month, that is to say, every 
other day from the beginning of 
the year down to the 15th of July, 
and never saw anything of the kind? 



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371 



Deposition of Dr. Y. 

Examined by Mr. S., of counsel 
for plaintiff: 

Q. Have you made a specialty of 
certain diseases? 



A. It may be he did not open his 
eyes or open his ears sufficiently. I 
cannot answer for him. 

Q. But he says he saw him and 
conversed with him and talked bus- 
iness with him as frequently as on 
an average of every other day in the 
month, down to the time he was put 
in the asylum, and that he saw 
nothing unusual about him at alL 
How do you account for that? 

Witness: Might I ask what wit- 
ness that was? 

Counsel: That was the witness 
McL. Did you read his evidence? 

A. I must have. Who is Mr. 
McL.? 

Counsel: Mr. McL. describes 
himself as an insurance agent 

A. Oh, yes ; I remember all about 
him now. 

Q. This witness saw M. right 
down to the time he went into the 
asylum, every other day on an aver- 
age. He had conversations with 
him every other day, and still 
noticed nothing unusual about him. 
How do you account for that? 

A. I cannot understand it. 

Q. Was he telling the truth? 

A. This gentleman must have 
lacked some quality of observation 
or as they were frequently meet- 
ing at the bar— I don't mean to say 
this in any bad spirit — they may 
have been taking some spirits. The 
only other explanation is that Mr. 
M. was a record case. I never 
heard or saw of a person suffering 
from melancholia who could discuss 
topics of this kind, as described, and 
still appear normal. 

Deposition of Dr. B. 

Examined by Mr. D. H., of coun- 
sel for defendant: 

Q. Are you practising your pro- 
fession in Montreal? 



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372 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



A. Of mental diseases for twenty 
years. 

Q. This implies that you have 
made special preparatory studies? 

A. Yes, sir. I entered the asyltmi 

of , where I spent seven years 

of practice. 

Q. You have been seven years 
there and afterwards you started 
to practice? 

A. I make a practice of mental 
and nervous diseases. I am attached 

to the Hospital, where I am 

consultant for all mental and nerv- 
ous diseases, and for two years I 
have been attached as alienist for 
the Recorder's Court, to examine 
all patients that are to be confined 
in any asylum, at the expense of the 
government and the dty. 

Q. Doctor, regarding your report 
of the interviews with G. M., the 
22d of February, the 28th of Feb- 
ruary and the 2d of May, will you 
enumerate what are the observa- 
tions you made as a physician? 

A. He (G. M.) appeared very de- 
pressed; talked with difficulty; 
questions had to be repeated before 
he would answer. Said he was 
ruined ; that his family was ruined ; 
that he was hunted; that they 
wanted to put him in prison and 
torture him. He heard voices. He 
imagined that there were detectives 
who were watching him; he heard 
them talking. 

Q. Voices? Not yours; voices 
other than yours? 

A. Other than mine or the em- 
ployees or other patients in the 
hospital. These were halludna" 
tions. This delirium of the first in- 
terview did not appear to me to be 
very coherent It did not appear 
to be a delirium well organized. It 



A. Yes. 

Q. As a general practitioner? 

A. Yes. 

Q. You have also given special 
attention for some years past to the 
subject of nervous diseases? 

A. I have. 

Q. Will you tell us briefly what 
has been your experience? 

A. Well, I studied a year in 
Europe, paying special attention to 
nervous diseases. 

Q. Did you examine G. M., the 
father of the plaintiff in this case? 

A. I did. 

Q. On what date? 

A. December 7, 1913. 

Q. What did you find his mental 
condition to be? 

A. I found him suffering from 
melancholia. 

Q. Have you been able to form 
any opinion from the evidence and 
documents which you have read, 
and which are filed in this case, as 
to the mental condition of G. M., 
and his sanity or insanity during 
the months of December, 191 1, Jan- 
uary, February and March, 1912? 

A. I believe he was sane. 

Q. That is your opinion? 

A. That is my opinion. 

Q. What, in your opinion, based 
on the evidence made in this case, 
was the mental capacity of G. M. 
to appreciate the nature of the 
transfer made to the defendant of 
certain mortgages on or about the 
5th of March, 1912, and the trans- 
action by which he endorsed a 
certain note and receipts for bonds 
as described in this case to Mrs. M. 
on February 21, 1912? 

A. I believe he could understand 
what he was doing. 

Q. That is your opinion? 



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C. A. PORTEOUS AND H. V. ROBINSON 



373 



appeared to me as if he had already 
presented at that date fresh intel- 
ligence. I could not very easily con- 
nect the different delirious ideas. 

By the Court: 

Q. You say at the first interview? 

A. From the first interview he 
appeared as having had a weak in- 
tellect. I came to this conclusion 
later, especially at the last examina- 
tion, where he did not remember 
the length of time he had been in the 
hospital He was not accurate as 
to facts, dates, or anything at all. 

Q. What conclusions have you 
come to yourself? 

A. That the sickness has existed 
a long time. 

Q. Would you be able to state 
approximately how long the patient 
has been suffering from the sick- 
ness which you have observed? 

A. The examination alone makes 
it difficult to give a precise date, but 
the state that he was in when I saw 
him gave the impression that he had 
already been suffering from a weak 
intellect, and would give one the 
impression that it had existed for a 
long time back. To arrive at the 
beginning of the disease and the 
weakness in intellect, I think one 
would have to consider or take into 
consideration the proof brought by 
other witnesses, who saw him at 
different periods of his life. 

Q. Exactly; and this brings us to 
what has been stated by the testi- 
monies which have been given here 
in court? 

A. Yes. 

Q. You have heard these testi- 
monies ? 

A. Yes. 

By Mr. L., of counsel for plain- 
tiflF: 



A. That is my opinion. 

Q. From the evidence adduced in 
this case and from the exhibits 
filed, would you consider that Mr. 
G. M. was su£Fering from progress- 
ive and continuous melancholia 
during these months ? 

A. No. 

Q. Do you consider that if G. M. 
was suffering from continuous and 
progressive melancholia at this time 
this condition would have been 
noticeable to the various friends 
whom he met and with whom he 
talked during the periods as de- 
scribed in the evidence? 

A. I believe it would have been. 
As far as I have seen in the evi- 
dence, the people who saw him de- 
pressed and with these ideas of ruin 
and so on saw him in the hospital, 
where he was in contact with his 
son, who was very ill and who was 
believed to be dying, or they were 
persons who had something to do 
with the business of his son, which 
was then in a very bad way, as far 
as the evidence shows. Of course, 
this was very depressing. At the 
same time, and on the same days 
practically, he would meet other 
people and appear in an ordinary 
mental condition. 

Q. How many cases of melan- 
cholia have you had under treat- 
ment? 

A. I don't know. I have had 
quite a few. 

Q. How many? 

A. I could not recollect 

Q. Surely you can recollect with- 
in five, or ten, or twenty, or twenty- 
five? 

A. No. 

Q. Did you have one? 

A. Yes. 



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374 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



Q. Now, considering the inter- 
mittence or non-intermittence of 
this disease, which you have stated 
is present, what have you got to 
say? 

A. In the disease G. M. suffers 
from there is no intermission. The 
disease is continuous. 

Q. If you please, will you give 
me precisely what are the facts in 
this proof that bring you to this 
conclusion, in the proof that you 
have heard that the malady was of 
long duration? 

A. There is what Dr. S. said who 
examined G. M. on the 8th of 
January, I believe, and he declares 
that Mr. M. had ideas of ruin at 
that time. He has the proof brought 
by Dr. T. who examined him a little 
later, and he declares that at that 
time he was insane. In January he 
commenced to want to look for a 
situation, pretending that he had 
need to work to support his wife 
and son, who were at the hospital. 
In December, from the ist of De- 
cember, I believe, he found himself 
absolutely incapable of regulating 
the affairs of his son. 



Q. Have 3rou had more than one ? 

A. Yes; I have had more than 
one. I see some of these cases in 
connection with the nervous clinic 
We do not have the certified cases. 

Q. You do not classify yourself 
as being an alienist, but you classify 
yourself as being an expert in nerv- 
ous diseases? 

A. We have mental diseases in 
the incipient, stages, too. 

Q. The nervous diseases form the 
greater part of your studies? 

A. Yes. 

Q. In cases where these patients 
can maintain their self-control and 
repress the outward expression of 
their symptoms do you believe they 
can maintain this self-control for 
any length of time? 

A. Not for any length of time. 
I think that especially meeting old 
friends and tsJking over old times 
the delusions would come to the 
surface very quickly. 

Q. Can you tell us how many 
cases of melancholia you have had 
under treatment and examination? 

A. No, I could not. 

Q. You cannot remember the 
number of cases? 

A. No. 

Q. Did you have two cases? 

A. I have seen far more than two 
cases. I have seen many cases at 
the hospital. 

Q. But I am not asking you that 
I am asking you how many cases 
you have had under treatment? 

A. I have had a certain number 
of cases in my private practice, 
and we have had many at the hos- 
pital. 

Q. I mean cases of melancholia 
which came under your observation 
as a physician — under your per- 
sonal treatment? 



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375 



Deposition of Dr. W. 

Examined by Mr. C. H. S., of 
cotmsel for plaintiff: 

Q. Dr. W., arc you an alienist? 

A. My specialty is mental dis- 
eases and tiieir treatment. 

Q. For how long have you been 
such? 

A. Ten and a half years. 

Q. You occupy a position in the 
Asylum? 

A. Yes. 

Q. What is your position? 

A. Assistant Medical Superin- 
tendent 

Q. You were there at the time 
G. M. was admitted to the asylum, 
as explained by Dr. U.? 

A. Yes. 

Q. In the meantime, can you state 
irom recollection on whose appli- 
<aition he was admitted? 

A. I am pretty sure it was Mrs. 
M., his wife, because her son was 
sick at the time. 

Q. Who are the medical men who 
tnade the necessary certificates? 

A. Dr. S. and Dr. T. 

Q. Did you examine G. M. when 
he was admitted? 

A. I did. I examined him within 
a few hours of his admission. It 
might have been the next morning, 



A. Yes, I understand. 

Q. How many have you had? 

A. I have no idea. 

By the Court: 

Q. You could not say whether it 
was one hundred or one thousand? 

A. It certainly was not one 
thousand. 

Q. Would it be one hundred? 

A. We certainly must have had 
one hundred showing melancholic 
symptoms. 

Deposition of Dr. C. 

Examined by Mr. S. L. D. H., of 
counsel for defendant: 

Q. Have you specialized in any 
particular branch of your profes- 
sion? 

A. Yes; I have specialized in 
mental and nervous diseases. 

Q. Will you give us briefly your 
experience in connection with these 
diseases as a professional man ? 

A. I spent four years in Europe, 
in Edinburgh, London, Paris and 
^S^enna chiefly, attending the best 
hospitals there in this branch of 
work. I have had a private hospital 
of my own for the better part of 
twenty years; so in that way I 
have had an opportunity of studying 
and examining nervous conditions. 
I established a ward in the general 
hospital for nervous troubles, with 
the special intention of demonstrat- 
ing the prevention of insanity. 

Q. What class of patients do you 
treat in this hospital? 

A. Nervous patients. 

Q. What do you mean by nervous 
patients? 

A. I mean patients suffering from 
psychical symptom s — i n other 
words, patients suffering from men- 
tal symptoms, in the proper sense of 



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376 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



but it was within a few hours of 
his admission. 

Q. Will you please describe to 
the court the condition in which 
you found him? 

A. I found him very depressed 
and emotional He spoke of suicide 
and claimed to have attempted it 
Do you want all these details? 

Counsel: Yes; we would like to 
have them. 

A. He had the delusion that de- 
tectives were continually on his 
track. He stated that he had lost 
several hundred thousand dollars 
in poor business deals and that he 
was financially ruined. He was 
worrying very greatly over his son, 
who was seriously ill with typhoid 
at the time of his admission, July 
15. His condition was one of mark- 
ed mental anxiety and mental pain 
or depression, and I had not the 
slightest doubt after my first ex- 
amination that it was a case of mel- 
ancholia. The case was very 
evident. 

Q. Was he sane or insane? 

A. He was insane. 

Q. Could you form any opinion 
as to how long he had been insane? 

A. For one thing, on the papers 
that accompanied him the statement 
was made 

Mr. G., of counsel for defendant, 
objects to the witness giving an 
opinion based upon what other doc- 
tors may have told him. 

By the Court: 

Q. Do you mean the statements 
of the doctors on the certificates? 

A. Yes. 

His Lordship: If the witness is 
going to base his opinion on the 
history as described by the other 
doctors, I think it is admissible. At 



the word. I do not distinguish be- 
tween psychical and mental symp- 
toms indicating insanity. I do not 
take insane cases in my own hospi- 
tal My hospital is not for tha^ 
but for a previous stage of the 
condition. 

Q. A pre-insane condition? 

A. Yes, a pre-insane condition. 
Of course there are the organic dis- 
eases of the brain, and so on, which 
are part of the work, but, more 
largely, the pre-insane conditions 
have been prominent in my work 
for many years. I devote my time 
exclusively to this work. I do not 
do any general work or that kind of 
thing. I am a specialist in the 
proper sense of the word, so far as 
devoting all my time to these nerv- 
ous and mental troubles is con- 
cerned. 

Q. Do you have to deal with de- 
pressed or melancholic conditions? 

A. Yes. I deal with both de- 
pressed and melancholic conditions. 

Q. I understand you have ex- 
amined Mr. G. M., the father of the 
plaintiff in this case? 

A. Yes. 

Q. At the Verdun Asylum? 

A. Yes. 

Q. When did you examine him^ 

A. On December 11, last, 1913. 

Q. What was his condition when 
you examined him? 

A. I found him in a condition of 
involutional melancholia with de- 
lusions. 

Q. From the evidence, and from 
the documents filed, did you form 
any opinion as to the sanity or in- 
sanity of Mr. G. M. during the 
months of December, 191 1, January, 
February and March, 1912? 

A. Yes. I believe he was sane. 



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C. A. PORTEOUS AND H. V. ROBINSON 



377 



the same time, I will take your ob- 
jection, Mr. G., and will allow the 
evidence mider reserve. 

Witness: On the papers accom- 
panying Mr. M., or preceding him — 
the papers of commitment — ^it was 
stated by the physicians that mental 
symptoms had shown themselves 
in November, 191 1, if my memory 
serves me correctly. From my own 
observation of the patient at that 
time, believing him to be a case of 
melancholia of his age and that 
type, to the best of my professional 
knowledge of that disease, I should 
say the mental symptoms had ex- 
isted for some time before he came 
to us. I say that on my own knowl- 
edge, not on the history as given to 
me or as given to us by the examin- 
ing physicians. I deduce that, 
from the man's condition, and the 
type of mental disease from which 
he suffered, his mental disease had 
existed for some time before he 
came to us. 

By Mr. S.: 

Q. One year? 

No answer. 

By the Court: 

Q. What length of time? 

A. Well, I must answer that to 
the best of my judgment in such 
cases. I could not state that, be- 
cause it is impossible to say defi- 
nitely; at the same time, from my 
knowledge of other cases, I should 
say it would have lasted certainly 
some weeks, possibly months, pos- 
sibly three or four months. 

By Mr. S.: 

Q. That is, the condition in which 
you found him? 

A. Yes, based on my own obser- 
vation of his case as a type of men- 
tal disorder. 



Q. That is your opinion? 

A. That is my opinion. 

Q. Basing yourself on the evi- 
dence and on the documents filed, 
what, in your opinion, was the men- 
tal capacity of Mr. G. M. to appre- 
ciate the nature of the transactions 
in question in this case? 

A. Quite good as far as G. M. 
was concerned. 

Q. Would you consider from the 
evidence in the case that Mr. G. M. 
was suffering from confirmed mel- 
ancholia (that is, I understand a 
progressive and continuous disease) 
during these months? 

A. I would not 

Q. Will you give us the reasons 
for the opinion you have expressed 
in regard to Mr. M.'s mental condi- 
tion during the months in question? 

A. You ask me why I would 
consider G. M. as being sane at 
this time. In order to judge of a 
man's sanity you first have to 
obtain his normal condition, as near 
as you can, in order to learn how 
much he deviates from that normal 
in whatever acts he may perform. 
What I think is an important item 
in regard to it is this: in looking 
over the evidence we find that G. M. 
was always subject to certain eccen- 
tricities and when crossed, for ex- 
ample, he would curse or swear, 
walk up and down and mutter to 
himself. We also learn that he was 
a practical joker; that he was a 
pessimist, that he always hesitated 
to begin business or undertake any- 
thing new ; that he lacked confidence 
in his own business ability. These, 
I think, are a few of his peculiari- 
ties as they came out in the evidence 
so far. They struck me as bear- 
ing on the case particularly. He 



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378 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



Q. What, in your opinion, would 
be the effect of the condition in 
which you found the patient on his 
capacity for transacting business? 

A. Well, if you put that as a hypo- 
thetical question, I should say he 
would not be in the full possession 
of his mental faculties. In all prob- 
ability there would be an inability 
on his part to conduct his own 
affairs with the same prudence and 
judgment as he would before the 
attack came on or before any sign 
of mental disease manifested it- 
self. 

Q. Was his mental condition due 
to any physical disorder, as far as 
you could discover? 

A. I think it was due to a combi- 
nation of physical causes and mental 
causes. I would put down arteri- 
osclerosis—disease of the arteries — 
as one cause, acted on by mental 
worry and grief over the illness of 
his son and possibly by other wor- 
ries. I think the underlying cause 
was long-continued and progressive 
arteriosclerosis — arterial disease. 

Q. Might I ask you a scientific 
question ? Is there a physical cause 
for every mental disease? 

Mr. G., of counsel for defendant, 
objects to this question as being 
irrelevant and illegal 

The question is allowed. 

A. In certain forms of insanity 
there is a well-marked physical 
cause; in others a physical cause is 
suspected, but it is obscure and not 
proven to be the cause. 

Q. Will you give us a little more 
detail as to the conduct of the 
patient after his admission to the 
hospital? 

Mr. C of cotmsel for defendant, 
objects to this question as being ir- 
relevant and illegal 



was always inclined to borrow 
trouble, as a natural man. These 
conditions existed in this particular 
individual for a number of 3rears — 
for instance at the time when he was 
a member of Parliament and was 
doing the business of the country. 
These were also characteristic con- 
ditions in the individual in later 
years. The next point I consider is 
the evidence of the doctors who saw 
him at the time. If we go into this 
medical evidence we find that Dr. S. 
examined Mr. M. early in January ; 
that he found certain physical symp- 
toms and certain nervous symp- 
toms. Dr. S. found certain nervous 
symptoms— he found insomnia; he 
found inability on the part of the 
patient to fix his attention. He 
states that he answered questions 
slowly but correctly; that he was 
considerably agitated, and he spoke 
of ruining his boy. I believe these 
are all the symptoms Dr. S. men- 
tions as a result of his examination 
in January. Of course, it is very 
hard to keep all these things in one's 
mind where there is such a mass 
of evidence, but I would like to feel 
that I had covered all the S3rmptoms 
mentioned by Dr. S., because, being 
a medical man in charge of the case, 
one would naturally expect to place 
a great deal of weight upon his 
opinion. Dr. S. says he saw M. 
from time to time, but he made no 
further examination and that there 
were no new symptoms up to the 
time he left, just prior to March 5. 
There was no mental alteration in 
the man that Dr. S. considered suffi- 
cient to add to these symptoms at 
that time. Mrs. M. made a state- 
ment that Mr. M. had a revolver or 
threatened to shoot himself. Dr. 
S. says distinctly that if she had not 



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C. A. PORTEOUS AND H. V. ROBINSON 



379 



The objection is reserved by the 
court. 

A. The patient continued to show 
this marked mental depression. He 
showed insomnia. He was restless. 
He refused his food frequently, be- 
cause he stated it was tainted with 
human fecal matter, put in by his 
persecutors. At one time, about a 
month after his admission, I think 
it was in August— he attempted to 
suicide by driving a pair of scissors 
which he clutched suddenly into his 
right eye. They penetrated several 
inches and resulted in loss of vision 
in the right eye. Of course, we 
watched him very carefully after 
that, as we considered him then to 
be dangerously and actively suicidal 
From that time on until the present 
he has shown a deterioration in 
every way, with a persistence of 
these depressing delusions of vari- 
ous kinds, and delusions of a perse- 
cutory character. For instance, he 
told me to-day that he was to be 
taken and exhibited through Phila- 
delphia and Chicago as a terrible 
example of human guilt; that he 
was to be made to eat manure on 
the main street of Montreal I just 
mention these to show you that his 
delusions are of a very horrible, 
terrifjring and depressing character. 

Q. What is the condition of G. 
M. at the present time? 

A. His condition is one of involu- 
tional melancholia, verging into pre- 
senile insanity, and with certain 
signs of general mental and intel- 
lectual deterioration. 

Q. Has there been any time since 
his admission to the hospital in 
which you would say he was better? 

A. Absolutely no. 

Q. Has there been any time in 
which you would call him sane? 



made that statement he would not 
have considered him insane, or ad- 
vised his going to an asylum. Dr. 
S., in the earlier stages, did not have 
any apparent anxiety as to this 
man's mental condition or as to his 
being insane, otherwise, he would 
have suggested a consultation, which 
is a very natural and ordinary thing 
to do. There is no evidence of his 
having done this. He prescribed 
for M.'s sleeplessness, which he said 
was the main cause for which he 
had examined him. I think it is 
clear that with no change in his men- 
tal symptoms, or nothing new in 
his mental symptoms (which I be- 
lieve are the exact words used by 
Dr. S.), there was not suflfident 
grotmd in them to consider him in- 
sane. We now come to Dr. T.'s evi- 
dence : When Dr. T. took the case 
over from Dr. S. I presume Dr. S. 
would give him some history of the 
condition ; in other words, would tell 
him what he had found on previous 
occasions and what the conditions 
were, so that Dr. T. would not have 
to go to the trouble of determining 
for himself the previous condition 
of the plaintiff ; Uiat he would have 
a history of the case from Dr. S. 
This is the usual practice and I think 
it is a fair inference to say it was 
done in this case. Dr. T. examined 
the general condition of the patient 
He says he has no recollection of 
making an examination from a 
mental point of view. If Dr. S. 
had said to Dr. T., "This man is 
insane," surely Dr. T., with his ex- 
perience in everything and with the 
practice he has had— if this man was 
in the position of a confirmed mel- 
ancholiac — ^would have considered 
the mental side of it However, the 
only statement Dr. T. makes in re- 



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380 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



A. No. 

Q. Is his present condition in 
accordance with what yon would 
expect from the nature of his dis- 
ease? 

A. Yes; it certainly is. 

Q. Is it in accordance with what 
the symptoms as described by the 
doctors who gave their medical cer- 
tificates for his admission would 
imply? 

A. It is exactly what I would 
look for in melancholic symptoms 
appearing in a man of his age, with 
his history of alcoholism plus arte- 
riosclerosis ; yes. 

Q. What is the effect of such a 
condition upon the capacity of the 
patient to transact business ? 

A. Well, insofar as his mind and 
emotions are dominated by these 
delusions, he is quite unable to form 
the same clear conception and judg- 
ment, because his mind fails to have 
the proper concentration that it had 
before and his judgment is not 
normal. 

Q. What have you to say about 
his will power? 

A. Well, his power of voluntary 
action and so on is affected by these 
delusions, as well as weakened or 
lessened — decidedly impaired. 

Q. Does it make the patient liable 
to be easily influenced? 

Witness: You might elaborate 
that question a little. 

Q. I mean to be led or influenced 
by others. 

A. Along the line of his delusions, 
possibly yes. In order to protect 
himself from these supposed perse- 
cutors he might be influenced quite 
easily along such lines, having delu- 
sions. 

Q. If the patient's will is weak- 
ened in consequence of the disease. 



gard to it is that he thought it was 
a mental condition rather than a 
physical one. He made no diagnosis 
— ^he said so distinctly— before the 
examination in July. It is true M. 
was depressed when Dr. T. saw him. 
and that he had a downcast look, 
and did not reply to Dr. T.'s ques- 
tions, and spoke of the ruin of his 
family. This, however, did not 
impress Dr. T. with the man's in- 
sanity, or that he was even suffering 
from delusions. These were to my 
mind simply examples of the great 
discouragement under which the 
man was at that time, and Dr. T., 
I think very wisely, says that he 
cannot state whether that condition 
was transitory or permanent As 
I say, that was the only examina- 
tion Dr. S. or Dr. T. made prior to 
the end of April and this examina- 
tion took place during the first two 
weeks of March. There is one im- 
portant point, I think, in Dr. T.'s 
evidence to which I should refer, he 
having been there at the time and 
seeing the case subsequently. He 
expressed the opinion that the case 
developed in the months of May and 
June. That, from the physician in 
attendance at the time, who saw the 
patient constantly, was a matter 
which impressed me in regard to 
the evidence. Another important 
point, to my mind, was the number 
of witnesses of all classes of life 
who saw Mr. M. during the months 
in question — ^that is, December, Jan- 
uary, February and March. We find 
members of Parliament, managers 
of large businesses, and so on. In 
fact, people in all walks of life, 
ladies as well. They arc prepared 
to say, and do state in their evidence, 
that many of them had known him 
for a number of years and had 



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C. A. PORTEOUS AND H. V. ROBINSON 



381 



as you have indicated, would it not 
result necessarily from that weak- 
ening of the will power that a per- 
son might be led to do, at the sug- 
gestion of others, things that he 
would not do in his normal con- 
dition? 

Mr. G. objects and the objection 
is maintained. 

Q. Where the mind of a patient 
is weakened, in consequence of the 
disease which you have described, 
what is your experience as to the 
patient's power of resistance? 

Witness : Power of resistance in 
regard to what? 

Counsel: To the will of others? 

A. That varies very greatly, de- 
pendent upon the form of mental 
disorder which one encounters. 

Q. I mean the form which ]rou 
have described? 

A. In cases of melancholia of 
that character, while they arc under 
the domination of their delusions 
more or less, they are very likely to 
follow out their dictates altogether 
regardless of anything that is 
brought to bear on them from an 
external source, especially if the 
influence has to do with trying to 
convince them that their delusions 
are delusions, because their delu- 
sions are really true beliefs to them 
as far as they go. My experience 
with cases of melancholia is that 
while acting under the domination 
of their delusions they are not 
easily led by outsiders. The delu- 
sions dominate them rather than the 
outsiders. 

ByMr.G.: 

Q. They are influenced by their 
delusions? 

A. Yes. 



talked with him on a great variety 
of subjects at various and irregular 
times throughout the whole interval 
— ^not for a week or two weeks at 
a time, but a day here, and per- 
haps three or four days later on. 
In that time they did not find that 
G. M. was in any way abnormal. 

Q. If Mr. G. M. had been suffer- 
ing from delusional melancholia 
(which I understand is continuous 
and progressive) in your opinion 
would it have been evident to the 
various persons with whom he came 
in contact during these months? 

A. I think it certainly would have 
been apparent. 

Q. Presuming that Mr. G. M. 
made a statement to his wife, about 
the end of February, that he thought 
the best thing that could happen 
would be for the three of them to 
die together (as appears from Mrs. 
M.'s evidence), would that indicate, 
in your opinion, that he was insane 
or suffering from conflrmed melan- 
cholia at that time? 

A. No. It would not; for the 
simple reason that, as a rule, any 
person suffering from melancholia — 
a melancholiac — the delusion would 
begin gradually, and would be re* 
peated much more frequently. This 
was an isolated statement to the 
effect that it would be better for 
them all to die together. He did 
not make any attempt or do any- 
thing to show that it was a delusion 
in any sense of the word. It was 
simply a statement made in a 
moment of depression. 

Q. Assuming that he made a 
statement to the effect that he had 
ruined his boy or ruined his family, 
and that he had ruined himself, dur- 



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382 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



By Mr. S.: 

Q. That is, with respect to the 
subject of ihdr delusions? 

A. Surely. 

By the Court: 

Q. Is the mind of a melancholiac, 
so far as it governs his ordinary 
conduct, liable to work along nor- 
mal lines? 

A. Absolutely no. It is not At 
no time is his mental condition not 
influenced and governed to a certain 
extent in all his intellectual proc- 
esses — all the processes of thought, 
emotion, judgment, perception and 
so on— except by the delusions and 
the depressed character. That influ- 
ences him at all times, and conse* 
quently you cannot say that a case 
of melancholia has a normal men- 
tal process going on at any time. 

By Mr. S.: 

Q. Did you hear the evidence 
given by Dr. T. and Dr. S.? 

A. Yes. 

Q. In your belief, from the time 
these gentlemen first examined G. 
M., considering the condition in 
which they found him, was there 
any time since then that he had 
been normal? 

A. To the best of my knowledge 
and belief and experience with men- 
tal cases of that character and of 
that age, and knowing what I may 
know of their development and their 
progress, I should say from the time 
Dr. T. and Dr. S. found that man 
as emotionally depressed as they 
say he was — from that time until the 
present day he has not been nor- 
mal mentally. 

Cross-examined by Mr. G. : 

Q. Do I construe your last an- 
swer correctly in sajring that you 



ing the months of January, February 
and March, in your opinion, would 
that indicate that he was insane and 
incapable of appreciating the nature 
of the transactions with M. referred 
to in this case? 

A. No. I think not If G. M. had 
believed he was ruined he would 
have shown it in his dress, and he 
would have shown it in his changed 
life, just as any other melancholiac 
would do. 

Q. Supposing, for the sake of 
argument, that G. M. was su£Fering 
from a delusion that he was ruined, 
or that his family was ruined, 
during the months of January, Feb- 
ruary and March, what have ]rou to 
say in regard to his failure to refer 
to this when speaking to the many 
people with whom he came in con- 
tact? 

A. Assuming that he had these 
delusions, he would have been talk- 
ing to every one about them. He 
would have been pounding it into 
everybody he came across. 

Cross-examined by Mr. L., of 
counsel for plaintiff : 

Q. Dr. C, for my own satisfaction 
and perhaps for the satisfaction of 
the court, will you kindly tell me 
what is a medical specialist? 

Witness: A mental specialist? 

Counsel: No, a medical special- 
ist? 

A. One who devotes his entire 
time to the treatment of a certain 
condition. 

Q. That implies first that a man 
has made a special study of medi- 
cine? 

A. Presumably, yes. 

Q. And, of course, the narrower 
the limits of the specialty the better 



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C. A, PORTEOUS AND H. V. ROBINSON 



383 



consider the man ceased to be nor- 
mal mentally when the delusions 
began or would you antedate it? 

A. I would state that the disease 
was in the early stage of establish- 
ment at the time Dr. S. and Dr. T. 
found him in that abnormally de- 
pressed condition, with these delu- 
sions that he had lost everything, 
and wasted his substance and so on. 
I would consider the disease was 
established then. 

In rebuttal: 

Dr. W., examined by Mr. C. 
H. S.: 

Q. You have already been ex- 
amined on behalf of the plaintiff 
in this matter? 

A. Yes. 

Q. You have heard the testimony 
which has been given with regard to 
the possibility of recognizing or de- 
termining whether a patient is or is 
not afflicted with cerebral arterio- 
sclerosis? 

A. Yes. 

Q. What is your opinion with 
regard to that? 

A. I think it is possible for a doc- 
tor to determine with a reasonable 
degree of assurance whether a case 
is suffering from cerebral arterio- 
sclerosis or not 

Q. Speaking with regard to the 
power of a patient suffering from 
delusional melancholia to conceal 
his condition, what have you to say 
to the court? 

A. My experience is that patients 
suffering from melancholia and who 
have the disease established, may 
for limited periods conceal their 
delusions, and may, at certain times 
of the day — notably in the late after- 
noon or early evening — really ap- 
pear brighter and seem to show 
that the melancholia has lifted 



the specialist, other things being 
equal? 

A. Provided it included the whole 
of that specialty; not half of it 

Q. So that a specialist who would 
have devoted all his time to the 
study of mental diseases would, 
other things being equal, be more 
competent than a specialist who has 
distributed his attentions to diseases 
of the nervous system and diseases 
of the mind? 

A. You ask my opinion about that, 
and I say emphatically no. 

Q. Give us the reason? 

A. Well, if I am not correct in 
my appreciation of your question 
I would be glad to be put right 
From a practical point of view the 
alienist sees these cases only after 
they are certified insane. The pre- 
ceding stage of the condition is 
certainly more or less unknown to 
him, and for the very simple reason 
that these people — 

Q. (Interrupting) Which people? 

A. The people who are admitted 
to the asylums. They are there in 
an advanced stage of the condition. 
They are declared insane, but prob- 
ably there is a long period of con- 
firmed mental condition preceding 
that which the alienist does not see, 
unless he is also a neurologist and 
among these cases. 

Q. So that a gentleman who like 
yourself, has devoted his time to the 
study of nervous diseases and what 
I would call the semi-ready stages 
of insanity — 

A. (Interrupting) The prelimi- 
nary stages of insanity— 

Q. Is better fitted to pronounce an 
opinion than the specialist who is 
known as an alienist? 

A. My opinion is that the man 
who is conversant with these con- 



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384 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



somewhat I have seen many cases 
of that kind. I might refer to a 
case which came under my obser- 
vation and treatment at the hospi- 
tal not long ago, as a typical case 
to prove the point I refer to. We 
had a case at the institution, a man 
aged 55 years. He came to us in 
April and went away in May. Dur- 
ing the last fortnight of his stay 
with us he appeared very well so far 
as his wife and family were con- 
cerned. When they came to see him 
he appeared to be very well and they 
objected very much to leaving him 
there. They took him out against 
our advice. We said that the man 
would be better with us and that 
he certainly was not a well man, but 
was a danger to himself. Notwith- 
standing this, they took him away. 
He did not show any depression to 
them and he did not talk over his 
delusions with them. When they 
came to see him he appeared to 
be sane. Indeed, he did not talk 
over his delusions very much with 
us, but, at the same time, we rec- 
ognized that he was not very well 
They took him out of the hospital 
on May 13, and about the middle of 
August he committed suicide. In 
other words, the disease was still 
there. It was continuous all the 
time. There was no remission and 
there was no intermission. The 
man was not well He had the dis- 
ease and he had these delusions 
which caused him to think that he 
should leave this world and that he 
should take his own life. As I say, 
he successfully concealed these de- 
lusions from his wife and family. 
Q. Was he capable of talking 
rationally during that time? 



ditions and who sees them every day 
would be able to give a better opin- 
ion than the man who only sees 
then when the pronounced stage 
is reached. 



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C. A. PORTEOUS AND H. V. ROBINSON 



385 



A. He talked very clearly and 
connectedly on many topics and in 
regard to many things. 

Cross-examined by Mr. A. G.: 

Q. Will you please listen to the 
question which I will read you from 
page 13 of your deposition given 
on behalf of the plaintiff in chief? 

By the Court: 

Q. Is the mind of a melancholic, 
so far as it governs his ordinary 
conduct, liable to work along nor- 
mal lines? 

"A. No. Absolutely. It is not 
At no time is his mental condition 
not influenced and governed to a 
certain extent in all his intellectual 
processes — all the processes of 
thought, emotion, perception and so 
on, except by the delusions and de- 
pressed character. They influence 
him at all times; and consequently 
you cannot say that a case of melan- 
cholia has a normal mental process 
going on at any time." Is that an- 
swer correct? 

A. Certainly it is correct The 
process is not normal. I did not 
consider the case of the man I men- 
tioned a moment ago as being nor- 
maL What I said was that he ap- 
peared so. 

Q. But you did not confine your- 
self in that answer to saying that it 
was not normal You went on to 
say that all the processes of thought, 
emotion, judgment, perception and 
so on, are influenced exclusively by 
the delusions and the depressed 
character? 

A. I still maintain they are. 

Q. You maintain that a man may 
absolutely create the impression he 
is cured, although every one of the 
processes of thought, emotion, 
judgment, perception and so on, 

25 



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386 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 



are influenced exclusively by these 
delusions? 

A. Not influenced exclusively. 

Q. You said in your answer, ** At 
no time is his mental condition not 
influenced and governed to a certain 
extent in all his intellectual pro- 
cesses — all the processes of thought, 
emotion, judgment, perception and 
so on, except by the delusions and 
the depressed character?" 

A. Yes; that is quite correct 

Q. They are influenced to a cer- 
tain extent by the delusions. Do 
you maintain that he can be in that 
state and influenced at all times in 
all his intellectual processes by his 
delusions ? 

A. To a certain extent, yes. A 
man may be influenced by his delu- 
sions that he is a terrible criminal, 
for instance, and must get out of the 
world, or must rid the world of 
himself ; yet, he may be able to con- 
ceal that delusion, so as to get an 
opportunity to kill himself. 

Q. You are now suggesting that 
he may conceal his delusion so as 
to get an opportunity to carry out 
his plans? 

A. It is merely one activity of 
the human mind. 

Q. Do you suggest that he can 
carry that out to the extent of abso- 
lutely hiding his condition so that 
he will appear sane? 

A. I do not suggest it I abso- 
lutely know it I have seen it 

Q. How do you know this man 
did not have a remission? 

Witness: Which man? 

Counsel : The man you mentioned 
a few moments ago as an example? 

A. Because he was under my 
personal care and observation every 
day up to the time he left the hos- 



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C. A. PORTEOUS AND H. V. ROBINSON 



387 



pitaL When he went out of the 
institution he was still suffering 
from melancholia, and he had these 
delusions, although, as I say, he did 
not show them to the very friends 
and relatives on whom he depended 
to take him away and who actually 
did take him away against our ad- 
vice. 

Q. Your idea is that this man was 
hiding his delusions for the purpose 
of being taken home? 

A. At the time, he was. 

Q. That would be the explanation 
of his behavior? 

A. Yes. 

Q. Nevertheless, he was not hid- 
ing his delusions from you? 

A. No. 

Q. He was perfectly confident 
that they were safely hidHen if he 
hid them from his relatives and 
friends, and told them to you? 

A. I could not say as to that 

Q. In any event, you did not 
think of suggesting to his relatives 
that they should question him in re- 
gard to these delusions? 

A. I told his relatives, as I have 
said two or three times, that I con- 
sidered the man dangerous. He 
mentioned these things to me, and 
I knew they were still in his mind, 
and that they ought not to take him 
away. 

A. What sort of melancholic was 
he? 

A. He was one of the involu- 
tional types of melancholia. 

Q. What do you mean by " one of 
the involutional types ? " 

A. Depending on retrogressive 
and degenerative change physically. 
He was a man about 55 years of age. 

Q. What was the cause of his 
melancholia? 



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388 EXPERT TESTIMONY BY AUENISTS AND NEUROLOGISTS 



A. I am not absolutely sure, with- 
out looking up the records. I think 
there was some statement made, but 
I am not sure what it was. 

Q. What was his delusion? 

A. He had the delusion that he 
ought to die. He thought he had 
lived a very sinful life, and it would 
be much better if he were out of the 
world. The man was a plasterer 
and had not been working for some 
time. He was not able to work, and 
he thought he was better out of the 
world. 

Q. Do ]rou suggest that these 
cases of men able to dissimulate 
completely to a certain class of 
people, while exhibiting their de- 
lusion to another class, are frequent 
cases, or do you deny the statement 
which I think I heard made that the 
general tendency of the melancholic 
is to harp on his delusions, unless 
there is some special reason which 
keeps him away from them? 

A. I should say the average case 
of melancholia docs dwell very con- 
tinuously on the delusions. There 
is no doubt about that 

Q. What was the age of G. M. ? 

A. He was said to be 66 at the 
date of his admission. 

Q. You say you can discover 
whether arteriosclerosis affects the 
brain or not? 

A. I did not say that I said that 
a doctor meeting certain symptoms 
in his patient might very reasonably 
come to a well-founded conclusion 
that cerebral arteriosclerosis did 
exist. That was the gist of my 
statement 

Q. Of course, you would not pro- 
nounce a man insane simply because 
you found evidence of arterioscle- 
rosis, or even of cerebral arterio- 
sclerosis? 



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C. A. FORTEOUS AND H. V. ROBINSON 



389 



A. .No. I certainly would not 

Q. A mental examination would 
be necessary? 

A. Decidedly. 

Q. You may have a man suffering 
from arteriosclerosis and showing 
some of these symptoms which, 
according to you, indicate the proba- 
bility of cerebral arteriosclerosis, 
and this man may be insane from 
other causes which have nothing to 
do with the arteriosclerosis? 

A. Certainly. 

Q. You have known of such men 
or have heard of such men having 
recovered. 

A. I will not say that I know 
I have had many cases of insanity 
recover, who have had arterioscler- 
osis in different parts of the body. 

Q. In the present stage of science, 
the fact that they recover would 
be a conclusive demonstration that 
the insanity was not due to arteri- 
osclerosis? 

A. Yes. 

Q. Take the case of a man who 
is insane, and who has arterioscler- 
osis and exhibits the symptoms 
which, according to you, indicate 
that he had not cerebral arterio- 
sclerosis ? 

A. I would say not If I found 
these symptoms pointing to arterio- 
sclerosis, I would not expect a man 
to recover. 

Q. That is not the idea I have in 
mind. I say take a case where the 
circumstances are such that, in the 
present state of science, your diag- 
nosis would be that the man was 
suffering from cerebral arterio- 
sclerosis. In other words, I ask 
you whether in the present state of 
science your diagnosis that he 
would not recover would be in- 
falHble? 



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390 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 

A. No ; nobodjr's diagnosis can be 
infallible. 

Q. Was the patient to whom yon 
referred as an example suffering 
from the same form of insanity as 
G. M. is suffering from? 

A. I would call it an involutional 
melancholia, but the sclerotic con- 
dition was not nearly as marked. 

Q. That is to say, the sclerotic 
condition in M/s case was more 
marked? 

A. Yes. 

Q. Was it the same class of mel- 
ancholia? 

A. Yes ; I would class it the same. 
We diagnosed M. as a case of in- 
volutional melancholia. I would 
also diagnose this other case as one 
of involutional melancholia. Of 
course, any two cases of involu- 
tional melancholia may show a 
diversity in certain symptoms. 

It is hoped that a perusal of the above evidence will establish 
beyond doubt the foundation of which this paper is the super- 
structure, viz : — ^that there is great need for more agreement in the 
rendering of evidence by alienists and neurologists, and that such 
a diversity of findings from known facts as appear herein can only 
obstruct and not hasten the ends of justice. 

Note: To Mr. Justice Cross, Mr. Henry J. Elliott, K. C, and Drs. G. 
ViUeneuve, F. E. Devlin, and T. J. W. Burgess, of Montreal, I am in- 
debted for valuable aid in the preparation of this paper. Dr. H. V. 
Robinson has compiled the expert evidence which was submitted in the 
case. 



DISCUSSION. 

Dr. Bancroft.— The placing of expert testimony in this country upon a 
satisfactory basis would seem almost as difficult a proposition as the pas- 
sage of a workable sterilization law. As long as the legal profession regard 
the appointment of medical experts by the court unconstitutional, it is not 
easy to see how the present method of presenting medical expert testimony 
can be changed, however much the medical profession may desire it The 
medical profession long for the time when expert witnesses can be sum- 



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C. A. PORTEOUS AND H. V. ROBINSON 39I 

moned by the presiding justice and their evidence presented in court in a 
fairly non-partisan manner. The legal profession declare that such sum- 
moning and presentation of expert evidence is a violation of our federal 
constitution and is not therefore practicable in the United States. 

The authors of the paper properly lay great emphasis on the importance 
of consultation between experts on different sides. Men who usually 
think alike on medical questions ought not to be prevented from personal 
consultation, neither should they be forced into a partisan position when 
their whole training and experience predisposes them to a rational and 
unbiased mental attitude. Many a fair minded and honest expert has felt 
the importance of a consultation with his professional brethren on the 
other side, but is confronted with the opposition of counsel who do not 
wish the case to run in unpartisan lines. It has always seemed to me that 
medical counsel on either side ought, if they desire it, to have the oppor- 
tunity of consultation ; and that, provided counsel opposes such conference, 
the court might make such consultation not only permissive but mandatory. 

I may add that in New England many of the leading alienists have in 
important criminal cases exerted such an influence in this direction that 
conference between medical counsel on opposite sides has been brought 
about with manifestly excellent results. If the truth is the main thing 
desired in a trial, then surely there ought to be no objection to consulta- 
tion between medical experts to the end that purely prejudiced and partisan 
evidence may be eliminated. 

Dr. Abthur H. Hasbington. — I would like to mention a practice that 
exists in Rhode Island and which has existed for several years in criminal 
cases, in which the counsel for the defendant enters a plea of insanity; 
a law exists by which the judges of the Supreme or Superior Court may 
appoint a commission of not exceeding three medical men to consider the 
case in all its aspects and to return a report to the court as to the mental 
condition and responsibility of the accused. During the past five or six 
years this has been carried out in several cases and it has saved the state 
in several instances the expense of a long trial, and the medical men 
appointed by the courts have been of such character and standing that 
no one could question the wisdom of the report 

Ds. B. D. Evans. — ^The question of a committee appointed by a court to 
determine the sanity or insanity of a person charged with criminality by law 
embodies some very good features indeed. I, however, hope I will not be 
considered over-combadve in taking issue with some of the statements 
made. I also hope that the medical profession will never get so weak that 
it is afraid ; that its best men, its strong men will falter because of fear of 
criticism. I grant you that a commission appointed by a court, an impar- 
tial commission of three or four men, can with prbpriety render its 
opinion and that the public cannot consistently subject them to serious 
criticism. I was recently appointed by the Governor of New Jersey one 
of a commission of three to determine as to whether a man was insane 
or sane; he had already been convicted and was in state's prison. I was 



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392 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 

firmly of the opinion that he was insane and was not, therefore, under the 
law guilty of the crime, which consisted of killing his wife and infant 
child ; the other members of the commission took an opposite view ; we got 
together several times and talked it over and I asked them to make a 
majority report and I would make a minority report They insisted that 
we come to an agreement and asked me to withdraw my most positive 
statement; I did so and the man was electrocuted. 

I only want to say that with a commission of that sort there will be 
disagreements, and it may be that some people who ought not to be elec- 
trocuted or hanged suffer the death penalty. I say this with all respect 
for the opinions of the profession. 

A commission appointed by a court cannot, under our constitution, ac- 
cording to the best constitutional lawyers I have consulted, deprive the 
defendant of the right to expert testimony, wherever he may elect to 
secure it, but the commission does rob him of an advantage such as he 
would obtain if both the prosecution and the defendant select their own 
expert alienists. I realize that my opinion on this matter may be classed 
as a personal opinion, but from a constitutional standpoint, we cannot rob 
the defendant of the right to have his medical expert testimony. I do 
think a commission giving an opinion in advance of testimony of other 
experts would be unfortunate in a good many ways, and when human life 
is at stake it is a question whether we can safely accept this scheme of 
court action. Some good people view it as a sort of business proposition — 
I do not ; I am not fond of expert testimony or expert work, but I do not 
entertain in full the views that some of my friends have expressed to the 
contrary. 

Dr. Briggs. — This matter came up in Massachusetts and was presented 
to the court last year, in regard to the appointment of a commission by 
a judge, which would be obligatory, but when it was referred to the 
attorney-general he rendered an opinion that it was unconstitutional; that 
we could not deprive any man accused of a crime and on trial for his 
life of the right to defend it in any way he saw fit In cases that are not 
capital our judges do appoint commissions. It is almost a daily occurrence 
for these cases to receive notice to appear at court; they summon a man 
and examine him and if they find him insane he is sent to an insane 
hospital without trial. 

Dr. Carlos F. MacDonald. — ^There seems to be a great deal of misap- 
prehension in the public mind, as well as in that of the general medical pro- 
fession, respecting the subject of medical expert testimony, and especially in 
regard to the attitude and conduct of those members of the profession who 
tire called upon from time to time to give such testimony, particularly in 
cases where mental conditions are in issue. It appears to have become the 
custom of late to denounce medical experts, not only in the public press, but 
in medical journals, and, I regret to say, by many members of our own pro- 
fession as unscrupulous and dishonest, and as lending themselves to one side 
or the other for pecuniary considerations. It also seems to be fashionable 



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C. A. PORTEOUS AND H. V. ROBINSON 393 

nowadays to criticise doctors who disagree, as if they were the only class 
of persons who differed in opinions, thus making no distinction between 
true and false experts, and condemning all alike. Now, the fact is, that 
in our profession there are experts and experts; many of whom are well 
qualified and conscientious, while certain others are apparently willing 
to lend themselves to the support of whichever side they are called, 
regardless of the facts in the case — in other words, who strive to make 
the facts fit the theory of that side as formulated by counsel. Certain of 
these experts are simply "hot house alienists" who "spring up in a 
night, so to speak, and who are wof ully lacking in special qualifications and 
experience in mental diseases. On the other hand, I believe that the great 
majority of alienists who appear as experts in medico-legal cases are 
conscientious and honest as regards their work, and are unwilling to lend 
themselves to the aid of the side on which they may be called, unless the 
facts warrant them in so doing. The point seems to be overlooked that 
expert testimony is quite different from that of the testimony of lay wit- 
nesses who are called to testify only to facts, such witnesses not being per- 
mitted, under the rules of evidence, to express opinions except as to 
whether the acts and declarations of a defendant which they have observed, 
and to which they have testified, impressed them at the time as being 
rational or irrational ; while the medical expert is allowed, under the rules 
of evidence, a much wider latitude, and may express his opinion, based on 
the evidence submitted to him, as to the mental condition of the defendant. 

Unfortunately the usage of courts permits of the selection of experts 
by counsel on either side, without due regard to their qualifications or 
standing, the only requirement being that the expert so selected, is 
willing to give an opinion in favor of that side of the case; and, second, 
is the absence of any standard of qualification fixed by the medical 
profession as regards special study and experience in a given branch of 
medical science which would, at least theoretically, render the would-be 
witness sufficiently skilled in that branch of the subject to properly con- 
stitute him an expert therein. If the medical profession, instead of con- 
demning medical experts, would fix a standard of qualifications based 
on special study and experience in a particular branch of medicine, which 
shall entitle a member to rank as an expert in that branch, and at the 
same time put its seal of disapproval and condemnation on the practice 
which now too frequently obtains of physicians posing as experts upon 
subjects respecting which they have no special knowledge or experience, 
it would, in my opinion, do much toward curing existing abuses in respect 
to the 'present methods of presenting medical expert testimony. More- 
over, it should utterly condemn the practice of so-called "pan experts," 
who do not hesitate to pose as expert witnesses on any and every branch 
of medical science. 

It seems to me the time has come when the medical profession, instead 
of condemning medical expert testimony indiscriminately, should raise its 
voice in solemn protest against the tendency which has lately grown up to 
heap upon it ridicule and abuse because " doctors disagree," and that, con- 



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394 EXPERT TESTIMONY BY ALIENISTS AND NEUROLOGISTS 

sequently, all or substantially all doctors are dishonest The fact is, 
doctors are no more prone to disagree than any other class of individuals 
where matters of opinion are involved. We know that lawyers are 
notorious for their disagreements, and that in substantially every case that 
is tried in court the contention of counsel on one side is diametrically 
opposed to that of the other side, and this, too, on substantially the same 
set of facts. Judges also are notorious for their disagreements, the 
higher courts frequently reversing the courts below clear up to the court 
of last resort, and if there were a still higher court, it would frequently 
be found over-ruling the Court of Appeals. Not seldom we find the body 
of judges constituting our Appellate Courts divided in decisions they render, 
the issue being decided frequently by a bare majority of one — and yet 
nobody would think of suggesting that these judges are dishonest simply 
because they happen to differ in opinion. 

It frequently happens that experts on opposite sides are called upon to 
testify to a different set of facts; the hypothetical question on one side 
usually includes everything which counsel thinks would tend to strengthen 
his side, whereas the h3rpothetical question submitted by counsel on the other 
side usually includes only such facts in the evidence as he thinks will tend to 
strengthen his side — the rules of evidence permitting counsel to omit any- 
thing in the testimony which he sees fit, and only requiring that he shall not 
insert into his hypothetical question anything which is not in evidence. Thus, 
under the rule, counsel, in framing a hypothetical question may, and fre- 
quently does, omit the most material facts in the case. This practice 
tends to put medical experts in a false position in the eye of the public 
and apparently contradicting each other. 

None of the schemes which have been put forward for improving 
existing methods of presenting expert testimony, such as the appointment of 
commissions by the courts, by governors, or by medical societies, are 
feasible. In fact our ablest judges have repeatedly declared that all these 
schemes are more or less visionary and impracticable, for the reason that 
under the rules of evidence a defendant may submit any testimony that will 
tend to help his defense, so that if experts appointed by courts report on 
investigation that a defendant is not insane, the latter still has the legal right 
to raise the plea of insanity on his trial and call experts to testify to the 
same. In the state of New York a law was passed in 1874 providing in 
substance that, where a defendant entered a plea of insanity, the court 
should appoint a commission to determine his mental condition, and that 
the findings of that commission should be final ; and if the commission re- 
ported to the court that the defendant was sane, the issue of his mental 
condition should not be raised again on the trial Under the provisions 
of that act, the courts, in a number of cases, appointed conmiissioners 
to inquire into the mental condition of the defendant, and in every in- 
stance where such commission found the defendant to be sane, the plea of 
insanity was raised again on the trial — as though no commission had 
existed. 



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C. A. PORTEOUS AND H. V. ROBINSON 395 

Curiously, the question of mental disease is something which courts and 
lay persons seem to regard themselves as perfectly competent to determine, 
even in most obscure and difficult cases, and they freely express opinions on 
the subject; whereas they would not think of making a diagnosis in obscure 
and difficult forms of physical disease, but would be quite willing to leave 
the diagnosis to the physicians. I don't claim that existing methods of 
eliciting medical expert testimony are by any means perfect, but it is the 
best that can be devised under present conditions. As to defining the 
responsibility of persons accused of crime by adopting some scientiiic legal 
definition of insanity, while it still might not agree with medical opinion, 
it undoubtedly would do much to improve the present system of medical 
expert testimony. It is a fact that existing legal definitions of insanity, 
which are practically alike in all of the states of the union, are much behind 
the age — no advance having been made in this respect since the adoption of 
the legal definition of insanity by the English judges in the celebrated 
McNaughten case, in 1843, which declared that, in order to constitute a 
legal defence of insanity, the defendant must be so far disordered in his 
mind at the time of the commission of the act charged as not to know 
the nature and quality of the act he was committing and not to know that 
the act was wrong. Insanity is thus defined in almost exact terms in the 
criminal code of the state of New York to-day, and, as before remarked, 
it is substantially the same in all other states. The defect in this defini- 
tion is patent to every experienced alienist We know that many insane 
patients know perfectly well the difference between right and wrong, so 
that the question to be determined in such cases is not as to whether the 
individual knew that the act he was committing was wrong, but should 
be as to whether he was able to control himself sufficiently to resist the 
wrong he was doing. 

I recall a case in which a distinguished physician in charge of a private 
institution was stabbed to death by a paranoiac who freely admitted that 
he knew it was wrong to kill a man, but declared he had to do it in this case 
in order to get his case before the court. He felt that he was persecuted 
by his relatives, by the police and by the physician whom he killed, but 
said he: "I knew if I killed this man I would be arraigned before the 
court, and, if so, I would be able to convince the latter that I was sane and 
rational, and that this persecution actually existed." He was subsequently 
committed to my care at the criminal asylum at Auburn, where he remained 
for many years. 

In conclusion, in my opinion, a change such as I have indicated in the 
legal definition of insanity and at the same time fixing a standard of quali- 
fications of medical experts by the medical profession, would greatly im- 
prove, and possibly cure, existing defects in the method of eliciting medical 
expert testimony. 



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ORGANIZATION OF THE WORK OF THE HENRY 
PHIPFS PSYCHIATRIC CLINIC, JOHNS HOPKINS 
HOSPITAL, WITH SPEQAL REFERENCE TO THE 
FIRST YEAR'S WORK. 

By ADOLF MEYER. 

A little over a year ago we had the honor and privilege to 
welcome many among you at the opening of the Psychiatric Qinic 
founded by Mr. Henry Phipps. It is a g^eat pleasure to welcome 
to-day the Medico-Psychological Association within these walls 
and to show you at least the beginnings of the organization of 
this clinic. We wish to demonstrate to you some activities in the 
department which always will be the center of this clinic, namely, 
the department of clinical service and its most essential laboratory 
annex, the laboratory devoted to the problems of the internal 
organs and metabolism and serum-reactions in our cases. I have 
not as yet been put into a position where I could organize either the 
neurological and neuropathological work, the aim of which will be 
to further research and more thorough study in the neurological, 
conditions of our cases, or the psychological and psychopatho- 
logical laboratory, which will standardize and push the behavior 
studies and psychobiological methods ; two departments of funda- 
mental importance for which we hope to get means of support in 
not too remote a future. 

The year has been one during which the economics of such a 
hospital had to be tried out. It has also been a year during which a 
tentative program for the second, third, and fourth year classes of 
the Medical School had to be planned for the first time, although, 
owing to the fact that the time of the students was already 
fully occupied, but little provision for the absolutely necessary 
practical basis of the courses could as yet be furnished. Taking 
it all in all, we can hardly speak of this year as one of leisure 
or even of normal work; and, while it has been a year of the 
highest interest and full of absorbing problems, you will realize 
also what a small staff has carried the burden of this organization 
and how heterogeneous the demands have been. The following 



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398 ORGANIZATION OF PHIPPS PSYCHIATRIC CLINIC 

physicians are upon the staff : Dr. C. Macfie Campbell, my asso- 
ciate, who has charge of the out-patient department ; Dr. D. K. 
Henderson, who is resident physician, Dr. S. R. Miller, Dr. Truitt, 
Dr. Kempf , Dr. Hall, Dr. Floumoy, and Dr. Kqrser. 

The first patient was received on May i, 1913. The private 
wards and one male and one female public ward were opened ; 
and, as we obtained a sufficiently large nursing staff, the first floor 
wards, and finally the third floor wards, were added, so that by 
November our entire equipment was at the disposal of the public 

In keeping with the desire of the trustees and with the provisions 
of our city ordinance, the admissions have, as far as possible, 
favored cases who entered the hospital voluntarily, or at any rate, 
without actual personal objection. This established, in a way, the 
principles which hold for general hospitals, inasmuch as it was 
considered perfectly satisfactory from a l^;al standpoint to admit 
without formality all patients who did not raise objections against 
detention, just as one would admit a case of delirium tremens or 
a case of typhoid fever without necessarily demanding either the 
assent of the patient or a l^al commitment. On the other hand, 
whenever a patient refused to co-operate, he was g^ven the oppor- 
tunity either to be examined by two physicians and to stay at the 
hospital under a legal form, or to be committed to another hospital, 
or the patient was allowed to leave the hospital in care of the 
family. Only 12 out of 370 patients were held under commitment 
and several of these because th^ happened to bring commitment 
papers. A certain number were committed to other institutions, 
not necessarily because of any unfavorable outlook, but often 
because it was considered best for the patient to be in a hospital 
located in the country with somewhat more latitude than that of 
our hospital. In all this, we have enjoyed the most cordial co-oper- 
ation on the part of the neighboring hospitals. 

The nature of the conditions of admission just mentioned and 
also the relatively limited provisions for excited cases naturally 
gave our experience a cast quite different from that of most of the 
other hospitals of a similar character. The clinic is not an admis- 
sion hospital for any special district, a matter which will be taken 
up later only when we feel that we are in a position to do produc- 
tive research leading to preventive and intensive study in some 
definite circtmiscribed locality. The admissions were selected 



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ADOLF MEYER 399 

from the applications and from the patients who presented them- 
selves in the out-patient department. Dr. Henderson has lately 
published in the Johns Hopkins Hospital Bulletin a brief account 
of some of the experiences with regard to the admission material, 
and especially of the principles on which we worked, namely, that 
we depend primarily not on the issue as to whether the patient is in 
a curable or incurable condition, but on the question whether he 
presents problems for solution, and whether or not in our plan of 
help, we find any adequate co-<q)eration with the patient and with 
the family. 

One of the great functions of the clinic is the diagnostic sizing up 
of the facts in a case, and the outlining of a safe program of care 
with which many ventures of expensive and useless experimenta- 
tion may be replaced by a plan adapted to the finances and the best 
opportunities of the family and the patient. If we find that a patient 
can profit under the intensive therapeutic work of the clinic, we can 
keep the patient as long as we feel that adequate progress can be 
made ; if we see that a treatment of a less strenuous and direct kind 
will furnish adequate results, it is our practice to direct the family 
and the patient to what seems to us the most practical and expe- 
ditious plan of care adapted to the prospects of the patient and to 
the means of the family. Therefore, patients presenting diagnos- 
tic or therapeutic problems, and lending themselves to intensive 
treatment, were g^ven the preference throughout. 

I may say in this connection, in the way of explanation, that the 
ward unit on each of the three floors consists of a ward with eight 
beds, with several single rooms, and on the first and second floors 
with provisions for continuous baths. The third floor is a ward for 
patients whose behavior is perfectly orderly, and for convalescents ; 
on the second floor we try to maintain, as far as possible, a similar 
r^me, keeping the ward as free as possible of actively disturbing 
elements ; while the first floor division offers opportunities for more 
complete separation of incompatible patients, and is also so 
arranged that in case of admission of a case with infectious dis- 
ease, the ward can be divided into two independently accessible 
divisions. On the fourth floor the private patients have rooms and 
suites, and on the first floor one room with adjoining continuous 
bath. The available means for study and for work with bed-treat- 
ment, bath and hydrotherapy, occupation, and mental readjust- 



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400 ORGANIZATION OF PHIPPS PSYCHIATRIC CLINIC 

(nent, are naturally such as to make undesirable the retention of 
many non-co-operative excitements and agitations, in which cases 
a transfer to a hospital with less compact wards often proved 
remaiicably beneficial. 

Over loo of the 370 admissions were free patients, with an 
average treatment of 37 days each ; 25 paid less than $10.00 a week, 
with an average treatment of 72 days. The ordinary rate has been 
put at $25.00 for ward care and $30.00 for special rooms, and 
varying rates for the private patients. The extremes of the stay 
at the hospital have been one day and 334 days. 

The extensive work of the out-patient department will be re- 
ported by Dr. Campbell. 

From a psychiatric point of view the most interesting problem 
has been not only to push the diagnoses of the disease processes 
as far as possible, but also to get at means of defining more closely 
the individual prognosis and the nature of the case. I have long 
felt that we are in danger of considering too many possibilities 
settled by making a diagnosis merely along the lines of the present 
division of constitutional and non-constitutional, and dementing 
and non-dementing disorders. For this reason we have pushed 
as far as possible the study of the etiological factors, and those 
components of the conditions which are decisive for the outcome 
and for the treatment; and it is our main interest then to see 
whether these factors are modifiable or not, and to what extent 
we can find therapeutic indications and modifications aiming at 
the best possible adjustment, considering the assets of the patient. 

A fairly large percentage of our cases consisted of organic 
disorders. Inasmuch as our neurological laboratory department is 
not organized as yet, the work was largely limited to clinical issues 
and to what the physician in charge of the laboratory of internal 
medicine undertook in the direction of serum work and salvarsan 
therapy. A slightly larger number of admissions belong to the 
opposite extreme, namely, the psychoneuroses. The intermediate 
group is formed by the standard psychoses of the usual psychiatric 
classifications. 

The experience of this year certainly has given us a keen insight 
into the frequency of minor mental maladjustments which would 
not to-day become a problem for state institutions, but which are 
of tremendous importance for a healthy development of individ- 



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ADOLF MEYER 4OI 

uals, families, and ultimately of communities. A study of personal 
assets, a study of the adjustment of the essential determining 
factors of adaptation and the induction of more normal resources 
for the conduct of life of our patients, and the development of 
standardized methods of discrimination in our work ; these have 
been the gliding lines of our program. 

It is natural that the general spirit in which the clinic is organ- 
ized brings with it many interesting consequences with which the 
average hospital for mental cases has little to do. 

In the first place, patients who are not committed, and many of 
those who are not even on the basis of the three-days notice stipu- 
lated in voluntary commitments, present problems much more like 
those of private practice. We are forced to do all in our power to 
develop means of helping the patients reach a correct understand- 
ing of the meaning of such a hospital and of any hospital for 
mental disorders and of helping them realize that it is important to 
get a careful study of the assets and the formulation of a plan 
of readjustment. Our division of the hospital deals with so many 
matters of a personal character that the mode of approach by the 
examiner and the way the facts are handled play a g^eat role in the 
attitude of the patient. 

We have no public ward rounds with semi-public discussions, 
and we g^ve all desirable consideration to our patients in the clinical 
demonstrations ; and in assigning students for collaboration in the 
work, we are favored with an unusually well-picked class of young 
men and women, so that I may well say that what worries about 
the collaboration of students may have existed, never came post 
factum, and rarely even " by anticipation " after the patient had 
learned to know the hospital. 

The greatest difficulty is encountered in certain cases of agitated 
depression and in cases of overactive and overtalkative or impul- 
sive states, where the routine of a hospital located in a city and the 
close association of patients become too narrowing and oppressive 
to the patient. In these conditions I have usually followed the 
principle of considering the feelings of the patient just as far as 
wisdom of action would permit, and that not infrequently with the 
result that a release of the patient to his home or a transfer to 
another hospital of his own preference had most beneficial results, 
and led to subsequent co-operation. To gain co-operation for the 
26 



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402 ORGANIZATION OF PHIPPS PSYCHIATRIC CLINIC 

period of cowvalesence is, after all, fully as important as prompt 
care at the begimiing of the attacks ; and if it is possible to tide 
over the frequently tantalizing intermediate period of maladapta- 
tion with as much collaboration as possible, we shall be able to 
overcome a g^eat deal of the rigidity of the insanity-concept that 
lingers in the public mind. 

The great lesson the public needs to take to heart here, as in so 
many other issues of practical life, is that no one is fit to be 
absolutely independent; we are social beings and members of a 
family and of a community, and act as a rule as agents of a 
common-sense consensus. Why should we not be able to harmo- 
nize with our dignity the conviction that there are times in every 
life when we had best accept the consensus of common-sense rather 
than our own temporary feelings? Let us try and make the 
public see that alienists and our laws want to lead to a realization 
of this and nothing more. 

In all this I hope we have been able to steer clear of the deplor- 
able tendency to create invidious contrasts with the existing hos- 
pitals and so-called asylums. I consider that one of the best 
contributions I can make to the solution of the problem of remedial 
and preventive psychiatry is to draw our state institutions from 
their isolation in the eyes of the public and the profession. We 
have common aims and common duties and we desire to work 
together on our difficult but, after all, most inspiring task. There 
may be diflferences in opportunities and equipment, and differences 
in the duties towards the community and state, but in principle 
our clinic shall never be used as a contrast to your institutions 
along the line of the traditional public notions concerning hospitals 
for the insane; on the contrary, I hope we shall be able to do our 
share to make patients and families grateful for the good help 
you offer them in times of need. 

This will, of course, be easiest if we can establish close, though 
informal, but all the more practical, collaboration. 

I consider it one of the greatest fxmctions of the clinic to give 
opportunities of work not only to our students, but to men who 
want to devote six months or more to intensive psychiatric work. 
So far we have worked with vacancies on the staff, which we 
want to fill with men and women of promise ; and I fed that the 



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ADOLF MEYER 4O3 

plan used in New York, by which a physician is given a leave of 
absence for study and special work, on full salary or half-salary, 
together with an opportunity for some of the workers to live in 
the clinic, should make it possible to get that kind of g^ve-and-take 
which forms the ideal of learning and teaching, and brings the 
state or private hospitals a valuable means of stimulating its physi- 
cians, fully worth the outlay of money. 

Another line of collaboration will, I hope, develop with the 
exchange of laboratory facilities and laboratory material. That 
we should be very appreciative of opportunities to study patients 
or materials for which most hospitals are not equipped, goes with- 
out saying, and I hope to see the day when you will consider it 
worth while to cultivate the habit of exchange wherever it is 
practicable. 

To-day's presentation cannot aim to g^ve you in any sense a 
demonstration of the trend of the actual activities of the clinic. 
What we want to do is to give you a sketch of some of the phases 
and interests cultivated by various members of the staflf. They all 
g^ve, in one way or another, illustrations of our common-sense 
effort to formulate the facts and of our diagnostic and thera- 
peutic work in the ways in which they are most likely to be intel- 
ligible at their true value, and effective. We have been favored 
with a sufficient variety of temperaments among the members of 
the staff to get good representatives of those aiming at formal diag- 
nosis, those interested in the organogenic and neurogenic, and 
those interested in the psychobiological or psychodynamic factors ; 
and we have, I hope, avoided undue partiality owing to the 
wonderfully manifold range of problems continually presenting 
themselves for practical solution and also owing to the calls of 
teaching. 

The program has been abbreviated somewhat, so that we might 
get some time for questions and discussions between the papers. 



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THE ROLE OF THE PSYCHIATRIC DISPENSARY: A 
REVIEW OF THE FIRST YEAR'S WORK OF THE 
DISPENSARY OF THE PHIPPS PSYCHIATRIC 
CLINIC. 

By C magpie CAMPBELL, M.D., 

Associate Professor of Psychiatry, The Johns Hopkins University, 
Baltimore, Md. 

The problems of the dispensary differ somewhat from those 
of the clinic and the aim of this review is to discuss some of these 
problems in the light of the first year's experience in the dispensary 
of the Phipps Psychiatric Clinic. It is obvious that in the dis- 
pensary it is not possible to carry out the same detailed studies 
which are possible when the patient is tmder continuous observa- 
tion in the hospital; the examination is frequently somewhat 
summary and conclusions have to be drawn from data which are 
recognized to be inadequate for the thorough tmderstanding of 
the case. The limitation of time tells especially in psychiatric 
worky for in this department we cannot always plunge abruptly 
into an examination; to establish satisfactory relations with the 
patient is essential for good results, but this requires time; the 
speed of the examination is largely dependent upon the condition 
of the patient ; the physician is occasionally not permitted by the 
patient to take notes of important facts. The fact that the anam- 
nesis, so important in psychiatric work, is often given by some 
friend with little knowledge of the case, helps to make the inter- 
pretation of many cases still more uncertain. It is not, therefore, 
from the dispensary that one expects a psychiatric discussion 
based on well-analysed clinical material. In the dispensary the 
practical demands of the patient stand in the foreground, and 
these demands usually require the investigation of a whole situa- 
tion and not merely that of the patient as a unit ; the attempt to 
modify this situation, which is essential for the satisfactory treat- 
ment of the case, takes one from the dispensary into the home and 
brings one face to face with the vital problems of the mental 
hygpiene of the community. 



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406 THE ROLE OF THE PSYCHIATRIC DISPENSARY 

If the inability to make a detailed study of the more complicated 
cases is at times to be regretted, there is compensation in the 
treatment of many interesting minor forms of maladjustment, 
which are included in the stream of dispensary material. The 
fact that so many of the cases present disorders to which it is 
hard to give a satisfactory name, and to group in any of the con- 
ventional diagnostic groups, is perhaps partly to be understood 
in the light of the changing conditions of psychiatric woric. The 
descriptions of mental disorders found in classical text-books 
have been chiefly based on the clinical material found in the hos- 
pitals for the insane, while the less severe but more common forms 
of maladjustment have received scant attention, and are even 
somewhat grudgingly allowed to belong to this special branch of 
medicine. It is therefore not surprising that there is little agree- 
ment at present as to the formulation of the diagnosis in many 
such cases. In the work of the dispensary the aim has been 
rather to formulate the diagnosis of the cases in intelligible work- 
ing terms rather than in terms of some rigid classification which 
does violence to the facts. It will be some time before we are 
in a position to diagnose our cases in uniform terms which will 
do justice to the dynamic factors in the individual case and at the 
same time indicate the relationship of the case to recognized forms 
of disorder. 

During the past year (May i, 1913, to April 30, 1914) 708 
patients registered at the dispensary ; in the accompanjring chart 
the distribution of the patients in large provisional groups is 
shown. 

By far the largest group is that of children under 16 years of 
age ; it contains 236 patients. No more important nor more fun- 
damental problems are brought before the dispensary than those 
furnished by this group of cases, which even numerically is so 
striking; it raises important questions as to the relation of the 
functions of the dispensary to the work of other social agencies. 

In close connection with the problems of these children may be 
discussed the group of adults in whom the crucial factors are 
mental defects similar to those which bring a large number of 
children of school age to the dispensary. 

Next in numerical importance to the group of the children is 
a large group of cases including not only well-recognized tjrpes of 



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C. MACFIE CAMPBELL 407 

psychoneurosis, such as hysteria and obsessional states, but also 
a great variety of cases of nervous invalidism; in these cases of 
invalidism the mechanisms of the psychoneuroses are also to be 
traced, but the clinical picture is less distinct and is largely de- 
termined by special constitutional traits of the individual. 

Chait z. — Phipps Psychiatric Dispensary. May i, 1913, to April 30, 
1914. Classification op Patients (708). 



Children under x6 yea 

Adult defectives 

Manio-depreasive depi 
Other forma of depreai 

Paychonetirosis and ot] 

invalidiam. 
Epileptic and epilept 

ditiona. 
Organic brain diaeai 

aclerotic* aenile, etc. 
Dementia precox and 

ditiona. 
Paranoic oonditiona.. 

Alcoholic and drug co 

Infective exhauative 

Unclaaaified. 



In another group is brought together a great variety of cases, 
where a reduction of mood or definite depression is in the center 
of the clinical picture; many of these cases might no doubt with 
equal propriety be brought into relation with the above group of 
cases of nervous invalidism. From this group of depressions it 
is possible to separate another group of 13 cases, which present 
in sufficiently clear form the manic-depressive type of depression 
(these, along with one case of excitement and two cases of the 
mixed type, form the total of 16 cases of manic-depressive in- 
sanity). To give this familiar name to these cases does not 
necessarily mean that we know more about them than we do 
about the other group of depressions ; in fact, it is apt to paralyze 
our thought about them, as the familiar diagnostic term brings 
with it an assumption of knowledge which is rather illusory. To 



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408 THE ROLE OF THE PSYCHIATRIC DISPENSARY 

think therefore of these manic-depressive depressions in the gen- 
eral framework of the whole group of depressions will help to 
keep alive the problems of the manic-depressive disorders; in- 
stead of trying to grasp the meaning of the other cases in relation 
to the superficially familiar group, we shall be encouraged to work 
seriously at the individual cases of the larger group and to utilize 
the principles discovered there to throw light on the familiar but 
little-understood manic-depressive depression. 

The larger group of depressions consists of 68 cases of rather 
heterogeneous nature. One must here repeat that these cases 
have been studied under dispensary conditions and that this pre- 
sentation merely gives a provisional grouping of these cases ; this 
whole group furnishes an exceedingly fruitful field for intensive 
work and there is no doubt that in a large number of these cases a 
fairly satisfactory reconstruction of the whole process could be 
arrived at. Without such an analysis we are working with 
rather crude measures. 

A provisional division of this group was made into two subor- 
dinate groups; the former of these was characterized by the 
prominence of somatic complaints, such as headache, dizziness, 
crawling feeling, vague pains and paraesthesias, " nervous indiges- 
tion,'' constipation and sleeplessness. 

In the other sub-group were included all cases of depression not 
otherwise classified. With regard to these two subordinate groups 
of depression, it is probably of significance to note that in the 
former group, with the marked prominence of somatic symptoms, 
only 12 out of the 37 patients were imder 40 years of age, while in 
the second group 19 out of 31 were under 40. With r^;ard to the 
sex-incidence, in the former group 28 out of 37 patients were 
women ; in the latter group 19 out of 31 were women. 

The symptom-picture, if one is entitled to use this term for 
symptoms so poorly knit together, in the first group is thus seen 
to be more frequently found in women and at a somewhat more 
advanced age than the symptom-pictures of the second group. To 
many of these cases it is evident that the term " involution-melan- 
cholia " may be applied without doing too much violence to our 
conscience; but the comfort supplied by this familiar term does 
not bring with it much illumination and again is apt to dull the 
interest in research. As a matter of fact, none of the patients 



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C. MACFIE CAMPBELL 4O9 

presented the classical picture of involution-melancholia, and it 
would have required a certain classificatory enthusiasm to have 
grouped many of the cases under this head. When one turns 
from these more formal points to the consideration of the indi- 
vidual cases, we find it possible, even imder dispensary conditions, 
to get considerable insight into the development of the symptoms 
and into the role which the symptoms play in the adjustment of 
the individual to the actual problems of life. Here the study of 
the personality and of the actual situation is essential ; it is usu- 
ally necessary to go beneath the compromise of the individual life 
to study the actual dynamic factors. It was striking to see in how 
many cases the symptoms seemed to arise in the setting of a diffi- 
cult marital situation. 

The line of treatment follows the above general indications, and 
the difficulties in the way of a satisfactory result are obvious. The 
personality of the patient is not easy to modify at this period; 
faulty adjustments have become habitual ; compromises and eva- 
sions have become an integral part of the individual's life; the 
symptoms have to a certain extent proved to be along the line of 
least resistance; the marital situation has frequently to be ac- 
cepted, even although we find that the marriage was originally 
entered into without affection in order to forget a first love. 
Frequently, however, a certain modification is possible; the break 
in compensation may have been due to factors which can be modi- 
fied ; the physical health of the patient can perhaps be improved, 
faulty hygiene corrected, sane recreation and wider interests in- 
troduced into a rather dreary and narrow life, and the patient 
brought to face in a more direct manner the underlying factors. 
By means of the social service department it is often possible to 
improve the situation at home, and some tactful advice to the 
husband or wife or family of the patient may bring good results ; 
an occasional visit to the park or even to moving pictures is a pre- 
scription not beneath the dignity of the physician and may be 
based upon more rational grounds than a routine tonic or hypnotic. 

In the more heterogeneous second subordinate group of de- 
pressions the same principles apply as in the group already dis- 
cussed. Here, too, the more opportunity one has of stud)ring the 
individual psychology of the case the further does one get from 
the standpoint of formal classification and the more anxious one 



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4IO THE ROLE OF THE PSYCHIATRIC DISPENSARY 

b to formulate the disorder in dynamic terms. To illustrate what 
has been said, the following case may be briefly reported : 

J. S., a man 68 years of age, had not been very successful financially 
for some time. He came to the dispensary because he did not rest well; 
he had swimming of ^e head, shortness of brea^ and some nausea. He 
himself referred the onset of the symptoms to financial troubles which 
began in 1911. He felt sad, but there was no retardation. He was rest- 
less during the examination. His memory was very good. Physically, 
there was little to notice ; he showed very slight arteriosclerosis. 

The case appeared to be a fairly simple type of depression, 
partly explained by his financial worry, and more or less intelligi- 
ble as an excessive reaction to this worry in a person of advanced 
age. 

In this case the opportunity for a fuller review of the patient's 
life brought up very important factors, which would have to be 
taken into consideration before one had a right to formulate the 
exact nature and mechanism of the disorder. 

It was found that the patient had had earlier in life several at- 
tacks of depression. These attacks of depression, however, were 
not merely to be looked upon as the expression of some obscure 
constitutional disorder. They were found to be directly related 
to the problems of his sexual life. The patient had worried con- 
siderably about masturbation. His physical health was running 
down, and at the age of 20 he went to a quack physician, who 
diagnosed some disease of the bladder and of the nervous system, 
whereupon the patient went to bed for two months. He had 
several similar weak spells during the following years. He 
married at the age of 26, and from that period until the age of 
66 (in 191 1 ) he was absolutely free from depression. 

The case illustrates the limitations of dispensary work and the 
wisdom of making the diagnosis in rather simple and c(Hnmon- 
sense terms. If the examination had been confined to the first 
two interviews the case might have been considered a reactive de- 
pression, to be explained partly by the organic changes so frequent 
at this period of life. The later discovery of the earlier attacks 
might have seemed to justify the designation of manic-depressive 
depression. The understanding of this case could only be attained 
by the analysis of the individual attacks, and in the light of the 
mechanism of the earlier attacks the onset of the depression at 



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C. MACFIE CAMPBELL 4II 

66 became a problem of much greater interest than one of classi- 
fication. 

The largest group of adult patients, as already mentioned, con- 
sisted of those who either presented a well-recognized psycho- 
neurosis or less well-defined forms of nervous invalidism; the 
group is obviously very far from homogeneous. Several cases 
could perhaps with equal propriety have been included in the 
group of the depressions, especially those showing a prominent 
h3rpochondriacal trend, and several cases grouped under the de- 
pressions might no doubt on a fuller examination have been found 
to belong to the psychoneurotic group. The problems of the psy- 
choneuroses are sufficiently difficult even under the most favor- 
able conditions of study and treatment; the diversity of opinion 
with regard to their fundamental mechanisms is extreme and the 
nomenclature is in a rather fluid state. 

The cases observed during the year fell into six provisional 
groups as seen in the following table : 

PSYCHONEUSOSES (INCLUDING ILL-DEnNED TYPES OF NEE70US INVALID- 
ISM) no 

Anxiety-neurosis 21 

Hysteria with attacks or purely physical symptoms 23 

Hysteria with morbid fears 19 

Obsessive thoughts and actions 14 

Hypochondriacal and neurasthenic states 13 

Nervous invalidism of less well-defined type (frequently 
inadequate data) 20 

It would be out of place here to take up the more fundamental 
problems of the psychoneuroses; it may be useful to discuss how 
far the conditions of dispensary work introduce special compli- 
cations. These cases will always be an important factor in dis- 
pensary work, because, owing to the less severe nature of their 
symptoms, the patients frequently are disinclined to come into 
a hospital, and because their treatment is as a rule too prolonged 
for continuous hospital residence. 

Whatever may be one's views as to the nature of the psycho- 
neuroses, most will agree on the necessity of a rather thorough 
review of the life of the patient in all its bearings. The special 
constitutional traits of the patient, the details of the individual 
life, have to be understood and the patient has to learn to bring 



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412 THE ROLE OF THE PSYCHIATRIC DISPENSARY 

to discussion much that has hitherto been strenuously repressed. 
There is no short-cut towards the necessary self-knowledge and 
any attempt to force the pace or to change the tedious step-by-step 
progress is apt to retard rather than accelerate the recovery of the 
patient. Re-education can never be made an abrupt process and 
the attempt to do so is futile. As the physician cannot delegate 
the work to any other person, but has to continue the detailed 
study and treatment of the case personally, great demands are 
made on his time. The possibility of treating the dispensary 
patients along these lines has been due to the comparatively large 
number of physicians who are associated in the work of the dis- 
pensary. It not infrequently happens, however, that for various 
reasons rather strict limitations of time are put on the treatment 
of the patient ; the patient may perhaps be spending a short period 
in Baltimore, or the demands of the other patients may not allow 
the physician to give the desired time to the special patient. There 
is a tendency in some quarters to dogmatize about the minimum 
time necessary for satisfactory treatment of these patients and 
the impression might be gained that, if these time conditions 
were not fulfilled, the treatment of the patient would be rather 
futile. There is of course much truth in this caution against 
expecting quick results. On the other hand, the physician must 
not demand too much. It is quite striking what excellent results 
may be gained from a rather limited series of interviews. The 
record of the case will of course not be a very convincing clinical 
document, and many interpretations may be borrowed from the 
physician's experience with other cases; the therapeutic result, 
however, may be very satisfactory and the patient may return to 
the home relieved of symptoms, and having acquired a degree of 
self-knowledge which is the best guarantee of satisfactory mental 
hygiene in the future. Useful statistical data as to the compara- 
tive results of the different forms of treatment of the psycho- 
neuroses are not available; results rapidly attained may be only 
transitory, but the impression from the dispensary work has been 
that dispensary conditions are not unfavorable for the treatment 
of this class of patients, and that even under great restrictions of 
time the physician, in the study and treatment of these disorders, 
should feel encouraged to make use of the same principles, the 
validity of which has been demonstrated on other material where 



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C. MACFIE CAMPBELL 413 

a more exhaustive analysis of the case is possible. It may not be 
out of place here to refer to a practical point of considerable im- 
portance ; where detailed study of the case over a prolonged period 
is necessary, the physician must be on his guard against the pa- 
tient's making use of the interviews for his or her own purpose, 
and making little real progress towards a satisfactory readjust- 
ment. The patient may derive from the interview a gratification, 
which simply becomes an additional factor in her complex neuro- 
sis. It must be emphasized that this situation is not to be immedi- 
ately attributed to the trend of the examination, for one finds 
frequently that the patient has already indulged in the same 
attitude towards other physicians, who have treated her for a pro- 
longed period for her neurotic symptoms along somatic lines. It 
is possible, no doubt, in many cases, for the physician to deal 
directly with this situation where it arises ; but that depends to a 
certain extent on the whole make-up of the patient. Here the 
social service department has been of invaluable assistance. In- 
stead of laying too much weight on the detailed analysis of such a 
case, it is essential to emphasize the positive side of the recon- 
struction of the patient's life and to do everything possible to 
raise the general level of the patient's interests and activities by a 
thorough investigation of the home situation and practical guid- 
ance with regard to definite activities. The social-service worker 
can here co-operate with the physician in a way which obviates 
certain very practical difficulties in the relation of the patient to 
the physician. 

Of the total work done in the dispensary, that in relation to 
children is socially perhaps the most important at present, and 
promises to develop extensively in the future. The children who 
came to the dispensary formed exactly one-third of the total num- 
ber of cases. The conditions for which the children were brought 
to the dispensary varied very widely, some cases being brought for 
small habits like thumb-sucking, or for peculiar tics, while others 
presented conditions of profound defect. These cases have been 
grouped as is shown in chart 2. 

Twenty-five children were foimd to be practically normal. 
Some of these were examined because they were members of 
families where many cases of defect had been f otmd ; others were 
brought by teachers on accotmt of difficulties at school; others 



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414 



THE r6lE of the PSYCHIATRIC DISPENSARY 



were brought for a thorough examination before the child was 
placed in some home. The children who presented distinct anoma- 
lies (211 in number) have been grouped according as they did 
or did not show a definite intelligence defect, this usually being 
standardized by means of the Binet-Simon scale. One hundred 

Chart 3.— Phipps Psychiatric Dispensary. May i, 1913, 10 April 30, 
1914. Chilosen Unter 16 Years (236). 



Normal 

Normal intellectually but with various neurotic or 
psychotic conditions — 

speech defect 

Epilepsy 

Neurotic traits (tics> etc.) 

Neurosis 

Psychosis 

Moral defect 

Organic nervous disease 

Unclassified 

Simple intellectual defect 

Intellectual defect with other symptoms- 
Speech defect 

Epilepsy 

Neurotic 

Hysteria 

Chorea 

Hemiplegia* etc 

Sense defect 

Moral defect 

Unclassified 



10 20 30 40 50 60 7D 80 



and forty-eight children showed a definite intelligence defect, and 
Dr. Hall has reviewed the cases in this group, and discussed the 
important problems that they present both from the medical and 
social point of view. 



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C. MACFIE CAMPBELL 415 

The children who did not show a definite intelligence defect 
presented a great variety of clinical problems. 

The importance of the early period of development in relation 
to the origin of nervous and mental disorders in the adult period 
has steadily gained recognition as the study of the adult psychoses 
has become more thorough. In stud3ring the individual adult 
psychosis there may always be some uncertainty as to how far 
the memories of the actual experiences of childhood have been 
distorted in the adult mind. In the group of children at present 
under consideration one has the opportunity of studying these 
factors more directly, and one can trace at an early stage the 
development of faulty habits fostered by the bad hygiene of the 
environment. Traits, which later on may be considered as inborn 
and constitutional, are seen in their relation to the actual situa- 
tion which develops them. The study of these children promises 
to give us very important information with r^^ard to the develop- 
ment of the child and the evolution of neurotic traits and other 
anomalies of adjustment. 

Several children presented already a well-marked psychoneu- 
rosis. 

At this early stage the mechanism of the psychoneurosis may 
be traced much more easily than when it has passed through the 
later adult elaborations. 

J. R, a boy of 7, was referred to ^e dispensary from the Harriet Lane 
Home. He had been brought to the hospital, as he had shown peculiar 
nervous symptoms. In January, 1914, he had suffered from chicken-pox. 
Four days after recovery he cried out that his feet were growing larger ; 
that his hands, and nose and mouth were growing larger. He began to 
dream of snakes. On account of this he was afraid to go alone into a room. 
One day his mother hurried to him, as she heard him crying. He was 
shaking and crying out that he had seen a black snake coming after him. 
He was now sensitive and did not want people to look at him. He 
dreamed frequently of robbers, and in the day-time he was afraid of 
robbers. 

In the second interview at the dispensary the following facts 
were elicited, the boy talking very frankly, even in the presence of 
his mother and several physicians : 

In his dreams he saw robbers, and robbers would kill his younger 
brother Bob and cut him up in pieces. He also had dreams that his 
brother was drowned. The mother said that when the younger brother was 



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4l6 THE ROLE OF THE PSYCHIATRIC DISPENSARY 

bom the patient would object to her nursing him, and would try to push 
the baby away with his feet The mother stated that the patient was very 
fond of his brother Bob. The patient, however, made the interesting state- 
ment, "Bob is the pet and sits on mother's lap, and if anything wrong 
happens, I do it." He also said: "Bob is the pet, because he always 
sleeps next to mother." 

In the dispensary the patient made the statement that he had been grow- 
ing small, just as small as Bob (the brother). Evidently some of the 
boy's morbid fears were closely related to the repressed jealousy of his 
brother. 

The date of onset of the symptoms was important It came on after 
the attack of chicken-pox. Before the chicken-pox he and his brother had 
shared the mother's bed, Bob sleeping next to the mother. When the 
patient had chicken-pox he was left alone in the bed, while the mother 
and Bob slept on a coucIl The patient now cannot bear to hear chicken- 
pox mentioned. 

This meager analysis of the case was sufficient to indicate that 
the boy was to a certain extent suffering from his jealousy and 
its repression, and the mother was advised to take quite seriously 
the utterances of the patient, and get him to feel that he could 
talk to her absolutely frankly about all that was in his mind. It 
was hoped that the development of the frankest possible atmos- 
phere in the home would prevent the further development of 
neurotic symptoms. 

In another case the clinical picture was a little more ominous, 
and the family atmosphere very difficult to modify. 

The patient, a girl of 8, had developed slowly in infancy, but showed 
no mental defect For many months she had suffered from a choreiform 
condition of rather peculiar nature. She had a strident and unnatural 
laugh; she asked questions incessantly, and the questions were frequently 
rather aimless and with self-evident answers, e, g., "Is mother sitting 
there?" (Looking at her mother.) "Arc you my doctor?" "Am I 
your patient?" 

The child showed an abnormal interest in water. On one occasion she 
had been rescued in the middle of an attempt to go down the sewer. 
Two months later she pointed to water flowing down the sewer and said : 
" Water can go down there, but little girls cannot" The flushing of the 
toilet fascinated her, and her mother had difficulty in keeping her away 
from the faucets. 

This obsessive curiosity of the child was interesting in relation to the 
strongly repressive atmosphere in which she was brought up, which tabooed 
many topics of childish interest The father was strictly religious, unable 
to ride on the trolley on Sunday, looking upon dancing as destructive 
of the soul. The mother was rigidly conventional, and felt that she should 



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C. MACFIE CAMPBELL 417 

punish her two-year-old boy for making reference to his sister being in 
the toilet When the patient at home would roll on the floor in a careless 
way, the mother was horrified at her scandalous behavior. 

In this case it was felt that every effort must be made to give a 
little more freedom to the development of the natural instincts 
of the child, and the social-service worker has spent much time 
in trying to interest the mother in studying and trying to imder- 
stand the child. She is trying to get the mother to give the child 
freer opportunity for development. The child has made weekly 
visits to the dispensary, where she plays contentedly with the toys 
provided for her, and has some respite from the continual nagging 
of her mother. It may be possible to arrange for the child to have 
a short holiday away from her parents, although in their anxious 
care for her they are rather averse to this. 

Actual studies of cases of this description will be an important 
contribution to our knowledge of psychopathology. Such work 
will have to be done as a rule in the dispensary, for the child will 
have to be observed for a very long period. Parents are fre- 
quently unwilling to be separated from their child, and treatment 
consists in the modification of the home, as well as in giving direct 
assistance to the child. 

The development of minor neurotic s}rmptoms in relation to 
faulty environment was well seen in a little girl of 6, who was 
brought to the dispensary, as she was subject to night terrors. 
She would wake up screaming " Mamma" (grandmother), and 
frequently had to be taken into her g^randmother's bed. The 
parents of the patient were dead. With regard to her other symp- 
toms, the patient was said to have comparatively little appetite, 
and to be somewhat capricious with regard to food. She was also 
timid if left alone, and would always have to reassure herself as 
to the whereabouts of her grandmother. As a matter of fact, 
the grandmother had been abnormally timid as to the child being 
allowed to go out ; she was always afraid that something would 
happen to the patient. She gave the patient ntmierous pennies, 
allowed her to buy candy constantly and to eat indiscriminately 
between meals. The grandfather thought it was a shame to try 
and force any food on the patient at meals, and the patient there- 
fore got whatever she wanted ; she was always able to get what 
she wanted by harping on it, or by crying until the end was ob- 
27 



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4l8 THE ROLE OF THE PSYCHIATRIC DISPENSARY 

tained. The patient had been given some sleeping medicine by 
another physician, and the grandmother rather favored the con- 
tinuance of this. Here the whole education of the patient was 
seriously at fault. The main problem was to organize the hygiene 
of the home, and, if possible, to instruct the grandmother, while 
the child herself required no special treatment. 

An extremely important group of cases consists of children 
who have shown evidence of what may roughly be called moral 
defect ; the patients have either been pilfering, or shown intolera- 
ble behavior of one type or another, or have shown sexual immo- 
rality of a more serious nature than mere incidental masturbation. 

In these cases it is very difficult to determine how far these 
undesirable traits can be related to more elementary disorders, 
and how far these underlying factors may be open to modification. 
In many cases one finds the association of these tmdesirable traits, 
such as stealing, with other evidences of neurotic instability — ^bad 
dreams, bed-wetting, masturbation. From the point of view of 
the criminologist, the material referred to here is extremely 
important. 

The work of the social-service department has been already 
referred to in connection with other groups, but in no group does 
the work of this department play such an important role, and it is 
in regard to this group that the responsibility of the dispensary 
for seeing that advice given is actually carried out, is very direct 
Unless the community has already available some efficient organ- 
ization which is able to deal with the situation in these cases, this 
duty seems to devolve upon the dispensary, and this work can only 
be done through a well-organized social-service department. The 
extent of the problem is considerable, and to have a department 
which will adequately cope with the situation probably means a 
very large extension of the work. The results of the work may 
not appear to be very striking; they are not quickly attained, but 
they are of far-reaching significance, and permeate deeply the 
whole social structure. To give an example of the work that is 
done: 

A boy of II was being treated at the dispensary for stammering. His 
home conditions did much to foster the general nervousness, of which 
his stammering was one expression. The boy was allowed to go to bed 
at all hours, usually rushed to school with practically no breakfast, had 
a rather injudicious diet, and drank coffee ad lib. His sisters delighted to 



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C. MACFIE CAMPBELL 4I9 

irritate him and to provoke outbursts of temper. His mother babyfied 
him and made him the sport of the other boys. These were facts that 
were obtained after careful investigation by the social-service worker, 
and they yielded immediate indications for treatment. The boy now 
has a regular daily regime; he is in bed at 8.30 p. m.; has a cold tub at 
7.30 in the morning, then punches the bag; has breakfast in a sensible 
manner, with no coffee, and goes to school in time. The sisters have 
been looked after to a certain extent, and the mother has been encouraged 
to allow the boy to develop more independently along with the boys of 
his own age. The boy is fond of manual labor; he has been given a 
garden in the back of the premises, and at the dispensary he enjoys 
basket-making. His general speech level has improved, although he still 
stammers. With regard to his sexual habits the boy is somewhat evasive, 
but it is hoped that a healthy regime may do much to reduce any difficulties 
in this sphere. 

Now that the boy has been adopted as one of the " gang " which pre- 
viously used to torment him, his mother, who previously reproached him 
for his timidity, is alarmed at his newly acquired '' toughness," but notices 
that when he is with his tough comrades there is no trace of stammering. 

F. B., a boy of 9, was brought to the dispensary because of screaming 
spells. He had been a child of slow development, and had a definite 
speech defect Whenever he was crossed he got into a violent temper, 
threw himself upon the ground and screamed until he was black in the 
face. The parents were dead; his sisters were unable to control him. 
The boy was nervous and restless at night; he was slovenly in his ap- 
pearance; he was a truant at school. The home environment was very 
poor, as the patient and his three sisters slept in one dark bedroom. The 
social-service worker found that it was possible to put the boy in a new 
environment; he was placed in the Home for Worthy Boys, where he 
is looked upon as a very promising child. He is now bright and tidy 
in appearance; is a regular attendant at school which he enjoys, and shows 
a very marked improvement in his speech. He comes regularly to report 
at the dispensary, where he gets speech training. 

The mere fact that the abnormalities of a child are taken 
seriously by the physician, and that the whole subject is investi- 
gated thoroughly, has probably a very considerable influence 
for the better on the home environment of the child. The atti- 
tude of the parents becomes fundamentally different. 

This was very noticeable in the case of A. A., a boy of Syi, 
who had been stealing. The father and brother looked upon a 
thief as a disgrace to the family, and therefore to be relegated to 
some state institution. To give the boy every chance they brought 
him to the dispensary to see whether an operation could be done. 
The boy was naturally reticent at the first interview. The father 



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420 THE ROLE OF THE PSYCHIATRIC DISPENSARY 

did not bring the boy back again, as he did not see that anything 
was to be gained by simply talking to the boy. The social-service 
worker investigated the environment, found that the boy was 
being brought up in the back of a saloon in a colored neighbor- 
hood. He was extremely timid, slept badly, was thrown into a 
panic by a thunder storm. It has been possible to get the boy 
to come back occasionally to the dispensary, where he makes 
baskets ; he is now on frank terms with the physician. The im- 
provement in the attitude of the father is shown by the fact that 
on the last episode of pilfering he at once called up the social- 
service worker on the telephone and asked what was to be done 
in the situation. 

This little episode has really a very profound significance. 
The work of tr)ring to carry out the treatment, which is essential 
in such cases, takes up a great deal of time ; the individual worker 
can deal with only a limited number of cases. We feel, however, 
that the community is responsible for these children, and that 
this responsibility can only be adequately lived up to when this 
type of efficient supervision is available for every child who 
needs it. 

Closely allied in its problems to the group of the abnormal 
children is the group of adults who presented a marked constitu- 
tional defect. This g^oup contained 58 patients ; 9 of these showed 
no marked defect of intelligence, but a marked psychopathic per- 
sonality which made their adjustment to the environment ex- 
tremely imperfect ; 22 patients showed a marked defect of intelli- 
gence with no special complication ; 27 patients showed a marked 
intelligence defect complicated by sexual immorality. Of the 42 
women in this group of defective adults, 21 were sexually im- 
moral; the accompanying chart (chart 3) shows the age and 
mental level of each of these women and the number of their 
illegitimate children. 

The chart indicates facts of very great social importance; it 
illustrates the future life history of many of the defective children 
under 16, unless society faces the responsibility of caring for these 
children. For one with a statistical mind the expense of rearing 
these children of defectives compared with that of preventing 
their occurrence would repay study. Another fact that comes out 
in this chart is the startling cessation of this material above the 



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C. MACFIE CAMPBELL 421 

age of 32. How is it that above that age the conditions are absent 
that bring these patients to the dispensary? Have these women 
succumbed to the terrible risks to which they are exposed? Or 
have they been disposed of in institutions ? Or do they not appear 
because they no longer become pregnant, nor develop other condi- 
tions which bring them to the attention of special organizations? 

Chast 3.— Phipps Psychiatric Dispensary. May i, 1913, to April 30, 

1914. Age and Mental Level of the 21 Defective Women 

Sexually Immoral 



White: Physical age. Shaded: Mental age (B. S. scale). 22 Illegiti- 
mate children. P: Pregnant The numbers beneath the individual cases 
represent illegitimate children. 

With regard to the cases of organic brain disorder in our dis- 
pensary material there are few special points to mention. These 
cases were distributed as follows : 

Organic Brain Disease (58 cases). 

Sypfiilitic Brain Disease (29 cases). 

General paralysis 15 

Cerebral lues 6 

General paralysis or cerebral lues 4 

Cerebro-spinal lues 3 

Tabes dorsalis i 

Non-syphilitic Brain Disease (29 cases). 

Cerebral arteriosclerosis 14 

Senile dementia S 

Brain tumor 2 

Brain abscess i 

Double athetosis i 

Unclassified 6 



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422 THE ROLE OF THE PSYCHIATRIC DISPENSARY 

It is worth noting that in the organic conditions, excluding the 
epileptic and epileptiform conditions, 50 per cent of the patients 
showed an organic brain disease which was the result of S3rphilitic 
infection. It may also be mentioned that the 15 cases of general 
paralysis in this group already showed a well-marked picture of 
the disease ; they came to the dispensary at a comparatively late 
period, and not when treatment would have the best chance of 
jrielding results. It will be a great step forward when these 
patients are brought to the dispensary at the first onset of their 
S3rmptoms, and it is hoped that as knowledge of these conditions 
becomes more general these cases will be seen at a very much 
earlier stage. 

Several of the cases of organic brain disease presented interest- 
ing neurological S3rmptoms, such as aphasia, and were admitted 
to the Clinic for the purpose of more accurate study. Several 
cases were admitted for special treatment. 

With regard to the group of schizophrenic states or dementia 
praecox and allied disorders, it was a rather striking fact that 
the patients usually presented symptoms for a very long period 
before they finally came to the dispensary, so that the possibility 
of modification of the condition by a systematic attempt at the 
reorganization of the life of the individual was seldom a matter of 
much promise. Here, too, the general increase of psychiatric 
knowledge among general practitioners, and the wider recogni- 
tion among the laity of the functions of the Psychiatric Clinic, 
will no doubt result in these patients being brought to the dis- 
pensary at a very much earlier stage, when the disorder is perhaps 
more open to modification. 

During the year, 78 of the 708 dispensary patients were ad- 
mitted to the Qinic for the purpose of more detailed study and 
special treatment. 

In reviewing the work of the dispensary during the past year 
one is impressed with the valuable nature of the material which 
is there offered for study. It is in the dispensary that one will 
find perhaps the best material for the study of many nervous and 
mental disorders in children, and of the incipient stage of many 
of the disorders of the adult. In connection with the dispensary 
one will be able to reach some conclusion as to the course which 



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C. MACFIE CAMPBELL 423 

such disorders run if at an early stage they are taken seriously 
and an earnest endeavor made to modify those factors which seem 
largely responsible for the disordered adjustment. After some 
years one will have material which may be useful in demonstrating 
that many disorders, which we are accustomed to look upon in a 
rather fatalistic spirit, can be very much modified by serious treat- 
ment, not only of the individual patient, but of the environment 
in which he is living. The dispensary material emphasizes very 
strongly how much is gained by considering the individual in rela- 
tion to his environment, not merely as a unit by himself. 

The problem of treatment of the individual case involves a 
study of the type of personality; of the amoimt of pliability of 
the individual ; an estimate of the possibility of modifying adjust- 
ments of long duration ; it involves the study of all those somatic 
conditions which have much to do with nervous and mental abnor- 
mality; it involves the study of the whole situation of the indi- 
vidual's life. The scientific problem is solved when we understand 
the mechanism of the symptoms in the light of the reaction of the 
individual to the actual tests put by the environment. The prob- 
lem of treatment will only adequately be met when we lay due 
weight on the modification of all the factors which are. open to 
modification, when we are not content with giving advice to the 
patient based on a detailed analysis of his case, but feel respon- 
sible for dealing with the complex situation of which the sickness 
of the patient is only one aspect. For the satisfactory fulfilment 
of our responsibilities, however, it is necessary to realize that a 
somewhat extensive organization will require to be slowly evolved ; 
an organization which should work in close co-operation with 
other agencies, especially the Committee of Mental Hygiene. 
An optimist can look forward to the time when it will be possible 
not merely to say what might be done for a patient, but to see 
that the actual steps are taken which will give the patient the best 
chance of returning to an efficient level. 



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KORSAKOW'S PSYCHOSIS OCCURRING DURING 
PREGNANCY. 

By DAVID K. HENDERSON, M.D., 

Resident Psychiatrist, The Henry Phipps Psychiatric Clinic, 

The Johns Hopkins Hospital, 

During gestation or the puerperium various forms of paralysis 
may occur, which may be either of (i) central or (2) peripheral 
origin. For instance, many cases of hemiplegia have been 
described which have developed during childbirth either as a 
result of a haemorrhage, embolus, or thrombus, and it is by no 
means rare to meet with cases of paralysis of the peripheral nerves 
either of traumatic {e. g., from pressure on the nerves as they 
pass through the pelvis), or of toxic origin. It is this last form — 
the so-called toxic form — to which I want to direct attention. 
The earliest reference to this subject which I have been able to 
find is an article written in 1854 by Fleetwood Churchill " On 
Paralysis Occurring During Gestation and in Childbirth." In 
this article Scanzoni of Wurzburg is quoted as having said that 
paralysis of the lower extremities may in some cases be due to 
pressure, but in other cases, as the paralysis did not appear until 
some time after labor, and as a similar affection is known to have 
attacked the upper extremities, pressure could not be the sole 
cause, and it may