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THE JOURNAL
OF
MENTAL SCIENCE
(Published by Authority of the Medico-Psychological Association).
EDITED BY
D. HACK TURE, M.D.,
GEO. H. SAYAGE, M.D.
“ Nos vero intellectnm longius a rebus non abstrahimus quam ut rerum Imagines et
radii (ut in sensn fit) coire possint.”
Francis Bacon, Proleg. Irutaurat. Mag .
VOL. xxx.
LONDON:
J. and A. CHURCHILL,
NEW BURLINGTON STREET.
MDCCCLXXXV. 0
Digitized by boogie
“ In adopting our title of the Journal of Mental Science, published by authority
of the Medico-Psychological Association, we profess that we cultivate in our pages
mental science of a particular kind, namely, such mental science as appertains
to medical men who are engaged in the treatment of the insane. But it has
been objected that the term mental science is inapplicable, and that the terms,
mental physiology, or mental pathology, or psychology, or psychiatry (a term
much affected by our German brethren), would have been more correct and ap¬
propriate ; and that, moreover, we do not deal in mental science, which is pro¬
perly the sphere of the aspiring metaphysical intellect. If mental science is
strictly synonymous with metaphysics, these objections are certainly valid, for
although we do not eschew metaphysical discussion, the aim of this Journal is
certainly bent upon more attainable objects than the pursuit of those recondite
inquiries which have occupied the most ambitious intellects from the time of
Plato to the present, with so much labour and so little result. But while we ad¬
mit that metaphysics may be called one department of mental science, we main¬
tain that mental physiology and mental pathology are also mental science under
a different aspect. While metaphysics may be called speculative mental science,
mental physiology and pathology, with their vast range of inquiry into insanity,
education, crime, and all things which tend to preserve mental health, or to pro¬
duce mental disease, are not less questions of mental science in its practical, that
is, in its sociological point of view. If it were not unjust to high mathematics
to compare it in any way with abstruse metaphysics, it would illustrate our
meaning to say that our practical mental science would fairly bear the same rela¬
tion to the mental science of the metaphysicians as applied mathematics bears to
the pure science. In both instances the aim of the pure science is the attainment
of abstract truth ; its utility, however, frequently going no further than to serve
as a gymnasium for the intellect. In both instances the mixed science aims at,
and, to a certain extent, attains immediate practical results of the greatest utility
to the welfare of mankind ; we therefore maintain that our Journal is not in¬
aptly called the Journal of Mental Science , although the science may only at¬
tempt to deal with sociological and medical inquiries, relating either to the pre¬
servation of the health of the mind or to the amelioration or cure of its diseases;
and although not soaring to the height of abstruse metaphysics, we only aim at
such metaphysical knowledge as may be available to our purposes, as the mecha¬
nician uses the formularies of mathematics. This is our view of the kind of
mental science which physicians engaged in the grave responsibility of caring
for the mental health of their fellow men, may, in all modesty, pretend to culti¬
vate ; and while we cannot doubt that all additions to our certain knowledge in
the speculative department of the science will be great gain, the necessities of
duty and of danger must ever compel us to pursue that knowledge which is to
be obtained in the practical departments of science, with the earnestness of real
workmen. The captain of a ship would be none the worse for being well ac¬
quainted with the higher branches of astronomical science, but it is the practical
part of that science as it is applicable to navigation which he is compelled to
study.”— J. C. Bucknill , M.D., F.R.S,
it
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THE
ME D I CO-PSYCHO LOGICAL ASSOCIATION.
THE COUNCIL, 1884-85.
president.— H. RAYNER, M.D., M.R.C.P., Ed.
PRESIDENT-ELECT.— J. A. EAMES, M.D.
ex-president.— W. ORANGE, M.D., F.R.O.P.
TREASDRBR.— JOHN H. PAUL, M.D.
EDITORS op journal
fD. HACK TUKE.M.D.
I GEO. H. SAVAGE, M.D.
AUDITORS
f J. MURRAY LINDSAY, M.D.
(W. J. MICKLE, M.D.
HON. SECRETARY POR IRELAND.— E. M. COURTENAY, M.B.
HON. SECRETARY POR SCOTLAND.— J. RUTHERFORD, M.D.
GENERAL SECRETARY. —HY. RAYNER, M.D.
T. OSCAR WOODS, M.B.
W. W. IRELAND, M.D.
H. HAYES NEWINGTON, M.R.C.P.
F. NEEDHAM, M.D.
HENRY F. WINSLOW, M.D.
H. R. LEY, M.R.C.S.
J. T. HINGSTON, M.R.C.S.
T. AITKEN, M.D.
D. YELLOWLEES, M.D.
W. BEVAN LEWIS, L.R.C.P.
D. M. CASSIDY, L.R.C.P.
W. STILWELL, M.D.
PARLIAMENTARY COMMITTEE.
Dr. LUSH.
Dr. BLANDFORD.
Mr. G. W. MOULD.
Dr. H. HAYES NEWINGTON.
Dr. WILLIAM WOOD.
Dr. SAVAGE.
Dr. CLOUSTON.
Dr. NEEDHAM.
Dr. RINGBOSE ATKINS.
Dr. PAUL.
Dr. STOCKER.
Mr. H. R. LEY.
STATISTICAL COMMITTEE.
Dr. ROBERTSON.
Dr. MAJOR.
Dr. ASHE.
Dr. BOYD.
Dr. HAYES NEWINGTON.
Dr. CLOUSTON.
Dr. 8IBBALD.
Dr. CHAPMAN.
Dr. T. W. McDOWALL.
Dr. HACK TUKE.
Dr. MANLEY.
Dr. PARSEY.
Dr. F. A. CAMPBELL.
Dr. SAVAGE.
Dr. RAYNER.
Members of the Association,
Adam, James, M.D. St. And., Private Asylum, West Mailing. Kent.
Adams, Joeiah 0., M.D. Dorh, F.R.C.S.Eng., late Assistant Medical Officer, City
of London Asylum, Dartford: Brooke House, Upper Clapton, London.
Adams. Richard, L.R.C.P. Edin., M.R.C.S. Eng., Medical Superintendent, County
Asylum, Bodmin, Cornwall.
Agar, S. H., L.K.Q.C.P., Burman House, Henley-in-Arden.
Aitken, Thomas, M.D. Edin., Medical Superintendent, District Asylum, Inverness*
Aldridge, Charles, M.D. Aberd., M.R.C.S., Plympton House, Plympton, Devon.
Alliott, A. J., M.D., St. John’s, Sevenoaks.
Argo, G. C., M.B., Assist. Med. Officer, Durham County Asylum.
Ashe, Isaac, A.B., M.D., Medical Superintendent, Central Criminal Asylum*
Dundrum, Ireland.
1.05413
Digitized by <^.ooQLe
ii,
Members of the Association .
Atkins, Ringrose, M.A., M.D. Queen’s Univ. Ire., Med. Superintendent, District
Lunatic Asylum, Waterford.
Atkinson, R., B A. Cantab., F.R.C.S., Assist. Med. Offioer, Powick, near Wor¬
cester.
Baillarger, M., M.D., Member of tbe Academy of Medicine, formerly Visiting Phy¬
sician to tbe Salp6tri&re; 7, Rne de l’Universite, Paris. {Hon* Mem.)
Baker, Benj. Russell, M.R.C.S. Eng., L.8.A., Assist. Med. Off, Prestwich Asylum,
Manchester.
Baker, H. Morton, M.B. Edin., Assistant Medical Offioer, Leicester Borough
Asylum, Leicester.
Baker, Robert, M.D. Edin., The Retreat, York.
Balfour, G. W., M.D. St. And., F.R.C.P. Edin., 17, Walker Street, Edinburgh.
Ball, Professor, Paris, Professor of Mental Diseases to the Faculty of Medicine,
179, Boulevard St. Germain, Paris. (Hon. Member.)
Banks, Professor J. T., A.B., M.D. Trin. Coll., Dub., F.K. and Q.C.P. Ireland,
Visiting Physician, Richmond District Asylum, 11, Merrion Square East,
Dublin.
Banks, William, M.B. Lond., The Retreat, York.
Barton, Jas. Edwd., L.R C.P. Edin., L.M., M.R.C.S., Medical Superintendent,
Surrey County Lunatio Asylum, Brook wood, Woking.
Bnr'on, A. B., M.D. St. And., Ticehurst, Sussex.
Bay ley, J., Lunatic Hospital, Northampton.
Beach, Fletcher, M.B., M.R.C.P. Lond., Medical Superintendent, DarenthAsylum,
Dartford.
Beatley, W. Crump, M.B. Durham, Somerset and Bath Lunatic Asylum, Wells.
Beattie, J. A., M D., Hospital for the Insane, Paramatta, Sidney, New South Wales.
Benedikt, Prof. M., Franciskanes Platz 5, Vienna. (Hon. Memb.)
Benham, H. A., M.B., C.M., Ass. Med. Officer, City and County Asylum, Staple-
ton, near Bristol.
Biffi, M., M.D., Editor of the Italian “ Journal of Mental Science,” 16,Borgodi
San Celso, Milan. (Honorary Member.)
Bigland, Thomas, M.R.C.S. Eng., L.S.A. Lond., Bigland Hall, Lancashire, and
Medical Superintendent, The Priory, Roehampton.
Bishop. Sidney O., M.R.C.S. Eng., Negriting, Upper Assam, E. Indies.
Blackall, John Joseph, M.D. Qu. Uniy., Rilladysert, Co. Clare, Ireland, late
Assist. Med. Officer, Richmond District Lunatic Asylum, Ireland.
Blair, Robert. M.D., Woodilee Asylum, Lenzie, near Glasgow.
Blake, John Aloysius, Esq., ex-M.P., 12, Ely Place, Dublin. (Horn Member.)
Blanchard, E. S., M.D., Medical Superintendent, Hospital for Insane, Charlotte
Town. Prince Edward’s Island.
Blanche, M. le Docteur, 15, Rue des Fontis, Auteuil, Paris. (Hon. Member.)
Bland, W. C., M.R.C.S., Borough Asylum, Portsmouth.
Blandford, George Fielding, M.D., Oxon., F.R.C.P. Lond., 71, Grosvenor Street, W.
(President, 1877.)
Bodington, George Fowler, M.D. Giessen, M.R.C.P. Lond., F.R.C.S. exam., Eng.,
Ashwood House Asylum, Kingswinford, Dudley, Staffordshire.
Bower, David, M.B. Aberd., Springfield House, Bedford.
Bowes, John Ireland, M.R.C.S. Eng., L.S.A., Medical Superintendent, Wilts
County Asylum.
Bowes, William, M.R.C.S. Eng., and L.S.A. Lond., 2nd County Asylum, Barnwood,
Gloucester.
Boys, A. H., L.R.C.P. Edin., Lodway Villa, Pill, Bristol.
Braddon, Charles Hitchman, Esq., M.D. St. And., M.R.C.S* Eng., Mansefield,
Cheetham Hill, Manchester, Surgeon, County Gaol, Salford, Manchester.
Brayn, R., L.R.C.P. Lond., Invalid Convict Prison, Knapp Hill, Woking.
Brodie, David, M.D. St. And., L.R.C.S. Edin., Ventnor House, Canterbury.
Brosius, Dr., Bendorf-Sayn, near Coblenz, Germany. (Hon. Memb.)
Brown, John Ansell, M.R.C.S. Eng., L.S.A. Lond., late Medical Staff, Indian
Army, Med. Supt., Peckham House, Peckham,
Brown, M. *L., M.D.. County Asylum, Colney Hatch.
Browne, William A. F., F.R.S.E., F.R.C.S.E., late Commissioner in Lunacy
for Scotland j Dumfries, N.B. (President, 1866.) (Honorary Member.)
Browne, J. Crichton, M.D. Edin., F.R.S.E., Lord Chancellor’s Visitor, New Law
Courts, Strand, W.C. (Honorary Member.) (President 1878.)
Brown-S6quard, C., M.D., Faculty de Medicine, Paris. (Hon. Memb.)
Digitized by <^.ooQLe
Members of the Association.
iii.
Brunton, C. E., M.B., M.R.C.S., Assist. Med. Officer, Colney Hatch Asylum,
Middlesex.
Brush field, Dr., Budleigh Salterton, Devon.
Bucknill, John Charles, M.D. Lond., F.B.C.P. Lond., F.R.S., J.P., late Lord Chan¬
cellor’s Visitor; The Albany, Piccadilly, W. (Editor of Jowmal , 1852-62.)
(President, I860.) (Honorary Member, 1862-76.)
Borman, Wilkie, J., M.D. Edin., Ramsbury, Hungerford, Berks.
Burrows, Sir George, Bart., 18, Cavendish Square, London, W. (JTon, Member .)
Butler, J. S., M.D., late Medical Superintendent of the Hartford Retreat, Connec¬
ticut, U.S. (Hon. Member.)
Byas, Edward, M.B.C.S. Eng.. Grove Hall, Bow.
CadeU, Francis, M.D. Edin., 20, Charlotte Square, Edinburgh.
Cailleux, Gerard de, M.D., formerly Inspector of Asylums in the Department of
the Seine, Buvin-les-Avenieres, Is&re, France. (Hon. Member.)
Callcott, J. T., M.B., Durham County Asylum.
Campbell, Cohn M., M.B., C.M., Medical Supt., Perth District Asylum, Murthly.
Campbell, John A., M.D. Glas., Medical Superintendent, Cumberland and West¬
moreland Asylum, Garlands, Carlisle.
Campbell, Donald C., M.D. Glas., M.R.C.P. Lond., F.B.C.P. Edin., Medical
Superintendent, County Asylum, Brentwood. Essex.
Campbell, P. E., M.B. C.M., Senr. Assist. Med. Officer, District Asylum, Caterham.
CaJmeil, M., M.D., Member of the Academy of Medicine, Paris, late Physician to
the Asylum at Charenton, near Paris. (Honorary Member.)
Cameron, John, M.B., C.M. Edin., Medical Supt., Argyll ana Bute Asylum,
Lochgilphead.
Case, H., M.B.C.S., Medical Superintendent, Leavesden, Herts.
Cassidy, D. M., L.R.C.P.Edin., F.B.C.S. Edin., Med. Superintendent, County Asylum,
Lancaster.
Chapman, Thomas Algernon, M.D. Glas., M.B.C.S. Edin., Hereford Co. and City
Asylum, Hereford.
Charcot. J. M., M.D., Physician to Salp6tri6re, 17» Quai Malaquais, Paris. (Hon,
Memb.)
Christie, Thomas B., M.D. St. And., F.R.S.E., F.B.C.P. Lond., F.B.C.P. Edin.,
Medical Superintendent, Royal India Lunatic Asylum, Ealing, W. (Hon,
General Secretary , 1872.)
Christie, J. W. Stirling, M.D., County Asylum, Stafford.
Clapham, Wm. Crochley S., M.D., M.R.C.P., The Lodge, Sydenham Hill, S.E.
Clapp, Robert, Assist. Med. Officer, Barnwood House, Gloucester.
Clapton, Edward, M.D. Lond., F.B.C.P. Lond., Physician, St. Thomas’s Hospital,
Visitor of Lunatics for Surrey; 10a ? St. Thomas Street, Borough.
Clark, Archibald C., M.B. Edin., Medical Superintendent, Glasgow District
Asylum, Bothwell.
Clarke, Henry, L.R.C.P. Lond., H.M. Prison, Wakefield.
Cleaton, John D., M.R.C.S. Eng., Commissioner in Lunacy, 19, Whitehall
Place. (Honorary Member.)
Clouston, T. S., M.D. Edin., F.B.C.P. Edin., F.R.S.E., Physician Superintendent,
Royal Asylum, Momingside, Edinburgh. (Editor of Journal, 1873-1881 J
Cobbold, C. S. W., M.D., Med. Supt., Earlswood Asylum, Redhill, Surrey.
Compton, T. J., M.B., C.M. Aberd., Assist. Med. Officer, Thorpe, Norwioh.
Cooke, Edwd. Marriott, M.B., M.R.C.S. Eng., Assist. Med. Officer, County
Asylum, Worcester.
Cooper, Ernest F., St. Andrew’s Hospital, Northampton.
Courtenay, E. Maziere, A.B., M.B., C.M.T.C.D., Resident Physician-Superinten¬
dent, District Hospital for the Insane, Limerick, Ireland. (Hon, Secretary
for Ireland.)
Cox. L. R., M.D., Med. Supt., County Asylum, Denbigh.
Craddock, Fredk, Hurst, B.A., M.R.C.S. Eng., L.S.A., Medical Superintendent,
County Asylum, Gloucester.
Crallan, G. E. J., County Asylum, Fulbourn, near Cambridge.
Orampton. John S., F.B.C.P. Edin., 77, Warwick Street, Belgrave Road,
Pimlico, S.W.
Cremonini, John, M.R.C.S. and L.S.A. Engl., Horton House, Hoxton, London, N.
Daniel, W. C., M.D. Heidelb., M.R.C.S. Engl., Epsom, Surrey.
Davidson, John H., M.D. Edinburgh, Medical Superintendent, County Asylum,
Chester.
Digitized by v^ooQle
iv.
Members of the Association.
Davies, Francis P., M.B. Edin., M.B.C.S. Eng., Kent County Asylnm, Bann¬
ing Heath, near Maidstone.
Daxon, William, M.D. Queen’s Univ., Ireland, F.B.C.S. Ireland, Besident
Physician, Ennis Distriot Asylum, Ireland.
Deas, Peter Maury, M.B. and M.S. Load., Medical Superintendent, New Cheshire
Asylum, Macclesfield.
Delany,.Barry, M.D. Queen’s Univ., Ire., Med. Superintendent, District Asylnm,
Kilkenny.
Delasiauve, M., M.D., Member of the Academy of Medicine, Physician to the
Bic&tre, Paris, 35, Bue des Mathurins-Saint-Jaoques, Paris. (Hon.
Member.)
Denholm, James, M.D., Mavisbank, Poitou, Midlothian.
Denne, T. Vincent de, M.B.C.S. Eng., Audley Heath, Brierley Hill, Staffordshire.
D£spine, Prosper, M.D., Bue du Loizir. Marseilles. (Honorary Member.)
DicksomF. F.B.C.P. Edin., Wye House Lunatic Asylum, Buxton, Derbyshire.
Dodds, Wm. J., M.D., D.Sc. Edin., Assist. Medical Ofiioer, Borough Asylum,
Birmingham.
Down, J. Langdon Haydon, M.D. Lond., F.B.C.P. Lond., late Besident Physician,
Earlswood Asylum? 81, Harley St., Cavendish Sq., W., and Normansfield,
Hampton Wick.
Drapes, Thomas, M.B., Med. Supt., District Asylum, Ennis earthy, Ireland.
Duncan. James Foulis, M.D. Tnn. Col., Dub., F.K. and Q.C.P. Ireland, Visiting
Physician, Farnham House, Finglasj 8, Upper Merrion Street, Dublin.
(President, 1875.)
Dunlop, James, M.B., C.M., 1, Somerset Place, Glasgow.
Dwyer, J., L.B.C.P.I., Med. Supt., District Asylum, Mullingar, Ireland.
Eager, Beginald, M.D. Lond., M.B.C.S. Eng., Northwoods, near Bristol.
Eager, Wilson, L.B.C.P. Lond., M.B.C.S. Eng., Med. Superintendent, County
Asylum, Melton, Suffolk.
Eames. James A., M.D. St. And., F.B.C.S.I., Medical Superintendent, District
Asylum, Cork. (President-Elect.)
Earle, Pliny, M.D., Med. Superintendent, Northampton Hospital for the Insane,
Mass.. U.S., (Honorary Member .)
Eastwood, J. William, M.D. Edin., M.B.C.P. Lond., Dinsdale Park, Darlington.
Echeverria, M. G., M.D., New York. (Honorary Member.)
Elliot, G. Stanley, M.B.C.P. Ed., L.B.C.S. Ed., Medical Superintendent, Cater-
ham, Surrey.
Eustace, L, M.D. Trin.Col.,Dub., L.B.C.S.Ire.; Highfield, Drumcondra, Dublin.
Evans, E. W., M.D., Munster House, Folham, London.
Ewart, Dr. 0. Theodore, M.B. Aber., O.M., Assist. Med. Officer, Fisherton House,
near Salisbury.
Falret, Jules, M.D., 114, Bue du Bac, Paris. (Honorary Member.)
Finch, W. Corbin, M.B.C.S. Eng., Fisherton House, Salisbury.
Finch, John E. M., M.B., Medical Superintendent, Borough Asylum, Leicester.
Finlayson, James, M.B., 351, Bath Crescent, Glasgow.
Finnegan, A. D. O’Connell, Northumberland County Asylum, Morpeth.
Fletcher, Bobert V., Esq., L.B.C.S.I., L.B.C.P. ana L.B.C.S. Ed., Medical Superin¬
tendent, District Asylum, Ballinasloe, Ireland.
Foville, Achilla, M.D., 177, Boulevard St. Germain, Paris, France. (Honorary
Member.)
Forrest, J. G. S., L.B.C.P., Assist. Med. Officer, Camberwell House, Camberwell.
Foumi6, Ed., M.D., 11, Bue Louis le Grand, Paris. (Hon. Memb.)
Fox, Edwin Churchill Pigott, M.B. and M.C. Edin., The Limes, Thornton Heath,
Croydon.
Fox, Charles H., M.D. St. And., M.B.C.S. Eng., Brislington House, Bristol.
Fox, Bonville Bradley, B.A.. M.B., Brislington House, Bristol.
Fraser, Donald, M.D., 44, High Street, Paisley.
Fraser, John., M.B., C.M., Assistant Lunacy Commissioner for Sootland, 31,
Begent Terrace, Edinburgh.
Gairdner, W.T., M.D. Edin., Professor of Practice of Physic, 225, St. Vincent St„
Glasgow. (President, 1882.)
Gardiner, Gideon G., M.D. St. And., M.B.C.S. Eng., 47, Wimpole Street, W.
Gamer, W. H., Esq., F.B.O.S.I., A.B.T.C.D., Medical Superintendent, Clonmel
Distriot Asylum.
Digitized by v^ooQle
Members of the Association . v,
Gasquet, J. R., M.B. Lond., St. George's Retreat, Burgess Hill, and 127, Eastern
Road, Brighton.
Gelston, R. P., Esq., L.K. and Q.C.P.I., L.R.G.S.I., Assistant Medical Officer,
Clonmel District Hospital for the Insane, Ireland.
Gibson, William R., M.B., C.M., District Asylum, Inverness, N.B.
Gilchrist, James, M.D. Edin., late Resident Physician, Crichton Royal Institution,
Linwood, Dumfries.
Gill, Stanley A, M.R.C.P. Lon., M.R.C.S. Eng., Med. Superint., Royal Lunatic
Asylum, Liverpool.
Gilland, Robert B., M.D. Glas., L.F.P.S. Glas., M.R.C.S. Eng., L.S.A., Medical
Superintendent, Berks County Asylum, Moulsford, Wallingford.
Glendinning, James, M.D. Glas., L.R.C.S. Edin., L.M., Assist. Med. Off. Joint
Counties Asylum, Abergavenny.
Gover, Robert Munday, M.R.C.P. Lond., Hereford Chambers, 12, Hereford Gardens,
London, W.
Granville, J. M., M.D., 18, Welbeck Street, Cavendish Square, London.
Gray, John P., M.D., LL.D., Medical Superintendent, State Lunatic Asylum,
Utica, New York. (Honorary Member.)
Grieve, R., M.D., Medical Superintendent, Public Asylum, Berbice, British
Guiana.
Greene, Richard, L.R.C.P. Edin,, Med. Superint., Berry Wood, near North*
ampton.
Grierson, S., M.R.C.S., Medical Superintendent, Border Counties Asylum,
Melrose, N.B.
Guy, W. A., M.B. Cantab, late Professor of Hygiene, King's College, London,
12, Gordon Street, W.C. (Honorary Member).
Gwynn, S. J., M.D., St. Mary’s House, Whiteohurch, Salop.
Hall, Edward Thomas, M.R.C.S. Eng., Blacklands House Asylum, Chelsea.
Harbinson, Alexander, M.D. Ire., M.R.C.S. Eng., Assist. Med. Officer, County
Asylum, Lancaster.
Harmer, Wm. Milsted, F.R.C.P. Ed., Physician Supt., North Grove House
Asylum, Hawkhurst, Kent.
Harrison. R. Charlton, 4, St. Mary’s Vale, Chatham, Kent, and 53, Temperly road,
Balham.
Hatchell, George W., M.D. Glas., L.K. and Q.C.P. Ireland, Inspector and Commis¬
sioner of Control of Asylums, Ireland, 25, Upper Memon Street, Dublin.
(Hon. Member.)
Haughton, Rev. Professor S., School of Physic, Trinity Coll., Dublin, M.D.,
T.C.D., D.C.L. Oxon, F.R.S. (Hon. Member.)
Hoarder, George J., M.D. St. And., L.R.C.S. Edin., Medical Superintendent,
Joint Counties Asylum, Carmarthen.
Hetherington, Charles, M.B., Med. Supt., District Asylum, Derry, Ireland.
Hewson, R. W., L.R.C.P. Ed., Assist. Med. Officer, Royal Asylum, Cheadle,
Manchester.
Hicks, Henry, M.D., Hendon House, Hendon.
Higgins, Wm. H., ML.B., C.M., Assist. Med. Officer, County Asylum, Leicester.
Hill, Dr. H. Gardiner, Assist. Med. Officer, Cane Hill Asylum, Purley, Surrey.
Hills, William Charles, M.D. Aber., M.R.C.S. Eng., Medical Superintendent,
Norfolk County Asylum, Norwich.
Hingston, J. Tregelles, Esq., M:.R.C.S. Eng., Medical Superintendent, North Riding
Asylum, Clifton, York.
Hitchcock, Charles, L.R.C.P. Edin., M.R.C.S. Eng., Fiddington House, Market
Lavington, Wilts.
Hitchcock, Charles Knight, M.D., Bootham Asylum, Fork.
Hitchman, J., M.D. St, And., F.R.C.P. Lond., F.R.C.S. Eng., late Medical
Superintendent, County Asylum, Derby j The Laurels, Fairford, (Phesidbnt,
1856.)
Hood, Donald, M.B., M.R.C.P. Lond., 43, Green Street, W.
Howden, James C., M.D. Edin., Medical Superintendent, Montrose Royal Lunatic
Asylum, Sunny side, Montrose.
Huggard, William R., M.A., M.D., C.M., M.R.C.P., Medical Superintendent,
Sussex House, Hammersmith.
Hughes, C. H., M.D., St. Louis, United States. (Hon. Memo.)
Humphry, John, M.R.C.S. Eng., Medical Superintendent, County Asylum,
Aylesbury, Bucks.
Digitized by <^.ooQLe
vi. Members of the Association .
Hutson, E., M.D. Ed., Medical Superintendent, Lunatic Asylum, Barbadoes.
Huxtable, Louis R., 99, Priory Road, West Hampstead, N.W.
Hyslop, James, M.D., Petermaritzburg Asylum, Katal, S. Africa.
lies, Daniel, M.R.C.S. Eng., Resident Medical Officer, Fairford House Retreat,
Gloucestershire.
Ingels, Dr., Hospice Guislain. Ghent, Belgium. (Hon. Member.)
Inglis, Thomas, F.R.C.P. Edin., Cornhill, Lincoln.
Ireland, W. W., M.D. Edin, Preston Lodge, Prestonpans, East Lothian.
Isaac, J. B., M.D. Queen’s Univ., Irel., Assist. Med. Offioer, Broadmoor, near
Wokingham.
Jackson, J.Hughlings, M.D. St. And., F.R.C.P. Lond., Physician to the Hospital
for Epilepsy and Paralysis, Ac.; 3, Manchester Square, London, W.
Jackson, J. J., M.K.C.S Eng., Cranbourne Hall, Grouville, Jersey.
Jamieson, Robert, M.D. Edin., L.R.C.S. Edin., Medical Superintendent, Royal
Asylum, Aberdeen.
Jarvis, Edward, M.D., Dorchester, Mass., U.S. ( Honorary Member.)
Jelly, F. A., M.B., C.M. Edin., Assist. Med. Officer, Wye House, Buxton.
Jepson, Octavius, M.D. St. And., M.R.C.S. Eng., late Medical Superintendent, St.
Luke’s Hospital; Medical Superintendent, City of London Asylum,
Dartford.
Jeram, J. W., L.R.C.P., Brooke House, Upper Clapton.
Johnston, J. A., L.R C.S.L, Assist. Med. Officer, District Asylum, Monaghan,
Ireland.
Johnstone, J. Carlyle, M.D., C.M., Assist. Physician, Royal Asylum, Morningside,
Edinburgh.
Jones, Evan, M.R.C.S. Eng., Ty-mawr, Aberdare, Glamorganshire.
Jones, D. Johnson, M.D. Edin., Senior Assistant Medical Officer, Kent County
Asylum.
Jones, David Rhys, Joint Counties Asylum, Carmarthen.
Jones, Rj, M.B. Lond., Colney Hatch, W.
Joseph, T. M., Gladesville Asylum, New South Wales.
Kay, Walter S., M.B., Assistant Medical Officer, South Yorkshire Asylum, Wadsley,
near Sheffield.
Kebbell, William, L.R.C.P. Lond., M.R.C.S. Eng., Senior Assist. Med. Officer,
County Asylum, Gloucestershire.
Kesteven, W. B., M.D., Little Park, Enfield.
Kirkman, John, M.D., 18, St. George’s Place, Brighton. (Pebsident, 1862).
Kitching, Walter, M.R.C.S. Engl., 39, Old Town, Clapham.
Komfela, Dr. Herman, Wohlaw, Silesia. (Corresponding Member.)
Krafft-Ebing, R. v., M.D., Graz, Austria. (Hon. Memb.)
Laehr, H., M.D., Schweizer Hof, bei Berlin, Editor of the “ Zeitschrifb fur Psychia¬
tric .” (Honorary Member.)
Lalor, Joseph, M.D. Glas., L.R.C.S. Ireland. Resident Physician-Superintendent,
Richmond District Asylum, Dublin. (Pebsident, 1861.)
Lawrence, A., M.D y County Asylum, Chester.
Layton, HenryA., L.R.C.P. Edin., Cornwall County Asylum, Bodmin.
Leeper, Wm. Waugh, M.D. Ed., L.R.C.S.P., Loughgall, Co. Armagh, and Visiting
Physician to the Retreat Asylum, Armagh.
Legge, R. J., M.D., Assist. Med. Officer, County Asylum, near Derby.
Leiaesdorf, M., M.D., Universitat, Vienna. (Honorary Member.)
Lennox, David, Royal Naval Hospital, Haslar.
Lewis, Henry, M.D. Bruss., M.R.C.S. Eng., L.S.A., late Assistant Medical Officer,
County Asylum, Chester; West Terrace, Folkestone, Kent.
Lewis, W. Bevan, L.R.C.P. Lond., Assist. Med. Officer, West Riding Asylum,
Wakefield.
Ley, H. Rooke, M.R.C.S. Eng., Medical Superintendent, County Asylum,
Prestwich, near Manchester.
Lindsay, James Murray, M.D. St. And., L.R.C.S. Edin., Medical Superintendent,
County Asylum, Mickleover, Derbyshire.
Lisle, S. Ernest, de, L.K.Q.C.P., Three Counties Asylums, Stotfold, Baldock.
Lister, Edward, L.R.C.P. Edin., M.R.C.S. Eng., Swaithdale, Ulverston.
Love. J., M.B., Assist. Med. Officer, Gartnavel, near Glasgow.
Lovell, W. Day, L.R.C.P. Edin., Mf.R.C.S. Eng., L.S.A., Bradford-on*Avon, near
Bath.
Lovett, Henry A., M.R.C.S., Plas Newydd, Swansea, Tasmania.
Digitized by <^.ooQLe
Members of the Association . vii.
Lush, John Alfred, F.R.C.P. Lond., M.D. St. And., 13, Redcliffe Square, 8.W.
(PBB8IDBNT, 1879.)
Lush, Wm. John Henry, F.R.O.P. Edin., L.M., M.R.C.S. Eng, F.L.S., Fytield
House, Andover, Hants.
Lvle, Thos.,M.D. Glas., Penbery Hill Asylum, near Bromsgrove, Worcestershire.
MacBryan, Henry C., L.R.O.S., County Asylum, Hanwell, W.
Macdonald, P. W., M.B., C.M., Assist. Med. Officer, Dorset County Asylum, near
Dorchester.
Macfarlane, W. H., New Norfolk Asylum, Tasmania.
Mackew, S., M.B. Edin., Hertford British Hospital, Rue de Yilliers, Levallois-
Perret, Seine.
Mackintosh, Donald, M.D. Durham and Glas., L.F.P.S. Glas., 10, Lancaster
Road, Belsize Park, N.W.
Mackintosh, Alexander, M.D. St. And., L.F.P.S. Glas., late Physician to Royal
Asylum, Gartnavel, Glasgow, 26, Woodside Place, Glasgow.
Madaren, James, L.R.C.S.E., Stirling District Asylum, Larbert, N.B.
Macleod, M.D., M.B., Medical Superintendent, East Riding Asylum, Beverley,
Yorks.
Madintock, John Robert, M.D. Aber., late Assistant Physician, Murray's Royal
Institution, Perth ; Grove House, Church Stretton, Shropshire.
MacMunn, J. A., M.B. St. And., 110, Newtownards Road, Belfast.
Macphail, Dr. S. Rutherford, Assist. Med. Superintendent, Garlands, Carlisle.
Madden-Medlicott, Charles W. C., M.D. Edin., L.M. Edin., Medwyn House,
Carlisle Road, Eastbourne.
Major, Herbert, M.D., Med. Superint., West Riding Asylum, Wakefield.
Manley, John, M.D. Edin., M.R.C.S. Eng., Medical Superintendent, County
Asylum, Knowle, Fareham, Hants.
Manning, Frederick Norton, M.D. St. And., M.R.C.S. Eng., Inspector of Asylums
for New South Wales, Sydney. (Honorary Member.)
Manning, Harry, B.A. London, M.R.C.S., Laverstock House, Salisbury.
Marsh, James Welford, M.R.C.S. Eng., L.S.A., Assistant Medical Officer, County
Asylum, Lincoln.
Marshall, William G., M.R.C.S., Medical Superintendent, County Asylum, Colney
Hatch, Middlesex.
Maudsley, Henry, M.D. Lond., F.R.C.P. Lond., Professor of Medical Jurisprudence,
University College, formerly Medical Superintendent, Royal Lunatic Hospital,
Cheadle; 9, Hanover Square, London, W. (Editor of Jowmal % 1862-78.)
(President, 1871.)
McDonnell, Robert, M.D., T.C.D., F.R.C.S.I., M.R.I.A., Merrion Square,
Dublin.
McDowall, T. W., M.D. Edin., L.R.C.S.E., Medical Superintendent, Northumber¬
land County Asylum, Morpeth.
McDowall, John Greig. M.B. Edin., Assist. Med. Officer, South Yorkshire Asylum,
Wadsley, Sheffield.
McNaughtan, John, M.D., Med. Supt., Criminal Lunatic Asylum, Perth.
M'Cullough, David M., M.D. Edin., Medical Superintendent of Asylum for Mon¬
mouth, Hereford, Brecon, and Radnor; Abergavenny.
M'Kinatry, Bobert, M.D. Giess., L.K. and Q.C.P. Ireland, and L.B.C.S. Ireland,
Resident Physician, District Asylum, Armagh.
McMunn, J. A.. L.R.C.S.Edin., 116, Newtownards Road. Belfast.
Mercier, C., M.B., F.R.C.S., Assist. Med. Officer, City of London Asylum, Stone,
near Dartford, Rent.
Merson, John. M.D. Aberd., Medical Superintendent, Borough Asylum, Hull.
Merrick, A. S., M.D. Qu. Uni. Irel., L.R.C.S. Edin., Medical Superintendent,
District Asylum, Belfast, Ireland.
Meyer, Ludwig, M.D. University of Gottingen. (Honorwry Member.)
Mickle, A. F. J., M.A., M.D., Surrey Dispensary, 6, Great Dover Street, London,
S.E.
Mickle, Wm Julius, M.D., M.R.C.P., Med. Superintendent, Grove Hall Asylum,
Bow, London.
Miokley, George, M.A., M.B. Cantab., Medical Superintendent, St. Luke’s
Hospital, Old Street, London, E.C.
Mierzejewski, Prof. J., Medico Chirurgical Academy, Rt. Petersburg. (Hon.Memb.)
Miles, Geo. E., M.R.C.S., Res. Med. Officer, Northumberland House, Finsbury
Park, N.
Digitized by <^.ooQLe
viii.
Members of the Association t
Millar, John, Esq., L.R.C.P. Edin., L.R.C.S. Edin., Late Medical Superintendent,
County Asylum, Bucks ; Bethnal House, Cambridge Heath, London, E.
Mitchell, Arthur, M.D. Aberd., LL.D., Commissioner in Lunacy for Scotland; 84,
Drummond Place, Edinburgh. (Honorary Member.)
Mitchell, B. B., M.D., Assist. Med. Officer, Royal Asylum, Morningside, Edin¬
burgh.
Mitchell, S., M.D. Edin., Medical Superintendent, South Yorkshire Asylum,
Wadsley, near Sheffield.
Moody. James M., M.R.C.S.Eng., L.R.C.P. and L.M. Edin., Senior Assist. Med.
Officer, County Asylum, Cane Hill, Surrey.
Moore, W. D., M.D., Assist. Med. Officer, Wilts County Asylum, Devises.
Monro, Henry, M.D. Oxon, F.R.C.P. Lond., Censor, 1861, late Visiting Physician, St.
Luke’s Hospital; 14, Upper Wimpole Street, London, W. (President, 1864.)
Moreau, M.(de Tours), M.D., Member of the Academy of Medicine, Senior Physician
to the Saltpdtnfere, Paris. (Honorary Member.)
Motet, M., 161, Rue de Charonne, Paris. (Hon. Member.)
Mould, George W., M.R.C.S. Eng., Medical Superintendent, Royal Lunatic
Hospital, Cheadle, Manchester. (President, 1880.)
Muirhead, Claud. M.D., F.R.C.P. Edin., 30, Charlotte Square, Edinburgh.
Mundy, Baron Jaromir, M.D. Wurzburg, Professor of Military Hygiene, Uni-
versitat, Vienna. (Honorary Member.)
Murdoch, W., M.B. C.M. Edin., Assist, Med. Officer, Kent County Asylum,
Banning Heath.
Murray, Henry G., L.K.Q.C.P. IreL, L.M., L.R.C.S.I., Assist. Med. Off., Prest-
wich Asylum, Manchester.
Nairne, Robert, M.D. Cantab., F.R.C.P. Lond., late Commissioner in Lunacy;
19, Whitehall Place, London. (Honorary Member.)
Needham, Frederick, M.D. St. And., M.R.C.P. Edin., M.R.C.S.Eng., late Medical
Superintendent, Hospital for the Insane, Bootnam, York; Bam wood House,
Gloucester.
Neil, James, M.D., Borough Asylum, Portsmouth.
Newington, Alexander, M.B. Camb., M.R.C.S. Eng., Woodlands, Ticehurst.
Newington, H.Hayes,M.R.C.P. Edin., M.R.C.S., Ticehurst, Sussex.
Newth, A, H., M.D., Haywards Heath, Sussex.
Nicholson, William Norris, Esq., Lord Chancellor’s Visitor of Lunatics, New Law
Courts. Strand, W.C. (Honorary Member.)
Nicholson, W. R., M.R.C.S., Assistant Medical Officer, North Riding Asylum,
Clifton, York.
Nicolson,David, M.B. and C.M. Aber., late Med. Off., H.M. Convict Prison, Ports¬
mouth. Deputy Supt., State Asylum, Broadmoor, Wokingham, Berks.
Niven, William, M.D. St. Ana., Medical Staff H.M. Indian Army, late Superinten¬
dent of the Government Lunatic Asylum, Bombay, St. Margaret’s, South
Norwood Hill, S.E.
North, S. W., Esq., M.R.C.S. E., F.G.S., 84, Micklegate, York, Visiting Medical
Officer, The Retreat, York.
Norman, Conolly, F.R.C.S.I., Med. Supt., District Asylum, Castlebar, Ireland.
Nugent, John, M.B. Trin. Col., Dub., L.R.C.S. Ireland, Senior Inspector and
Commissioner of Control of Asylums, Ireland; 14, Rutland Square, Dublin.
(Honorary Member .)
O’Meara^T. P., M.B., Med. Supt., District Asylum, Carlow, Ireland.
Orange, William, M.D. Heidelberg, F.R.C.P. Lond., Medical Superintendent, State
Asylum, Broadmoor, Wokingham, Berks. (President, 1883.)
Owen, R. F., Tue Brook Villa, Liverpool.
Paley, Edward, M.D., M.R.C.S. Eng., late Res. Medical Officer, Camberwell
House, Camberwell j late Inspector of Lunatic Asylums for the Colony of
Victoria, and Med. Superintendnt, Yarra Bend Asy., Melbourne, 10,
Addison road, Kensington, W.
Palmer, Edward, M.D. St. And., M.R.C.P. Lond., M.R.C.S., Medical Superin¬
tendent, County Asylum, Lincoln.
Parkinson. John R., M.R.C.S., Medical Officer, Whittingham, Lancashire.
Pater, W. Thompson, M.R.C.S. Eng., L.S.A., Medical Superintendent, County
Lunatic Asylum, Stafford.
Patton, W. J., B.A., M.B., Ass. Med. Off., Three Counties Asylum, Herts.
Patton, Alex., M.B., Resident Medical Superintendent, Farnham House, Finglas,
Co. Dublin.
Digitized by <^.ooQLe
Members of the Association ,
IX.
Paul, John Hayball, M.D. St. And., M.B.C.P. Lond., F.R.O.P. Edin.; Camber¬
well House, Camberwell. {Treasurer.)
Peeters, M., M.D., Gheel, Belgium. {Hon. Merrib.)
Peddie, Alexander, M.D. Edin., F.R.C.P. Edin., F.R.S. Edin., 15, Rutland Street,
Edinburgh.
Pedler, George H., L.R.C.P. Lond., M.R.C.S. Eng., 6, Trevor Terrace, Knights-
bridge, S.W.
Petit, Joseph, L.R.C.S.I., Med. Supt., District Lunatic Asylum, Sligo.
Philip, Jas. A., M.A., M.B.and C.M. Aberd., Monte Carlo, Italy.
Philipps, Sutherland Rees, M.D., Qu. Univ., lrel., C.M., F.R.G.S., St. Anne’s
Heath, Chertsey.
Philipson, George Hare, M.D, and M.A. Cantab., F.R.C.P. Lond., 7, Eldon Square,
Newcastle-on-Tyne.
Pim, F., Esq., M.R.C.S. Eng., L.K. and Q.C.P. Ireland, Med. Supt., Palmerston,
ObapeJizod, Co. Dublin, Ireland.
Pitman, Sir Henry A., M.D. Cantab., F.R.C.P. Lond., 28, Gordon Square, W.C.,
Registrar of Royal College of Physicians. {Honorary Member.)
Platt, Dr.. Upton Villa, Kilbum.
Plaxton, Joseph Wm., M.R.C.S., L.S.A. Eng., Medical Superintendent, Lunatic
Asylum, Ceylon.
Powell, Evan, M.R.C.S. Eng., L.S.A., Medical Superintendent, Borough Lunatic
Asylum, Nottingham.
Pringle, H. T., M.D. Glasg., Medical Superintendent, County Asylum, Bridgend,
Glamorgan.
Pullon, G.S., M.B., C.M., Assist.Med. Officer, District Asylum, Murthly, near Perth.
Pyle, Thos. Thompson, M.D. Durh., L.M., M.R.C.S. Eng., L.S.A., J.P., 6,
Lower Seymour Street, Port man Square, W.
Rayner, Henry, M.D. Aber., M.R.C.S. Eng., L.S.A., Medical Superintendent,
County Asylum, Hanwell, Middlesex. (President.) {Honorary Gen.
Secretary.)
Rice, Hon. W. Spring, late Secretary to the Commissioners in Lunacy. {Honorary
Member.)
Richardson, B. W., M.D. St. And., F.R.S., 25, Manchester Square, W. {Honorary
Member.)
Robertson, Alexander, M.D. Edin., Medical Superintendent, Town’s Hospital and
City Parochial Asylum, Glasgow.
Robertson, Charles A. Lockhart, M.D. Cantab., F.R.C.P. Lond., F.R.C.P. Edin.,
Lord Chancellor’s Visitor, New Law Courts, Strand, W.C. {General Secre¬
tary. 1856-62.) {Editor of Journal, 1862-70.) (President, 1867.) (Honor¬
ary Member.)
Robertson, John Charles G., Esq., L.R.C.P. Edin., M.R.C.S. Eng., L.S.A. Lond.,
Medical Supt., County Cavan District Asylum, Monaghan, Ireland.
Rogers, Edward CouJton, M.R.C.S. Eng., L.S.A., Co. Asylum, FuJboum, Cambridge.
Rogers, Thomas Lawes, M.D. St. And., M.R.C.P. Lond., M.R.C.S. Eng., Medical
Superintendent, County Asylum, Rainhill, Lancashire. (President, 1874.)
Ronaldson, J. B., L R.C.P. Edin., Medical Officer, District Asylum, Haddington.
Roots, William S., M.R.C.S., Canbury House, Kingston-on-Thames.
Rorie, James, M.D. Edin., L.R.C.S.Edin., Medical Superintendent, Royal Asylum,
Dundee. {Late Honorary Secretary for Scotland.)
Rowe, E. L., L.R.C.P. Ed., Assist. Med. Officer, Gloucester County Asylum.
Rowland, E. D., M.D., C.M. Edin., Whittingham Asylum, near Preston.
Russell, A. P. f M.B. Edin., Lunatic Hospital, Lincoln.
Russell, F. J. R., L.K.Q.C.P. Irel., 48, Lupus Street, London, W.
Rutherford, James, M.D. Edin., F.R.C.P. Edin., F.F.P.S. Glasgow, Physician
Superintendent, Crichton Royal Institution, Dumfries. {Hon. Secretary for
Scotland.)
Sankey, H. R., M.B., Medical Superintendent, County Asylum, Hatton, Warwick.
Sankey, R. Heurtley H., M.R.C.S. Eng., Medical Superintendent, Oxford
County Asylum, Littlemore, Oxford.
Sankey, W. H. Octavius, M.D., F.R.C.P. Lond., Boreatton Park, near Shrewsbury,
and Almond’s Hotel, Cliiton Street, Bond Street. (President, 1868.)
^ ulle, M. Legrand du, M.D. Paris, 9, Boulevard de Sebastopol, Paris. {Honorary
Member.)
: .unders, George James S., M.B. Lond., M.R.C.S. Eng., Medical Superintendent,
County Asylum, Exminster, Devon.
Digitized by <^.ooQLe
X.
Members of the Association.
Savage, G. H., M.D. Loud., Resident Physician, Bethlem Boyal Hospital, London.
(Editor of Journal.)
Schlager, L., M.D., Professor of Psyohiatrie, 2, Universit&ts Plata, Vienna.
(Honorary Member.)
Schofield, Frank, M.D. St. And.. M.R.C.S., Camberwell House, Camberwell.
Scholes, H. B., Callan Park Asylum, New South Wales.
Scott, J. Walter, M.R.C.S., &c., Assist. Med. Offioer, County Asylum, Fareham,
Hants.
Seaton, Joseph, M.D. St. And., F.R.C.P. Edin., Halliford House, Sunbury.
Seccombe, Geo., L.R.C.P.L., The Colonial Lunatic Asylum, Port of Spain, Trini¬
dad, West Indies.
Seed, Wm., M.B., C.M. Edin., Assistant Medical Officer, Whittingham, Lanca¬
shire.
Semal, hL, M.D., Mons, Belgium. (Hon. Memb.)
Seward, W. J., M.D., Med. Superintendent, Colney Hatch, Middlesex.
Seymour, F., M.R.C.S. Eng., L.S.A., Odiham, Hants.
Shapley, Dr. F., Assist. Med. Officer, County Asylum, Bridgend, Glamorgan.
Shaw, Thomas C., M.D. Lond., F.R.C.P. Lond., Medical Superintendent, Middle*
sex Countv Asylum, Banstead, Surrey.
Shaw, James, M.D., 133, Lower Kennington Lane, S.E.
Sheldon, T. S., Assist. Med. Officer, Somerset and Bath Asylum, Wells.
Sheppard, Edgar, M.D. St. And., M.R.C.P. Lond., F.B.C.S. Eng.,42, Gloucester
Square, Hyde Park, W.
Shuttle worth, G. E., M.D., Heidelberg, M.R.C.S. and L.S A. Engl., B.A. Lond.,
Medical Superintendent. Boyal Albert Asylum, Lancaster.
Sibbald, John, M.D. Edin., F.B.C.P. Ed., M.B.C.S. Eng., Commissioner in Lunacy
for Scotland, 3, St. Margarets Bead, Edinburgh. (Editor of Journal ,
1871-72.) (Honorary Member.)
Simpson, Alexander, M.D., Professor of Midwifery, University, Edinburgh, 52,
Queen Street, Edinburgh.
Skae, C. H., M.D. St. And., Medical Superintendent, Ayrshire District Asylum,
Ayrshire, Glengall, Ayr.
Smart, Andrew, M.D. Edin., F.B.C.P. Edin., 14, Charlotte Square, Edinburgh.
Smith, Patrick, MA. Aberdeen, M.D., Sydney, New Soutn Wales, Resident
Medical Officer, Woogan Lunatic Asylum, Brisbane, Queensland, Australia.
Smith, Robert, M.D. Aber., L.R.C.S. Edin., Medical Superintendent, County
Asylum, Sedgefield, Durham.
Smith, W. Beattie, F.B.G.S. Ed., Yarra Bend Asylum, Melbourne, Australia.
Snell, Geo., M.R.C.S., Ass. Med. Off., Berbice, British Guiana.
Spence, James B., M.D. Ire., Med. Supt., Burntwood Asylum, Lichfield.
Spence, J. B., M.A., M.B. Edin., Assist. Phys., Boyal Asylum, Morningside,
Edinburgh.
Spencer, Robert, M.R.C.S. Eng., Med. Superintendent, Kent County Asylum,
Chartham, near Canterbury.
Squire, R. H., B.A. Cantab., Assist. Medical Officer, Whittingham, Lancashire.
Stewart, James, B.A. Queen’s Univ., L.R.C.P. Edin., L.R.C.S. Ireland, late
Assistant Medical Officer, Kent County Asylum, Maidstone; Dunmurry,
Sneyd Park, Bristol.
Stewart, Robert L., M.B., C.M., Assist. Med. Officer, County Asylum, Glamorgan.
Stilwell. Henry, M.D. Edin., M.R.C.S. Eng., Moorcroft House, Hillingdon,
Middlesex.
Stocker, Alonzo Henry, M.D. St. And., M.B.C.P. Lond., M.R.C.S. Eng., Medical
• Superintendent, Peckham House Asylum, Peckham.
Strahan, S. A. K., M.D., Assist. Med. Officer, County Asylum, Berrywood, near
Northampton.
Strange, Arthur, M.D. Edin., Medical Superintendent, Salop and Montgomery
Asylum, Bicton, near Shrewsbury.
Sutherland, Henry, M.D. Oxon, M.R.C.P. London, 6, Richmond Terrace, Whitehall,
S.W.; BlacMands House, Chelsea j and Otto House, Hammersmith.
Sutton, H. G., M.D. Lond., F.R.C.P., Physician to the London Hospital, 9,
Finsbury Square, E.C.
Swain, Edward, M.B.C.S., Medical Superintendent, Three Counties* Asylum,
Stotfold, Baldock, Herts.
Swanson, George J., M.D. Edin., Lawrence House, York.
Tamburini, A., M.D., Reggio-Emilia, Italy, (Hon. Memb.)
Digitized by boogie
XI.
Members of the Association .
Tate, William Barney, M.D. Aber., M.R.C.P. Lond., M.B.C.S. Eng., Medical
Superintendent of the Lnnatio Hospital, The Coppice, Nottingham.
Terry, John, M.B.C.S. Eng., Bailbrook House, Bath.
Thomson, D. G., M.D., C.M., Senior Assist. Med. Officer, Surrey County Asylum,
Cane Hill.
Thompson, George, M.D., L.B.C.P., M.B.C.S., Medical Superintendent, City and
County Lunatic Asylum, Stapleton, near Bristol.
Thurnam, Francis Wyatt, M.B. Edin., C.M., Yardley Hastings, Northampton.
Toller, Ebenezer, M.B.C.S. Eng., 2, Barrington House, Clarence Parade, Southsea,
Hants
Townsend, Charles Percy, M.B.C.S. Eng., Tring, Herts.
Tuke, John Batty, M.D. Edin., 20, Charlotte Square, Edinburgh. (Honorary
Secretcurujor Scotland, 1869-72.)
Tuke, Daniel Hack, M.D. Heidel., F.B.C.P. Lond., M.B.C.S. Eng., late Visiting
Physician, The Betreat, York ; Lyndon Lodge, Hanwell, W.,and 4, Charlotte
Street, Bedford Square, W.C. (Editor of Journal.) (President, 1881.)
Tuke, Thomas Harrington, M.D. St. And., F.B.C.P. Lond. and Edin.,
M.B.C.S. Eng., Visiting Physician, Northumberland House, Stoke New¬
ington ; 87, Albemarle Street, and The Manor House, Chiswick. (General
Secretary, 1862-72.) (President, 1878.)
Take, Chas. Moulsworth, M.R.C.S., The Manor House, Chiswick.
Turnbull, Adam Robert, M.B., C.M., Edin., Medical Superintendent, Fife and
Kinross District Asylum, Cupar.
Tweedie, Alexander, M.D. Edin., F.B.C.P. London, F.B.S., late Examiner
in Medicine, University of London, Visiting Physician, Northumberland
House, Stoke Newington, 119, Pall Mall, and Bute Lodge, Twickenham.
(Honorary Member.)
Urquhart, Alexr. Reid, M.B., C.M., Med. Supt., Murray Royal Institution, Perth.
Virchow, Prof. R., University, Berlin. (Hon. Memb.)
Voisin, A., M.D., 16, Rue Seguin, Paris. (Hon. Memb.)
Wade, Arthur Law, B.A., MJD. Dub., Med. Supt., County Asylum, Wells, Somerset.
Walker, E. B. C., M.B., C.M. Edin., Assist. Med. Officer, County Asylum, Hay¬
wards Heath.
Wallace, James, M.D., Medical Officer, Parochial Asylum, Greenock.
Wallis, John A., M.B. Aberd., L.B.C.P. Edin., Medical Superintendent, County
Asylum, Whittingham, Lancashire.
Walmslev, F. H., M.D., Leavesden Asylum.
Walsh, D., M.B., C.M., Assistant Medical Officer, Kent County Asylum, Banning
Heath.
Ward, Frederic H., M.R.C.S. Eng., L.S.A., Assistant Medical Officer, County
Asylum, Tooting, Surrey.
Ward, J. Bywater, B.A., M.D. Cant., M.B.C.S. Eng., Medical Superintendent,
Wameford Asylum, Oxford.
Warwick, John, F.B.C.S. Eng., 25, Woburn Square, W.C.
Weatherly, Lionel A., M.D., Portishead, Somerset.
Weight, Rowland H., M.D. Edin., Melrose.
West, Geo. Francis, L.B.C.P. Edin., Assist. Med. Officer, District Asylum, Omagh,
Ireland.
Westphal, C. Professor, Kronprinzenufer, Berlin. (Honorary Member.)
Whitcombe, Edmund Banks, Esq., M.B.C.S., Med. Supt., Winson Green Asylum,
Birmingham.
White, Ernest, M.B. Lond., M.B.C.P., Senior Assist. Med. Officer, Chartham, Kent.
Wickham, B. H. B., F.R.C.S. Edin., Medical Superintendent, Borough Lunatic
Asylum, Newcastle-on-Tyne.
Wiglesworth, J., M.D., Rainhill Asylum, Lancashire.
Wilks, Samuel, M.D. Lond., F.B.C.P. Lond., Physician to Guy’s Hospital; 72,
Grosvenor Street, Grosvenor Square.
Wilkes, James, F.B.C.S. Eng., late Commissioner in Lunacy; 18, Queen’s
Gardens, Hyde Park. (Honorary Member.)
Willett, Edmund Sparshall, M.D. St. And., M.R.C.P. Lond., M.B.C.S. Eng.,
Wyke House, Sion Hill, Isleworth, Middlesex; and 4, Suffolk Place, Pall Mall.
Williams, S. W. Duckworth, M.D. St. And., L.B.C.P. Lond., Medical Superin¬
tendent, Sussex County Asylum, Haywards Heath, Sussex.
Williams, W. Rhys. M.D. St. And., M.R.C.P. Ed., F.K. and Q.O.P., Ire.,
Commissioner in Lunacy, 19, Whitehall Plaoe. (Hon. Member).
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xii. Members of the Association .
Wilson, Jno. H. Parker, Snrg. H.M. Convict, Prison, Brixton.
Winslow, Henry Forbes, M.D. Lond.. M.R.C.P. Lond., 14, York place, Portman
Square, London, and Hayes Park, Hayes, near Uxbridge, Middlesex.
Winslow, Lyttleton S. Forbes, M.B. Camb., M.R.C.P. Lond., D.C.L. Oxon, 23,
Cavendish Square, London, W.
Wood, William, M.D. St. And., F.R.C.P. Lond., F.R.C.S. Eng., Visiting Physician,
St. Luke's Hospital, late Medical Officer, Bethlehem Hospital ,* 99, Harley
Street, and The Priory, Roehampton. (Pbesident, 1865.)
Wood, Wm. E. R., M.A., M.B., F.R.C.S, Edin., Assist. Medical Officer, Bethlem
Royal Hospital, London.
Wood, Thomas Outterson, F.R.C.P. Edin., F.R.C.S. Edin., M.R.C.S. Engl.,
Norbury Hill, Beulah Hill, Upper Norwood, S.E.
Wood, B. T., Esq., M.P., Chairman of the North Riding Asylum, Conyngham,
Hall, Rnaresboro. {Honorary Member.)
Woods, Oscar T., B.A., M.B. Dub., Medical Superintendent, Asylum, Killamey.
Woollett, S. Winslow, M.R.C.S. Eng., Kersingland, Lowestoft.
Worthington, Thos. Blair, M.A., M.B., and M.C. Trin. Coll.. Dublin, Senior
Assistant Medical Officer, County Asylum, Haywards Heath.
Wright, Francis J., M.B. Aberd., M.R.C.S. Eng., Northumberland House, Stoke
Newington, N.
Wright, John Fred., M.R.C.S. Eng., L.S.A., High Street, Alton, Hampshire.
Wyatt, Sir William H., J.P., Chairman of Committee, County Asylum, Colney
Hatch, 88, Regent’s Park Road. {Honorary Member.)
Vellowlees, David, M.D. Edin., F.F.P.S. Glas., Physician-Superintendent, Royal
Asylum, Gartnavel, Glasgow.
Young, W. M., M.D., Assist. Med. Officer, County Asvlum, Melton, Suffolk.
Younger, E. G., M.D. Brass., M.R.C.P. Lond., M.R.C.S. Eng., Asst. Medical
Officer, County Asylum, Han well, Middlesex.
Members are earnestly requested to send changes of address , ^c., to Dr, Rayner, {he
Honorary Secretary , County Asylum , Ban well, Middlesex , and in duplicate
to the Printer of the Journal, H. W. Wolff, Lewes , Sussex .
Digitized by Google
THE JOURNAL OF MENTAL SCIENCE.
[Published by Authority of the Medico-Psychological Association]
No. 129. NE Vo E r s * APBIL, 1884. Yol. XXX.
PART 1.—ORIGINAL ARTICLES.
Remar to on the Results of the Collective Record of the Causation
of Insanity. By Herbert C. Major, M.D.
Read at the Quarterly Meeting of the Association held at Bethlem Hospital,
Feb . 6 th, 1884.
It will be well known to all to whom these remarks are
addressed, that Statistical Tables of the Causes of Insanity
in the Admissions into Asylums began to be collected by the
English Commissioners in Lunacy for the first time in 1876.
In that year returns upon a definite system and plan were
asked for and received from all asylums throughout England
and Wales, the results being published in the Commissioners*
Blue Book for that year. In the following year, 1877, the
corresponding statistics were not collected, but in 1878 they
were resumed in a slightly modified form as regards the list
of causative agencies from that originally issued, and, on
the amended plan, they have since year by year been con¬
tinued.
A passing word merely need here be bestowed on the con¬
stitution and plan of these tables, for their nature is probably
only too well known to most of us. As regards the list of
causes adopted, while doubtless it is not perfect, I think it
may be considered as upon the whole a fairly comprehensive
and satisfactory one, and certainly as not more open to criti¬
cism than any other classification as yet attempted. With
respect to the working of the table, I would merely remark
that the cardinal error, as I think it may be termed, of allow¬
ing only a single causative agency to a given case is avoided,
and the opportunity of recording, when necessary, two causes
per case is afforded. In the result, therefore, there is arrived
at, not the number of cases accurately chargeable to a given
XXX. 1
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2 The Collective Record of the Causation of Insanity , [April,
cause, but tbe proportion of cases which any given cause has
contributed to produce—a form of result which, from the
nature of tbe case, is maintained to be the only one reason¬
able and possible.
These tables, as compiled in our asylums for the insane,
and collected and published by the Commissioners, having
now been in operation for a series of six years, some review
and comparison of the results shown in the several years
would seem to offer a field of reasonable and perhaps profit¬
able inquiry. Such review and comparison it will now be my
endeavour briefly to institute.
Domestic Trouble {including loss of relatives and friends ),
stands first on the list of causes given. With regard to it, it
is observed on comparing the results for the various years—
1. That in every instance this cause is represented as
materially higher among the female as compared with the
male admissions.
2. That the proportions for both sexes and the ratios of
those proportions are maintained with striking uniformity
in the several years.
Thus, the proportions in the six years over which the
tabular record extends, run as follows:—
M.
F.
1876
t • •
3-4
... 9-2 per cent.
1878
3-8
... 9-8 „
1879
3-8
... 9-6 „
1880
4-2
... 9-1 „
1881
4-3
... 101 „
1882
4-2
... 10-3
It follows also that the proportion for males and females
(that is the total proportion) is very uniform. Thus, in the
six years the total percentage runs year by year, 6*3—6*8—
6-7—6-8—7*3—7-3.
And now, before going further, I would ask the most scep¬
tical on the subject of these tables—and I desire to speak
with all respect of such scepticism—to consider the fact just
adduced—the invariably greater potency of the domestic
trouble factor among the female admissions. Bearing in
mind how these statistics are collected, without the possibility
—not to speak of the probability—of collusion between those
furnishing them, is he prepared to argue that the result is a
mere coincidence having no significance ? and if not, can he
escape from the conclusion that it probably points to a definite
Digitized by Google
3
1884.] by Herbert C. Major, M.D.
fact ? And if a definite fact be demonstrated, will be refuse
to accord to it some value for purposes of science ? And if a
fact of some value, may not other facts of equal or greater
value be elicited by the same means, i.e,, these tables ?
In the present instance it is possible that the experience of
most of us has been in accordance with the result here in¬
dicated, but I am not aware of the fadt having been before
this clearly demonstrated statistically.
Taking the next cause on the list, Adverse Circvmstances
{including Business Anxieties and Pecuniary Difficulties ), I note
that the result, as regards the two sexes, is directly contrary
to that which obtained in the case of domestic trouble, the
excess being invariably on the side of the male admissions.
Thus, in the several years the proportions run
M.
F.
1876
6-4
3-3
1878
7-2
3-2
1879
8-3
3-6
1880
7-9
3-3
1881
8-8
3-3
1882
9-2
4-0
per cent.
99
99
99
99
99
Mental Anxiety and Worry (from other sources than the two
agencies previously dealt with) and Overwork, taken together,
are, according to these tables, about equally potent in the
two sexes ; and I would merely further call attention to
the similarity of the total results in the several years as
follows:—
1876
1878
1879
1880
1881
1882
5*3 total
5- 9
6*2
5*7
6- 7
5-6
proportion per cent.
99
99
99
99
99
99
99
99
99
99
Religious Excitement .—This cause is shown in all the years
as higher for females than males; in two of the years only
very slightly so, but in the others with a decided disparity.
This result is probably in accordance with the general expe¬
rience. Total proportion per cent, from 2 to 3.
Love Affairs {including Seduction ).—Here the preponder¬
ance is seen to be very decidedly and in every year on the
side of the females, the proportion for males being uniformly
low and insignificant.
Fright and Nervous Shock. —The results here show each
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4 The Collective Record of the Causation of Insanity , [April,
year an excess for the females, and this quite decisively, not¬
withstanding that, with respect to both sexes, the recorded
proportion presents some degree of variation:—
M.
F.
1876
•7
...
T9 per cent.
1878
1-2
20 „
1879
•9
1-6 „
1880
•7
1-9 „
1881
1-0
21 „
1882
•9
1*7 „
With respect to Intemperance in Drink I note in these
tables:—
1. That in accordance with previous and general experience
it is a much more frequent causative agent in men than in
women.
2. That the proportion for either sex remains remarkably
close in all the years, but that in 1880, 1881 and 1882 the
proportions are slightly lower than in 1876, 1878 and 1879.
The foregoing facts will become apparent when T give the
figures, thus:—
1876
M.
22-7
F.
7'3 per cent.
1878
21-3
7-9 „
1879
211
. • 1
7-6 „
1880
19-3
§#|
6-5 „
1881
19-3
• • •
6-6 „
1882
19-6
...
6-8 „
With respect to the total proportion, varying from 13
to 14 per cent, according to these tables, it may be regarded
by some as too low, and I am myself disposed to think that
probably a more searching inquiry, speaking generally,
would have made it higher. I would only further remark that
inasmuch as these figures deal exclusively with alcoholic ex¬
cess acting directly , it might perhaps be well to indicate
the fact in the table. If this were done it might serve
to avert the confusion liable to result from statements
publicly made (and passing unchallenged) indicating a far
higher proportion of cases chargeable to this agency than
any shown by our statistics, by showing that in such state¬
ments the influence of alcoholic excess acting indirectly has
been guessed at and included.
Sexual Excess is a small average proportion and is every
year returned as higher for men than for women; and the
Digitized by Google
1884.]
5
by Herbert C. Major, M.D.
same remark applies to the next cause on the list, viz..
Venereal Disease. With regard to both of these agencies
many will probably decline to accept the estimate of their
influence given, as indicating their full and real influence.
Self-abuse {sexual) shows a marked excess each year in
the case of males. It is, however, noted as singular that
in 1881 and 1882 the proportions referred to this agency show
a fall from about 3 per cent, in the previous years to about
2 per cent. I am not able to account for this unless upon the
supposition that, of late, the habit may have been more fre¬
quently regarded as a symptom or concomitant of mental
disease rather than as the cause of the cerebral disorder.
Over-exertion (physical) yields a very small percentage
of cases in both sexes and in all the years. I would venture
to suggest the omission altogether of this as a supposed
causative agency deserving of separate mention. Probably
in these days more people break down from under , than over ,
bodily exertion.
Sunstroke yields a very uniform percentage in the several
years of slightly over 2 per cent, in the male admissions; the
proportion of female cases thus caused being hardly appre¬
ciable.
With regard to the cause Accident or Injury the pro¬
portion for males is each year about 5 per cent.; that for
females being on the other hand about 1 per cent. only.
Taking Pregnancy , Parturition and the Puerperal State , and
Lactation together—and as to the general advisability of
such a conjunction I should be glad to elicit the opinion
of others—these causes are observed to have contributed to
produce each year from 9 to 10 per cent, of the female ad¬
missions; in the year 1880 only the proportion given being
lower, viz., 8*2 per cent.
Privation and Starvation show each year an excess of
influence on the side of the female admissions.
With respect to Old Age it is noted with interest that each
year, without exception, the influence is recorded as greater
for the female admissions, thus :—
M.
F.
*1878
3-5
4’1 per cent.
1879
3-3
4 • •
4-5 „
1880
3-1
...
4-3 „
1881
3-6
4'1 „
1882
3-7
...
4-3 „
* In 1876 “ Old Age ” was given in combination with other causes.
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Google
6 The Collective Record of the Causation of Insanity , [April
I am not aware that previous statistics have pointed to the
conclusion here indicated, and should this be the case the
point would seem to be well worthy of careful scrutiny.
Other Bodily Diseases and Disorders give a proportion
of from 9 to 11 per cent, in both sexes, a proportion so high
that even with the result of expanding the list of causes
slightly, I am disposed to suggest some indication of the
diseases thus included as likely to afford useful information.
Previous Attacks are recorded in all the years under con¬
sideration as materially higher among the female admissions
than among the male. An enumeration of the figures will,
1 think, show how clear appears to be the conclusion thus
indicated:—
M.
F.
*1878
||f
Ill
• • •
14 - 8 per cent.
1879
• • •
11-2
...
14-4 „
1880
• • •
13-4
...
16-6 „
1881
14-5
...
18-8 „
1882
• . 1
13-2
...
18-4 „
With respect to Hereditary Influence it is noted that each
year the proportion is given as highest for females ; and the
point would appear to be well worthy of attention even if, as
may be admitted, all the percentages given are lower, pro¬
bably, than more complete information would make them.
The figures for the several years are:—
M.
F.
1876
• • •
141
...
17*1 per cent.
1878
• • •
16-3
18-8 „
1879
• • •
17-3
20-2
1880
19-6
•. .
210 „
1881
• • •
18-2
21-2
1882
• • •
18-6
...
21-8 „
Upon the other hand Congenital Defect shows invariably a
greater ratio for males than for females, a result in accord¬
ance, as I believe, with the previous conclusions of Boyd and
others.
cent.
The figures
are : —
M.
F.
1876
6-7
... 41 per (
1878
6-9
... 3*7 „
1879
4-8
3*5 ,,
1880
5-4
... 3*5 „
1881
5-3
... 3*3 „
1882
6-4
... 3*3 „
# “ Previous Attacks M
not given in 1876*
Digitized by Google
7
1884.] by Herbert C. Major, M.D.
Mr. President and Gentlemen, within the limits of 'the
time which I feel myself entitled to occupy, I am unable
to prolong further my remarks, which, however, such as
they are, may, it is hoped, be considered worthy of atten¬
tion. The facts and figures adduced must be left to speak
for themselves. Only, if the general feeling should be in
accordance with my own, that we have in these collective
results, at least, the “ promise and potency 99 of reliable and
useful knowledge, it may not be out of place if I urge that
it behoves us to give increasing diligence, care and labour to
the collection of the facts upon which these tables are
founded, as a matter of serious obligation. If in such a
spirit the causes of insanity in our cases are sought after and
recorded by us 1, for one, shall have no fear for the result.
Gradually our previous deductions will be confirmed, cor¬
rected or modified; our conclusions will go on increasing in
reliableness and value; and, perhaps, in time our reproach
in this matter, for such I have long considered it to be, may
be blotted out.
The Data of Alienism . By Charles Mercier, M.B.
IV.
The Bodily Health.
At a time when Insanity is commonly looked on as a bodily
disease; when the only aspect of it that receives systematic
study is that of disturbed bodily function; when a leading
neurologist speaks of the mind as u a force evolved from the
brain; ” when the main difficulty in the exposition of the
facts of insanity lies in procuring an acknowledgment that
there is anything besides the bodily health to be studied;
little insistence need be laid on the importance of a syste¬
matic and methodical examination of the condition of the
bodily functions in cases of Insanity.
Not every aberration of bodily function, however, has a
significance for the alienist. The existence of an epithelioma
of the lip, of a broken arm, a contracted cardiac valve or
orifice, of a hernia, an aneurism, or a local inflammation, has,
or may have, no bearing whatever on the question of the
sanity of the person in whom it occurs, and may be altogether
left out of consideration in studying that question. So that,
however thorough and searching may be the schemes that
physicians have drawn up for the investigation of the bodily
Digitized by <^.ooQLe
8 The Bata of Alienism , [April,
functions from their point of view and for their purposes, it
by no means follows that those schemes will be suitable for
the investigation of cases of insanity. Nay, by reason of
their thoroughness, they must be, to a large extent, unsuit¬
able, since, the more comprehensive they are, the more
numerous will be the facts that do not concern the question
of sanity that they include.
On the other hand, there are many facts of bodily func¬
tions which, since they give indications more or less direct of
the physical and physiological activity of the highest nerve-
centres, have a very important significance for the alienist,
and yet have but little attention bestowed on them by physi¬
cians, to whom, indeed, they are of subordinate interest and
importance. Such considerations are the precise origin,
march, and character of an epileptic paroxysm, and the
nature of the actions that follow it. Moreover, of the signs
and symptoms of bodily disorder which concern both the
physician and the alienist, many have very different mean¬
ings, according as they are seen from the point of view of the
one or from that of the other. A chilblain, for instance, is
to the physician a trifling matter. He looks on it as a source
of discomfort, perhaps of actual pain; but since it involves
no danger to life or limb, and very rarely incapacitates from
employment, it attracts but a very small share of his notice.
Even if he takes it as an indication of debility or, “ low
vitality/’ he does not need to greatly concern himself about
it. In short, a chilblain on a patient’s limb, a simple chil¬
blain is to him, and it is nothing more. But when an alienist
has to treat a person of weak mind, and finds her hands a
mass of chilblains, he has obtained a fact of the utmost
significance. This observation is in the forefront of the
data whence he derives his prognosis, which is now many
degrees less favourable than it would otherwise have
been. Conversely, when a physician is consulted by a
patient who has defect of speech and weakness of the right
arm and leg, he is confronted by a malady of great gravity—
one which will tax all his resources to investigate, and all his
skill to treat; but to the alienist this group of symptoms has
no special significance. Its meaning to him is that the
patient has suffered damage of certain of his instruments for
acting; but his defect of speech does not necessarily mean a
disorder of the process of adjusting himself to his environ¬
ment, any more than his defect of movement of arm or leg
means such disorder. All it signifies is that he has lost
Digitized by C^ooQle
9
1884.] by Charles Mercier, M.B.
certain means and methods of carrying out the adjustment.
It is, of course, true that in the great majority of cases an
alienist acts as a physician also; but the two sets of duties
are no more on that account the same than the duties of
Prime Minister and Chancellor of the Exchequer are the
same because they were recently discharged by the same
individual. The kinds of work of the two departments are not
only distinct, but must be clearly distinguished and kept
apart if either is to be properly done. It is true that the
existence of insanity, if it do not actually produce, certainly
does not prevent the occurrence, in the person so affected, of
the various bodily ills the flesh is lieir to. The lunatic is
“fed with the same food, hurt with the same weapons, sub¬
ject to the same diseases, healed by the same means, warmed
and cooled by the same summer and winter/’ as a sane
person; and these bodily affections it commonly falls to the
alienist to treat. But their investigation and treatment form
no part of his special function. He treats them, not because
he is an alienist, but because he happens to be a physician
as well. And although these bodily affections in many cases
do not run precisely the same course, and are not attended
by precisely the same manifestations as commonly occur in
the sane—although the lunatic, as Dr. Bucknill says, is a
lunatic to his fingers’ ends, and, as Mr. Darwin says, to the
extremity of each particular hair—although disorder of the
highest nervous processes affects the nutrition, and therefore
the function, of every portion of the body—yet in estimating
these bodily functions, with a view to their rectification, the
condition of the highest nervous processes is considered not
per se, but as an extrinsic disturbing influence, just as the
climatic conditions, or the sequelae of a former disease might
be taken into account. It is considered, in short, from the
S oint of view of the physician, not from that of the alienist.
►nly when we deal with the question—What is the influence
of this bodily state on the highest nervous processes? or
with the other question-—What condition of the highest
nervous processes does this bodily symptom indicate ? are we
dealing with the problems of alienism.
From the foregoing considerations, it appears that va¬
riations of the bodily functions have a significance to
the alienist very different from that which they have to the
physician; but the importance of a given variation in the
estimation of the former bears no relation to its importance
in the estimation of the latter; and that a scheme of investi-
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10
The Data of Alienism , [April,
gation which is adapted to the requirements of the one, must
for that very reason fail to satisfy the requirements of the
other. For the just estimation of the facts of bodily func¬
tion, and for their relegation to an appropriate position
among the data of alienism, it is necessary therefore to
formulate a scheme of investigation different from that of
the physician, and having reference to the special end in
view.
From a purely physical aspect, the organism is an ap¬
paratus which absorbs and distributes matter and force; and
its functions admit of a broad and sweeping division ac¬
cording as they subserve the redistribution of matter or the
redistribution of force. While it is, of course, true that the
rearrangement of matter is always effected by the redistribu¬
tion of force, and that the redistribution of force is always
accompanied by the rearrangement of matter, and that these
conditions are as inseparably linked within the organism as
without it; yet, since one portion of this duplex process is in
every case primary while the other is merely subsidiary, the
distinction between the two is thoroughly valid. That this
division of the functions follows an actual line of cleavage
which penetrates to the very foundation of the consti¬
tution of the organism, is indicated not more by a priori
considerations than by the multitude and importance of the
minor lines of difference that it passes through, coincides
with, and connects; and of the complementary factors that it
refers to the one side and the other. The functions which
subserve the reception and redistribution of matter are those
by which the organism exists, while the functions which sub¬
serve the reception and redistribution of force are those by
which it acts. The first are the so-called vegetative func¬
tions; the second are those which are more conspicuously
indicative of animal life. The continuance of the first are
essential to the continuance of life. Stop the heart, and the
man drops dead; arrest the breathing, and he dies rapidly;
abolish the function of the kidney—block the intestine—
and he has but a few days to live. But the functions of the
second group may be abolished seriatim without directly or
necessarily affecting the duration of life. Blindness or deaf¬
ness is no bar to longevity. Many a paraplegic lives to
advanced life, and if his malady is fatal, it is so not because
of the loss of movement, but because of the nutritive changes
that accompany the loss. So with hemiplegia, with tabes,
with muscular atrophy, with chorea, and with all other dis-
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11
1884.] by Charles Mercier, M.B.
orders of movement, life is not threatened except by the
concomitant changes of nutrition or by the invasion of the
functions of the first order. Again, the redistribution of
matter is continuous; the redistribution of force is inter¬
mittent. The blood never ceases to circulate; the interchange
of gases in the lungs is never interrupted; the structural
changes of growth and development, waste and repair, nutri¬
tion, excretion and assimilation, are continually going on.
In sleep and in waking, in activity and in repose, day and
night, year after year, the structure changes ceaselessly. In
life these changes never cease, and when life ends they merge
without a break into the final redistribution that takes place
after death. But the redistributions of force are not con¬
tinuous ; they occur only at intervals. In the separate
pulsations of the heart, in the composition of a muscular
contraction, in the to and fro movements of breathing, in
the undulations of peristalsis, in the fatigue and repose that
follow exertion, in the sleep that alternates with waking life,
we see exemplified the irrefragable law that within the
organism the redistribution of force is always intermittent—
conforms always to that greater law which asserts through¬
out the universe of Space and Time the rhythm of all
motion. Yet, again, while the redistribution of force is the
primary function of -the highest nervous centres, the redis¬
tribution of matter is altogether independent of their direct
control. Which of us by taking thought can add a cubit to
his stature ? or determine the deposition of fat in this place
or the absorption of fluid from that ? Who can check the
proliferation of cells which is forming a cancer in this part,
or keep up to the normal standard the defective nutrition
which is resulting in atrophy in that ? On the other hand
not only are the redistributions of force which affect the
outward movements of the organism under the control of
these centres; not only are the movements of locomotion,
handicraft, and speech the direct outcome of their activity,
but even the redistributions of force which subserve those of
matter—the movements of the digestive, respiratory, and
circulatory apparatus—are more or less under their direct
control. Differences so pervading and so fundamental fully
justify the division of the functions into these two orders.
As the organism must exist before it can act—as in the
course of our investigation we have found it necessary to
consider it as existing at rest before considering the actions
and reactions between it and the environment—an obvious
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12
The Data of Alienism , [April,
extension of the same principle will render advisable the
consideration of the functions by which it exists as a preli¬
minary to tbe consideration of those by which it acts.
Insomuch as the great statical functions with which the
investigation begins, and by virtue of which the organism
exists, underlie and are presupposed by the dynamical func¬
tions—since the functions of the first class are the most
general of all the functions, while the highest nervous pro¬
cesses, in which the dynamical functions culminate, and
with which the inquiry terminates, are the most highly
special of all the functions, it will tend to preserve the
continuity of thought if all the bodily processes are con¬
sidered in the order of decreasing generality and increasing
speciality. By this means we obtain a concept based on the
widest foundation and gradually attaining the highest pre¬
cision. Moreover, in the detailed investigation of separate
organs a further application of the principle stated will in¬
volve the expediency of considering the statical aspect before
the dynamical, of estimating first the structure and then the
function.
Although absent at the dawn of life, and preceded by
several other tissues, both in the primitive living forms
from which man traces his long line of descent, and in the
development of the individual germ; yet in man the most
general, the least differentiated, of all the tissues is unques¬
tionably the Blood. It may be regarded as potentially
holding every tissue in solution, since molecule by molecule
they fall into its current and are swept away, and at the
same time they are continuously reconstructed out of the
material that it supplies. To the alienist its condition is
important, not only because the nutrition of the highest
nervous centres, which is the proximate end of his investi¬
gations, depends on its wealth in appropriate materials, but
because the presence of certain substances in the blood pass¬
ing through the brain directly produces alienation. Varia¬
tions in the composition of the blood may for our purposes
be said to be of two kinds—one in which some normal
component of the blood is deficient in quantity; the other
in which there is either an excessive quantity of some normal
component or there is added some altogether foreign material.
If there is deficiency in the blood of a normal component,
then all the tissues to whose nutrition that component con¬
tributes must be imperfectly nourished, and if imperfectly
nourished, must work inefficiently. In every case in which
such a state of blood exists, the nervous centres will suffer a
Digitized by Google
13
1884.] by Charles Mercier, M.B.
lack of nutrition, and will display this lack by imperfect
function. Hence we find that in chlorosis, in oligocythsemia,
in aglobulism, in anaemia, there is always under-activity.
The total movement of the organism is less than normal,
showing general defect of nervous discharge. Corresponding
with this bodily symptom there is the Feeling of languor,
and on the intellectual side of Mind there is that slight
degree of hebetude which shows itself in sluggishness and
defective range of thought. Such people are dull; they
“ take no interest in things ; 99 their attention is not aroused
quite so readily as is normal, nor maintained quite so long;
they are “ apathetic/ 5 When you find them sitting lump-
ishly, staring before them with a vacant expression, and ask
them of what they are thinking, they rouse up and answer,
tc Nothing, 55 and this is no doubt approximately true. Now
what is the meaning of all this ? What general condition
of Mind does it indicate? It means that consciousness is
defective; that mental states and processes are less vivid
than normal; that the tide of feeling is at its ebb; that
there is a slight degree of what, if carried to the full ex¬
tent, would be loss of consciousness. Then if a certain lack
of these components in the blood bathing the highest ner¬
vous centres is attended by defects of consciousness, with
a greater deficiency of them, consciousness will be altogether
lost ? Certainly it will. If the movement of the blood be
arrested, so that no more supplies arrive to take the place of
that which has been emptied of its pabulum, consciousness
will cease ; and we know that in syncope consciousness does
cease. Hence it is, in a rigorous scientific sense, as literally
true to say that an anaemic person is to a certain extent
alienated as it is to say that when I move my hand to my
head I shift the centre of gravity of the earth. The imme¬
diate practical consequences of the aberration are certainly
not very much more important in the one case than in
the other, but the value of a fact to science and to
humanity does not depend on the magnitude of its im¬
mediate practical consequences. The discovery of the
Law of Gravitation did not, as far as we know, cause much
excitement among the farmers of the seventeenth century,
nor much rejoicing among the proletariat; yet, apart from
its value as pure knowledge, it has taken an important part,
through the improvements in navigation that have been
effected by its means, in bringing a cheap loaf to the door
of every cottager in the kingdom. The view of disease that
regarded it as a separate entity that jumped into a man
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14
The Data of Alienism, [April,
from outside, lias become extinct, together with the belief in
other demoniacal manifestations. We now know that among
the variations of the processes of life there are no differences
in kind. All the processes of disease are but deviations in
degree from the processes of health. Every disorder has its
physiological counterpart, of which it is an exaggeration.
There is nothing new under the skin.* If, then, we would
discover the how and the why of this disorder, shall we best
do so by confining our attention to the full-blown malady,
or shall we trace its manifestations backwards to the point
at which the first trivial deviation from the normal can be
recognised? If we would discover the source of a river,
whether is it better to sit down and watch the broad stream
rolling past us, guessing at its origin from the debris that it
throws up at our feet, or to follow it up to where its re¬
motest tributary trickles from the rocks? If we want to
discover the mode in which a plant developes, shall we care¬
fully root out and discard the seedlings, and confine our
attention to the full-grown tree? Surely not. What would
be thought of a farmer who spent abundance of time,
money, and trouble in extirpating a phylloxera or a Colorado
beetle, but refused to concern himself about the eggs, be¬
cause they were so little, and did no harm P Would he not
be thought a fit person to occupy our attention ? Why, then,
should we regard every trivial defect of consciousness, every
temporary aberration of conduct, every form of delirium,
every case of drunkenness, every occurrence of vertigo,
every "absence of mind,” every temporary listlessness or
irritability, or despondency as an affair with which the
alienist has no concern? Should we not rather study these
things with special care, as the biologist studies the amoeba,
because they show in the simplest and most easily analysed
form those phenomena which are elsewhere presented in
such inextricable complexity ? But the trivial alienation of
anaemia goes no further—never developes into actual insanity
or dementia? No, nor does the free amoeba develope into a
vertebrate. In the one case as in the other, the process of
development stops short at an early stage, and presents for
our study a ‘permanent larval form . It is not too much to
say that it is of far more importance to study such nascent
and intermediate forms than to study the phenomena in
* Without desiring to claim a shred of priority for this doctrine, it is only
fair to say that the whole of this article was written, and in the hands of the
Editors of the Journal, several months before Dr. Creighton’s admirable
Address in Pathology was published.
Digitized by <^.ooQLe
15
1884.] by Charles Mercier, M.B.
their full development. If biologists had rejected the study
of invertebrate animals as unimportant, we should not now
know much about the development of vertebrates ; and when
alienists speak of the difficulty of the study of insanity after
having laboriously framed their definitions so as to exclude
these larval forms of alienation, they are in the position of
men who have wilfully blocked up their windows and then
complain of want of light.
In the various forms of anaemia, then, we are confronted
with a derangement of the function of the highest nervous
centres which is not only very slight in degree, but which is
the simplest possible form of derangement—a pure defi¬
ciency of action.
The presence of abnormal materials, or of abnormal
quantities of normal materials, in the blood bathing the
highest nervous centres, gives rise to aberrations of a
different, and commonly of a much more prominent cha¬
racter. Among the foreign materials that occasionally gain
access by means of the blood to the elements of the central
nervous system, are lead, mercury, arsenic, and other metals,
opium, belladonna, stramonium, and other vegetable pro¬
ducts ; alcohol and its allies; chloroform and ether; the
poisons of the specific fevers, of malaria, of hydrophobia,
and perhaps of tetanus. Among the normal constituents of
the blood whose presence in abnormal quantity may disorder
the action of the highest nervous centres, are carbonic acid,
the poisons of gout and of uraemia, whatever they may be;
sugar, cholesterine, and perhaps other waste products.
The manifestations of the action of alcohol and of anaes¬
thetics upon the organism are of enormous importance to
the study of insanity, since by them we can artificially pro¬
duce alienation of any degree, from a trifling confusion of
thought and unsteadiness of hand, through the various
stages of maniacal excitement, to the profoundest coma,
with total loss of consciousness and of voluntary movement,
or even to complete ablation of the functions of the nervous
system in death. There is no form of mania that occurs
among the inmates of lunatic asylums that may not be ex¬
hibited by a drunken man. Violent, destructive, amorous,
maudlin, dolorous, lachrymose, or what not; subject to
illusion, hallucination, delusion, imbecility, whatever dis¬
order of Feeling, Intellect, or Conduct can be discovered in
a lunatic, has its counterpart, allowing for individual differ¬
ences, in some cases of drunkenness. And the stertorous
coma into which the drunkard at last subsides is identical
Digitized by
Google
16
The Lata of Alienism.
[April,
in form with the coma which marks the closing stage of
a fatal maniacal attack. This being so, it is astonishing
that the occurrences in drunkenness have not of late years
been scientifically investigated, and it behoves the students
of insanity to bestir themselves betimes, before all oppor¬
tunity for this most important study is abolished by Sir
Wilfrid Lawson and his disciples. Just as, by the uniform
character of the delirium produced by belladonna, we are
shown that the same substance acts similarly on the nerve
centres of different people,; so by the multiformity of the
symptoms that follow the ingestion of the same amount of
alcohol by different people we see the share taken by the
inherent disposition of a man in determining what form, if
he becomes insane, his insanity shall assume.
Delirium, which is, of course, a form of alienation,
although from its transient duration and assignable cause
it is not clinically considered as insanity, is common in
the course of the specific fevers. When it occurs at the
climax of the fever, it may be due to the high tempera¬
ture ; and when it occurs toward the end, it may be con¬
sidered due to the waste of the highest nervous centres
concurrent with the general waste; but when it occurs at
the outset of the malady, it can have no other cause than
the presence of the poison in the blood and the action of
this poison on the brain. It is a very noteworthy fact that
the invasion of the organism by a specific poison is usually
announced by the excessive discharge of some nervous
centre or group of centres. Ordinarily the vaso-motor and
its allies are the centres affected, and their discharge pro¬
duces directly the contraction of the vessels, dilation of the
pupils, erection of the hair follicles (cutis anserina), and
indirectly the lividity, the shivering and the feeling of cold
that together constitute a rigor. Often, and especially in
children, the discharge proceeds from a group of motor
centres, and the effect is a convulsion. Sometimes the
centres discharged are the highest of all, and the mani¬
festations, direct and indirect, of this discharge constitute
mania. I have notes of a case of typhoid fever which was
tor some days regarded as a case of insanity, the earliest
o served. occurrences being extremely vivid and persistent
hallucinations, culminating in acute delirious mania.
(To-be Continued.)
Digitized by Google ,
Constant Watching of Suicidal Cases . By G. H. Savage,
M.D.
Read at the Quarterly Meeting of the Medico-Psychological Association, held
at Bethlem Hospital, Feb. 5, 1884.
The feeling of the sacredness of human life, which springs
from the selfish feeling of the sacredness of the life of
each person to himself, has extended in many directions,
so that the murderer’s life is often spared, and the suicide is
considered as not responsible for his acts.
The public is in England greatly affected by a suicide, and
most people dread insanity more from its connection with
self-murder than from anything else.
The ordinary Englishman cannot be convinced that a sane
man can kill himself.
The public and the Commissioners look to the officers of
asylums to prevent suicides as one of their most serious
duties, and, I fancy, an unlucky Superintendent who had a
series of suicides would not escape blame.
It becomes a very serious consideration how suicides are
best avoided, but above all I would say that, in my opinion,
this consideration should be secondary to the cure of curable
cases.
I have taken up the subject because I believe it to be
a thoroughly practical one, and one which can be decided
by the experience of those present.
The Commissioners are, I believe, equally anxious to get
to the opinion of the Superintendents, though they have very
strong opinions on the necessity of constant supervision.
First, I shall discuss cases which are to be considered as
actively suicidal, and for whom such provision is to be
made. Yearly, in Bethlem, we have from 20 to 30 per cent,
of our patients described on admission as suicidal, and if
these have all to be placed under constant inspection, the
hospital must cease to exist as one in which patients have
separate rooms, and are treated in a home-like way. But
the above numbers are misleading, for though many speak
of suicide, but few really determine to .attempt it.
I do not think that more than five per cent, of our admis¬
sions are “ actively suicidal/’ that is, patients who have
made serious attempts on their lives, and are likely to
repeat them.
xxx. 2
Digitized by <^.ooQLe
18
Constant Watching of Suicidal Cases 9 [April,
I should say patients with hallucinations of hearing are
among the most dangerous; those who are persecuted, in¬
jured, &c., or who hear their relations being tortured;
those with profound mental misery, even with few or no
delusions, may be equally dangerous patients. Young
women who feel themselves to be “unnatural,” are always
regarded with suspicion. “Miserable sinners” are more
dangerous than hypochondriacal cases, unless the latter be
suffering from sexual hypochondriasis.
I should consider the above classes as most dangerous,
but I do not think they should all be treated alike. The
“ persecuted ” man is generally more at peace if in a room
by himself; and I have one man who is very suicidal,
who would certainly attempt to murder the night atten¬
dant or any patient who coughed, or moaned, or even
moved at night, because he would consider the action was
done to annoy him.
The patients who have attempted suicide, and who Come
of a suicidal stock, are above all the worst; but their only
safety is to get relief from the thought of suicide, and I
maintain this is best done, though with some risk, in single
rooms. Again, the girls who are unnatural are just of that
plastic type which will be made more and more suicidal by
association with others. They are as bad as the hysterical
mimic, who will become hystero-epileptic in an epileptic
hospital.
Other suicidal cases may belong to any one of the
forms of insanity from the general paralytic, who kills him¬
self to prove his immortality, to the sensitive woman who
destroys herself as she is awaking to reason after a storm of
mania, horrified by the thought of her faintly-remembered
past, and by her presence in an asylum. I maintain no one
can avoid suicides at all times unless he destroys all privacy,
and makes the wards of asylums barracks with night-patrols.
What is Constant Watching ?—The only real method is in
associated dormitories, and here I can foresee danger in
having but one attendant.
It has been suggested that there should be inspection slits
or holes in the doors so that the night-watch can see as he
passes how the patients are without disturbing them.
I have suggested that part of a gallery should have the
doors taken off, and the patients be allowed to sleep in the
doorless rooms while the attendant walks about the ward.
In this way there would be less irritation, but, of course, not
Digitized by Google
19
1884.] by G. H. Savage, M.D.
quite the same amount of security as in the open dormitory
plan.
It may be said that after all there is little, if any, more
irritation to a patient in an open dormitory than in a room
the door of which is hourly opened; and I should like to
have the opinion of members on the subject.
Can anyone suggest other plans P
What are the Special Benefits of Constant Watching ?—Is it
for the patients* good ? I should emphatically say No.
Patients have repeatedly told me that when constantly
watched they felt as if they were being dared to do a
thing, and naturally set themselves to evade their tor¬
mentors. A perfect attendant does not irritate a patient,
perhaps, but I have not found one yet.
There is, doubtless, a feeling of security to the Superin¬
tendent when he knows that certain very anxious cases are
secured, but if he has his heart in his work, he will have
much greater pleasure in thinking the same patient is placed
more favourably for recovery, though with more risk to him¬
self, in a single room.
The public will be better pleased with fewer suicides in
asylums, it is said.
I fear I do not care what the public think about it, as
they are certainly the least fit to judge collectively of the
good of the insane, for they are ever ready to cry “ Away
with him 55 on impulse, and, again, to consider him unjustly
imprisoned where he is best cared for.
My own opinion is that, as a general rule, the constant
watching of actively suicidal cases is not for the good of the
patients.
In practice, when a patient is admitted with “ suicidal 55
to his name, I put him for a few nights in strong clothes
and strong sheets in a single room. I examine him and
decide whether this is necessary, and very often accept the
statement of the patient that he will exercise self-control.
By encouraging self-reliance the patient very generally gets
well, and I believe this would not so often be the result if he
were not trusted.
We all know how, from time to time, “ cured* 5 cases kill
themselves later, but this must continue as long as disease
is likely to recur.
Some risk must be run if good is to result, and we must
be considerate to each other when accidents do happen.
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20
[April,
Rectal Feeding and Medication. By Wm. Julius Mickle,
M.D.
Head at the Quarterly "Meeting of the Medico-Psychological Association , held at
Bethlem Hospital , October 26, 1883.
Rectal Feeding .
In reading a paper on rectal feeding and medication I am
not desirous of unduly extolling that form of alimentation
and treatment, or of substituting it for the more direct,
usual and natural methods, where the latter are feasible
and effective. Deprecating any misunderstanding on that
point, I speak in the first place of the principal conditions
in which rectal feeding may prove useful in asylum-practice.
These I will speak of in groups of diseases, or of cases,
loosely bound together, for the nonce, by the tie of suita¬
bility for the use of nutritive enemata.
One group consists of cases such as cut-throat, inflamma¬
tion of throat from the swallowing of caustic substances
(as a case under Dr. Pringle), diphtheria or diphtheritic
paralysis of throat, severe stomatitis or quinsy, post-pharyn¬
geal abscess. Or, again, where the oesophagus is com¬
pressed, or cancerous, or strictured, or in spasm made worse
by attempts to swallow or to pass a tube. Or laryngeal
phthisis or syphilitic laryngeal stenosis with extreme dys¬
phagia may call for rectal feeding.
Another group consists of gastric and abdominal affections
often associated with vomiting, severe pain on eating, and
so forth ; affections such as cancer, ulcer, atrophy, or severe
catarrh of stomach; or dilatation of stomach with other co¬
existing conditions; or extreme dyspepsia and irritability of
stomach ; or obstinate vomiting with ovarian disease or with
hysteria; some cases of obstruction, ulceration, or haemor¬
rhage of small intestine; tabes mesenterica; peritonitis;
renal calculus with reflex gastralgia and emesis.
Still another group consists of cases where nutritive rectal
injections are given in such affections as the anaemias, neu¬
ralgia, phthisis, or to supplement the stomach’s work where
there is either general or digestive weakness.
But I would speak more especially of cases such as in¬
sanity with refusal of food, if, and when, the passage of an
oesophageal tube causes vomiting or severe dyspnoea; or
such as tetanus; or excessively frequent and numerous true
Digitized by <^.ooQLe
1884.]
21
Rectal Feeding and Medication .
epileptic convulsions, or epileptiform convulsions; or coma,
stupor, and apoplectiform symptoms. It is perhaps in these
latter we most often find rectal feeding useful in lunacy prac¬
tice. Of these the most frequently suitable are severe and pro¬
tracted or quickly recurring epileptiform and apoplectiform
seizures in general paralysis, in various states of sclerosis,
and with local cerebral haemorrhages or softenings, or with
their histological sequelae. In some cases of these and anal¬
ogous kinds the use of the stomach-tube causes vomiting, or
gives rise to severe dyspnoea and threatened asphyxia; in
others there is vomiting independently of the passing of any
tube. Here the use of the stomach-tube introduces an ele¬
ment of danger; the patient, helpless, in stupor or comatose,
paralysed, or convulsed, or locally anaesthetic, as he may be
according to the circumstances in each case, and eructating
or vomiting ineffectually the incoming food, is apt to inhale
portions of it into the lungs; by strong inspirations the in¬
haled food is drawn into the far-distant ramifications of the
bronchi and into the alveoli; and a destructive, traumatic,
form of lobular pneumonia ensues. Nor is it absolutely im¬
possible in some of these cases that the tube may be passed
into the air-passages themselves ; or that, doubled up in the
pharynx and oesophagus, the. tube may allow the food to find
exit in such manner as to force its way into the trachea. In
a manner, the parts are passive and helpless, the janitor at
the glottis is not on the alert, effectual cough is not roused,
and the intruding food is not ejected by an expulsive blast of
air and a preservative effort.
Lastly, there are not a few patients who refuse food and
resist feeding when, by reason of their diseased state of
brain, heart, or lung, efforts and straining against the
stomach-tube endanger life.
Therefore is rectal feeding appropriate in cases of these
kinds, when not only is food refused, or the swallowing of it
unsafe and inefficient, but also the stomach-tube excites
vomiting or suffocative spasm, or the food regurgitates with
danger of entering the air-passages, or vomiting and severe
gastric symptoms pre-exist, or the patient’s resistance en¬
dangers life. If the tube can be passed, and this course is
judicious, good and well;—if the patient can swallow, so
much the better;—let the tube be passed, let the patient
swallow. But failing these make use of rectal feeding.
There are several points of management desirable to bear
in mind.
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[April,
Rectal Feeding and M edication,
In using nutritive eneraata :—
Alcohol should not be added to albuminous food.
If necessary, the bowels should previously be cleared out
by a simple or aperient clyster, and a daily copious cleansing
clyster is required in some instances.
The bowels may have to be rested, but we must persevere
if the first attempt fails.
Where it is apt to return, the patient’s best position to re¬
ceive the enema is on the back or left side. The nozzle or
tube should be comfortably warm, so should the food in¬
jected.
The amount injected may sometimes with advantage be
small at first, gradually increasing from 2 to 10 ozs.
If the foods are ejected we may try Dr. Hime’s plan of
depositing them higher up in the viscus by means of elastic
tubing and a funnel.
But plugging the anus is often necessary, and has been
done in many of my cases. Mr. H. H. Newington has re¬
ferred to the value of plugging, in the Journal of this Asso¬
ciation.
Then as to the kind of food for use per anum , and the
methods of preparing it.
Having decided to feed by rectum, the question arises,
what form shall the injection take, and to what preparation
(if any) shall it previously be submitted ?
Many adhere to the older plan, and still use enemata of
food (and stimulants) not specially prepared, such as ordinary
milk, beef-tea, and brandy.
Conflicting as are the results of experiments on the subject
I nevertheless conclude that the rectum and colon digest but
little, and that, even when inverse peristole is set up, the
action of the bowel upon enemata is chiefly absorptive. If
so, the food should either be introduced mixed with digestive
substances, or else before administration should in some way
or in some measure be digested, and ready for absorption
into the venules and lymphatics of the intestinal walls.
Several methods have been devised to attain these objects.
For example, Dr. Leube gives three parts of meat with
one part of pancreas, both finely minced, and mixed with a
sufficiency of warm water for clysis. He avoids a greater
proportion of fat than one-sixth. Others, however, using
this plan, carefully remove all fat and connective tissue. For
this method the hog’s pancreas is the favourite.
Surgeon Rennie directs as follows :—Into a basin of good
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1884.]
23
by Wm. Julius Mickle, M.D.
beef-tea put : ^lb. shredded lean raw beef; 3 i fresh pepsina
porci; 3 ft dil. hydrochloric acid ; warm on the hob for four
hours, stirring frequently. Beaten egg or alcohol may be
added, he says.
Dr. Dobell’s formula (Dr. Sansom says) is :—Cooked, finely
grated beef or mutton, lib. Pancreatic emulsion (Savory and
Moore), loz. Pancreatic powder, 20 grs. Pepsine (pig's),
20 grs. Mix the whole quickly in a warm mortar, add half an
ounce of brandy, and warm water sufficient to bring to the
consistence of treacle, inject quickly from an elastic enema
bottle.
For enema, M. Catillon recommends :—A saturated solu¬
tion at 19°C. of peptone of meat 40 grammes. Water 125
grammes. Laudanum 3 to 4 drops. Bicarb, of soda 3
centigrammes.
M. Henninger gives a complicated formula. Omitting
quantities, the following is an abstract of his process.
Yery lean meat, finely minced, is placed in a glass receiver;
water and H.C1. are poured on, and pepsine, at the maximum
of its activity, is added. The whole is left in a water-bath or
stove to digest for 24 hours at 113°F.; it is then decanted
into a porcelain capsule, brought to boiling point, and
whilst the liquid boils a sol. of sod. carb. is added to it until
it shows a very slight alkaline reaction. Then the boiling
liquid is passed through a fine linen cloth. The liquid is
reduced in bulk in a water bath. White sugar is added be¬
fore administration.
Benger prepared an artificially digested meat by a pan¬
creatic method; finally evaporating it to the consistency of
a solid extract; and Darby sold a fluid meat, artificially
digested by a process apparently not made known (Roberts).
Nutrient suppositories have been made, as by the Slingers
of York, and consist more or less of pure peptones.
Dr. Wm. Roberts, in a very few lines in his Lumleian
Lectures, recommends the adding of liq. pancreaticus to
milk-gruel and beef-tea immediately before they are injected'
into the bowel, thus leaving the ferments to act on the food
when within the rectum.
In actual practice I have departed considerably from this
plan of Dr. Roberts, preferring to inject food in the already
peptonized form and ready to pass from the bowel by
absorption. Therefore, for enemata, I have used, in a
slightly modified form, his method of preparing the food as
if for administration by mouth. Thus the enemata I have
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Rectal Feeding and Medication , [April,
employed were prepared as follows; and it will suffice to
mention the mode of preparing milk, as being the simplest,
and a type of all.
A thermometer being employed throughout, and either
kept in the liquid or frequently introduced to test the tem¬
perature, a pint of milk, with £ or £ pint of water, is care¬
fully heated in a clean dish to 140°F. At that temperature
two drachms of Benger’s liquor pancreatic us are added, and
twenty grains of bicarbonate of soda dissolved in one or two
ounces of water. The whole is put into a covered jug or
dish, and kept near a fire for from an hour to an hour and a
half, and still kept constantly at a temperature of 140°F.
At the end of that time it must be thoroughly boiled for two
or three minutes. Each step should be carefully carried out, to
secure success. Thus prepared, the food keeps for half a day
or a day. For convenience the process is given as for one pint
of milk, but multiples of that measure may be made ready.
Various modifications of this plan are employed in preparing
foods other than milk, but there is not time to speak of
them here.
These enemata offer advantages not at present surpassed, I
think, unless possibly by those of defibrinated blood, or of a
solution of desiccated blood; a method of feeding which has
come to us from America.
I avoid mention of the administration of peptonized food
by mouth; that is entirely outside the scope of my paper.
But I will now briefly refer to cases which, I think, fairly
illustrate the employment of peptonized enemata. The
limits of space, and of our time, demand that these cases
merely be limned by a few strokes. No full clinical descrip¬
tion can be set forth, no minute details of treatment can be
inserted.
I.—JEt. 49, of large and heavy frame. Epileptic attacks had
been followed by strange and violent behaviour, suspicion, rambling
conversation, and dirty habits. He had scarcely taken any food for
a while before admission ; and was carried in helpless, shouting out
occasionally, and soon passing in a condition of stupor and then of
coma, with palsy of right face and arm, some rigidity of the latter,
and twitches of left leg. The pupils were contracted, the respiration
was stertorous, he was unable to swallow. Next day and afterwards
he was aphasic and locally paralysed, confused, restless, urgently re¬
sisting being fed or tended in any way. I need not describe the
treatment in detail, or the course of his recovery, but distinct benefit
resulted from the use, every two hours, of Of? of peptonized milk for
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25
1884.] by Wm. Julius Mickle, M.D.
several days, the first being given after the bowels had been relieved
by an aperient clyster.
II. —Admitted at the age of 50, thin, feeble, and with advanced
pulmonary phthisis, was seized with violent convulsions soon (hours)
after admission, and lay subsequently in a state of profound coma
and generalized muscular weakness. Peptonized milk was given by
the rectum each second hour for some days, and the patient was tided
over the difficulty without losing ground, and without incurring the
risk of damage to his already much diseased lungs, or of further
limitation of the already embarrassed respiratory function.
III. —Aged 26, suffered from a severe and protracted attack of
diarrhoea. When this subsided, symptoms of pleurisy, with effusion
came on, some pulmonitis, refusal of food, dry, brown tongue, ob¬
stinate vomiting. Treatment was successful, and parts of it con¬
sisted of rectal administration of peptonized food, and the aspiration
of the left chest, once to 80ozs. of sero-fibrinous effusion, and again
to the amount of 30ozs.
IV. —Aged 35, severe protracted diarrhoea ; phthisis, with muco¬
purulent and sanguineous expectoration. Next, severe and obstinate
vomiting, feeble pulse, coldness of surface and limbs. Later, with
vomiting of thin greenish fluid, and the passing of loose foetid stools,
there were a shrunken, sunken, livid face, ami a cold surface, aphthous
tongue and mouth, and a parotid abscess. Yet he pulled through,
and lasted some weeks longer, under treatment I need not detail,
except that peptonized food was diligently administered by enema
every two hours, in quantities varying from 10 to 3ozs., thus sup¬
plementing the food and the stimulants retainable in very small
quantities only, and occasionally, by the stomach ; while hot-bottles
afforded constant warmth to the surface.
Some atrophy of brain and of olfactory bulbs and tracts, some
softening of central parts. Some caseous changes in the lungs, and
lobular pneumonia; and in the left lung a semi-gangrenous patch, as
also local pulmonary collapse. Heart flabby, friable. Embolic,
ashen-grey patches in kidneys. Liver yellowish. Small intestine
pale, walls thin, contained a little ochre-hued fluid material. In the
large gut a few patches of redness.
V. —JEt. 36, general paralysis for about seven years, recurring
epileptiform convulsions during the greater part of that time. To¬
wards the last these convulsions became more severe and frequent ;
they were associated at one time with right hemiparesis, but later
with palsy, generalised, but more marked on the left side, and in¬
sensitive conjunctivas. Eventually, the status epilepticus was fully
established, and what with this, and the large unwieldy frame of my
patient, and his coma and inability to swallow safely, I was glad to
be able to keep up a constant supply of nourishment by peptonized
food enemata, which were plugged into the rectum. This organ, how¬
ever, had already served him well before. For, so long as four and a
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Rectal Feeding and Medication , [April,
half years previously, he had been supported during seven and a half
days by nutritive eneinata alone, except as regards a few ounces of
milk swallowed on the sixth day. On this former occasion, also, there
were frequent and severe convulsions, with widespread paresis affecting
the left limbs in greater degree, the respiration being stertorous, the
patient protractedly comatose, and signs of pulmonary congestion and
pleurisy being present, with severe cough and vomiting. Throughout
this seven and a half days, at the older date, the rectal feeding main¬
tained nutrition and the forces well.
At the necropsy ; of the flabby, soft, atrophied brain, with softened
central parts, the left cerebral hemisphere was the more advanced in
disease, and the posterior spinal meninges and columns rather than
the others. Heart flabby, friable. Lungs congested and oedematous.
With the abdominal viscera there was not much amiss.
VI.—Age 43, a demented general paralytic. Recurrent convulsions,
especially affecting the left side, were followed by left hemiparesis with
conjugated deviation of head and eyes to right. Later, left facial
6pasm, right arm resistant to passive motion and its tendon-reflexes
increased, left conjunctiva insensitive, coma, pulmonary congestion and
pneumonia, cough severe and frequent. He was unable to swallow.
Peptonized enemata were employed 6afely and beneficially for four
days.
Brain-lesions of general paralysis. Left lung some old pleuritic
adhesions, hypostatic congestion and pneumonia; right lung more
adherent, and the site of lobar pneumonia. Gastric mucous mem¬
brane much mottled with ramiform and punctate vascular injection.
VII. —Aged 39. When admitted his heart was feeble. In an
apoplectiform attack the limbs were temporarily rigid and helpless,
especially the right arm and left leg. Subsequently, semi-stupor,
right hemiplegia, head and eyes to right (sic.), severe convulsions,
some aphasia, inability to swallow, cough, foetid breath, pulse 120.
Put on peptonized enemata ; the pulse went down, and the symptoms
abated. Subsequent attempts to swallow brought on return of con¬
vulsions ; spasm persisted about mouth, neck and trunk ; dyspnoea ;
hypostatic pneumonia right side. For six days the food taken was
mainly by rectum, and peptonized. Fits persisted, and the patient
died.
Atrophy and slight sclerosis of brain, particularly in frontal regions;
morbidly facile separation of firm grey from firm white of left third
frontal gyrus ; meninges thick, opaque, posteriorly tough ; slight
hasmorrhage in left middle and posterior fossae of skull-base. Con¬
gestion and patches of hypostatic pneumonia in right lung. Atrophy
of spleen; slight cirrhosis of liver ; patchy congestion and green-grey
hue of gastric mucous membranes.
VIII. —iEt. 46. Mitral stenosis, irregular and intermittent heart,
widened percussion-dulness ; later, mitral bruit. Hepatic tenderness
and slight enlargement. Ague attacks. Recurrent bronchitis. Once,
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27
1884.] by Wm. Julius Mickle, M.D.
left pleuritic effusion with oedema of legs and ascites. Later, abdo¬
minal and hepatic pain, effusion in right pleura, thrice tapped, viz.,
to one pint, to six pints, and again to one. Finally, albuminuria,
oedema of legs and chest, bronchitis and emphysema, congestion of
lungs posteriorly, very rapid irregular and paroxysmally tumultuous
heart, vomiting, obstinate refusal of food. Enemata of peptonized
foods for last four days of life.
Necropsy. Stenotic mitral changes. Dilated and hypertrophied
left auricle and right cardiac chambers. Brown induration of lungs,
especially of right. Some pleuritic adhesions, traces of cured phthisis,
bronchitis, congestion and oedema of lungs, emphysema anteriorly.
Unduly firm, rounded, mis-shapen, “nutmeg” liver, with capsule
irregularly thickened in parts. Spleen 8^ozs., its capsule thickened
and pigmented. Very dark medullary cones of kidneys, and slightly
adherent capsules. Mucous membrane of stomach deeply congested,
in parts almost to eccbymosis. Transverse colon sunken, curve-wise,
towards pelvis.
Other cases might be added, but the above will suffice.
What was stated in an early part of this paper sufficiently
explains why nutritive enemata were employed in these
cases ; a procedure which sometimes helps us, however little,
towards the great aim of the physician—to obviate the ten¬
dency to death—and I would end, as I began, by guarding
against any notion that I advocate rectal feeding when the
stomach-tube or funnel can be used with ease and safety;
on the contrary I prefer, both for my patients and myself,
that food and medicine be received by way of the upper,
rather than of the nether, orifice.
Rectal Medication .
So far has rectal feeding, the first part of our subject,
exceeded the limits anticipated, that what will be said on
rectal medication will be very brief. Two or three points,
only, will now be glanced at.
One, I will merely mention, and relatively to epileptiform
convulsions. It is the great abatement of the convulsive
tendency in some cases by the regular or frequent use of
simple or aperient enemata, and the avoidance by this or by
other means of the not infrequent constipation.
A second point is more important, and it concerns similar
cases. It is the use of enemata of chloral hydrate, plugged
into the bowel, to cut short and prevent epileptic and
epileptiform seizures. I have made extensive use of this
method of treatment in many cases of epilepsy; and of
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Rectal Reeding and Medication , [April,
epileptiform seizures in general paralysis, brain-syphilis, and
local haemorrhage, softening, or induration of the encepha¬
lon. Thirty grains, say, dissolved in two ounces, say, of
water are administered with the precautions mentioned in
the first part of this paper. At the same time the patient’s
surface should be kept well covered up and warm, and the
effect must be watched, especially should it be necessary to
repeat the enema; when, if the pulse and heart fail and the
surface grow pale, diffusible stimulants must be supplied by
mouth or by rectum, by subcutaneous injection or by inhala¬
tion. Usually, the enema is not to be repeated.
A third point, is the value of enemata of brandy in some
cases of threatened sudden dissolution, when, for various
reasons, the fluid cannot be swallowed. The faltering, fail¬
ing circulation, the ceasing respiration, and the abolished
consciousness, are often recalled by artificial respiration, and
timely enemata of brandy. Several examples will now be
mentioned. I might add a number of other cases, but these
suffice as illustrations. Hypodermic injections of some sub¬
stances; inhalation of others; and the application of the
electric currents; are all extremely useful in some of these
cases, if readily available, may, indeed, act better. But the
physician can always instantly bring artificial respiration
into play, and if he has with him, at the moment, even only
one intelligent attendant, a brandy enema can be given
simultaneously.
J. G., aged 38, had suffered severely from constitutional syphilis ;
had had also delusions, vivid hallucinations, with excitement and
violent conduct. Whilst under notice here, he had extraordinary de¬
lusions as to injuries to, and influences on, his body; scaly spots,
cranial nodes, and indications of pachymeningitis towards the base of
the brain. Between two and three years after admission, he passed
through a time of extreme excitement for several months, the face
often being flushed, the expression wild and bright, and the delusions
of injury mingled with exalted ones. Noisy excitement, restlessness,
violence, and insomnia were scarcely held in check by varied treat¬
ment. At last, after prolonged excitement, and a feebleness and
emaciation so marked that he was usually in bed, he, one morning,
had four fits in quick succession. Called to him instantly, I found
him cold, with a feeble, slow, irregular and intermittent pulse. Twice,
his respiration ceased altogether, and he appeared to be dead. Arti¬
ficial respiration was carried on by Silvester’s method for a long time,
and brandy enemata were given. Under this treatment he rallied,
but for days afterwards the pulse and heart were slow and feeble, and
Digitized by A^OOQle
1884.] by Wm . Julius Mickle, M.D. 29
the respiration feeble. For many weeks afterwards he had to keep
his bed; emaciated, restless, noisy, incoherent, and, though feeble,
resisting and aggressive.
T. A., set. 37, a general paralytic.
In earlier period: speech much affected, face less ; quasi-syncopal
attacks like petit mal; once slight right hemiparesis; pains about
back and chest; increased knee-jerk.
One day, sitting quietly, he grew dark in the face, and was severely
convulsed, mainly on the left side. Coming immediately, I found
him apparently dying, respiration having ceased, and the pulse failing.
At once artificial respiration was employed, and as soon as possible
enemata of brandy were given, yet he continued now and then to
grow dark in the face, respiration failing ; therefore artificial respira¬
tion was frequently resumed. Later, tonic spasm occurred, general in its
distribution, but more on the right side ; pleurosthotonos, opisthoto¬
nos succeeded one another. Then came rigidity of arms, grinding of
teeth, champing of jaws, spasmodic thrust of tongue between teeth
—to its mutilation. Paresis of third left cranial nerve followed.
Three days later there was paralysis of the left limbs and right face.
During part of this time, by the way, he was supported by nutritive
enemata. Later, were fits; left hemiplegia; return of fits. In the
fits of convulsions he always nearly died. At last, nine months later,
in a frightful bout of convulsions, he did die. Mentally, he had
virtually recovered some time before death.
M. G., aet. 36. A history of syphilis, delirium tremens, and ex¬
posure to Indian climate. An agitated suicidal melancholiac.
Though a ravenous eater at times, he was frequently given to refusal
of food, and was constipated ; hence the use of the stomach-pump and
of aperient enemata. One day, after crying and praying, with
heated head, he had an aperient injection, and later was fed by the
stomach-pump. Some vomiting occurred after this ; and, subsequently,
I was called to see him. He was lying on a sofa, cold all over, with
a slow, irregular, intermittent pulse, 51 per minute; rather wide
and sluggish pupils, about equal in size ; pale face; flaccid limbs.
At times he appeared to be dying. But under brandy enemata, a
little swallowed brandy, frictions, heat to the surface, hot pediluvia,
and sinapisms to the chest, he recovered; though the vomiting of
pale amber-colour fluid did not immediately cease, and some peri¬
toneal effusion was found next day, and several days later some muco-
enteritis.
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80
[April,
Studies of Postures Indicative of the Condition of Mind, as
Illustrated in Works of Art. By Francis Warner,
M.D. Lond., F.R.C.P. (Illustrated.)
The term posture indicates the relative situation of the
several members of the body with regard to each other, or
the relative situation of the parts of the member. Now, the
posture is the result of the last movement; the description
of a posture is the description of the effect of the last move¬
ment of the part. Postures may be seen as the result of the
action of any part of the muscular system. We may speak
of the posture of the hand and upper extremity, the head
and neck, the back, &c. Postures depend upon the resultant
action of opposing muscles, the relative tone of the flexors
and extensors, the adductors and abductors, &c. In the
limbs the opposing muscles act upon the bones and move the
joints. In the face the contending muscles dilate and con¬
tract the apertures for the eyes, mouth, and nose, and other¬
wise alter the features; hence alterations in these characters
in the face may be called its postures. The movements of
the eyes being due to antagonistic muscles, the various
ocular positions may be similarly termed.
Now, all these kinds of postures are produced by the
action of the central nerve-mechanism, and, being the
direct outcome of its function, are indices of its condi¬
tion, and, as such, are worthy of study by observation,
description, and analysis.* Many admirable treatises have
been written on Expression, describing in such terms as
are above referred to the motor outcome of those brain
conditions whose mental manifestations are the emotions.
As an aid to the exact study of the nerve-mechanism, one
of whose functions is mentation, it is here proposed to study
the motor action accompanying mentation, this motor func¬
tion being expressed in terms of postures.
I trust I may not be considered egotistical in referring to
the lines of thought that led me to look to works of art as
an aid in these studies. Having during some years given
special study to the conditions of the nervous system in
children, my attention was especially drawn to the various
postures presented by children brought for examination at
the Children’s Hospital, and from 1878 I have kept notes
of the spontaneous postures observed. The muscles of
♦ See “ Brain,” Farts 12, 14 .—** Visible Muscular Conditions.”
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31
1884.] Studies of Postures ,, <f*c.
the hand are probably the most specialised as nerve-
muscular agents of the mind. These muscles suffer most
in their movements from central affections. Another
reason for speaking of the hand as specially indicative of the
brain condition is because the hand has a large number of
small muscles capable of performing delicate actions and
bearing slight weights. The muscles of the hand are parti¬
cularly under the guidance of the brain. The children were
requested to hold out their hands, and the passive condition
or posture of the hand was noted. At first it was difficult
to describe the postures in anatomical language, though
some were seen to be characteristic of certain nerve condi¬
tions. In 1879, while visiting
Florence, it struck me that
the posture of the hands of
the Yenus de Medici was ex¬
actly similar to the posture so
often seen in nervous children.
Later, at the British Museum, I
saw the English Venus side by
side with the Diana—feminine
coyness and nervousness repre¬
sented side by side with the ex¬
pression of energy and strength,
and the contrast of the hand
postures showed them to be in
direct antithesis. While looking
at the marble hands it became
easy to describe their anatomi¬
cal postures.*
Now, what can we learn from
the study of the Yenus de Me¬
dici ? It may be assumed that
the whole figure expresses femi¬
nine modesty with self - con¬
sciousness, indicated partly by
the general position of the body
and limbs, and specially by the
hands being used to screen the
body, though they do not touch it.
Yenus de Medici. The figure is that of a nervous
woman. Now, as to the posture of the hands, both are
* See paper on “ Becurrent Headaches in Children ”—“ Brit. Med. Jonrn.,”
Deo. 6th, 1879.
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32
[April,
Studies of Postures , <f<\,
similar. The wrist is slightly flexed, or bent, the metacarpo¬
phalangeal joints are moderately hyper-extended (extended
back beyond the straight line), the first and second inter¬
nodes being slightly flexed. The thumb is extended back¬
wards, and somewhat abducted from the fingers. This
posture is commonly used in art to express beauty or
weakness and nervous excitability. It is common in female
figures, uncommon in those of males. This posture I have
therefore called the “nervous hand.”
Can any explana¬
tion be given why this
particular posture
should be caused by
a brain in the con¬
dition of “nervous¬
ness ? ” It seems to
me no physiological
explanation to say
that the individual
inherited from his
progenitors the tendency to assume this hand posture, of which
most people know nothing, under the emotion of “ nervous¬
ness,” and that such posture was of use to his progenitors.
Our business is to explain how the machine works as it
exists, much as we may desire to know how it came to be
what we now find it. I have entered further into this ques¬
tion in an article in “ Brain,” Oct. 1883, Part 23, but I do not
Digitized by Google
33
1884.] by Francis Warner, M.D.
think any real explanation can be given till we better under¬
stand “heredity ” and “retentiveness” in the nervous system.
I hope to be able to throw some light upon such questions by
an experimental method described in the “ Journal of Physio-
l°gy,” Yol. iv., No. 2.
Adjoining is an exact copy of engraving by Mr. Kirk, in
“ Outlines from Figures upon Greek Vases, &c., of the late
Sir William Hamilton, MDCCCXIV.”
“ Plate L. represents festival in honour of Bacchus, and
consists of both sexes, who seldom or never were together
except in these feasts.”
All the hands present some features of the nervous hand,
with hyper-extension of the metacarpo-phalangeal joints, so
ancient is this mode of expression.
In the Diana of the British Museum we see the figure of a
strong, energetic woman. Our com¬
mon experience tells us that it is
such. The head is erect, the ad¬
vanced right foot gives an expression
of firmness, &c. Now examine the
postures of the hands. The right is
grasping a spear; the left arm
hangs by the side, but the hand is
free—it is not engaged in anything,
but its posture is the representation
of the outcome of the brain action
only (right hemisphere). As to the
posture of this free hand, the wrist
is extended backwards, the fingers
and thumb are all in moderate flex¬
ion. This hand-posture, being often
seen accompanying strong energetic
conditions of the mind, and in
children when running and excited
in play, I have named the “ener¬
getic hand.” As the result of
numerous observations, I believe
that this posture of the hand is
common as an accompaniment of
an active energetic condition of the
mind, and that the brain-condition
which causes “an energetic condi¬
tion of the mind” causes also the
“energetic hand.”
xxx. 3
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84
Studies of Postures , fyc.,
[April,
Let us now re¬
view the probable
physiological con¬
dition of the nerve-
muscular system of
the subject here
represented. We
cannot say with
certainty that the
posture of the right
Energetic Hand. hand, which grasps
the spear, expresses simply the condition of the nerve-centres
(in the left hemisphere) which act upon the muscles of the
limb, for it is engaged in grasping the spear. In the left
hand there is no proof that the posture is the result of any
purposive act; on the contrary, evidence might be brought
forward to show that an
energetic condition of the
nerve-mechanism, whose
function is mind, causes
the hand spontaneously
to assume this posture.
Here, then, the right
hemisphere is not send¬
ing purposive nerve-cur¬
rents to the muscles of
the left hand, but the
left hemisphere is sending
much motor force to the
muscles of the right arm.
Does not the skill of the
artist appear in the com¬
position which thus indi¬
cates to us the nerve-mus¬
cular energy of one hemi¬
sphere and the “ mental ”
state of the other? Here
we find the nerve-muscular
condition indicating the
state of the nerve-me¬
chanism, whose function is
mentation, and did we
know exactly the location
of the motor centres, it
might guide us to the
localization of the mental centres.
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by Francis Warner. M.D.
35
Now, let us look at the Cain in the Pitti Gallery,
Florence. The whole figure expresses horror or mental fear.
Each hand is free or disengaged, and in similar posture.
The wrist is extended backwards, the knuckles, fingers, and
thumb are extended straight. This posture could serve
no useful purpose to the man; it seems to be only the
result of the spontaneous nerve-
muscular force coming off
from the brain (both hemi¬
spheres) during that condition,
whose “ mental ” action is
horror or fear. Here, as in the
Yenus, the motor action of both
hemispheres is represented as
similar, and if the artist’s re¬
presentation be true to life and
experience founded upon obser¬
vation, we may conclude that
in the living man, under the
emotion of fear, both motor and
mental action occurs in each
hemisphere. It should be
stated that in clinical observa-
Hand in Fright. tion postures are often asym¬
metrical, e.g.y the left hand is often in the “ nervous pos¬
ture,” the right hand not being so.
In the dying gladiator we learn a different lesson. Neither
hand is here free. All the postures of the composition in
marble are the representation of a man in mortal agony,
whose urgent dyspnoea determines the position of the body
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86
Studies of Postures, fa..
[April,
and of the limbs, which are thus not left free or disengaged,
to be acted upon solely by the spontaneous action of the
central nerve-mechanism. Sir Charles Bell * drew attention
to this point in his critical analysis of this posture.
In Hercules at rest the
figure leans upon a club to
support his body, and the
posture of the right arm is
determined mainly by grav¬
ity. In neither of these ex¬
amples do the postures in¬
dicate directly the condition
of the mind or the nerve-
mechanism, whose function
is mentation.
It is in the free or disen¬
gaged hand that we must
look for examples illustra¬
ting the condition of the
brain which governs it. I
have observed many works
of art for the purpose of
noting in how many cases
the limbs are left free to
express by their posture the
action of the brain, and have
found that but few artists
think it necessary to em¬
ploy this means of repre¬
senting the condition of
the mind of their subjects.
Hands are most usually re¬
presented holding some object or resting upon some part of
the figure, or otherwise engaged in trifles. In real life we
see the same thing. In society the self-conscious man carries
his hat; the very young lady has fan and flowers ; the
awkward boy thrusts his hands deep into his pockets during
conversation to prevent them from performing antics mean¬
ingless as the disjointed utterances of his untrained mind.
If so many art-workers do not use postures, i.e, the motor
function of the brain as the means of expressing the con¬
dition of the mind, what is the principle most commonly
* " Philosophy and Anatomy of Expression,” 3rd edition.
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1884.]
37
by Francis Warner, M.D.
used ? It is not only by the postures and other signs of
nerve-muscular action that the mind is indicated; there is
the colour and the physiognomy of the face independent of
its expression.* By the term physiognomy I understand the
shape of the skull or brain-case, and the face, together with
the character of the facial tissues and the structure and
shape of the features and parts of the face. In a vulgar -
faced man we see coincident defective or coarse development
of the face and of the brain or nerve-mechanism of the mind.
A large lower jaw may be very useful for mastication, de¬
fence, or attack, but it does not serve to facilitate nerve-
muscular action, and is not usually found coincident with a
refined action of brain. The form of the subject and the
drawing of it may, then, afford much indication of the brain
condition; still I believe that the art-representation of nerve-
muscular conditions as expressing the brain (mental) con¬
dition is a much higher mode of expression than mere
indications of the passive physiognomy. Many a face with
an indifferent physiognomy is capable of fine mental expres¬
sion in its mobile conditions.
Much might be said about coincident postures, their
analysis, and the principles involved in their study, but
tliis subject is intricate, and requires further elucidation.
It is impossible here to do more than touch upon some
examples illustrating the subject, but I wish to urge the
importance of studying the motor phenomena accompanying
the expressions of the mind as signs of its growth and modes
of action.
LIST OF ILLUSTRATIONS.
Nervous Hand.
Energetic Hand.
Hand in Fright.
Venus de Medici (Florence).
Diana (British Museum).
Cain (Pitti Gallery, Florence).
Dying Gladiator.
Hercules at Rest.
* See “ The Study of the Face as an Index of the Brain: *’ u Brit. Med.
Journal,” Aug. 19th and Oct. 21st, 1882.
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38
[April,
Precautions against Fire in Lunatic Asylums . By James C.
Howden, M.D., Medical Superintendent Royal Lunatic
Asylum, Montrose.
Head at the Quarterly Meeting of the Medicc- Psychological Association t
held at Edinburgh , November , 16, 1883.
The importance of the subject which I propose for discus¬
sion is sucb that I need make no apology for bringing it
under your notice. Fire, always a dreaded calamity, be¬
comes complicated with many additional horrors when it
breaks out in an asylum for the insane. The crowding
under one roof of a mass of human beings, most of whom
are incapable of acting for themselves, the locked doors, the
secured windows, the often insufficient means of egress, are
conditions which render a conflagration an exceptionally
appalling calamity.
In the construction of these institutions sufficient atten¬
tion is seldom given to fire-precautions, either by Architects
or Managing Boards ; and, though the approval of the Com¬
missioners in Lunacy is required for the site and general
plan of a District or County Asylum, I am not aware that
they exercise an active censorship over such details until the
building is actually occupied. It seems to me that the ex¬
pression of the individual views and experiences of mem¬
bers of this Association might indicate the precautionary
measures best suited for general adoption. Omitting origi¬
nal architectural precautions, such as iron girders, brick
arches, and iron partitions, I shall confine my remarks to
precautions applicable to any existing building under two
heads—first, the means of extinguishing fire, and second,
the means to be adopted for the escape and safety of the in¬
mates in the event of a conflagration.
Means of Extinguishing Fire.
Water-Supply. —The first requirement for an asylum, as
for any other building, is an abundant water-supply. Insti¬
tutions near a city or large town have this condition gener¬
ally fulfilled by a public company or corporation, but in the
case of rural asylums the supply is too often insufficient for
the daily needs of the establishment, and would be quite in¬
adequate in case of fire, unless means were taken to store
water in a reservoir for emergencies. It may be suggested
Digitized by Google
39
1884.] Precautions against Fire in Lunatic Asylums .
that where the supply is defective, water may be employed
of a quality quite unfit for culinary or even laundry use.
Besides rain water from the roofs, water drained from
the land, and even surface water, may be collected in
underground tanks, and thence pumped when needed by
steam or manual labour, or still better, when practicable,
supplied to the fire plugs by gravitation. An advantage
of this separate system is that the general water service
of the establishment is in no way interfered with, and that
at brigade drill the water may be freely used for cleaning
windows, flushing drains, and many other purposes.
Water Mains and Fire Plugs .—The course and position of
these must vary in different institutions. The mains should
be three or four inch iron pipes, and when practicable the
plugs should be kept well off the building, say'80 feet from
the nearest wall.* The number of plugs must be regulated
by the character of the building, but, cceteris paribus , their
usefulness is not necessarily increased by their number,
for in rural asylums it is seldom that more than one at a
time can be worked effectively, while if you have plenty
of hose, easily coupled, any part of the building can be
speedily reached if the ground is unimpeded by walls or
other obstacles.
Hose Couplings .—The quick-linking coupling should en¬
tirely supersede the clumsy old screw, which was so liable to
get out of order, and required the employment of a key,
easily mislaid in the confusion and darkness of night. The
new couplings link instantaneously, and are so constructed
that a coil of hose unwinds from them very rapidly.f
Precautions inside the Building .—However important the
arrangements outside the building may be, those inside are
more so. Fire must be stifled on its first outbreak, and not
allowed, if possible, to reach that stage when the outside
hose is needed. Rising mains in the staircases, with fire
plugs on the landings, extincteurs, portable hand engines and
water buckets are among the precautions which most ob¬
viously suggest themselves for this purpose. I am disposed
to put most reliance on water buckets and hand engines.
Fire plugs in staircases cannot be tested without much in¬
convenience, and when actually needed will probably be
found unworkable, especially as they are in situations which
* I have frequently observed fire plugs so close to the building as to be
quite unworkable in the event of an extensive conflagration.
t One of the best of these couplings is Morris’s patent.
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40
Precautions against Fire in Lunatic Asylums. [April,
would often be inaccessible if there was much smoke. The
extincteur again, is certain in its action, and the charge once
exhausted, an interval mast elapse ere it is ready for use
again. The buckets and hand engines, on the contrary, are
always ready, can be moved anywhere, can be used con¬
tinuously for any length of time if fed from baths or ordi¬
nary water taps, and at brigade drill they can can be tested
by both men and women without inconvenience, and employed
for the purpose of cleaning windows.
Light during the Night. —A jet of gas should be kept burn¬
ing on each stair landing, and lanterns (common stable candle
lanterns are the best) should be in conveniently acces¬
sible places, especially in the shed where the fire brigade
apparatus is kept. The electric light would be invaluable,
and perhaps may be in some cases available.
Fire Brigade. —Every asylum should have its fire brigade
which should drill periodically—say once a month, and there
should be a detached shed accessible by an ordinary house
key where all the brigade gear is kept ready for use. At
drill everything should be tested and defects at once re¬
paired.
Precautions for the Safety of Inmates in the Event of a
Conflagration.
To ensure speedy exit from the buildings all outside doors
communicating with passages and stairs should open out¬
wards, and as many doors as possible, especially those of
single rooms, should open from the outside by an ordinary
handle without using a key. For the safety of the inmates,
among many other reasons, it would be better that an asylum
should not be more than two stories in height. Such a
building is more easily commanded by the fire hose, and
escape more easily effected than from a higher one. Hap¬
pily our experience is very limited, but in the event of a
serious fire breaking out in an asylum the danger of the in¬
mates would probably be greater from the smoke than the
flames. The doors of the apartment where the fire occurs
should if possible be kept closed so as to prevent the smoke
getting access to the staircases. Fire escapes such as are
used by City fire brigades would probably be of little service
to an asylum where so many persons are congregated, but
outside iron staircases would be very useful when the ordi¬
nary passages of exit were obstructed.
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1884.]
by James C. Howden, M.D.
41
In conclusion, it may be well to consider what temporary
arrangements we could make for the safety of our patients
in the event of it being necessary to remove them from the
main building, and to bear in mind that our difficulties in
this respect are increased where there are no airing courts.
The Physical Conditions of Consciousness . By A. Herzen,
Professor of Physiology, Lausanne. Translated by T. W.
McDowall, M.D.
I have read with much interest Prof. Cleland's article a On
the Seat of Consciousness.” I agree with many of the author’s
opinions, especially with those contained in the critical or nega¬
tive part of his work; but it appears to me that the positive
portion, notably the extension of consciousness to the peripheral
terminations of the nerves, is scarcely in agreement with the
facts supplied by clinical observation and physiological experi¬
ment.
I propose so to examine the physical conditions of conscious¬
ness as to show, I hope, that it is possible to give full weight
to the objections to the current ideas as to consciousness, with¬
out starting a theory which is met at the very beginning by
most serious objections, and to arrive at a theory which, how¬
ever incomplete it may be, appears to me to be at least a pro¬
visional expression of the truth, and not in opposition to any
important fact, physiological or pathological.
L
Whilst the majority of psychological physiologists are
agreed upon the fundamental principles of monism and upon
the necessity of abandoning traditional dualism, they utterly
disagree as to the relation of consciousness with the central
nervous activity. The English especially have frequently jdis-
cussed this question. I will quote the two principal repre¬
sentatives of the opposing views: H. Maudsley and G. H.
Lewes.
In his “ Physiology of Mind/’ Maudsley often returns to
this question a propos of the different nervous centres. He
absolutely refuses all consciousness to the spinal cord, and
attributes the surprising reactions, the co-ordinated reflexes
which are obtained from the cord of decapitated frogs, to an
unconscious mechanism charged with transmitting the excita¬
tion by preformed nervous paths, innate or acquired. He
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The Physical Conditions oj Consciousness , [April,
endeavours to deny consciousness to the sensori-motor centres
between the medulla oblongata and the corpus callosum, and
attributes the greater complexity of the reactions furnished by
animals deprived only of the cerebral hemispheres to the
greater complexity of the impressions received through the
special senses ; just as the blind mechanism of the spinal cord
responds by uniform or slightly varied reactions to the monoto¬
nous impressions which it receives, so the sensori-motor centres
respond unconsciously by groups or series of co-ordinated
movements to the groups and series of external impressions;
the true agent, the only one, is here again the organised
mechanism, the nervous excitation travels by pre-established
paths acquired by the individual or the race. But in saying
this, Maudsley is more prudent than when he speaks of the
spinal cord ; he acknowledges that we cannot say with cer¬
tainty that sensori-motor acts are always unconscious, and ends
by admitting that the question is still open. Finally, even
when treating of the cortical centres in the cerebral convolu¬
tions, the seat of intelligence and will, he appears to admit re¬
luctantly the participation of consciousness in their activity,
and tries to convince the reader of the possibility of their act¬
ing unconsciously.
We ought, he says, strongly to combat the error of con¬
sidering consciousness as identical with or equivalent to
mind. When all the energy of an idea discharges itself
directly externally and gives rise to an ideo-motor reaction, we
are not conscious of it. In order that we may be conscious of
an idea it is necessary not only that it have a certain intensity,
but that it be not entirely expended upon the organs of move¬
ment. An idea which disappears from consciousness, does not
thereby cease to exist; it may continue to act in a latent state,
and, so to speak, under the horizon of consciousness, whilst the
molecular currents which constitute it, become slower by de¬
grees before stopping altogether; in this sub-conscious state it
may still have motor effects, or influence upon other ideas;
if we see effects, which were previously only manifested subse¬
quent to ideas perceived in consciousness, arise unconsciously,
we are justified in supposing the identity of the producing cause
in the two cases, especially as frequently, when our attention is
distracted from other objects which occupied it for the time, we
suddenly perceive that which we were about to do unconsciously,
and we thus seize the unconscious idea in the very act. Con¬
sciousness appears, therefore, to require, as the first condition,
a certain degree of persistence and intensity of the molecular
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1884.]
43
by Professor A. Herzen.
current which traverses the circuit of ideation. It thus results
that, when meditation is accomplished regularly and rapidly and
the chain of ideas is not interrupted, we have afterwards no con¬
sciousness of any of the ideas which followed each other; one
calling forth the other, without individually impressing the con¬
sciousness of the thinker, so that the result at which he arrives
may seem to him unexpected or accidental, and it is often
difficult, even impossible, to recall singly the different ideas
which have led his mind to this result. How many thoughts,
bora we know not how, do not present themselves in the course
of a single day on the threshold of our consciousness ! The
first current of ideation appears in this case to awaken immedi¬
ately another and to spread itself in the labyrinth of the cerebral
cortex, being constantly transformed, with such rapidity, that it
nowhere leaves permanent traces of its intermediate phases.
Since the works of Laycock and Carpenter, no one will deny
the fact that the superior cerebral centres may act uncon¬
sciously; but that surely will not justify us in assuming the
productive cause as identical in their conscious and unconscious
activity; on the contrary, just because there is consciousness in
one case and not in the other, we are compelled to admit a
difference in the conditions of the phenomenon ; the question is to
know when and why (or rather in what circumstances) the central
nervous function is conscious. To this Maudsley answers :
When the excitation has a certain degree of persistence and
intensity. This explanation is at least insufficient; what
can be more persistent and more intense than the “ music ” of
the celestial spheres, of which he speaks in a note at page 17?
And yet we do not hear it. What less intense than the noise
of the wings of a gnat, which we hear distinctly enough?
What less persistent than an electric spark which we see in all
its brilliancy ? We must not forget, however, that in the
majority of the examples usually quoted in this connection,
we have to do with influences which are not apt to excite the
activity of the afferent nerves; as long as we have to do
with external impressions, consciousness evidently can perceive
only the changes induced by the peripheral nerves; conse¬
quently when these nerves are not yet excited, or are so no
longer, or cannot be so, consciousness perceives nothing at all.
Maudsley, in support of the thesis that to persist in the same
state of consciousness is to be unconscious , quotes the fact that
we do not feel the enormous but constant pressure of the atmos¬
phere upon the surface of our body ; but how could we feel it
seeing that our nerves are made in such a manner as to be un-
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The Physical Conditions of Consciousness , [April,
excitable by it 9 We do not feel it for the same reason that a
blind man does not perceive colours and a deaf man does not
hear sounds; we have no organ for feeling it. I think we
ought to select examples from intercentral reflex action of the
cortical layers (that is to say of psychical or mental activity in
the limited sense of the word), for it constantly affords
empirical examples showing that exercise and habit reduce a
crowd of psychical acts at first conscious to complete auto¬
matism, independently of their intensity and persistence . This
is admirably expressed by H. Spencer in his “ Principles of
Psychology," (Vol. i., p. 499) from which I shall extract the
following passage :—
.... “ When actions which were once incoherent and voluntary are
frequently repeated, they become coherent and involuntary , [i.e. auto¬
matic, unconscious]. Just as any set of psychical changes, originally
displaying Memory, Reason, and Feeling, cease to be conscious,
rational, and emotional, as fast as by repetition they grow closely or¬
ganized, so do they at the same time pass beyond the sphere of
volition. Memory, Reason, Feeling, and Will, simultaneously dis¬
appear in proportion as psychical changes become automatic. Thus, the
child learning to walk, wills [and is conscious of] each movement be¬
fore making it ; but the adult, when setting out anywhere, does not
think of his legs, but of his destination, and his successive steps are
made with no more volition [nor consciousness] than his successive
inspirations. Every one of those vocal imitations made by the child
in acquiring its mother tongue, or by the man in learning a new lan¬
guage, is voluntarily made ; but after years of practice, conversation is
carried on without thought of the muscular adjustments required to
produce each articulation: the motions of the larynx and mouth
respond automatically to the trains of ideas. Similarly with writing,
and all other familiar processes.”
In general, we may say that the various physical co-ordina¬
tions, which at first were deliberately and voluntarily accom¬
plished, that is, with an anticipated consciousness of them,
become so easy and so rapid, that they take place at once upon
adapted stimulation, external or internal, and cease to require
a lapse of time sufficient to permit their producing conscious¬
ness : they thus become unconscious , or automatic.
In spite of these facts, demonstrated by the daily experience
of everyone, Lewes will not admit it. In his remarkable
work, “The Physical Basis of Mind/ 5 he attempts to prove
that just as nerves have the special and characteristic pro¬
perty, which he calls neurility, the nervous centres have also a
characteristic and special property, which he calls sensibility .
Digitized by Google
1884.] by Professor A. Herzen. 45
It need scarcely be said, that far from wishing to indicate
imaginary and metaphysical entities by these two words, he
simply proposes them to give a name to the activity peculiar to
nervous structure, and so to avoid the continual repetition of
the phrase “ the special molecular movement awakened by ex¬
ternal impressions in the nervous fibres and cells ; 99 he even
endeavours to give to these two words a purely objective mean¬
ing ; that is easily done for neurility, but with great difficulty
for sensibility; an objective sensibility is evidently a contra¬
diction in terms, and impossible, since sensibility is not and
cannot be anything else than just the subjectivity or the subjec¬
tive aspect of central change, of nervous vibration. And
indeed, in spite of the efforts of the author to exclude from
what he calls “ sensibility ” sensation or feeling, in a word,
consciousness—in spite of him, subjectivity encroaches on
the use he makes of this word, and compels him to attribute
memory, judgment, reason, and will to every active nervous
centre , including the spinal cord of decapitated frogs. The re¬
flex movements observed in them, consequent to peripheral
stimulations, he considers to be intelligent and voluntary; now
a movement cannot be intelligent and voluntary without being
felt subjectively, and that in a definite manner. Lewes quotes
a portion of the passage from Spencer which I have just cited,
and criticizes it severely; after having admitted that we call
automatic only those psychical changes which have lost those
special qualities which rendered them conscious, intelligent,
and emotional, he refutes the assertion according to which
psychical acts become physical by frequent repetition, and
maintains that, though ceasing to be conscious, they still con¬
tinue to be psychical, and thereby differ from physical acts.
Doubtless if, following the example of some spiritualists, we
accord the status of psychical only to conscious central acts,
we err in depriving unconscious central changes of their
psychical character; but those who describe unconscious
psychical acts as automatic do not commit this error; accord¬
ing to them there is no essential distinction between conscious
and unconscious acts ; in their opinion there is even no essential
distinction between psychical and physical acts. In what do
the former really differ from the latter ? Are not both only a
special form of dynamo-material changes, having a subjective
aspect for each of us solely because they take place in us,
and having the objective aspect only when they take place in
another ? And what is consciousness, if not precisely the subjec¬
tive aspect of certain of these changes, of which the objective
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The Physical Conditions of Consciousness , [April,
aspect is “purely physical ?” Lewes himself is obliged to say
that we may indifferently call sensation “ a nervous process,”
or “ a mental process,” a molecular movement, or a state of
consciousness, because it is both at the same time 9 and because
we ha,ve to do with the two aspects of one and the same reality.
But if this is so, there cannot be any essential difference be¬
tween the psychical and physical changes, and we must
cease to speak of such a difference; the more so as other¬
wise we fatally approach that dualism which we combat; and,
instead of constructing a bridge between obsolete spiritualism
and obsolete materialism, we enlarge the abyss which separates
them, and which engulfs the unity of being.
It is truly strange to see these two powerful minds, Lewes
and Maudsley, both zealous champions of monism, adopting in
regard to consciousness two extreme opinions, and thus both
approaching by different ways, the abyss which both endeavour
to fill up; whilst Lewes attempts to demonstrate the omni¬
presence of consciousness, not only in intellectual acts, but
in every nervous act, not excluding the most direct and most
automatic spinal reflex, Maudsley tries to prove the omni-
absence of consciousness, not only in the inferior order of
nervous acts, spinal and sensori-motor, but even in the most in¬
direct and least automatic cortical reflex, without excluding in¬
tellectual activity. From the commencement of his work
Maudsley warns the reader that intelligence and consciousness
are two entirely distinct things, that the first may do without
the second, that man would be a no worse intellectual machine
without consciousness than with it, and that “ the agent
would continue his activity in spite of the absence of the wit¬
ness.” Does this mean that the agent and the witness are
two personages independent of each other ? And what is con¬
sciousness if psychical activity can continue as well in its
absence? We are again at the brink of the abyss: a con¬
sciousness which appears at intervals, irregularly, arbitrarily,
i.e.y accidentally, instead of appearing under determined
conditions, and therefore necessarily detaches itself from its
nervous substratum, abandoning it in the arms of materialism,
and throws itself into the arms of spiritualism. The bridge is
destroyed, and the unity of being with it.
It is evident that if on one side we admit the most ele¬
mentary spinal reflex to be a conscious psychical, and not a
physical act; and on the other hand, the highest mental opera¬
tion to be a physical act of which consciousness is only a
frequent, but by no means necessary concomitant, it is evident.
Digitized by Google
1884.]
47
by Professor A. Herzen.
I say, that on both sides we totally sacrifice the evolutionary
transition of the simple to the complex, of the least to the
most perfect; and that, od either side, we suddenly introduce,
either by the termination of the spinal cord or the vault of the
cortical layers, a new and absolutely different element, the con¬
tinual presence of which is as incomprehensible in the first case
as its accidental presence in the second. But we are not com¬
pelled to choose between these opposite views, the opposition
of which arises from the fact of Lewes and Maudsley having
each exaggerated the portion of truth in his own view, and
neglected the portion of truth in the other; the truth lies, in
my opinion, in the synthesis of the two rival opinions, and
teaches us, if I am not mistaken, that whatever may be the
active centre, the conscious and unconscious always and every¬
where co-exist; but sometimes the one, sometimes the other,
predominates, according to certain conditions, i.e., to a law,
which I shall now attempt to explain.
II.
General physiology shows that nervous tissue, fibres and
cells, is no exception to the universal biological law, according
to which in life, the period of activity is the period of disorgani¬
sation, and that disorganisation is followed step by step by
reparation, without which life would be death. My standing-
point was thus clear: the nervous elements are disintegrated
through action, and are immediately afterwards reintegrated,
so that every nervous act has a phase of disintegration and
another of reintegration ; this latter being accomplished ac¬
cording to the modality of the disintegration which preceded it.
At once there arises this first question: To which of these
two phases is consciousness bound ? To answer this question
there is no possible experiment; only observation can guide
us ; but it guides us safely and speaks so clearly that we cannot
be mistaken : the integration and reintegration of the nervous
centres are absolutely unconscious. No one is conscious of the
embryonic development of his own brain, nor of the appear¬
ance and evolution of his cerebral organs, which proceed as
unconsciously as his growth, and as the nutrition of his muscles
and bones. Once developed, the central elements are stimulated
by incidental impressions. Their activity disintegrates and
fatigues the central organ; fatigue is the measure of decom¬
position depending on activity; fatigue of the brain produces
sleep ; during sleep it rests, that is it reintegrates; the result¬
ing freshness is the measure of the reparation accomplished.
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The Physical Conditions of Consciousness , [April,
Now we are conscious whilst awake, unconscious whilst sleeping
profoundly ; this is a first indication, though very crude, of the
bond which unites consciousness with the disorganisation of the
active elements. I will prove later that this intermittence occurs
in each central act taken separately; the brain may, in fact, be
compared to a hall provided with an immense number of gas-
burners, but lighted only by a relatively small and constant
number of jets, which are not always the same; on the contrary,
they change every minute: as one goes out another is lighted;
they are never all lighted together, sometimes they are all ex¬
tinguished. Thus it appears that consciousness is exclusively
connected with the disintegrative phase of central nervous acts.
This being established, the second question arises : Is every
disintegration conscious ? Evidently not, as automatic acts are
subconscious or unconscious, although they also are accom¬
panied by disorganisation; gas can also burn without giving
light, or only a small, bluish, almost invisible flame. Now,
observation shows that if, on one hand, the acts which fatigue
the most, which give the largest amount of products of de¬
composition, which, in short, disintegrate most, are the least
automatic and the most conscious; on the other hand, the
acts which fatigue least, which are accomplished with the
minimum of functional decomposition, are exactly the least
conscious and the most automatic. It therefore appears that
disintegration produces consciousness only when it is of a certain
intensity. Here experiment becomes possible if guided and
enlightened by the indispensable control of internal observa¬
tion ; this is why the majority of these observations should be
made on man, and why we should not have recourse to animals
save where absolutely necessary. I mean the experiments on
the duration of psychical acts and on central calorification.
Every central act is necessarily connected with the production
of a certain quantity of he^t; the heat produced is one of the
expressions of the functional disorganisation. Unfortunately
the observations on this subject cannot be made on man with
the desired precision; but the admirable researches of Schiff
on animals have thrown a bright light on the relations of cen¬
tral thermogenesis and psychical activity. * I shall only mention
here that the production of heat is greater according as the im¬
pression received by the animal may be, for whatever reason,
agreeable or disagreeable to it, in a word interesting , and
especially if it be apt to attract its attention, that is to produce
* Vide the original paper in “ Archives de Physiologie,” 1869, No. 1 and 2, and
1870, No. 1, 2, 3 and I, or my rhume in “Bevue Philosophique,” January, 1877.
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49
by Professor A. Herzen.
a vivid conscious impression; if, on the contrary, the impression
leaves it indifferent, that is, if it passes unperceived or almost
so, and awakens little or no consciousness , very little heat
is evolved; consequently the influence of the same frequently
repeated impression rapidly diminishes, and we soon arrive
at a constant minimum of calorification, due simply to the
nervous transmission. These facts clearly indicate that the
central acts accompanied most vividly by consciousness are
those which require a more extended decomposition and cause a
greater calorification; and that consequently, the intensity of
consciousness is in direct ratio to the intensity of the functional
disintegration .
Now what characterises central acts accompanied by the
minimum of consciousness or that are altogether uncon¬
scious ? We have already said it: it is a restricted decompo¬
sition and a calorification reduced to a minimum; but it is also,
and more particularly, a relatively very rapid transmission. In
fact, every central nervous act requires a certain time for
accomplishment; repetition, exercise, habit, diminish this time,
reducing it to the half, to the third, of what it was in the
beginning; it is at its maximum when the act to be accom¬
plished is new to the subject, and consequently awakens a very
intense consciousness of the sensations which provoke, accom¬
pany and follow it; it diminishes in proportion as the act be¬
comes habitual, and thereby approaches the automatic state; it
is at its minimum when the act has become altogether auto¬
matic and is accomplished unconsciously. Here, I may add, as
a drop of rain to the ocean, some observations of my own. I
wished to demonstrate on man that the automatic unconscious
reactions are really more rapid, and much more so, than the
most simple voluntary conscious reactions; this is a fact of
daily experience; but it was desirable to demonstrate the rela¬
tive rapidity of the two kinds of reaction. I have long searched
for a method, for it is not easy to find registerable automatic
reactions in man. At last the idea struck me to utilise corns ;
the subject had to withdraw his hand and foot with a strong
volition to withdraw them simultaneously , the moment he per¬
ceived the tactile sensation I produced by lightly touching his
foot; having clearly established that, except at the first trials,
which were always uncertain, the individual regularly withdrew
his hand a little before his foot , I struck, without warning, a
little sharp blow on a painful corn; the foot was then with¬
drawn before the hand, so distinctly so that the individual
could frequently himself state that at the moment when he
xxx. 4
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50
The Physical Conditions of Consciousness, [April,
voluntarily and consciously withdrew his hand, “ his foot had
long before withdrawn itself that is to say, involuntarily and
unconsciously. Here are two examples : 1st. Simple touching
of the foot: the hand precedes the foot by 0"*037 (thrice run¬
ning) ; touching of a painful corn : the hand precedes by only
0 // *025 (twice); sharp and unexpected blow on the corn : the
foot precedes the hand by O'* 100. 2nd. Simple touching of a
painful corn : the hand precedes by 0"*050 (three times); slight
fillip on the corn: the foot precedes by O^OSO; sharp blow on
the corn: the foot precedes by 0"*125.
Thus, since automatic acts are characterised by the small
amount of disorganisation and calorification which accompany
them, and especially by the rapidity of their accomplishment,
it is evident that the intensity of consciousness is in an inverse
ratio to the facility and rapidity of central transmission .
The three partial results that we have obtained directly from
observation and experiment when united constitute what I
have called the physical law of consciousness , which may be
formulated in the following manner
Consciousness is exclusively connected with the functional
disintegration of the central nervous elements; its intensity is
in direct proportion to this disintegration, and, simultaneously,
in inverse proportion to the facility with which each of these
elements transmits to others its functional vibrations, and with
which it relapses into repose, into reintegration.
in.
Now let us see how this law applies to the activity of the
different nervous centres.
In the daytime, during our waking state, we are continually
exposed to all those impressions which our constitution permits
us to receive from the external world and from the different
parts of our organism. These impressions light successively
some of our cerebral “ gas-burners ”—that is, excite sometimes
the one and sometimes the other region of our nervous centres,
thus provoking in them a disintegration, which is fluctuating
as to the elements concerned, but continuous in itself, and
which greatly exceeds the reintegration. Therefore we are
continually conscious, now of one thing and now of another.
All the stimuli which are not transmitted too rapidly, auto¬
matically, from one element to another, or which meet, in
the elements they invade, a resistance sufficient to hinder
them from passing on without stopping, all which finally have
sufficient energy not to be exhausted at the threshold of the
central element, but to force an entry and to stimulate its in-
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1884 .]
by Professor A. Herzen.
51
tenor, each awakens its own quantum of consciousness, which
unites with that of the other elements simultaneously disin¬
tegrated, to form the jpancesthesia * of the individual, whatever
may be the contents of it, be it personal or impersonal. At night,
when the employment of the nervous system has reached cer¬
tain limits, we experience a feeling of fatigue, a want of sleep,
the sensations become dull, external impressions are no longer
sufficient to stimulate the nervous centres, which require to be
drained and irrigated; the cerebral flames are extinguished one
by one, and we fall asleep. Now during sleep, during this
periodic preponderance of reintegration over disintegration, we
are unconscious.
How about dreams—do you object ? But what are dreams,
if not sporadic eruptions of disintegrating activity during the
periods of reintegration ? It may be, indeed, that some region
of the brain, having worked less than the others, enters into
vibration on its own account, in consequence of impressions too
feeble to cause the fatigued regions to vibrate, and produces cor¬
responding states of consciousness, or that some region of the
brain, having worked more than the others, continues to be the
seat of a vibration not yet completely stilled, and awakens
echoes, more or less clear, of the corresponding representations ;
or it may be, finally, that these two processes combine, and
both participate in the representations evoked by the state of
the viscera, and so furnish the varied, strange and absurd asso¬
ciations, which constitute the framework of (breams. At any rate,
it is certain that we are conscious only of the cerebro-psychicai
disintegration, and never of the reintegration.
Instead of the total interruption of consciousness due to pro¬
found sleep, let us examine its partial interruptions in the state
of wakefulness. You read a chapter which interests you, or
you are present at an important lesson, or you reflect in silence
on a problem which pre-occupies you: certain regions of your
nervous centres suffer profound and extended disintegration,
caused by the multiple impressions which affect them, and by
the innumerable reflex sensations which they awaken : you are
vividly conscious of what is taking place in you. But after
some time this occupation fatigues you; you suspend it, in
order to have food or take a walk ; or for some reason, perhaps
unperceived, your psychical activity passes to some other
* I propose this name of pancesthesia to express the totality of what an indi¬
vidual feels at a given moment. One often designates the same thing by the
word coeruesthesia ; bnt it seems to me etymologically less suitable, because the
entire consciousness may be occupied by one single sensation, and psychologi¬
cally because one often employs it to indicate the groups of organic or visceral
sensations.
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52
The Physical Conditions of Consciousness , [April,
regions of the brain, and allows the reintegration to take place
in those parts which have been working ; immediately you lose
all consciousness of the preceding activity, and are only con¬
scious of the actual activity. In the meantime reintegration
takes place, you are rested, you return to your first occupation,
and, as soon as the functioned vibrations affect there integrated
parts, the contents of your consciousness become what they
were before—but with this modification: the chaos of im¬
pressions then received is now duly arranged into a harmo¬
nious whole; reintegration having taken place according to the
modality of the disintegration which preceded it; you are in
possession of a synthesis, of a new conclusion, of an idea
which would not come, but which now comes of its own accord;
you have learned something, you have acquired a new faculty;
and all this without the least consciousness of the reintegra¬
tion to which you owe this progress.
Let us restrict ourselves to narrower limits. Whilst read¬
ing a chapter you are only conscious, at each single moment,
of the phrase that you are reading, and not of the one you have
read. The latter has already passed from disintegration to
reintegration; and if at the end of the chapter you possess the
contents duly co-ordinated, it is due to the unconscious reinte¬
gration of the series of conscious disintegrations.
The same thing may be said of each word which enters into
the composition of a phrase; a fact evident in people un¬
familiar with the subject of their reading, or the language in
which they read. The same may again be said of each letter
which enters into the composition of a word; a fact evident in
individuals who are learning to read. If we reverse our mode
of procedure, we see that whereas the impression of each letter
produces in him who is learning to read a conscious disinte¬
gration, however transient, he ceases to be conscious of it at
the moment when reintegration preponderates, consciousness
passes then to the word considered as a whole and taken as a
sign or symbol of a group of associations. To him who can
read pretty fluently it is no longer each letter but each
word which produces a conscious disintegration, immediately
replaced by that of the following word; with a little more
practice he has no longer consciousness of the partial disinte¬
gration produced by each word, because it passes too quickly
and easily to the phase of reintegration ; the consciousness of
single words fuses into a whole from which results the under¬
standing of the meaning of the phrase in its entirety, considered
as the expression of a series of more complex associations.
Finally, in him who not only reads fluently and understands the
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1884.]
53
by Professor A. Herzen.
language very well, but is also familiar with the subject, the
same thing happens in regard to entire phrases ; through
exercise and habit the conscious disintegration produced by
each of them passes so rapidly and easily to the phase of rein¬
tegration that he has no consciousness of them; but he has con¬
sciousness of the extremely complex disintegration which the
impression of the successive phrases communicates, with ex¬
treme rapidity, to other nervous elements, according to the
laws of the association of ideas. Whilst reading he reflects on
the meaning of what he reads, that is to say, his consciousness
manifests itself by turns in the nervous elements or groups
thereof, which the progress of associations stimulates, and dis¬
appears in those which have transmitted to their neighbours
the phase of disintegration to pass themselves to the phase of
tlie reintegration.
Every moment of our life, every one of the innumerable
nervous elements which are called upon to act, continually
oscillates between disintegration and reintegration, between
consciousness and unconsciousness. The personal or impersonal
paruesthesia which we have at a given moment is the resultant,
or rather the algebraic sum, of the conscious disintegrative
phases of all these partial activities. Consciousness (we
speak of consciousness in general , and not of ^//-conscious¬
ness) is continuous, due partly to the continuity of the process
of functional disintegration, so that the states of conscious¬
ness, whilst passing from one group of central elements to
another, are always connected by this or that form of associa¬
tion, and are, from this point of view, really the continuation
of each other; and partly to the reviviscence of states of past
consciousness, consolidated, or rendered latent, by reintegra¬
tion, and again liberated when a wave of disintegration disturbs
their repose. Thus these numerous isolated vibrations and
revibrations are fused into what is sometimes called our coences -
tkesia, or total consciousness, which we possess without inter¬
ruption as loug as we are awake; in this total consciousness
there is no solution of continuity except when there is an
arrest in the neuro-psychical disintegration : during profound
sleep, during syncope, and during lethargy.
It seems to me sufficiently clear that the law which I pro¬
pose applies perfectly to the psychical activity of the cortical
centres. I must next show that it applies equally well to the
subordinate centres, sensori-motor and spinal.
{To be continued .)
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54
[April,
CLINICAL NOTES AND CASES.
Case of Insanity of Seven Years' Duration: Treatment by
Electricity . By Alex. Robertson, M.D., F.F.P.S.G.,
Physician to the Town’s Hospital and City Parochial
Asylum, Glasgow.
Read at the Quarterly Meeting of the Medico-Psychological Association held at
Glasgow , 18£A April , 1883.
The value of electricity as a therapeutical agent, par¬
ticularly in diseases of the nervous and muscular systems,
has of late years become widely recognised. There is, how¬
ever, less assurance of its usefulness in disorders of the
mind. This is probably largely due to the comparatively
small experience which has been acquired of its action in
the treatment of the insane. Still, two important series of
observations have been made in this country—besides a few
abroad—the one by Dr. Allbutt, of Leeds, in the West
Riding Asylum, the other by Dr. Newth, in the Sussex
Asylum ; and both observers obtained some satisfactory
results. But it must be admitted that there is considerable
difference in their respective conclusions. Thus Allbutt
found very little advantage from it in most cases of melan¬
cholia, whereas it was in that class of cases that Newth
records the most distinct successes. In narrating its action
in a melancholic, Newth states that the result was “ most
marvellous, and satisfactorily attributable to the treatment.”
Allbutt noticed most improvement in acute dementia. Just
possibly, irrespective of the difference in the cases them¬
selves, the mode of application of the galvanism may have
had some influence in determining the character of the
effects. Both physicians used the continuous current, but
Allbutt applied the two poles to the head, while Newth
applied only one to it, the other being in the hand of the
same or opposite side, and sometimes in a basin of acidu¬
lated water, in which the hands or feet were placed.
It is now many years since I first tried electricity in the
treatment of insanity, but the results at that time were of
a negative kind. This, I think, was due mainly to the
instrument with which I worked not being very reliable,
and also to my own want of familiarity with the use of
batteries. In the Town’s Hospital, of late years, we have
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Clinical Notes and Cases .
55
employed both Faradic and continuous currents freely in
the different forms of paralysis, and it was the observation
of the occasional benefit derived from their action in these
conditions that led me lately to think of resuming the use
of galvanism in the treatment of mental disease. My
observations in this sphere, as yet, are too few to warrant
the deduction of any general conclusions. I, therefore,
restrict this paper to the record of a single case.
Margaret D., age 50, dealer in old clothes, was admitted into this
asylum on 13th August, 1881. She suffered from melancholia, with
delusions of suspicion. Thus she imagined that when at her employ¬
ment people were following her from place to place, were making signs
to her, and that the magistrates had employed detectives to dog her
steps. These notions, according to her own statements, which were
afterwards corroborated, had troubled her for nearly six years before
admission, but, notwithstanding their presence, she had been able
to attend to her occupation till a few weeks before being certified
as insane. Then they had been so dominant as to lead her to stop
strangers in the streets and charge them with causing her imaginary
troubles.
These were her delusions on admission, and they were associated
with a melancholic feeling of average severity. This would some¬
times become very intense, so that she had to be carefully guarded
against suicide. Her general condition was a little reduced, but there
was no organic disease observable. Menstruation had ceased about
the time the mental trouble first set in.
The treatment pursued, prior to the use of galvanism, need not
be mentioned in detail. The medicinal part of it comprised opium,
sulphuric ether, cannabis indica, tonics, and cod-oil; and fly-blisters
were applied to the back of the head and neck.
Not long after admission imaginary voices afflicted her very much,
and by-and-bye she refused food, so that she required feeding by
means of the stomach-pump. In October, 1882, her condition was
worse than when she entered the asylum fifteen months previously.
At the same time, though there were many hallucinations and
delusions, and the mental frame was one of depression, with much
misery, outside the morbid circle she talked rationally, and showed
considerable intelligence.
On 27th October, 1882, treatment by galvanism was commenced.
The continuous current was used, and was obtained from a Leclanche’s
40 cell battery. The positive pole was applied over the superior
cervical ganglion of the sympathetic, and the negative was slowly
moved over the same side of the head, from the brow to the
occiput, and up to the middle line of the skull. The current was
passed for about seven minutes on the one side, then the electrodes
were changed to the other side, and an application for the same
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Clinical Notes and Cases.
[April,
length of time made to it. This was continued every second day
till the end of February last, with the exception of three or four
occasions, when it was overlooked. The first two applications did not
seem to be beneficial; but some hours after the third one, on 4th
November, the current being from 15 to 20 cells, she said that
her head felt clearer. This improvement, if real, did not continue,
for on the 10th November the entry in the journal is : “ Complaining
of her head being painful to-day ; hears imaginary voices of men ;
thinks her life is in danger ; talks much nonsense.” On the 13th and
15th of the same month 25 cells were used, the duration of the
application being reduced to five minutes on each side of the head.
On the 28th the entry is more favourable : “ Says her head feels
lighter, and thinks that the battery is doing her good; before
beginning this treatment complained much of a heavy feeling in
the head.” Passing over intermediate entries, I find the one of
January 10th records marked improvement. It is: “ Does not
now hear the voices, unless she makes an effort, and then only a
little. This, she says, makes her think the voices are in her head
and not real. So convinced is she of the benefit she is deriving
from the battery that she asks to have her hair cut very short
again in order that the current may produce its full effect.”
Her progress towards complete recovery was now very rapid, and on
March 19th she was dismissed fully recovered. I have since'(January
20th, 1884), learned that she continues well. The entry in the journal
at the time of her dismissal is : “ States that now and for about two
months has felt quite well; both voices and the ‘ nonsense * (to use her
own word) about being watched by people have entirely left her. She
attributes her recovery to the galvanism ; remarked, ‘ I used to
feel my head so heavy that I could not carry it. What a good
that battery has done me.’ ” Latterly her head became much
more sensitive to the current than at first, so that at the close
of the treatment ten cells was as much as she could bear.
During the earlier applications, which were made by myself,
when the current was from ten to twelve cells, no change was
observed in the general condition of the patient, beyond a little
flushing of the face. The pulse was not accelerated, nor were
the pupils dilated. I cannot tell of the effect of the after applications,
as these had to be entrusted to an attendant, owing to the pressure
of other duties on the medical staff.
Remarks .—The question arises, may not the influence
arising from her mind, having been directed away from
her morbid thoughts, have been chiefly instrumental in
inducing recovery? As against this supposition, it is to
be observed that there was no improvement after the first
two or three applications, and, further, that the patient
is not a woman of a hysterical or impressible temperament.
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Clinical Notes and Cases .
57
1884 ]
My idea coincides with that of the patient's, that a direct
and beneficial change was produced on the substance of
the brain by the action of the electricity. I shall not
seek to theorize about the modus operandi. It was hoped
that the current might perhaps penetrate to the ganglion
of the sympathetic and influence the vaso-motor nerves
passing to the brain. Besides, it was thought that its
direction corresponded, as near as might be, with that
of the fibres radiating upwards and outwards from the
medulla oblongata to the nerve cells of the hemispherical
ganglia, and as these cells are normally affected by stimuli
coming upwards along these fibres, so the current would
be following a more natural course than if I had passed
it between the brow and occiput, or across the head.
Somewhat strong currents were used at most applica¬
tions. In previous cases treated by me, ten cells was the
maximum strength, but in these both poles were applied
to the head.
On Cases of General Paralysis with Lateral Sclerosis of the
Spinal Cord. By G. H. Savage, M.D.
Bead at the Section of Psychology at the Annual Meeting of the Brit. Med. Ass.,
Liverpool, Aug., 1883.
General Paralysis of the Insane with Changes in the Lateral
Columns. —“ General paralysis ” is now generally recognised
to be a term of convenience for a large number of cases
that agree but in the outline of their histories, and are
uniform or nearly so in their fatal terminations.
As one mode of careful examination after another is
developed in medicine it throws side lights on the conditions
of diseases which at first were not supposed to be directly
connected with it. Thus the ophthalmoscope, which began as
an instrument for the assistance of the ophthalmic surgeon,
soon passed into the hands of the physician, to be used by
him as a most important aid to diagnosis. Again, electricity
and the galvanic battery, which were used to detect the
malingerer or to rouse the hysterical, have become most im¬
portant aids, which the physician can have both for differ¬
ential diagnosis and for therapeutical help. A kind of
wave has recently passed over the medical world, and every¬
one ha8 been talking of reflexes and the battle of their
causation; and if their value is still undecided yet much has
been learnt, and in this case I believe much that may be
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58
Clinical Notes and Cases.
[April,
added to the store of knowledge, and not much which will
be found to have had but an ephemeral life; for happily
the observation is one that is easily made, and requires no
costly instrument and little skilled training. When general
paralytics came to be tried as to their reflexes it was soon
seen that these were, generally speaking, abnormal; and
when speaking of reflexes I generally mean the patella
reflex, as it is the most easily observed, and is most char¬
acteristic. In the one class, reflexes were found to be
deficient, and these were generally called ataxic cases; but
another class was found to have great exaggeration of the
reflexes, and these I have specially to notice in this paper.
I shall give a few examples, and shall now only say that they
differed in many respects from the cases of general paralysis
as more commonly seen.
I would guard myself by saying that I do not pretend that
the cases I bring before the meeting are a class apart, as I
know similar ones have been described over and over again,
but not quite in the same relation and with the same interest
as now; simply because several new points have been cleared
up by the advance of knowledge. Several of these cases
have occurred in young single men who have certainly not
led lives of sexual indulgence; whether they had other allied
vices I cannot say; but I think not as far as I can judge
from their histories, and from their general habits. It is
not easy to say whether a young man has been addicted to
masturbation, but it is easy to say if he has or has not
suffered in general health, and some of the cases were
markedly healthy and strong men who had led athletic lives.
There was no special relation to the family history, and there
was no one causation. Syphilis was acknowledged in several.
There was in all more or less exaltation; but I must not
leave it implied that such cases occur only in unmarried men
or in men alone, as I have had two fatal cases in which it
was present in women.
The course of the disease resembles that of most general
paralytics, but may be more rapid. The walking is early
noticed to be of a peculiar springy kind, so that the foot
seems to rise suddenly from the ground on coming in con¬
tact with it; I have been in the habit of saying it was of
the nature of an exaggerated reflex. At the same time the
speech becomes very thick, and there is much more tremor
both of lips and tongue than is common. Many of the cases
have to fix their eyebrows before they begin to speak, the
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Clinical Notes cmd Cases.
59
1884.]
cheeks become fat and expressionless, the voice becomes
generally changed in a way hard to describe, but yet I
think characteristically; restlessness is marked till the
patient becomes bedridden. The muscles I think waste
more in this variety than in most of the others of general
paralysis. The reflex.es are much increased, so much in
fact that I have known a patient jerk herself out of her
chair by a foot slipping accidentally on the ground. The
next stage is contraction of the lower limbs. This may be
associated with a slight fit of unconsciousness, but the fit is,
as a rule, slight. Grinding of the teeth is very common,
and I have known a girl literally grind out all her top teeth;
the limbs contract, and bedsores developeboth on hips and on
sacrum, yet the patients will live long in a perfectly demented
state, with wasted contracted limbs, and finally die of some
secondary trouble.
These cases may have optic disc changes, and I have had
several in which there was marked atrophy, a thing I was
hardly prepared for, as I was more used to see atrophy with
ataxic symptoms. Post-mortem there is a wasted brain with
large quantities of fluid in the lateral ventricles, and only
few adhesions. There are some wasted convolutions, but I
am not in a position to say which are more commonly
wasted; but I believe they are the ascending frontal and
parietal. The spinal cord, too, is often greatly wasted, and,
beside this, there is great change in the lateral columns, and
this may occur also in Turck’s column in the anterior column
of the cord. The point of most interest is to know if the
wasting of the lateral columns is primary or if it is secon¬
dary, if it is ascending or descending. I think in some
cases the changes were first in the cord, and in others that
the lateral sclerosis is secondary to wasting or degeneration
of the motor areas of the cortex.
I have already stated the fact that syphilis was certainly
present in several of the male cases, and among the women
another striking fact was that there had been either no
children or no living children.
Whether it is only a coincidence or not I do not know, but
most of the above patients have bright capillary congestions
over the malar bones. These resemble the patches seen in
cirrhosis of the liver.
Case I.— Francis K., admitted September, 1881 ; single ; student;
aged 30 ; no history of insanity in the family; no history of injury ;
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60 Clinical Notes and Cases . [April,
no exact history of syphilis, but there were stated to have been ex¬
cesses of all kinds.
Six months before admission he began doing odd things, and for¬
got himself in various ways ; he was naturally vain, and this became
more marked. On admission he had the wildest ideas of his power,
wealth, and ability. He was restless and amiable. He dressed
fantastically, and walked constantly about the grounds. There was
much change in his speech, so that his words seemed to come out
suddenly, and without his full power to control his lips. His tongue
was very tremulous. He was restless, and did not sleep well at night.
The pupils were equal at first. The patellar reflexes were somewhat
exaggerated.
In November the right pupil was one millimetre larger than the
left; both acted to accommodation, but hardly to light. The discs
were normal. He steadily became weaker in mind, very emotional,
and restless ; he got fat for a time, and lost power over the bladder
and rectum.
In March, 1882, he had some tremors of the limbs, followed by
stiffness. The muscles re-acted normally to galvanism. He had
grinding of the teeth.
He picked up strength for a time, but his speech went on from
bad to worse, and any effort to speak set the whole of his facial
muscles twitching.
His lower limbs became wasted and contracted, and he lay on a*
water bed senseless but automatic.
He had a slight convulsive seizure March, 1883, and died in three
days.
Post-mortem examination .—The brain was wasted, weighing 44
ounces. There was an excess of fluid, especially in the ventricles.
The membranes peeled easily, the surface of the frontal convolution
on the left 6ide being rough and pitted. The pons Varolii and the
floor of the fourth ventricle had a gelatinous appearance. The spinal
cord showed degeneration in the lateral columns.
Case II.— J. L., married, aged 36, without children, having no
neurotic history, a teetotaler, was admitted May 10th, 1881. The
first symptoms were causeless worry, she said that words addressed
to her u turned to gas inside her.’’ Her memory was feeble. She
seemed absent and lost. At one time she was melancholic. She had
some bodily illness, the nature of which was unknown, some months
before admission. Her mind was clear, there were no pains in the
limbs, she had some loss of power over her rectum. The patella-re-
flex was greatly increased, ankle-clonus was well marked on both
sides. She steadily lost power and fancied her husband was dead.
By May 30th a bed-sore had begun to form. The spinal cord only was
examined. Marked changes were found in the lateral columns.
Case III.—Mrs. A., aged 29, married, without children, was ad¬
mitted Sept. 16th, 1882. She had no neurotic relations. This was
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her first attack, she was said never to have menstruated properly, only
once or twice having had some slight discharge. She was lively,
irritable and industrious. The first symptoms, two months before
admission, were that she had increased irritability, she saw imagi¬
nary people; said she had been burned, and also that she had
been married fifty years. Shortly before admission her gait and
speech became affected, but there was no exaltation. It was found her
reflexes were much exaggerated; ankle-clonus also was present.
Speech on admission was accompanied by hesitation, and there was
great tremulousness of the tongue and lips, she was restless and
irritable. At present (July 1883) she is restless, and at times both
lewd and violent. Her speech is unsteady and her voice has a pecu¬
liar harsh twang. There is marked exaltation ; so that she says she
has many children and is a countess. Discharged uncured.
Case IY.—Frank S., single, age 27, clerk. Was admitted June 13,
1877. There was no neurosis, but his father was “ odd.” Patient had
an injury to his head when eight years of age, and was trephined by Mr.
Bryant. Before the present symptoms he had a love disappointment.
The first attack which had lasted five weeks began with delusions, he
fancied he had a contagious disease, would not go out of doors for fear
of the police, and thought people looked at him. He was sleepless,
and fancied he could not swallow. He was said to have had syphilis.
About three weeks after admission he had a slight fit of some kind,
the pupils were widely dilated, unequal, reacting to light, the conjunc¬
tive were sensitive. Some changes in discs were reported. Facial
and lingual tremor were much marked, and articulation became diffi¬
cult. He had no grandiose ideas. He stripped himself constantly.
He gradually became fat, and had a greasy skin. He was
more weak in mind. His memory was variable, but not very
bad. Temperature in axilla 100°. In November he had a
series of fits affecting the left side. The pupils were dilated,
the left more so, temperature 103°. He recovered and was much as
before, till in December he had some loss of mental power and also of
muscular power in the right side ; later he had fits affecting the left
side again. Tremulousness became more and more marked; and I
can recall the fact that his reflexes were most readily started, giving
rise to jerks when he was touched. He gradually became weaker and
bedridden, his left arm and leg being more contracted than the right.
There were rhythmic tremors of the right arm and leg, and the left
arm and leg were contracted. It was almost impossible to get his
tongue protruded, it was so tremulous. In November, 1878, he had
other fits followed by profuse sweating, and considerable rise in tem¬
perature; he sank and died. At the post-mortem examination there
was do sign of brain lesion from injury. The brain weighed 47 ounces,
and appeared much wasted. The membranes were thickened,
especially at the vertex. There were adhesions over the right as¬
cending frontal and parietal convolutions ; and a great excess of sub-
Digitized by
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Clinical Notes and Cases.
[April,
arachnoid and intraventricular fluid. To the naked eye the spinal
cord showed little noteworthy. The heart was large, with some
changes in the large vessels. Microscopically the spinal cord showed
marked excess of connective tissue in the lateral columns and in the
columns of Turck.
Case V. —Edith E. C., a printer’s wife, aged 85, without children,
was admitted March 2nd, 1888. She had had no marked or serious ill¬
ness save acute rheumatism as a child. She was not known to have
any insane relations. This was her first attack of insanity. The first
symptoms, five months before admission, began as suspicion of and
dislike to her husband, she made accusations against him. She left
her home at night in her bed-gown. There was great incoherence in
speech and excitability. She talked about great riches and fancied
poison had been given to her. On admission she was in rather weak
general health. There was great hesitation in her speech. Her
appetite was good ; sleep bad. The pupils were minutely contracted,
equal, reacting to light feebly. Taste was perverted. The tongue was
tremulous. Her walk was unsteady. The reflexes were much exag¬
gerated, ankle-clonus was present. Her handwriting was very shaky.
She rapidly became weaker in mind and body, the tremulousness
being very great. On May 6th she had a fit which was general, but
more on the right side ; it was not severe. She swallowed with diffi¬
culty. She sank and died on May 13th, 1883. At the post-mortem
examination there was great wasting of the ascending frontal convolu¬
tion on the right side. The membranes were adherent over the right
first frontal. There was great dilation of the right lateral ventricle.
The brain weighed 43 ounces. The spinal cord was small. There
was nothing special in the other viscera, save atheroma of the arteries.
A Case of Circular Insanity (Folie Circulaire). By W.
Herbert Packer, M.D., L.R.C.P., Senior Assistant
Medical Officer, Salop County Asylum.
In the following case the lights and shades are so clearly
defined, that it seems worthy of record. The history in
detail of the last six months only is given ; her state during
the early part of her residence was briefly as follows :—
E.P., aged 61, was admitted into the Salop and Mont¬
gomery Counties Asylum on March 22nd, 1880, from the
County Gaol, where she had served two out of the three
months to which she had been sentenced for stealing a
drake. There were at least two previous convictions against
her, one for violence and one for receiving.
In the state on admission she was noted to be thin, but
wiry; medium height; pale complexion $ slight paralysis
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1884 .]
agitans of head. She had an aortic obstructive murmur,
but no marked disturbance of the circulatory system due to
it was observed. Mentally, she was noisy and abusive, and
threatening everyone; the warders from the gaol especially
came in for their share, as she accused them, among other
things, of beating and bewitching her. In this state, com¬
bined with extreme restlessness, she continued until April
5th, when she became silent and melancholic.
Since then she has alternated between extreme restless¬
ness and excitement combined with great destructive powers,
on the one hand, and profound melancholia on the other.
In the latter state she can be persuaded to dress and feed
herself, but pays no attention to anything going on around
her, and only whispers when addressed. Her countenance
is pale and expressionless, and she appears physically ill.
If permitted she would stay in bed all day, and when got
up and dressed lies on a couch for hours without moving.
When she awakes, as it were, from this lethargy, she re¬
members all that has been said or done in her presence
whilst it lasted. The duration of each condition has been
longer of late; soon after admission each lasted from two to
three weeks, whereas now it is about six weeks before a
change occurs. The interval of something approaching
rational conduct is present, but of short duration; the
patient passing in the course of one to four days from
melancholia to mania, and vice versd. That she was a
criminal lunatic is also an interesting point in this case, as
it agrees with the statement put forward by several authors
that circular mania in its phase of excitement and exaltation
often simulates moral insanity, and is confounded with it.
The following rough notes are a fair description of her
condition at the various dates on which they were made:—
March 22, 1883.—After a very noisy time is this morning lying
on a sofa, never speaking or moving, and neatly dressed. When
spoken to apparently understands, but for a reply only nods. Trem¬
bling of head well marked. Takes food readily, but appears feeble
and ill.
April 20.—To-day eyes have a more intelligent look, and patient
appears to notice what is going on in the ward. Is not speaking or
moving about, but keeps to couch.
April 23.—Answers when addressed. Wished medical officer
“ good morning.” These are the first words he has heard her speak
for several weeks.
April 24.—Wide awake. Eyes bright, and face all life and action.
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Clinical Notes and Cases.
[April,
Looks generally in much better bodily health. Laughing, threatening,
and scolding. Using bad language freely. Dressed tidily, and fairly
obedient. Not destructive or violent.
April 25.—Destroyed bed-clothes during the night, and is dressed
in rags this morning. Never seems to rest; abusive, threatening,
and language most obscene.
May 27.—Somewhat quieter to-day.
May 31.—Now silent and melancholic. Lying still when permitted,
but dresses, undresses, or goes to dining-table when told.
June 27.—Yesterday spontaneously got up and walked the length
of the ward twice, but would not answer when spoken to, and only
shook her head when asked if happy and comfortable. To-day silent
and motionless as before.
July 15.—After a stage of incubation of two or three days has to¬
day become excited, noisy, and restless. Interferes with everyone and
everything. All about her are thieves and liars, and also closely
related to herself by blood or marriage. Very destructive, and never
satisfied till wrapped in rags, with strips wound round her feet instead
of shoes. Is very erotic, and invites every man who approaches her.
Sept. 5.—Silent and still; only moves lips slightly when questioned.
Became quieter and fairly tractable yesterday.
Oct. 14.—Reading a book to-day.
Oct. 16.—Restless, talkative, and interfering. Not yet reached
the abusive and destructive stage.
Case of Dementia with Aphasia: Atrophy [with Sclerosis?) of
Left Cerebral Hemisphere . By Arthur Rannie, M.B.,
Pathologist, West Riding Asylum, Wakefield. (With
Plate).
Robert S., aefc. 51, married, labourer, was admitted into the West
Riding Asylum on the 30th March, 1883.
His insanity commenced two years before admission with a fit, with
which he was seized one evening while he was sitting by the fire. His
wife’s statement respecting the fit was that “ he appeared to drop to
sleep with his eyes open, and could not speak for a few minutes ; he
then came to himself, and said he felt very 1 queer; ’ at the same
time his right arm and left (?) leg were paralysed. His speech was not
affected at this time, but he was quite unable to read after the fit.”
His power of speech remained unaffected for several months, and then
gradually began to fail. Loss of memory soon manifested itself, and
in about six months he was quite incapacitated for work. He grew
steadily worse, and became excitable and violent at times.
He had been a hard drinker for over twenty years, but had never
suffered from delirium tremens . He had sustained several injuries to
his head through his love of fighting; had never suffered from
Digitized by Google
TO ILLUSTRATE TYRANNIES CASE
Google
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Clinical Notes and Cases.
65
1884.]
syphilis or rheumatism; was naturally left-handed . His brothers
are intemperate, but otherwise the family history is good. On
admission he was found to be suffering from Amnesic Aphasia;
could comprehend very little of what was said to him; was quite
unable to read or write. On being asked to read he made a
great effort to do so, and struggled hard to make out what was
before him, but could not distinguish a single letter. To most
questions he answered *• yes ” or “ no ” indiscriminately. On being
asked if he was fond of fighting, he smiled and gesticulated in
fighting attitude. He was friendly and attentive, though rather ex¬
citable ; his expression was considered indicative of a passionate
nature. The pupils were of equal size, responded sluggishly to light;
horizontal nystagmus to the right; right buccal muscles tremulous
when the tongue was protruded; tongue protruded straight and
steadily ; articulation not impaired; gait slightly reeling ; patient
reeled slightly when standing with feet together and eyes shut; right
knee reflex seemed the greater, though the examination was not satis¬
factory ; right cremasteric and plantar reflexes present ; left plantar
very slightly marked; no other superficial reflexes present. The
grasping power of the right hand was considerably less than that of
the left. General bodily condition good. Examination of the other
systems revealed nothing abnormal.
From the entries in the case-book, it would appear that, for some
time after admission, there was no material change in patient’s state.
He was at times excitable and noisy, and occasionally required a seda¬
tive. All his actions were exaggerated, e.g ., when showing his tongue
he would raise himself in bed, stretch his mouth to its widest extent,
and glare fiercely. He was fairly clean in his habits, and fed himself
carefully. His vocabulary was a very limited one, the only words
usually distinguishable being “ yes,” “ no,” and “ God damn.” The
last-mentioned words he frequently used when annoyed in any way.
On one occasion—about three weeks after admission—when asked how
long he had been the asylum, he replied “ fortnight,” and said he had
only had “ one ” meal that day. He never regained the power of
reading or writing. On June 10th he had a congestive (?) seizure,
involving the right side, without loss of consciousness. The right
arm and leg were convulsed, and there was some twitching of the
right facial muscles. The convulsions lasted about a minute, and
were followed by marked paresis of the right limbs, which, however,
passed off in a day or two, leaving the patient in his usual state.
He was very excitable, noisy, and troublesome, both before and after
the attack. Marked nystagmus to the right was observed after the
attack, and persisted until death. After this seizure he gradually be¬
came more demented; was frequently restless, mischievous, and
troublesome; did not appear to understand anything that was said to
him; would assent to any absurdity mentioned, or make no response.
On October 1st he was reported as getting thinner and much more
xxx. 5
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66
Clmical Notes and Cases .
[April,
feeble, though still able to get up; would still say “ yes ” or “ no ” in
reply to a question. On the morning of October 30th he began to
pass into a state of coma, which gradually deepened, and he died the
following day.
Autopsy 29£ hours after death.
Body emaciated ; post mortem rigidity present in all the limbs.
Skull cap symmetrical ; the bones thin and somewhat dense at
parts; no adhesions of dura mater; intra-cranial sinuses empty.
The membranes covering the vertex had a milky appearance, and
were decidedly tough; their meshes were filled with serum, and they
stripped with great case from off the convolutions, more especially
those of the left hemisphere. The convolutions were considerably
wasted, and the wasting was decidedly greater in the left hemisphere
than the right. The left hemisphere was observed also to stand less
high than the right. The left supra-marginal, angular and superior
temporo-splienoidal convolutions were very markedly aflVcted, as also,
though to a lesser extent, were the ascending parietal and the convo¬
lutions of the frontal lobe. There was no indication of coarse lesion
externally. The gyri of the insula on the left side, were less volu¬
minous than those on the right, but otherwise appeared unchanged.
No difference as regards size could be detected between the lobes of
the cerebellum. The occipital lobe of the left hemisphere was
distinctly harder and firmer than that of the right; in the other
parts of the left hemisphere, though less noticeably than in the
occipital lobe, there was a condition of greater firmness than that of
the right side—indicative, in all probability, of a certain degree of
sclerosis.
The lateral ventricles were greatly dilated and filled with clear
serum. The caudate nucleus and optic thalamus on the left side were
distinctly smaller and less plump than the corresponding ganglia of
the right side. Incisions carried deeply into the ganglia failed to dis¬
close any coarse lesion, but the grey matter of the atrophied ganglia
was shallower than that of the right ganglia.
The vessels at the base of the brain were not affected with clot or
atheroma. The cranial nerves were of normal size and colour on
both sides. About 6oz. of fluid escaped from the cranial cavity.
The whole brain weighed ... ... ... 1165 grammes.
Right half of Encephalon ... ... ... 625 „
Left ,, ,, ,, ... ... ... 540 ,,
Right lobe of Cerebellum^ C 74 „
Left „ „ „ t after hardening } 74 „
Pons and Medulla ) [ 19 „
The spinal cord was not examined.
The other organs presented no conditions of special interest.
Remarks. —The two halves of the encephalon were hardened
in a saturated solution of corrosive sublimate and subse¬
quently photographed. I regret that, owing to the action of
Digitized by Google
1884.]
Clinical Notes and Cases .
67
the hardening fluid, the brain was rendered unfit for micro¬
scopic examination, and hence the case is pathologically in¬
complete. It is hoped, however, that a fair idea of the
macroscopic appearances may be obtained from the figures
in the accompanying plate, which are taken from photo¬
graphs and represent very fairly the unilateral character
of the wasting. The weight of the right cerebral hemi¬
sphere exceeded that of the left by eighty-five grammes.
The main clinical features of this man’s case were : (1),
Amnesia with agraphia; (2), paresis of the right limbs;
(3), convulsive seizures affecting the right limbs and right
facial muscles; (4), horizontal nystagmus to the right. In
connection with the first three symptoms it is interesting to
note that the ascending parietal, supramarginal, angular and
superior temporo-sphenoidal convolutions were more atro¬
phied than any others, and it is highly probable that if
a microscopic examination of these parts could have been
made, the ultimate structural elements would have been
found to be seriously implicated.
Insanity of Twins.—Twins suffering from Melancholia. By
Arthur Fflintoff Mickle, M.B., Kirklington, Yorks.
I have already reported in the Journal two cases of a
similar nature to the following, and through the courtesy of
my friend Dr. Bowes, Medical Superintendent of the Wilts
County Asylum, I am now permitted to send you the follow¬
ing account of twins suffering from melancholia, with strong
suicidal propensities.
The twins were the children of working people (agricul¬
turists), and lived together until they were old enough to
earn their own livelihood. They then separated to enter on
different occupations, and later in life one of them married
and went to America. There was always a strong tie of
affection between them, and it exists up to the present time,
for though in separate wards in the asylum they are often
together in the airing courts, and at other times when cir¬
cumstances permit. There is a striking resemblance in the
personal appearance of the two sisters, and were it not for a
slight eruption on the face of the elder it would be difficult
to identify them ; for they are very much alike in manner and
tone of voice, and in the way they express themselves, as well
as being similar in feature. Although there is a great
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68
Clinical Notes and Cases.
[April,
difference in the life history of the twins, they are at present
in very similar mental states. Thus, both are melancholic
and much absorbed in their own miserable condition; each
fears her soul is lost, and both make use of very similar
phrases when expressing themselves on this topic. They
have shown very strong suicidal tendencies, and frequently
ask to be put out of the way, saying they are not fit to live.
Case I. — M.B., admitted into the Wilts County Asylum on the 14th
day of October, 1865. She is 29 years of age, single, the younger of
twins; can read and write, has been a domestic servant, and was an
attendant at an Independent chapel.
The facts for the following history were obtained from the relieving
officer and the patient’s sister. She is the daughter of respectable
working people, was well brought up, has led a moral life, and is of a
religious disposition. Twelve years ago she was in a very depressed
state of mind, and was very much troubled with the thought that there
was no chance of her soul being saved, and other morbid ideas of a
religious nature. Whilst suffering from this attack, which lasted six
or seven months, she was treated in her own home, and on her recovery
she obtained a situation as a domestic servant, and has been thus
occupied until twelve months ago, when the first symptoms of the
present attack began to develope themselves. She was in her last
situation five years, and had a very dull and lonely existence, as she
was the only servant of a single elderly lady, who had but few friends
and acquaintances, and who frequently left her in sole charge of the
house for several weeks together, at the same time forbidding her to
have any visitors. Twelve months ago, being in a depressed state of
mind, she left her situation, and two months since received a funeral
card informing her of the death of her late mistress, which event
preyed so much upon her mind that she became very melancholy, and
foolishly attributed the death of her late mistress to a broken heart,
and imagined she herself was the cause of it. About this time
symptoms of a suicidal tendency developed themselves, and she said
she was lost, and that the devil was constantly appearing before her.
She has five sisters and one brother, and there is no history of here¬
ditary taint; her twin sister, however, has a rather melancholy ex¬
pression. There was no history of phthisis, chorea, cancer, or intem¬
perance. The predisposing causes appear to be the previous attack—
twelve years ago—and the lonely existence in her last situation;
whilst the news of the sudden death of her late mistress seems to have
acted as an exciting cause, and a love affair which she lately told me
of seems to have had a good share in the business. In this case, no
doubt a state of mental depression was the beginning of the alienation,
and the morbid religious ideas and delusions about her soul were
simply evidences of pre-existent disease.
State on admission .—She is a short and thickly-built woman, has
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Clinical Notes and Cases .
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1884.]
brown hair and irides, a florid healthy complexion, a narrow forehead,
and a fairly well shaped, straight nose. She enjoys fair bodily health.
The facial expression, manner, and general appearance would give one
the impression that she is a somewhat peculiar and weak-minded
person. She is in a state of mental depression, and has a melancholic
aspect; her conversation is not irrational, but she wanders from the
subject on which she is being questioned ; says she was very foolish
to leave her place, and thinks her late mistress was so fond of her that
she died broken-hearted on account of her leaving.
Oct. 23.—She is now much improved in spirits, appearance, and
manner; is of opinion that she should not have been brought here,
and denies that her conduct or language was such as to justify it. At
the same time she says she ought to have done better, for Jesus Christ
called her.
Nov. 7th.—Since the last entry she has worked in the laundry, and
at first seemed much better, but during the past few days has been
very talkative and excitable.
Nov. 10th.—Is full of apprehension about her mother, very excited,
talkative, and exceedingly troublesome. She was ordered a nightly
draught of tincture of hyoscyamus.
Nov. 16th.—Is now a little quieter, and engaged with needlework.
She is, however, still sleepless at night, notwithstanding the hyoscya¬
mus, and her mind is taken up with the idea that she must go before
the Queen, and she frequently leaves her seat and walks quickly down
the ward as though going on this errand. The hyoscyamus was now
omitted, and liq. morph, substituted.
Nov. 21st.—To-day she behaved in a most insane manner; she pro¬
tested that the medical superintendent had a letter belonging to her,
containing directions for her to go before her Majesty; at the same time
she refused to take a letter which had been sent by one of her friends.
Jan., 1866.—She is now considerably improved, works in the
kitchen, where she is considered a “ busy-body/’ and has been sent to
the convalescent ward. The morphia is discontinued.
March 18th.—She continues to work in the kitchen, and is stout
and strong ; there is, however, no further mental improvement. Two
letters were written by her to-day, and both were quite coherent and
rational. One of them was to a young man in Manchester, with whom
she had kept company when in her last situation. It has always been
observed that she is fond of attracting the attention of the opposite sex.
April.—During this month she had an attack of maniacal excite¬
ment, and was noisy both day and night. She wishes everyone to be
married ; frequently quotes passages of Scripture, and boasts of her
own safe and satisfactory state as regards her hopes hereafter.
Nov.—The attack of maniacal excitement from which she was suffer¬
ing at the last entry, gradually subsided, and she soon became quiet
and well-behaved. She is now industrious and useful, but very talk¬
ative, and still most enthusiastic on all matters connected with religion.
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70 Clinical Notes and Cases . [April,
She has had an interview with her friends, and was not mnch excited
by it.
Dec.—She has continued to improve since the last note, and at the
earnest appeal of her friends was allowed to go home on trial, and is
now discharged “ recovered.**
Sept. 80th, 1875.—On this day she was re-admitted, suffering from
melancholia with delusions. A sister gave the following account of
her :—“ She has been very well since her discharge from the asylum
in 1866, until four months ago, when she became very much depressed
and got into much the same 6tate as she was in previous to her first
admission. Within the last fortnight she has attempted to drown
herself on three or four occasions, and has once been dragged out of
a pond. She has also threatened suicide with a knife, and refused
food. As regards her bodily condition she is in her usual state of
health. Mentally, she is very depressed, has an anxious expression
of countenance, and is self-absorbed and reticent. When alone she
speaks to herself, and frequently repeats— u Lord have mercy upon
us, Christ have mercy upon us.** She hopes her soul is not lost ;
though very much afraid such is the case, and fears she will be killed.
Oct. 5th.—There is no change in her mental state.
Nov. 5th.— She is extremely agitated and desperate, and has made
an attempt to strangle herself, of which there are marks left on her
neck. As she was sleepless and very restless during the night, she was
ordered a draught of chloral, and tinct. of hyoscyamus, and tinct. of
opium thrice daily.
Dec. 7th.—She has made another attempt at strangulation.
Dec. 10th.—Yesterday she secreted a long strip of cloth in the
vagina, and again attempted to strangle herself this morning.
Jan., 1876.—Since last entry she has improved wonderfully, and is
now both cheerful and industrious.
March 27 th.—She is now considered quite well, and was this day
discharged “ recovered,** for the second time.
April 18th, 1878.—To-day she was again admitted. It is now a
little over two years since the date of her last discharge, and during
this interval she has had to depend almost entirely on parish relief—
38. a week—and it is stated that she has been peculiar nearly all the
time, and has spoken very much on religious topics. A month ago she
began to alter in her manners, and a week since became excitable and
violent. She again said she wished to see the Queen about a call she
had received from God, but had neglected. Her twin sister is now an
inmate of the asylum.
On admission .—She is fairly quiet, and answers questions on ordi¬
nary topics in a rational way. She adheres to the delusion that she
has neglected a call from God, but that the Queen has power to obtain
her pardon, and asks if she ought to have gone to London to see
her Majesty.
Her bodily health is, as usual, pretty good.
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1884.]
April 26th.—Is quiet, and gives little trouble.
May 21st.—She says she ought to be allowed to go before the
Queen.
June 10th.—Much improved mentally, and very useful in the wards.
Feb., 1879.—She now seems to have lost her delusion, but is childish
in manner.
May 10th.—Is improving rapidly.
May 23rd.—She is now improved so much that she has to-day been
sent out on trial.
June 17th.—She has been so troublesome since leaving the asylum
that she was to-day brought back by the relieving officer. She is in
a very restless and loquacious mood, confused in her ideas, and con¬
tinually quoting passages of Scripture.
Oct. 29th.—Patient has now improved very much mentally, and
never mentions her delusions. She is industrious, and makes herself
generally useful.
Feb., 1880.—She continues quiet and well-behaved, rational in her
conversation and actions.
May 3rd.—She makes very satisfactory progress.
June 30th.—To-day she was ordered to be discharged on trial.
July 4.—She has unfortunately again become peculiar in her
manner, and talks to everyone near her on religious subjects, and
consequently it has been necessary to withdraw the order for her dis¬
charge.
Dec. 20.—There is no improvement in her mental state.
March, 1881.—She is now not so loquacious as formerly, but her
delusions still exist, and she will look at some of the pictures in the
ward and say she sees Jesus- Christ. Lately she has become very dull
and lethargic, seldom speaks, and will sit still for two or three hours,
occupied with needlework.
April 27th.—She has improved very much since last note, and was
to-day discharged on trial, and on May 25th discharged recovered for
the third time.
July 26th, 1882.—To-day she was admitted for the fourth time, after
an interval of little more than a year. She is in a very depressed
state of mind, fears she may be tempted to commit suicide at any
time, and cannot control herself when near water, as she feels an irre¬
sistible impulse to jump in. She can give no reason for nor explana¬
tion of her state of mind, though she can converse in a fairly rational
manner, and has no apparent loss of memory. Her sister states that
she remains awake all night, and walks about the house with a lamp,
that instead of going to bed she lies on the floor, that she has
attempted to drown herself in the rain-water tub, and that she will
crouch in a corner of her room and pray for hours, as she fears her
soul is lost.
July 27th.—Slept fairly well last night, and is in better spirits this
morning, employing herself with needlework.
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July 3l8t. —Is quiet, evidently contented, and is industrious.
During the months of August and September she continued to
progress very satisfactorily, and was considered well enough to have
the caution against suicide withdrawn. In October she again became
very excitable, sleepless and restless, and was oppressed with very
unpleasant thoughts regarding her future state, but soon recovered.
In January, 1883, I made the following notes. She is at present
in one of her best moods, not nearly so depressed as usual, and con¬
verses freely ; her memory, perception, and attention are fairly good.
She takes an interest in her surroundings, is pleased to attend the
weekly associated entertainments, and to go for walks beyond the
grounds, and is very anxious to get well and go home.
I did not again see her till the following September, and then found
her not nearly so well. She was in a state of great depression and
mental and bodily inactivity, was in great doubt and anxiety about
her future state, and seemed quite incapable of making any exertion
to overcome her morbid thoughts. She had no inclination to con¬
verse, and usually sat mute. Occasionally she would exclaim, “ I am
lost; whatever shall I do to be saved ? ” She told me she thought it
was very foolish of her to get into this state of mind, and was quite
conscious of the change since I last saw her, but said in explanation
that something had come over her which she could neither explain
nor understand, and 6he had neither the will nor the strength of mind
to make an effort to overcome it.
Case II.—M. G. was admitted into the Wilts County Asylum on
the twenty-eighth day of June, 1877. She was 41 years of age, a
widow, the elder of twins, could read and write, was by occupation
a sempstress, and of the same religious persuasion as her sister.
History.—This is the first attack, and commenced about six months
ago on her return from America. Some years ago she and her hus¬
band went to America, and a little more than six months since, when
they were returning home, her husband was taken ill on the voyage
and died. This sad and sudden event preyed very much on her mind,
and was probably the exciting cause of her mental disturbance, the
first symptom of which was great depression ; but a short time before
admission she became excitable and very troublesome, both by day and
by night, and strong suicidal propensities exhibited themselves. No
further particulars could be obtained.
On admission .—I think it would be quite superfluous to give a de¬
scription of her general appearance, for her image reflected by a mirror
could scarcely present a more striking resemblance to her than the
twin sisters do to one another. She unfortunately has a nasty habit
of picking her face, and the eruption thus produced serves as a good
distinguishing mark. She was in fair bodily health.
As regards her mental state, her certificate gave the following ac¬
count :— u Very low-spirited, distressed, and much absorbed in melan¬
choly. Is very much lost and confused in her ideas, and says that she
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Clinical Notes and Cases .
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cannot make it out, that she feels neither one thing nor the other, and
thinks she must have given way to the wicked one.” As she was
very restless and sleepless she was put on chloral and tincture of
hyoscyamus thrice daily.
July 2nd.—She has been quieter and not so distressed since taking
the medicine, but is still very melancholy.
July 18th.—She is not now so self-absorbed, and assists in needle¬
work.
Sept. 18th.—She is going on quietly, and is industrious.
Jan., 1878.—There is no change in patient either bodily or
mentally.
June.—She is now not nearly so well as at last note, but is fre¬
quently noisy and very troublesome, untidy, and does not always
attend to the calls of nature.
During the next twelvemonths she had periods of depression and
mental exaltation alternating with one another, and exhibited suicidal
propensities.
Sept., 1879.—Patient is in a low and desponding state of mind, is
very suicidal, restless and talkative at times, and cannot be induced
to occupy herself with needle or other work for any length of time.
She frequently bemoans her unhappy existence, and expresses a wish
to get out of this world.
Dec. 20th.—There is no change for the better in her mental state,
she is still extremely low-spirited, has strong suicidal tendencies, and
is never left out of sight of an attendant.
March, 1880.—During this month she had a smart attack of facial
erysipelas, which was successfully treated by painting with a mixture
of liq. ferri perchlor. and glycerine, and the internal administration of
iron. No change was produced in her mental state.
Nov.— She has been in a weak and somewhat critical state of health
since the attack of erysipelas. She is in a very miserable frame of
mind, and says she feels she cannot be of any use to anyone in this
world, that her life is worthless, and expresses a wish to die. She is
now taking at bedtime a draught of liq. morph, and tr. hyoscyamus,
and this produces sound sleep.
March, 1881.—She is now in fairly-good bodily health, but her
mental state remains exactly the same as before.
July 10th.—She is in a very low and desponding state of mind,
and constantly makes use of the following expressions:—“ Put
me out of the way, I want to die. I wish you would kill me.”
Sometimes she is a little more rational in her behaviour and conver¬
sation, and more cheerful in spirits, and will assist with the work of
the ward. She still has the habit of picking her face, and thus dis¬
figures herself very much. She continues to take the draught of
morph, and hyosc. at night.
June, 1882.—Latterly she has become very troublesome and de¬
structive in her habits, has attempted to get up the chimney, and
shown strong suicidal tendencies.
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74 Clinical Notes and Cases. [April,
July.—She is very noisy and troublesome, and there is no mental
improvement
Dec.—She continues in much the same state as at last note, and
there is really no 6ign of improvement.
In Jan., 1888, I took the following notes of her mental state.
She is now much more melancholy and desponding than her twin
sister, who at present is fairly well. She has a distressed and anxious
facial expression, is disinclined for conversation, takes no interest in
her surroundings, and seems entirely occupied with her own morbid
ideas. Her memory is impaired, and there is an absence of will and
decision, an incapacity for either mental or bodily exertion, and she
says she feels weak-minded and has no sense. She frequently ex¬
claims, “ Oh ! dear, what shall I do ? I am lost. I wish I was dead.
I had no business to be born/ and regrets she did not jump into the
sea on the voyage home. After conversing for some time she would
brighten up and then express a wish to get well.
I again saw her in the following September, but there was but
little change in either her mental state or bodily condition. She
told me she felt too weak-minded and too nervous to struggle against
her state of depression, and that she would much rather die than live
in such a state of misery.
On some Mental Symptoms of Ordinary Brain-disease . By
Dr. Gasquet, St. George’s Retreat, Burgess Hill.
Read at the Quarterly Meeting of the Association held at Bethlem Hospital ,
Feb. 5, 1884.
In reading the following notes of some cases that have
fallen under my observation during the last few years, my
object, I may say at once, is not to impart information. It
would hardly be becoming that I should do so, since I have
much smaller means of observation than most of you
enjoy. My desire is rather a selfish one—to learn myself,
not to teach others—and to ascertain whether you have
noted the symptoms I am about to describe. If it appears
that they are tolerably frequent, and not merely due to a
“ run ” of coincidences in my own practice, which I cannot
determine, they seem to me of importance, in both pathology
and diagnosis.
Before reading the cases, I had better say that I have
omitted, for the sake of brevity, all account of the bodily
symptoms where these have no immediate reference to the
state of mind. The omission may be supplied by the
general remark that all were typical examples of their
several diseases, and that the bodily symptoms were com-
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1884.]
pletely developed. I have purposely abstained from includ¬
ing any instance of obscure or doubtful disease, as I a might
have done.
I. The first is a well-marked case of multiple sclerosis in a male,
aged 52. In less than a fortnight after the first appearance of the
bodily symptoms of his disorder he began to call himself a Duke ; in¬
vited the Prime Minister, the Pope, and the Lord Mayor to breakfast,
and tried to spend money recklessly, saying he was enormously rich.
He then came under my care, and I found him continually occupied
with ideas of his own grandeur. He was only satisfied when talking
of great people ; he said he had recently been made a Duke ; he had
five millions at call in the Bank of England.
He was not a Prince or a King, he said, but “ might be one by-
and-bye; ” at another time he was “ the trustee appointed by God
to administer the affairs of this country.” A little later his delusions
of grandeur became more varied and inconsistent. He continually
ordered palaces to be pulled down and rebuilt; he passed laws for
the extermination of the labouring classes ; at another time he had a
steamer which would convey all but the poor to some remote earthly
paradise. He quartered (he said) the Royal arms; Napoleon III.
died in a palace he had lent him ; if he had been consulted, he could
have cut the Emperor for stone, and saved his life ; he was going to
take all the costermongers in a balloon to America.
Delusions, of which these are examples, continued until his death,
nearly two years from the beginning of his illness. They were inter¬
rupted only by four attacks, which each began with heat of head and
flushing of face, and ended with epileptiform convulsions; at these
times he occupied himself in devising instruments of torture for his
enemies.
He never had any delusions of muscular strength ; h6 was quite
aware of his feebleness; the tremors annoyed him exceedingly, and
he fully realised that he was suffering from a serious disease.
II. The second case I have to relate is one of syphilis, which had
been neglected, a male, aged 32. It began with two fits, followed
by an attack of acute mania, which had lasted some weeks before he
came under my care. As soon as this had sufficiently cleared off for
me to test his state of mind, I found he had well marked delusions of
grandeur. He said he was the true God, Christ, a King, all in one
breath. He owned 160 millions, and more if one pressed him to say
so ; “ his proper place is above the heavens, but he owns every palace
on earth.”
He had at no time any delusions of strength, agility, or bodily
dexterity, all of which he very rationally disclaimed. He was com¬
pletely demented for some two months before his death, which was
preceded by a prolonged series of fits of Jacksonian epilepsy.
I could unfortunately not obtain leave from his friends to make a
post mortem.
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III. The third case, that of a male, aged 58, presented well marked
symptoms of chronic cerebral softening (“ multiple thrombosis ”).
He had been a literary man of some eminence and had worked hard
to maintain his position. He was usually in the jovial condition of
a general paralytic ; everything in the asylum is lovely, perfection,
charming, all around him are the best of good fellows, and he is per¬
fectly happy. He is making enormous fortunes, for which he cares
little, as he is also making continual discoveries. These are to re¬
volutionize the world, especially the world of thought; he has
devised a mathematical formula for estimating the value of any act
of intellect or benevolence; but the nature of his discoveries is con¬
tinually varying, always, however, grandiose and extravagant. He
never manifested any delusions as to his health or strength, which he
correctly appreciated. It may be worth noting, though not my
point, that this mental condition was interrupted by days or hours of
depression and terror, during which he would cry out (apparently
under the influence of vivid hallucinations of hearing) that torturers
were awaiting him, and that he was to be “finished off” by dogs.
IV. The fourth case, a male aged 48, is one in which about two
months after an apoplectic attack, symptoms of mental derangement
began. The patient had imperfectly recovered the use of his right
leg (the side on which he had been hemiplegic) ; and descending de¬
generation of the motor tract had set in, as shown by ankle-clonus,
exaggerated knee-jerk, contraction of the right arm, and constant
twitching of the hand. He was angry for the moment at being placed
in an asylum, but immediately became perfectly friendly with all
around. He talked as volubly as some amount of interference with
speech would allow him; boasted of his skill as an artist, by which he
was going to make a large fortune. He had also some vines in a
greenhouse at home, of which the fruit was to bring him in a large
sum which he could not state. He said he had received a higher
dignity than any man in the world, but he declined to claim any
specific title. His main subject of conversation was his brother’s
wealth, influence, and position ; and his own beauty, and elegant,
though muscular proportions ; both of which were entirely mythical.
But he had no delusions whatever of muscular strength, and always
spoke of himself as being very ill, and feeling so.
These delusions gradually merged into complete dementia and in¬
coherence after about three months.
Such are the cases I propose to bring before you to-day.
In the course of the last few years I have met with one or
two others which seemed to be of the same kind. But they
were seen in consultation with general practitioners, and it
will therefore be readily understood that I had no sufficient
opportunity of observing them to justify me in relating them
to you.
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Of course this material is much too scanty to allow of any
conclusion being drawn from it. But it seems to me that it
certainly suggests further inquiry. It would doubtless be
interesting to know whether delusions of grandeur, so like
those of general paralysis, occur in other forms of organic
brain-diseases often enough to allow of their study, or whether
these were rarities which accident brought before me. If the
former, their pathological interest seems to be, that by com¬
parison of the cases presenting these symptoms with those
that did not, we might hope to approach a true explanation
of the physical condition producing delusions of grandeur.
They have also a certain diagnostic importance, as it seems
probable that patients such as I have described might be
supposed, on a hasty examination, to be suffering from general
paralysis. This would be all the more likely if we had a
history of fits, and found our patient in a state of general
loss of motor power without true paralysis, both conditions
often seen in cases of chronic softening (multiple thrombosis).
Indeed, the first and third of the cases I have related, were
described to me as being general paralytics, before I saw them.
And this suggests the second question which I will put to
you. Supposing you have observed cases of grandiose delu¬
sions in disease other than general paralysis, were delusions
of muscular strength present or absent ? It will have been
remarked that they were absent in those which I have de¬
tailed ; and, if this is found to be the rule, we shall obtain a
differential character to assist our diagnosis, should it ever
be doubtful. Here, again, my cases are too few to do more
than allow me to ask you for your experience.
I may remark, in this connection, that none of these
patients took that delight in lewd conversation, or in boast¬
ing of their sexual powers, that is so common in general
paralysis ; although two of them at least had the reputation
of having led lives of excess in this respect.
I have thought it better to narrow the scope of my paper
to these two points ; but I may briefly recall the other points
of similarity between general paralysis and other “ coarse 99
brain-diseases. Such are the fits already mentioned; the
vivid hallucinations, the easily-roused emotions, and the
stage of acute mania. All of these, as far as my own
experience goes, are more common in cases of multiple
thrombosis than in others.
Dr. Savage will probably recognize that these cases, like
more illustrious personal histories, serve to point a moral
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Clinical Notes and Cases.
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which he has very forcibly expressed. He remarks, in his
account of exophthalmic goitre, that, if alienists are open to
the blame of neglecting bodily symptoms in insanity, general
physicians are at least as guilty of neglecting the mental
symptoms of ordinary disease. It is tantalizing to think of
the wasted opportunities for advancing mental pathology
which must come before every practitioner; but which are
wasted because he does not know what to look for, and how
to look for it.
Digest of Essays on Hallucinations by Asylum Attendants.
Prepared by A. Campbell Clabk, M.B., Glasgow Dis¬
trict Asylum, Bothwell.
The interest awakened in the subject of a special training
for asylum attendants, and the complimentary references
which have been made to these essays by those who have
perused them, will I trust, be sufficient excuse for my pre¬
senting the following digest of them in the Journal.
I.—Case of M. R., aet. 62. Climacteric melancholia. Hallucina¬
tions of hearing, sight, tonch, taste, and smell.
(a.) By M. M. F. “ When not excited is pliable; has a good
memory, and is always coherent; hearing acute, but 6ight is not good.
She suffers from hallucinations of hearing, sight, taste, smell, and
touch. Examples : (1.) She hears her children calling to her, and
says that some persons are tempting her to kill them. At such times
is much excited, depressed, wrings her hands and weeps. (2.) She
sees her children in the fields, and points to them. (3.) Sometimes
complains of her food, which she says 4 tastes and smells like arsenic/
(4.) Often fights with some imaginary person whom she feels catch¬
ing her. When persuaded to employ herself, or when having outdoor
exercise, her hallucinations subside, and she is less noisy/ 7
(6.) By I. j$. “Has hallucinations of hearing and sight;
generally hears and sees at the doors and windows. Hears people
scolding and ill-treating her children, and answers the voices back in
a scolding tone. It is mostly men’s voices that she hears. Seldom
strikes, but threatens. At times will reason, and say she knows it is
imagination ; but only for a moment is she doubtful, for she is im;
mediately as noisy as ever. Hallucinations of sight: Sees people
running after her children in the fields, and stabbing them with
knives. Sees her father and mother in their grave clothes. Hallu¬
cinations of touch : Not so well marked. Feels men pulling at her
clothes in an indecent manner; but I believe they would be easier
noticed if she had less control, for she seems to try to hide her ideas
of indecency from us.”
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(n.) By D. M. “ She is as healthy a patient as we have, but she
gets extra feeding, and my idea is that patients with such hallucina¬
tions need extra diet to keep up their body, for the excitement must
be very sore. She is willing to do a little work, and I believe would
do more if she were not troubled with voices laughing at her. When
people walk past her she fears they may be going to tell ‘ these black¬
guards ’ that she is working. So the work is pitched down, so great
is her dread of the people she imagines laugh at her.”
Case II.—M. F., set. 38. Chronic mania, with hallucinations of
sight and hearing. Has two sisters insane.
(a.) By C. T. “ She is very fond of staring in the fire, and sees
in the flames visions and witches . She also hears them speaking to
her, and has a great hatred of them. Nothing gives so much delight
as to get hold of anything dry and inflammable. This she puts in
the fire, and in the flames arising therefrom she sees her inveterate
enemies, ‘ visions and witches burning.’ Her face then has a look of
genuine triumph. She sees the visions, &c., writhing in their agony
while being charred and burned, and she sometimes hears them laugh¬
ing at and mocking her from amidst the flames. ,,
(6.) By M . M. F, u Appears to hear voices by both ears; some¬
times ‘ through a glass, or a telephone, or a horn/ As a rule, the
persons who address her are of high rank. Example, the Duke'of
Hamilton, Prince Bismarck. The hallucinations of sight are shown
by what she calls seeing visions which are visible in pieces of iron,
bones, stones, fluff, hair, &c. These she will hide for hours, and
when opportunity offers put them in the fire, exclaiming as the flames
arise, ‘There are the visions/ She also sees living creatures like
needles coming out of her body, and then she tries to bum her
clothing. She sometimes complains of sulphur being burnt and of
vegetables having the odour of sulphur/’
(c.) By J. C . “ Sees the spirits of her dead friends, and says
that spirits arise from her bed during the night and beats her bed,
saying that she is killing them. She says also that they are in her
body, and she tries to leap off the table to kill them. Is threatening
sometimes to attendants, but good to her fellow-patients.”
Case III.—M. C., set 67. Chronic mania, with delusions of
exalted character, and hallucinations of hearing and sight.
(a.) By M. M. F '. “ Hearing not very acute, sight very defective.
She suffers from hallucinations of hearing and of sight, and has a
great many delusions of an exalted character. Example of hallucina¬
tions : The King of Sardinia\sked her to find out a wife for his son;
a doll asked her to give it food ; a cat tells her that it is a cousin in
disguise; converses with pictures ; sees little creatures on the floor
and calls out not to tramp on them/’
(h .) By C. G. “ She sees the spirits of her friends, and hears
them speaking to her ou both sides of her head ; holds long conver-
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sations with people under the floor ; and they don’t always tell her
things to please her, for sometimes she will be quite sad after talking
to them. Is very fond of two dolls, and says that she distinctly saw
the spirit of her aunt, which told her that the dolls are her two
children.”
Case IV.—P. D., set. 36. Mania, with hallucinations of hearing
and violent paroxysms.
(a.) By C. T. 44 Seems to be persecuted most by the voice of one
person called Biddy, who visits him at no stated times. I have noticed
that after the patients’ meal is over, and while the attendants are at
their meal, there is generally a subdued hum in the dining hall. At
that particular time I have seen him repeatedly spring suddenly to
his feet, his face pale, eyes wild-looking, and whole body convulsed
with passion, and he shouts to her if she does not clear out he will
twist her neck.”
(b.) By J. M . L. 44 Is a little dull of hearing; asks a question
frequently more than once before he hears properly. On one occa¬
sion when polishing the floor he heard Biddy underneath, and brought
the heavy polishing brush on the floor with such violence as to make
a hole in it.”
Case V.—Mrs. C., set. 57. Chronic puerperal mania, with religious
exaltation and hallucinations of all the senses.
(a.) By C. T, 44 She has delusions of identity, calling those
around her by other names than their own ; and these never change.
She has a wonderful memory, and is very good at calculation. What
seems to affect her health most is her incessant and violent excitement,
due to her delusions and hallucinations. Sees imaginary persons and
things with both eyes, and hears imaginary voices with both ears.
Her hallucinations are most common during the night. She feels a
man called Tait jumping on her at night and striking her with a
poker, and declares she is 4 black and blue.’ ”
(5.) By J. M. L. 44 It has been noticed on several occasions when
working in some corner of the house that she holds conversation in a
low tone with some one imaginary, and keeps her eyes fixed on one
particular spot. She is violent, noisy, and abusive, but not really
dangerous. Even in her most angry passions there is observed a
little humour, and her outburst frequently ends in a hideous laugh.”
Case VI.—Mrs. M., set. 62. Climacteric mania, with paroxysmal
excitement and hallucinations of hearing.
By S. S, 44 Inclines to be dangerous ; her dangerous attempts are,
when interrupted in her conversation, with invisible parties. Hears
voices with both ears, more so with the left, which suppurates at
times, when at these times she is generally excited and annoyed with
people talking to her; calls them by their names ; can hear them from
the ceiling annoying her about money matters ; answers them back in
an angry tone, telling them they 4 will make nothing of her.’ Sud
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1884 .]
denly starts up, places herself in an attitude which would make one
think she had hallucinations of sight and touch. I have seen M. M.
pass for weeks without showing any hallucinations of an open charac-.
ter, but during that interval I have observed her constantly talking
to herself; the cause, I should think, of her not giving vent to them
is that we restrict her for making a noise. Clean and tidy in habits,
sews and does housework, refuses food at times ; from experience, I
have always thought her much better after an aperient medicine, as
she is inclined to be constipated. ,,
Cask VII.—Mrs. H., set. 40. Mania, with hallucinations of hear¬
ing, sight, and probably touch. Suicidal tendency well marked.
By S. S. “ Has a proud, stem appearance; ideas very exalted ;
shows a great deal of muscular excitement during hallucinations of
touch, such as throwing parties away from her whom 6he feels draw¬
ing her mind and reaping her high talents. Has close communica¬
tions with a gentleman named ‘ Sir Oswald/ who is her husband ;
gets messages from him and also sends him messages about murderers,
and also about an old, grey-haired man who is the principal perpetrator
of these crimes, the old man even tries to betray and kill the Mar¬
chioness of Lome, but the old * villain * then draws her mind and she
has no power of throwing him off. Sees parties throwing darts at her
from the clouds while walking out. Is of a very suspicious disposition.
Have observed the hallucinations in this case very bad at night and
morning, and also at menstrual periods. At menstrual periods very
profuse, nervous voice, and shows a feeble expression and craving
sympathy. Have not discovered any symptoms of suicide as yet, but
would be apt to doubt her, as she shows it her duty to sacrifice for
the good of other patients, which I would say might occur through a
motive.”
Case VIII.—M. 8., aet. 40. Chronic dementia, with homicidal
tendency. Has hallucinations of hearing and sight.
By S. S. “ Swarthy complexion ; expression at times very plea¬
sant, at other times equally savage. Hears people singing in a low,
sweet tone ; asks the nurse if she hears them; walks stealthily out
of the room to listen to the voices, and then comes back laughing,
singing, and dancing, and says she saw a regiment of soldiers. Very
subject to homicidal attacks; attempts to seize patients with her
teeth, or nails, or whatever is most convenient for her ; such attacks
are usually on the Irish patients. In this case hallucinations of hear¬
ing and sight generally go together. Does a little knitting indif¬
ferently at times. At menstrual periods inclines to be profuse, and a
sallow look comes over the face. Homicidal attacks are oftener before
menstrual periods than after them. The only controlling influence at
such attacks is to remove her from the parties she takes aversion to.”
Case IX.—Mrs. L., aet. 50. Climacteric melancholia now much
less acute. Has hallucinations of hearing and sight.
xxx. 6
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By J, C. “ A case of melancholia, with determined suicidal ten¬
dencies. First attempted to cut her throat, at another time stabbed
herself behind the ear with a pair of scissors ; wished her days were
at an end, as she is tired of life. Has hallucinations of hearing and
sight; hears her husband speaking to her from under the floor, asks
him how the children are keeping; hears other voices speaking to
her constantly, and after a conversation about the family gets very
excited.”
Case X.—M. B., aBt. 85. Religious mania, with hereditary predis¬
position, and hallucinations of hearing.
By J. C. “ Has hallucinations of hearing. Hears God telling her
to work for His sake, and to pray for the other patients, or they will
suddenly perish ; hears Christ calling her His wife. Noticed that
when she prays she always goes to the lavatory, or upstairs to one of
the bedrooms ; states that it is the Lord’s will that she should pray
for them. While praying stands at one of the windows in a nude
state, with arms stretched out. If interfered with she turns on the
attendant, and often a struggle ensues. Bodily health good.”
Case XI.—Mrs. H., ®t. 37. Mania, with hallucinations of hear¬
ing and smell.
By C. O. “ A case of hallucinations of hearing and smell. Hears
on both sides. Is told by people to prophesy, and quotes portions of
Scripture in support of her prophecy. Gets excited now and again
for about three weeks at a time ; when excited tears her clothes and
burns them, as she thinks they have got a bad smell. Goes occa¬
sionally to the water taps and lets the water run up her nose to take
the bad smell out of her head. She is told to do these things by
people. When not excited is very useful, and does any housework or
knitting with a will. Takes food well, and, as a general rule, sleeps
well.”
Case XII.—Mrs. P., set. 36. Insanity of lactation. Has hallu¬
cinations of hearing, and is subject to violent impulses.
By C . Q. “ Has hallucinations of hearing. When first admitted
was very impulsive, and would suddenly run to the door, saying her
husband and children were calling her; at other times it would be the
powers above. Heard God and people say the whole earth would be
set on fire and this place put in an uproar. When out walking heard
people calling her, and she was sure to be in the opposite direction
from where she was wanted to go ; when sitting she is always in a
listening attitude, with her head leaning to the left side. I have
never seen her talking to her imaginary friends, only listening to
them.”
Case XIII.—J. S., aet. 52. Congenital imbecility. Has halluci¬
nations of sight. Is fairly intelligent for an imbecile.
By J . M. L. “ Has hallucinations of sight, can scarcely utter three
words without swearing, and his mind is entirely absorbed with his
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Clinical Notes and Cases .
83
hallucinations, which he sees with both eyes. His chief hobby is pick¬
ing up stones, &c., and looking at them, to see if there are 4 ponies/
4 mares/ or 4 diamonds ’ inside them. Makes elephants of soft mud,
holds them up and admires them, telling you to look at them moving,
what a fine tail he has got, and the 4 bonny head.’ His chief halluci¬
nation is seeing a pair of wings floating in the air; blows them with
his mouth with the intention of making them move; he is to fly up to
the clouds with the wings. Eyes exceedingly black, and a little
shining at times, but he appears to see well. No hallucinations of
smell, touch, or taste, and there is no particular time when the hallu¬
cinations are most common.”
Cask XIV.—E. B., aet. 55. Climacteric mania. Delusions of
exaltation, and hallucinations of hearing.
By D . M. 44 Has always a very discontented look upon her face ;
has always a great many strange hallucinations, both in hearing and
sight. She is sometimes awful noisy, and speaks about people that
sit in her head annoying her. She only hears these voices on the
right side. The people inside her head annoy her to the extent that
she strikes herself with great violence on the right side of head
with her own hand until it is black. More noisy in the morning than
at night. In the middle of her work stops often to cry at the people
annoying her, and then strikes herself with renewed violence. Is a
great smoker, and if she does not get tobacco regular, blames the
people in her head for being the cause of it. Every person in this
house dresses themselves with her money ; but though in one of her
greatest rages, any person asking her anything she gives a very civil
answer. More excited when she has not the tobacco ; very thin, and
rio wonder when she excites herself to such an extent that the per¬
spiration is on her face. Particular about her dress, and is cleanly in
habits. One strange delusion is that the left side of her head is
where the society rooms are, and there her friends reside; they seldom
speak to or annoy her/’
Case XV.—M. P., set. 67. Climacteric melancholia. Has hallu¬
cinations of hearing, but they are much less severe.
By D. M. “ A very quiet patient, with a good many hallucina¬
tions of hearing. When admitted would not sit at the window after
dark for anything, as she was frightened some men outside the window
would take her life; thought she heard them fire shots through the
window at her. Does not hear the shots so often now, but hears
voices speaking to her, and answers them in a very quiet way ; the
voices are generally those of some men from the town. Very con¬
tented, and never asks for home but when she hears these voices. Is
a little dull of hearing ; never gets angry at anyone/ 1
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84 Clinical Notes and Cases . [April,
Case of Acute Mania Exhibiting a Quasi-aphasic Speech-
Affection. By R. B. Mitchell, M.D., Boyal Edinburgh
Asylum.
A. Y. set. 50, married, farm-steward, was admitted to the
Royal Edinburgh Asylum on 15th September, 1883.
History .—Seven weeks ago, while out shooting in an open boat, he
was exposed while overheated to a cold wind and rain. On the follow¬
ing day he suffered from a bad attack of diarrhoea, which, however, was
cut short by medicine. Next day he was confined to bed, and suffered
from severe pains all over the body, dreadful headache and high fever.
He was not able to rise for a fortnight, and during most of that time ate
and slept very little, suffering much from intense headache and wander¬
ing pains. No swelling of joints was noticed. After getting up he un¬
fortunately exposed himself too soon, and had a relapse which further
weakened him very much. About four weeks from the time when he
got u chilled ” in the boat, and three weeks before his arrival at the
asylum, he began to wander in his talk, became very restless and slept
very little.
Previous to this illness the patient had been a healthy, strong man.
He was intelligent, fairly educated, and of a cheerful, amiable dis¬
position. His habits are, and always have been, particularly steady
and temperate. He has one sister who has been insane for some
years, but apart from this the family history is very good.
On Admission .—He looked worn and fatigued, as might have been
expected, but the expression of his face was fairly intelligent. There
was nothing to indicate either exaltation or depression of mind, but
there was considerable excitement as evidenced in his continuous
articulation. He 6at in his chair, gesticulating mildly now and then,
and apparently taking no notice of his surroundings. He seemed to
understand every request made of him, however, and obeyed an order
at once, but in reply to a question one could get nothing but a flow of
words conveying no meaning whatever. The following were written
down just as he uttered them on the second day after admission, and
may be taken as a fair sample of his utterances:—
“ Nothing would prove a lass a mouth so many she might give
copper deep sea wink the next all storm but I could find any store for
Elgin old bright might spare I have old good socks in German
nothing blast up town as remarks equal weight,” and so on ad
infinitum . The pitch of his voice never varied, and all the utterances
came forth in the same quiet monotone.
Physical State .—Patient was a tall, strongly-built man (weight
12st. 41b.). Thoracic and abdominal organs all healthy. Tongue
tremulous ; pupils dilated, equal, sensitive ; temperature (E.) 99°*2.
The motor powers, with the above exceptions, were normal, as were
also the reflex motor and sensory functions.
Progress of Case (condensed).—The patient got a liberal supply
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Clinical Notes and Cases.
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1884.]
of food and an abundance of milk, and was sent out daily for exercise
in the grounds. For the first two days there was no change, and he
was sleepless at night. On the 17th Sept, the occiput was shaved and
blistered, and he had an aperient dose of calomel and jalap. On the
morning of the 18th there was a great improvement ; he sat silent
in his chair, and only spoke when addressed. He was now able to say
“ yes,” and “ no,” and “ better,” intelligently, in reply to questions,
but if a longer reply were needed, he simply uttered a string of
words ; e.g, when asked if he felt better he said—“ Yes—but away
never more might then sleep.”
Sept. 22nd. —Only three hours sleep since last note. Mental con¬
dition unchanged.
Sept. 21th. —Got only fourteen hours of sleep since last note. His •
mental state has varied considerably during the week. He has been
sometimes able to say “yes” and “no” intelligently in reply to
questions, but no more than this, except on one or two occasions,
when he replied, “ All right,” and “ Quite well, thanks,” propo-
6itionally. On one occasion, when asked if he had headache, he
nodded, and immediately pointed to his occipital region, but when he
tried to tell something more about it only a string of meaningless
words came. He was able to name common articles, such as a knife
or key, at once ; he read a simple sentence correctly, and wrote another
from dictation.
Sept 28 th. —To-day he wrote the following letter :—
My Dear Mother,
if nothing yet is proof yon have now sold my own manse. You may
yet teach my dear Revd. Dr. Jones his birth as proof I am yet alive in Mrs.
Smith’s in Nairn and the light house is no longer alive in Abdn. John Wales his
inanse to cheat in Nairn to the same bride and bridegroom in all I remain to
Mrs. Johnston and Mr. Johnston of Renfrew to view in all they have to teach to
poor proof in in the Scott to bleed in old Abdn, but I am in the class I now
came all in the street to the lighthouse a marsh to the summer I taught in
simple rage till the whole S. G. T. prove my in the Isles yet
I am my dear nothe (mother ?)
your.weloome mother
A— Y—
Oct. 2nd. —The attendant said that the patient conversed quite
sensibly with him for nearly an hour to-day.
Oct. 1 1th. —Since last note the patient has been able once or twice
to converse rationally for a short period with the attendants. He is
now very much quieter, and sleeps every second night nearly, for four
hours or thereby. To-day he wrote to his sister a note, short, but quite
free from mistakes, requesting her to come to see him.
Oct. 1 6th. — Since last entry he frequently relapsed into his old style
of utterance, but be has been quite coherent and rational in his conver¬
sation all to-day. When asked whether he knew he had been formerly
using wrong words in reply to questions, he said that be remembered
doing so quite well, but that he could not help himself, and that “ they
liad just to come out in the order they came.”
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86
Clinical Notes and Cases .
[April,
Oct 18*A.—Wrote to his wife a long letter quite free from mistakes.
He had no more relapses after this, and made a complete recovery,
being finally discharged on 19th November.
Commentary .—At first the case seemed an ordinary one of
acute mania, but on careful observation it was seen that the
utterances of the patient were of a peculiar kind. His
articulation was perfect. There was no halting, no spas¬
modic or explosive utterances, no half-finished words. His
talk was totally incoherent to be sure, and the string of words
he uttered really conveyed no visible meaning at all, no dis¬
cernible sequence of ideas even, such as one can generally
make out by listening attentively to the babble of most cases
of maniacal excitement.
His power to “ propositionize” was entirely gone for the time,
and in this sense he may be said to have been entirely aphasic,
notwithstanding his perpetual utterances. The faculties of
attention and perception were not appreciably impaired, and
in this lies another point of difference between his case and
one of ordinary acute mania or delirium. He obeyed all
orders quietly and with alacrity, looking one intelligently in
the face all the time. When he began to improve after the
first week or so, he could at first reply to questions only by
“Yes” and “No” for assent and dissent, uttering these
words somewhat hesitatingly, as if not quite sure that they
were the right ones; and if he attempted a longer reply at
this stage only a string of meaningless words came—words
that he did not wish to use. He would sometimes smile
(although ordinarily grave-looking) at his own mistakes. It
was pretty clear at this stage that the eight or ten words
that came were the result of a disappointed effort of his will,
and quite different from an ordinary incoherent answer, such
as one may get any day from an insane person. At the same
stage he was able to convey his meaning by signs (e.g., when
asked if he had headache he immediately nodded, and then
pointed to his occiput). When he tried to tell one about his
headache, however, he could get out only a string of mean¬
ingless words (half-a-dozen or so.)
It will be observed that in the first part of his letter there
is seen a much nearer approach to speech than in his utter¬
ances. Indeed, the first part of the letter does not differ
materially from the letter of any patient who talks inco¬
herently. But in the latter part there seem to be distinct
indications of a variety of aphasia (“ Defect of Speech.”)*
* See “ Brain, 1 ” Vol. i., p. 314.
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Digitized by <^.ooQLe
.} curnal of Mental Scie.nc.t-
Apk:l.1884.
Fig 1
L.P.Mark del
Mintern Bros
TO 13 _.LVSTRA.TE D R M9 D OWALXlS CASE
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1884.]
Clinical Notes and Cases .
87
Thus I think that he meant, e,g, y to write “steamer” where
he wrote “ street,” My reasons for believing this are founded
on certain circumstances connected with the mode employed
to bring him from his home to the Asylum. Again, in clos¬
ing his epistle, he wrote “nothe,” where he evidently meant
to write “mother,” and finally subscribed himself “your
welcome mother” where he meant to put your “affectionate
son .” This is strong additional proof of the existence of a
distinct aphasic feature in the case.
According to some authors aphasia would appear to be
due to some lesion of the efferent fibres passing between the
convolutions and the great co-ordinating centres in the basal
ganglia, while others hold that the phenomena are the result
of morbid change in the convolutions themselves. In A. Y.’s
case it would seem as if the physiologically lower speech cen¬
tres (internal speech is meant), being rendered free from the
control of the higher (inhibitory) centres, the nervous arrange¬
ments used in speech had taken on an automatic and ataxic
action; hence a free flow of utterances both in reply to and
apart from questions, but without there being any power to
choose or guide them in any way.
The pathology of the case is, of course, extremely obscure.
The patient possibly suffered from a meningitis of rheumatic
origin, and, if so, this condition may have determined the
phenomena observed. It may be worth while to note here,
in relation to this idea, that in the “Journal of Mental
Science,” Yol. xiii., p. 528, a case is mentioned—that of a
hospital patient, whose loquacity for a few days before death
was extraordinary, and who was found after death to have
the two anterior lobes of his brain affected with scirrhus
cancer, illustrating the possible effect of a local irritation of
the convolutions on the speech-function.
Case of Endothelial Tumour of the Dura Mater: General Paralysis,
By T. W. MoDowall, M.D. (With Plate.)
J. G. T., aet. 48, admitted 14 Dec., 1880, married, inspector of
naval machinery, well educated.
Medical certificate :—“ Although I have known him for long, he
does not now know who I am. When spoken to he does not under¬
stand what is said. When asked questions, he simply repeats his own
name. He raves indifferently on various subjects. He says his wife
has defrauded him of all his money and is conspiring against him.
u His wife states that he has been violent and dangerous. He
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88 Clinical Notes and Cases. [April,
wanders about all night and has been apprehended by the police. He
has threatened her life, add attacked his father with a poker.”
History .—He has usually enjoyed good health, but 6ome years ago
he received a severe blow on the head by the falling of an iron door,
which fractured his skull and caused the loss of his right eye. He was
originally an engine-fitter and has always had good wages. For the
last twelve months he has been ailing, and during that time he has had
two or three “strokes,” the last having occurred about a week ago, when
he lost the power of speech entirely. He has become weak and tottering
on his legs, has developed delusions of suspicion, and has been oc¬
casionally violent. He has been intemperate, but not of late. Since
his mind became affected he has been depressed at times. He is
cleanly in his habits. Communicated by his wife.
Family History .—Nothing definite can be found out at present.
15th Dec.—Since admission he has been quiet and well-behaved.
He has taken his food and slept well.
Physical Condition .—Body well nourished. The right eye is de¬
stroyed ; signs of an old fracture of right tibia low down. He is weak
and tottering on his legs. The patellar-tendon-reflex is markedly in¬
creased ; no ankle-clonus ; plantar reflex much increased. Lips and
facial muscles tremulous. Pronunciation halting and blurred. Eye
grey; pupil rather small.
Respir . Syst. Normal.
Circul. „ Normal.
Digest. „ Tongue pale and slightly furred : tremulous.
Mental State. —He is most attentive when spoken to, and answers
some questions, but it is a long time before he can form his ideas and
express them. He has no notion where he is, or why he was brought
here. His memory is almost obliterated. Facial expression demented,
but pleased and contented. He does not appear to have any grand
delusions, but he evidently does not appreciate his infirm mental and
bodily condition. No hallucinations or illusions. He admits in¬
temperance but denies syphilis. He can remember a few past events,
e.g.y the accident by which his head was hurt, but he is quite at fault
as to recent occurrences.
Diagnosis. —Dementia with general paralysis.
16 Dec.—He slept well. Has taken food well. Is cleanly, quiet
and sociable.
17 Dec.—Sleeps well ; quiet ; sociable ; cheerful and self-satisfied.
23 Dec.—To-day he is noticed to be pale and very stupid. He
falls about, and when assisted on to his legs, is found to be very
tottering. The left leg and side seem to be semi-paralysed. Pupil
contracted. Ordered to remain indoors.
24 Dec.—Very restless all night. Is quite demented ; takes food
fairly ; feeble on legs. No distinctly localised paralysis. Pulse
80-100.
7 .Tan.—Quiet, demented, feeble. Kept in bed in Infirmary.
Generally restless at nights ; is generally found searching all round
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Clinical Notes and Cases.
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1884.]
his single room or under the mattresses ; says he has lost his way and
cannot find his station, owing to having overslept himself or having
got into the wrong train. Takes food well.
19 Jan.—In much the same state ; sometimes awkward and
troublesome. Requires chloral at night and brom. of potass, by day.
29 Jan.—Less restless by night and day. Still confined to bed ;
feeble on legs. Appetite excellent.
28 Feb.—No change.
16 March.—Gradually becoming more demented, more feeble, and
losing flesh though he eats well. Often restless at night, “ losing his
way ” and “ searching for things.”
13 Ap.—Becoming rapidly worse. He had a slight attack of para¬
lysis about a week ago. He could not speak intelligibly, and could
scarcely swallow : great tremor of facial muscles. The right arm was
almost quite powerless ; mental powers much enfeebled. Now he has
somewhat recovered. He talks fairly distinctly, feeds himself, but
is kept in bed.
21 Ap.—To-day he had a prolonged convulsive attack, the left side
of face being chiefly affected. The left eye turned to the right side.
The left arm was paralysed and helpless ; the right rigid and oc¬
casionally convulsed ; the right leg slightly. He is semi-conscious.
Passes water in bed.
22 Ap.—Still in same state : can take a little milk when carefully
given. Bowels well moved.
23 Ap.—He has now recovered consciousness and convulsions have
ceased.
28 Ap.—In his usual state: very feeble and tottering ; cannot
stand without support. He now requires to be fed.
7 May.—Feeble and demented. Takes food well and is now able
to feed himself.
8 May.—To-day he had two severe epileptiform attacks. The con¬
vulsions were general and followed by stertor, complete insensibility,
then by prolonged semi-consciousness. Has taken a little milk with
difficulty.
14 May.— Since last note, patient has had fits more or less every
day. Has been taking chloral in 3 B doses twice daily, and the
seizures have markedly diminished in frequency and severity. The
left arm is chiefly convulsed now, though sometimes the convulsions
are general or affect the whole left side. He has not spoken for some
days ; has difficulty in swallowing.
19 May.—Fits slight. Patient very dirty in habits ; smears every¬
thing with filth. Very feeble.
24 May.—He has in a measure recovered consciousness, and can
answer when spoken to ; looks about him ; swallows plenty of food
without difficulty. He is decidedly stronger and can walk if assisted.
Occasionally he has a very transient convulsive attack. Very dirty.
Chloral discontinued.
3 June.—Has had no fits since last note: is quiet, cheerful, de-
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90
Clinical Notes and Cases.
[April,
mented ; when asked how he is, he always says “ first rate.” Is in
bed, feeble and helpless. Not quite so dirty in his habits. Takes
food well, and sleeps a good deal: does not lose flesh.
27 July.—Has so much recovered strength as to be able to be out
of bed daily and to feed himself; has lost flesh considerably during
last month ; is cheerful and self-satisfied.
26 Sept.—Gradually he is becoming more feeble and demented, and
has been confined to bed for the last week. During that time he has
had several epileptic seizures, but they can at once be stopped by the
administration of chloral. The fits are general, but most marked on
right (?) side.
18 Oct.—During the last two days the fits have been more frequent,
and chloral seems to have lost its former influence over them. He
had nearly 40 fits yesterday ; to-day they occur about every 10
minutes, and each lasts about 1 minute. The right side of the body
jerks as if a succession of electric discharges were being passed
through it. The facial muscles on the same side are affected in a
similar manner. Each fit is preceded by a piercing cry.
19th Oct.—During the last 12 hours his general condition has
changed much for the worse. He cannot take any nourishment, and
the fits succeed each other rapidly.
21 st Oct.—Yesterday the fits were not so numerous or severe, but
he was in a too exhausted state to recover. Died this morning at
8 . 8 °.
Post-mortem examination, 27 hours after death.
Rigor mortis well marked in legs, slightly in arms. No bed sores,
bruises, or other marks of injury. Hypostatic congestion well marked.
Body well nourished.
Skull-cap of average thickness and density ; firmly adherent to dura
mater in frontal region.
The brain was removed with difficulty, because the tips of the frontal
lobes and, talking roughly, their orbital surfaces were either adherent
to the dura mater or continuous with it. The area mentioned con¬
tains a hard tumour, which projects deeply on each side of the crista
galli. So far as can be made out the bones of the skull are not in¬
volved, though reddened in a peculiar way (they are of normal hard¬
ness), but the dura mater anterior to the 6ella turcica cannot be
separated or distinguished from the tumour.
Under surface of brain .—A tumour extends from optic commissure
to tip of frontal lobes. It seems only to displace the convolutions, and
involves mainly the first frontal on each side. Its posterior extremity
touches, but does not involve the optic commissure and nerves. The
right optic nerve and left tract are markedly atrophied. The internal
half of tip of left tempero-sphenoidal lobe is represented by a bag of
serum as large as a walnut. There is no atheroma of vessels at base.
Superior surface .—Vessels full of dark blood. The convolutions are
flattened. The membranes are clear and transparent except to a slight
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1884.]
Clinical Notes and Cases .
91
extent in the parietal region. The membranes are adherent in many
spots to the subjacent convolutions.
On section antero-posteriorly (see illustration) the tumour is found
to occupy nearly the whole of each frontal lobe. The tumour is so
hard that it creaks under the knife, like an ordinary scirrhus. Near
the under surface it contains a few small bony spiculse. The tumour
is not surrounded by softened brain-tissue, and it can in most places be
separated from the neighbouring textures. A large portion of superior
surface of left frontal lobe is soft to touch, but not changed in external
appearance.
Whole brain, freed from fluid, weighs 49 oz.
Microscopic examination of the tumour (in fresh state) showed it to
be very rich in vessels. It is evidently cancerous in nature, and the
cells are arranged in nests, as is so frequently seen in epithelial growths.
When the nests have opened out the cells are as a rule very long and
narrow, very much like connective tissue of fibres and corpuscles. Juice
scraped from surface of tumour contains cells of a variety of shape ; all
evidently cancerous.
Floor of 4th ventricle rough and thickened. Cord removed. Both
layers of arachnoid opaque, thickened, and, as a rule, adherent,
especially in dorsal region.
No further examination of body permitted.
Remarks .—The drawings which accompany this record
sufficiently show the position and structure of the growth.
No. 1 shows the internal aspect of the left hemisphere and the
surface of the tumour after section antero-posteriorly. It
is a typical example of its kind, and lithograph No. 2 show¬
ing its minute structure does so exceedingly well. As to its
mode of growth, it may be as well to quote from Ziegler's
“ General Pathological Anatomy ” (translated by Macalister).
He says: “ The way in which the alveolar structure is de¬
veloped can often be clearly made out, especially in tumours
of the central nervous system. The normal intervascular
tissue is transformed into masses of sarcoma-cells, while
septa are formed between the cell-masses by the fibrous
tissues lying along the course of the vessels. In other cases
it looks as if a plexus of pre-existing or new-formed vessels
took on as it were an investment of cells, and this grew
thicker and thicker till at length the intervascular spaces
were entirely filled up. Accordingly we find this form of
growth described as a plexiform angio-sarcoma. It has also
been described, and not infrequently, as endothelioma. On
this view the cell-nests arise by proliferation from endothelial
cells. This certainly happens when masses of cells are
formed from the endothelial covering of the subarachnoid
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92
Clinical Notes and Cates.
[April,
meshwork and pia mater; the masses afterwards group them¬
selves into ‘ nests/ M In a note Ziegler states that the
vessels of the brain, lymphatic glands, serous membranes,
and testis possess what is called a perithelium, that is the
adventitia is invested with endothelial cells. Proliferation
begins in the cells of this perithelium, and the vessel is thus
invested with a stratified covering.
OCCASIONAL NOTES OF THE QUARTER.
The Isle of Man Asylum and Dr. Outterson Wood .
It will aid the understanding of the circumstances under
which recent changes have taken place in the Isle of Man
Asylum, if we briefly explain the character of the manage¬
ment and government of that institution.
The government is vested in the Tynwald Court. This
consists of two branches, (a) The House of Keys (or the re¬
presentative branch) The Government of the Island, and (6)
The Council, the latter being composed of eight members
appointed by the Home Government.
The House of Keys and the Council meet as separate
bodies, each in their legislative capacities; and combined,
they act in their executive capacities for the purpose of dis¬
cussing important public questions, passing bills, and the
appointment of Committees, such as the Highway Board,
the Harbour Board, and the Lunatic Asylum Committee.
The latter is appointed annually, a fact not without signifi¬
cance in recent troubles.
The present asylum was built and opened in 1868. From
that time till 1881 Sir William Drinkwater had been a
member of that Committee, and acted as Chairman. The
number of the patients had steadily increased, and more
accommodation was imperatively called for. To meet this
Sir Win, Drinkwater, and Committee, laid before the Tyn¬
wald Court a plan to provide increased accommodation for
the female patients. This was objected to by the House of
Keys. The resignation of Sir William Drinkwater and his
colleagues followed, a Committee of the House of Keys
having been formed to consider the necessity (if any) of
providing increased accommodation in the asylum. In the
meantime another Asylum Committee had been appointed
by the Tynwald Court, under the chairmanship of the
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Occasional Notes of the Quarter .
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1884.]
Speaker .of the House of Keys, Major J. S. Goldie Taubman.
The Committee of the House of Keys was composed of
seven members. Two of them went to Scotland, visited
Momingside, Woo dilee, and the Stirling District Asylum
at Larbert, and on their return they presented a report in
writing to their Committee, based upon what they had
witnessed, in favour of converting a range of new work¬
shops into patients’ rooms, and converting the large dining
and recreation hall of the asylum into day-room space; and
they made other suggestions unnecessary to mention here.
Upon this the Committee of the House of Keys founded
their report, which was published. The report was replied
to by the Asylum Committee, which laid plans before the
Legislature adopting in toto the plan advocated by Sir Wm.
Drinkwater and his Committee for female accommodation,
and, in addition, pointed out what would be necessary for
the men. The annual election of the Asylum Committee
took place, and it was the desire of the House of Keys to
place upon that Committee members of the House of Keys
only. This the Governor and Council resolutely opposed,
and a dead-lock in the Legislature ensued. A compromise
was, however, arrived at; and two of the principal opponents
of the asylum extension scheme were allowed to be placed
upon the Asylum Committee on the understanding that no
change whatever should be made in the management of the
asylum, and that the Committee should continue in office
only until the opinion of the Scotch Board of Lunacy
should be obtained as to the extension of the asylum. * The
Scotch Board was selected as a concession to the strong wish
expressed by the opponents of the extension scheme. The
Governor of the Island (Mr Spencer Walpole,), at the request
of the Tynwald Court, applied to the Home Secretary, and
asked that the Scotch Commissioners should visit the Island
to report on the question in dispute. The consent of the
Home Secretary was obtained, and the Governor asked the
Scotch Commissioners to send over to the Island one of
their body. The Scotch Lunacy Board, however, declined
to interfere, and suggested the names of four gentlemen of
eminence in the asylum world. One of these—Dr. Clouston
—was selected. He visited the Island, and prepared an
elaborate report, with plans, showing the amount of accom¬
modation necessary in his opinion, and the manner in which
* This Committee acted under the Chairmanship of Sir James Cell, Her
Majesty’s Attorney General.
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Occasional Notes of the Quarter . [April,
it should be made. This plan advocated what was clearly a
compromise as to the manner in which it should be provided,
condemned the idea of making the central dining hall a day-
room, and praised the management of the institution. Dr.
Clouston proposed making the population of the asylum
equal to 219 patients. On Dr. Clouston's report being laid
before the Tynwald Court the Asylum Committee, according
to agreement, resigned office ; and as the annual election of
the Committee was to take place within three months, a
provisional one was appointed to carry on the asylum till
1883. When the time for electing the Asylum Committee
arrived, a dead-lock again occurred, the Council refusing to
admit the two principal opponents of the asylum scheme to
sit on the Committee, and ultimately others were appointed.
The election of the Committee took place in the middle of
July. The Committee held its first sitting at the asylum
Aug. 14. Everything appeared harmonious and pleasant—
the Chairman of the Committee (Mr Clucas) leaving the
Island for a holiday. He returned on September 4, and a
meeting of the Committee was held on the following day;
and it appears that, without anything being said to the
Medical Superintendent, a resolution was passed* to the
effect that it was to the interest of the Island and its insane
that the asylum and the patients therein, including such
pauper patients as might be boarded out, should be man¬
aged according to the Scotch system, and that to carry this
out, it was essential that the asylum should have a man who
had acquired his experience in Scotch asylums. Further that
it would probably be a failure to employ anyone to carry out
the boarding-out proposed by Dr. Clouston, who had not so
acquired his experience, and had formed an adverse
opinion to it. Consequently the Committee decided that it
was necessary that “ the present arrangement existing
between Dr. Wood and the Committee should terminate, in
order to secure to them full liberty of action.” This, it
should be added, has reference also to another point not
then determined upon, namely, whether the office of Medical
Officer and Superintendent should be held by one person.
The Chairman was authorised to communicate this decision
to Dr. Wood.
The resolution is professedly based on the information
obtained from the Scotch Lunacy Board and Dr. Clouston’s
* From the debate in the Tynwald Court we gather that two members out of
five were opposed to this resolution.
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1884 .] Occasional Notes of the Quarter .
report. That it was totally unnecessary to dismiss Dr.
"Wood, however, and import a man from Scotland, is proved
by Dr. Clouston's own statement: “ If a boarding-out system
is established, I think it essential that Dr. Wood should
come over to Scotland to see our asylum in operation; one
of the Deputy Commissioners would, no doubt, give him
every facility” (p. 20). This was all that was necessary.
For reasons best known to themselves the Committee of
Management pursued a different course, and declined to
follow Dr. Clouston’s advice.
How this resolution was received by his Excellency the
Governor can readily be seen by the correspondence between
him and the Chairman of the Committee of Management,
Mr. Clucas, and so indignant was Sir Wm. Drink water and
others high in office, that a motion expressing regret at the
course pursued was brought forward in the Tynwald Court,
and a debate, which lasted for two days, in which every
opportunity was given to support and explain the conduct of
the Committee in passing such a resolution utterly failed,
and no charge was made against the Medical Superintendent
which could possibly justify such a resolution. On the
question being put to the vote it was lost in the House of
Keys and carried in the Council, so that no resolution was
arrived at on the subject, seeing that the resolution to be
effective must be carried by both houses sitting together.
In consequence of the resolution of the Committee, the
Medical Superintendent tendered his resignation, which was
accepted.
Such is a plain statement, undisputed, so far as we are
aware, of the course of events which has led to what we
cannot but regard as a lamentable result. A Medical
Superintendent is dismissed from his office, after eight years 5
devotion to his duties, during which time the annual reports
of the Committee speak of him in uniformly favourable
terms,* without the slightest charge being brought against
his moral character or his administrative ability, on the
ground that it is desired to introduce into the asylum and
* Thus in the annual report of the Asylum, made to the Tynwald Court,
July 5, 1883, we read—“ that the members of the Committee considered it
inadvisable to interfere in the management of the Asylum beyond seeing that
it was worked by the Medical Superintendent in the manner approved of by the
preceding Committees, of which his Honour, Deemster Drinkwater presided as
Chairman for many years. They are satisfied that it has been so managed ;
that the patients have been kept clean, healthy, and comfortable, and that the
Asylum itself has been kept fresh and clean.”
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the treatment of the Manx lunatics what is called the
Scotch system. We cannot but think that our intelligent
colleagues north of the Tweed must by turns smile and blush
to read the absurd statements made in the course of this
discussion, about their peculiar powers in the treatment of
the insane. We are not blind to what has been done in
recent years in and out of asylums in Scotland, while the
admirable labours of the Lunacy Board have revolutionized
the frightful abuses in the treatment of the insane in that
country. But a stranger might suppose, to listen to the
way in which some persons have spoken during this debate,
that there was some radical difference between the treat¬
ment of lunacy in England and Scotland, greatly to the dis¬
advantage of the former, and one which would properly lead
to the application for advice on the part of the Isle of Man
Asylum to the Board in Edinburgh in preference to that in
London, and, as a corollary, to the dismissal of an English¬
man and the substitution of a Scotchman. “ There is no dif¬
ference whatever/ 5 well observed Sir Wm. Drinkwater in the
debate referred to,* “ in the general system of the treatment
of lunatics in England and Scotland. . . An English
gentleman of high standing, recommended as Dr. Wood was,+
is as capable as regards the treatment as any superintendent
of an asylum in Scotland. I say nothing against the gentle¬
men in Scotland. They are as able as the gentlemen in
England. Let the Committee of Management point out, if
they can, any difference in the general treatment of the
lunatics in Scotland and in England. They say there is a
difference in the boarding-out. . . . But what is there in
the system of boarding-out which one week’s acquaintance
with it in Scotland could not discover ? . . . Is Dr. Wood
to be dismissed because he cannot be trusted to the boarding-
out of a certain number of lunatics ? 55 On the subject of
open doors in asylums, the same speaker remarked —“ I don 5 t
say whether it is right or wrong that the doors should be
locked. . . . They have hitherto been locked in England,
* “ The Isle of Man Times and General Advertiser,” Nov. 17, 1883. In the
same debate a member of the House of Keys, in favour of the importation of a
man from Scotland and the exportation of Dr. Wood, said—“ Nothing which I
have listened to throughout a discussion, which must be exhaustive if ever a
discussion deserved that character, has materially altered the opinion I have
long held with regard to Dr. Wood, viz , that he is an able, humane, conscientious
and honourable man.*’
t Dr. Wood was recommended to the asylum authorities, as medical superin¬
tendent, by the English Board of Lunacy. (See Asylum Report, 1876.)
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97
Occasional Notes of the Quarter.
and are still in many places in Scotland, but if you don’t
lock the doors you do what is the same thing—you put a
warder near so that the patients cannot get out whenever
they wish, for to suppose they can go wherever they please,
many of them being most anxious to escape, is not the case
anywhere. . . . But supposing the Committee wish it to
be so, there is nothing to prevent the Committee informing
Dr. Wood that in future they wish him to take the locks off
the doors. Was he to be dismissed because he did not carry
out the Scotch system of open doors ? ”
These observations appear to us to be unanswerable, and,
as a matter of fact, they were unanswered.
We pass from them to the still more important protest of
his Excellency the Governor of the Island. It is a protest
of more than ephemeral interest, for it applies to all similar
acts which may be committed by factious Committees and
tyrannical Boards. It merits wide circulation. We have
space for only a few paragraphs from his Excellency’s letter
to the Chairman of the Committee of Management (Sept.
10, 1883), the whole of which does infinite credit to his
common-sense as well as his good feeling.
Mr. Walpole writes : “ I do not understand that in making
this communication to Dr. Wood you were authorised to state
to him any grounds for his removal from office; and I under¬
stood you—when I asked you myself what these grounds
were—to state that the Committee had an impression that
Dr. Wood was opposed to the views of the Committee, and
would not loyally carry them out. I at once admit that if
the apprehensions of the Committee proved correct, and Dr.
Wood were to prove reluctant to carry out its policy, it
would be the duty of the Committee to remove him from his
office. But I do not understand from you that Dr. Wood has
in any way declined to carry out the wishes of the Com¬
mittee in any respect—on the contrary, it is almost impos¬
sible that he can have done so. The Committee, I need hardly
remind you, has only been some six weeks in office. Its
most important member, the Chairman, has almost through¬
out this period been absent from the Island; and it is un¬
reasonable to suppose that Dr. Wood has had even an oppor¬
tunity of refusing to carry out the policy of the Committee,
or of thwarting the Committee in any way. If this be so,
however, the action of the Committee seems to me fatal to
the best interests of the Asylum of the Island, and of the
cause of good government.
xxx. 7
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Occasional Notes of the Quarter.
[April,
€t Nothing has done so much to promote the cause of good
government in the United Kingdom as the knowledge that a
change of Ministry would not involve a change in the per¬
manent officials of the Government. Nothing has done so
much to injure the cause of good government in the United
States as the knowledge that the permanent officials were
liable to arbitrary removal by each incoming President, yet
the Committee of the Asylum is introducing a system which
has produced endless confusion in America . . . and are aban¬
doning, without cause, or without any cause of which I have
been informed, the system which has given stability to our
own institutions. Such a decision, if it be acted on, can
only lead to one result. It must prevent the best men from
accepting service from the Insular Government. No one
whose services are worth securing, or who has a reputation
to lose, would accept office from a Committee which is merely
elected for a year, if the succeeding Committee were at liberty
to terminate an engagement without adequate reason.”
The Governor thus ends his admirable letter:—“I trust
that if the Committee will do me the favour of considering
the arguments which I have used, its members will perceive
the impolicy and injustice of carrying out its resolution, and
that instead of doing so, it will at once take stepa to consider
the manner in which the asylum should, in future, be
managed ; and that it will give Dr. Wood the opportunity of
carrying its decisions into effect.”
In reply the Chairman fully admits that no opposition had
been made by Dr. Wood to the proposed changes. “ Your
Excellency is quite right in assuming ,” he says, “ that Dr.
Wood has not declined to carry out anything suggested by us.”
In spite, however, of the Governor’s appeal to the Com¬
mittee to retrace their steps and withdraw their unjust and
we had almost said childish resolution, the latter persisted
in their action, and had even the hardihood to take credit to
themselves for the manner in which they did it. Truly the
tender mercies of certain people are cruel! The Chairman
writes to the Governor:—“ The Committee think it right to
observe that in any action as yet taken under the resolution
in question, every consideration has been shown for the feel¬
ings and interest (!) of Dr. Wood. By suggesting to him to
resign voluntarily instead of obliging him to leave under
formal notice on the ground of general or specific unsuit¬
ability, the Committee think they were consulting Dr.
Wood’s interest.”
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To Dr. Wood’s fitness for the post he held, Dr. Clouston
renders testimony. When speaking in his “ Eeport ” of the
bad and good points of the construction of the asylum of the
Isle of Man, he asserts that “Dr. Wood has made the best
of it ” (p. 8). Under “ Management of the Asylum ” Dr.
Clouston emphatically says, “ The management of the
asylum impressed me as admirable, especially under the
great difficulties Dr. Wood and the staff have had to contend
against through overcrowding. . . . The wards were bright
in colour, clean, and well ventilated, and the dormitories
neat, airy, and comfortable. The patients were neatly
and comfortably clothed, and were generally quiet, and well
cared for. The dinner I saw served was abundant and well
cooked ” (p. 16). “ The former dietary scale was one more
in accordance with the ordinary diet of some parts of Eng¬
land than of the inhabitants of this island. Dr. Wood has
drawn out most elaborate and valuable tables in regard to
the dietary, showing its present nutritive value, so I agree
with the proposals laid down in those tables ” ( l . c.). Lastly,
under the head of “Private Patients,” Dr. Clouston, ob¬
serves, “ With an energetic doctor, of good medical reputa¬
tion like Dr. Wood, there would be little fear of non-success
in the Isle of Man ” (p. 21).
We judge, therefore, from the printed documents before
ns, that a great wrong has been done not only to Dr. Wood,
but to the just interests of medical superintendents in
general. Such groundless acts and high-handed proceedings
must shake the confidence of men holding this position in
their tenure of office, however conscientiously they may dis¬
charge their duties. A change of Committee, some new fad
or sudden freak, or love of change, may remove a valuable
public servant from a post which he has held for years with
credit. No man who has regard to his good name and
honour will care to hold such a position, and no honourable
man will take it, when it becomes vacant under such circum¬
stances. So long as it is otherwise, so long will asylum-
superintendents be liable to such action as that which seems
good to a Manx Committee.
We offer to Dr. Wood our sincere sympathy for the un¬
justifiable manner in which he has been dismissed from ser¬
vice, but he may rest satisfied that every unprejudiced person
who reads the undisputed facts of the history of this un¬
fortunate affair, will not only acquit him of blame, but will
regard the action of the leaders of the movement, which has
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100 Occasional Notes of the Quarter . [April,
terminated so unhappily, as little less than scandalous, and
deserving the reprobation of all who desire to see justice done
to an honourable class of men entrusted with most respon¬
sible and anxious duties. He may also rest assured that
when party-feeling has subsided, and a dispassionate judg¬
ment is formed of the whole transaction, many of those who
have been carried away by misrepresentation' will recall
their verdict with regret, and unite in the opinion publicly
expressed by His Excellency the Governor in favour of
the late Superintendent of the Isle of Man Asylum.
Note. —We think it due to Dr. (Houston to append a
letter written by him to Dr. Wood after his enforced resigna¬
tion :—
Tipperlinn House,
Morningside Place,
Edinburgh.
Dec. 9,1883.
Dear Dr. Wood,
I have hitherto not expressed to you my opinion in regard to your treat¬
ment by the Asylum Committee because I thought it might do more harm than
good, and I had a lingering hope that justice might prevail. I now beg leave
most sincerely to sympathise with you, and to say that had I known the course
things were to take, or the spirit that was to be manifested, 1 should never have
had anything to do with the Isle of Man Asylum, my visit to which I now
sincerely regret for your sake.
Not that I could alter my report had I to make it again, for all I said there
was to the best of my belief and experience. Contrary to my first fear on
that point I am assured on the most varied and unimpeachable authority that
my visit and report have had nothing to do with your leaving your office, which
I still think, as I expressed in that report, you have faithfnlly and successfully
fulfilled.
There was not a word of truth in the newspaper paragraph that the Asylum
Committee were in treaty with one of my assistants for your office.
My first news of your difficulties I received when I was asked to recommend
a man, as you were said to have resigned, or to be about to resign. My im¬
mediate step on learning this was my letter to the Governor, which has been
published. I then feared you had not been able conscientiously to agree with
or carry out my views, and so had really resigned, or had been placed in some
unpleasant position where resignation was the only way apparent to you out of
the difficulty. I was greatly distressed, and offered to mediate. I never
alluded to your successorship. Since reading the debate in the Tynwald Court
no assistant of mine, or any man over whom I had influence, would have been
recommended by me to go to the Isle of Man Asylum in present circum¬
stances.
No other communications but those published, or to which I have referred,
ever took place between the Committee or any member of it and me with
reference to your resignation, or to the appointment of your successor.
I am, yours very faithfully,
T. S. Clouston.
Dr. Wood.
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Occasional Notes of the Quarter .
101
Reg . v. Strong.
At the Devon Spring Assizes, held at Exeter, January
25th, William Strong was charged with receiving lunatics
into his house without a licence. The following is from “ The
Exeter and Plymouth Gazette,” January 26th, 1884:—
AN UNLICENSED ASYLUM.
William Strong, 70, farmer, of Huxbeare Barton, Hennock, near
Chudleigh (on bail), was indicted for receiving to board and lodge in
his house, on the 13th December, two or more lunatics, not being
licensed for the reception of the same.
Mr. Collins, Q.C., and Mr. Bucknill prosecuted on behalf of the
Lunacy Commissioners, and Mr. Pitt-Lewis defended.
The defendant pleaded guilty.
Mr. Collins said that the defendant could not plead ignorance of the
law, for in 1880 he applied at the Quarter Sessions for a licence to
keep lunatics, but it was not granted, and the application was not pro¬
ceeded with. On the 20th February, 1880, he received into his house
a certified lunatic named Steele. In December last certain reports
reached the authorities, and the Lunacy Commissioners sent Dr.
Phillips to examine the premises. He found no less than seven
lunatics in the house, including a clergyman and two or three females.
The defendant’s house was a large, fairly-furnished farmhouse, and it
was clean and apparently comfortable. There was not the slightest
idea that any of these people were ill-treated ; in fact they appeared to
be well cared for, and they said that they were well fed and sorry to
be taken away. The Lunacy Commissioners, however, considered
this a very serious offence indeed, for after the defendant had applied
for a licence and it had been refused, in defiance of the law he took
six or seven lunatics in. He was instructed to ask that the defendant
should not be imprisoned, but that if the Court should think fit to let
him off with a fine the Commissioners would be satisfied.
Mr. Pitt-Lewis admitted that the licence was refused, although not
upon any personal objection to his client, but upon general grounds
that it was not desirable to multiply such houses. The defendant
only intended his house for persons in a nervous and depressed state
of mind, and the great majority of the patients were recommended to
him by medical men, and were sent for the purpose of obtaining a
change, rest, and quietness. He promised to send away all the
lunatics, and had made an endeavour to get rid of at least one before
the Commissioners interfered. For fifty years previous to 1880 the
defendant lived at Stockleigh Pomeroy, and he produced a memorial,
strongly in his favour, from the inhabitants, including two Vicars in
the neighbourhood and three medical men. Everybody agreed that
the patients were well looked after, and as one of them was certified,
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102 Occasional Notes of the Quarter . [April,
the Lnnacy Commissioners had a right to visit the premises whenever
they chose.
His Lordship (Mr. Justice Cave) said that it was strongly in the
defendant’s favour that the house was well conducted, and that the
inmates were treated with great kindness, care, and attention. The
object of the Act was, of course, to ensure that such persons should
be under proper supervision, as a precaution to their well-being, and
to ensure that, as far as might be, they should be cured. It appeared
that the defendant had done nothing opposed to that view of the
Legislature. If there had been any suspicion of the slightest ill-
treatment, or even of neglect, or if it had been shown that the house
was not sufficient and proper, he should have felt bound to impose
either a heavy pecuniary penalty, or if the case had been grave, a con¬
siderable term of imprisonment. But under the circumstances, and
the defendant having undertaken to get rid of the persons still
remaining in his care, the requirements of justice would be met if he
now set him at liberty to come up upon his own recognizances of £20
when called upon. If there was any improper delay in sending away
the patients of which the Commissioners might fairly complain, or if
there was any repetition of the offence to which he had now pleaded
guilty, he would undoubtedly be called up to receive judgment.
Mr. Collins asked for the costs of the prosecution ; but his Lord-
ship thought that it would be sufficient punishment for the defendant
to pay his own costs.
This trial has occasioned considerable animadversion on
account of the lenient manner in which the defendant, Mr.
Strong, was dealt with. The man’s age, and the way in
which the patients had been treated, rendered imprisonment
out of the question. It is difficult, however, to see why the
man should be allowed to escape without a fine, as he had
deliberately broken the law. Still more inexplicable is it
that he should not have been made to pay the costs. A very
pleasant Judge must Mr. Justice Cave be—for the defaulter.
From some of the newspaper statements the Commissioners
would appear to have been wanting in their duty in pressing
the charge and penalty, but they undoubtedly asked through
their counsel that he should be fined, and we do not think
they would have been wise to do more.
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1884.]
108
PART I L—RE VIEWS.
Insanity: Its Classification , Diagnosis , and Treatment . A
Manual for Students and Practitioners of Medicine. By
E. C. Spitzka, M.D. New York: Bermingham and Co.,
1883.
This is an octavo volume of about four hundred pages, and
the general style of the book gives a favourable impression.
The author implies in the preface that it is the first syste¬
matic treatise on insanity published in America since the
days of Rush, a claim that is remarkable if it can be really
established. However this may be, the work before us is
fairly entitled to a high place amongst the recognised text¬
books, notwithstanding some defects, which are only the
more conspicuous from the general excellence of the matter
in which they are found.
The work is divided into three parts. The first treats of
the General Characters and the Classification of Insanity;
the second, of the Special Forms of Insanity; and the third,
of Insanity in its Practical Relations.
In the opening chapter a definition of insanity is given,
which, though it is representative of the meaning of the
word, is, nevertheless, so long and so cumbersome that it
can scarcely be regarded as available for practical purposes.
Here it is : “ Insanity is either the inability of the individual
to correctly register and reproduce impressions (and concep¬
tions based on these) in sufficient number and intensity to
serve as guides to actions in harmony with the individual’s
age, circumstances, and surroundings, and to limit himself
to the registration as subjective realities of impressions
transmitted by the peripheral organs of sensation; or the
failure to properly co-ordinate such impressions, and to
thereon frame logical conclusions and actions: these in¬
abilities and failures being in every instance considered as
excluding the ordinary influence of sleep, trance, somnambu¬
lism, the common manifestations of the general neuroses,
such as epilepsy, hysteria, and chorea,.of febrile delirium,
coma, acute intoxications, intense mental pre-occupation,
and the ordinary immediate effects of nervous shock and
injury.” It may be remarked, in passing, that the manner
of excluding febrile delirium and the other congeners of
insanity by name instead of by their qualities is peculiar, and
is certainly not in accordance with the requirements of
scientific definition.
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104
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[April,
In regard to delusions, the author very properly lays much
stress on the difference between systematized and unsyste¬
matized delusions, those that have a pseudo-logical organiza¬
tion and those that have no organic cohesion. This distinc¬
tion occupies a more prominent position in the writings of
Continental authors than is accorded to it by most English
writers. It serves, nevertheless, as an almost indispensable
guide both in diagnosis and in prognosis.
The frequency with which pathological conditions of the
brain can be recognised after death in cases of insanity
according to the experience of the author and of other
writers is summarised roughly as follows: In acute melan¬
cholia, almost zero; in true and recent mania and in mono¬
mania, about 5 per cent.; in epileptic insanity, about 20 per
cent. In terminal states about 60, in imbecility and idiocy
80, and in paretic dementia (general paralysis of the insane)
upwards of 99 per cent. These figures are, of course, given
only as approximate, but probably they come very near the
mark. With the exception of general paralysis, however,
there is little characteristic in the morbid anatomy of any of
these forms of insanity.
Perhaps the most interesting chapter in the first portion
of the book is that on classification. The author remarks
that though in France, Germany, and the Continent
generally, the proper classification of insanity is approach¬
ing perfection, it is in England and America still in a
chaotic condition. While there are only slight differences
between the classifications of the best foreign writers, and the
general principle is the same, only confusion can result from
comparing the systems of English and American writers.
The author’s classification is based on that of Krafft-Ebing,
or, perhaps might more correctly be said to bear a general
resemblance to it. We give it here in tabular form.
Insanity.
GROUP FIRST. PURE INSANITIES.
Sub-Group A.
Simple insanity, not essentially the manifestation of a
constitutional neurotic condition.
First Class.
Not associated with demonstrable active organic changes
of the brain.
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105
1884.]
I. Division. Attacking the individual irrespective of the
physiological periods.
a Order. Of primary origin.
Sub-Order A. Characterised by a fundamental emotional
disturbance.
Genus 1. Of a pleasurable and expansive character.
{Simple Mania.)
Genus 2. Of a painful character. [Simple Melancholia.)
Genus 3. Of a pathetic character. {Katatonia.)
Genus 4. Of an explosive transitory kind. (Transitory
Frenzy .)
Sub-Order B. Not characterised by a fundamental
emotional disturbance.
Genus 5. With simple impairment or abolition of mental
energy. ( Stuporous Insanity.)
Genus 6. With confusional delirium. (Primary Con-
fusional Insanity.)
Genus 7. With uncomplicated progressive mental impair¬
ment. (Primary Deterioration.)
£ Order. Of secondary origin.
Genus 8. Secondary Confusional Insanity.
Genus 9. Terminal Dementia.
II. Division. Attacking the individual in essential con¬
nection with the developmental or involutional periods (a
single order.)
Genus 10. With senile involution. (Senile Dementia.)
Genus 11. With the period of puberty. (Insanity of
Pubescence, Hebephrenia.)
Second Class.
Associated with demonstrable active organic changes of
the brain. (Orders coincide with genera.)
Genus 12. Which are diffuse in distribution, primarily
vaso-motor in origin, chronic in course, and destructive in
their results. (Paretic Dementia.)*
Genus 13. Having the specific luetic character. (Syphi¬
litic Dementia.)
Genus 14. Of the kind ordinarily encountered by the
neurologist, such as encephalo-malacia, haemorrhage, neo¬
plasms, meningitis, parasites, &c. (Dementia from Coarse
Drain Disease.)
Genus 15. Which are primarily congestive in character,
* General paralysis of the insane.
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and furibund in development. ( Delirium Grave , Acute De¬
lirium, Manie grave.)
Sub-Group B.
Constitutional insanity, essentially the expression of a
continuous neurotic condition.
Third Class.
Dependent on the great neuroses (orders and genera coin¬
cide).
I. Division. The toxic neuroses.
Genus 16. Due to alcoholic abuse. ( Alcoholic Insanity.)
(Analogous forms, such as those due to abuse of opium,
the bromides, and chloral, need not be enumerated here,
owing to their rarity.)
II. Division. The natural neuroses.
Genus 17. The hysterical neurosis. ( Hysterical Insanity .)
Genus 18. The epileptic neurosis. (Epileptic Insanity.)
Fourth Class.
Independent of the great neuroses (representing a single
order.)
Genus 19. In periodical exacerbations. (Periodical In¬
sanity .)
S Genus 20. Idiocy and Im¬
becility.
Genus 21. Cretinism .
Genus 22. Manifesting itself in primary dissociation of
the mental elements, or in a failure of the logical inhibitory
power, or of both. (Monomania.)
SECOND GROUP. COMPLICATING INSANITIES.
These may be divided into the following main orders,
which, as a general thing, are at the same time genera:
— Traumatic , Choreic , Post-febrile , Rheumatic , Gouty , Phthisi¬
cal , Sympathetic , Pellagrous.
This classification, like every other, is open to many objec¬
tions, several of which are examined in detail by the author.
It is impossible, in the course of a short review, to go into
the defects and into the justification of the scheme; but on
the whole it may be said to be quite as good as any of its
rivals, and better than most of them.
The second portion of the work is devoted to the descrip¬
tion in full of the special forms of insanity. The clinical
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pictures leave little to be desired. As a rule they are full,
clear, and accurate. A few points may be briefly noticed.
Katatonia, a recently differentiated form of insanity, is
noticed. It was first described, about eight years ago, by
Kahlbaum, of Gorlitz, and since then it has been studied by
Kieman and others. The chief features are an initial stage
of depression, followed by an almost cyclical alternation of
atony, accompanied by a cataleptoid state, excitement
marked by a parade of pathos or by a theatrical manner,
and then again confusion and depression. Kahlbaum takes
a favourable view of the prognosis. Spitzka’s experience
points to dementia as the termination, for, although after
one or two cycles the patient can generally be discharged
from the asylum recovered, relapses occur in the majority of
cases.
Monomania is adopted as an equivalent of the French
monomanie , and of the German primare Verriicktheit , to
represent all the systematized ‘ insanities. The group in¬
cludes cases of “ imperative conceptions ” and cases where
the delusions have an organized coherence and a pseudo-
logical basis.
The third division of the work deals with the practical
relations of insanity. In the chapters on “ How to Examine
the Insane ” and “ The Differential Diagnosis of the Forms
of Insanity ” there are a good many hints that will prove
useful to a young practitioner.
There are some omissions which should not occur in a
text-book purporting to give a complete account of the
subject. The most obvious one is that the second group
of insanities, or the complicating forms, are hardly even
mentioned, much less described, though their position in
the tabular classification would lead one to expect that
they would at least receive some little attention. Mastur-
batic insanity, too, a tolerably well-marked clinical variety,
is not recognised; and we are told that a form of mental
deterioration occurring in masturbators, a kind of “ primary
dementia,” is the only one to which the term “ insanity of
masturbation” can be properly applied.
In regard to the author’s style, the remark may be made
that, though generally lucid, it is not always elegant. Never¬
theless, the writing is, on the whole, pleasant reading. At
the same time, not much effort would have been necessary to
find words better fitted than “artefacta,” “ abulia,” “hyper-
bulia,” “verbigeration,” and many others to put the student
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in possession of his teacher’s meaning. The author speaks,
too, of the “ fundament ” of insane thought. This is, of
course, not absolutely incorrect; but the word might, we
think, be allowed to remain in undisturbed possession of the
more useful, though less scientific, meaning ordinarily be¬
longing to it.
If there is throughout the work a somewhat dogmatic
tone, this may be admitted to have a certain merit in a text¬
book. So far, however, as there is anything like bitterness
of spirit in the criticisms that the author makes upon other
American alienists, it is matter for regret, and can be
regarded only as a blot in a meritorious book.
Whatever may be its defects, the work is a good one, and
we heartily wish it success.
W. R. H,
Diseases of the Brain and Spinal Cord. By David Drum¬
mond, M.A., M.D.
Having read this book from board to board, we can
honestly recommend it to the portion of the profession for
whom it has been prepared.
In his preface Dr. Drummond makes it to be clearly
understood that his work does not aim at being an ex¬
haustive treatise, but only a text-book for the instruction
of students and busy practitioners. He is, therefore, to be
congratulated that he has produced what he intended. There
are abundant internal evidences that he is, by reading and
observation, familiar with his subject, and that he must have
been frequently tempted, whilst engaged on his book, to en¬
large on specially interesting or difficult topics. But he has
resisted these temptations, and, without sacrificing clearness,
has put into a short though readable form as much informa¬
tion as could be expected.
At this time of day it is not necessary to review such a
book at great length. The topics with which it deals are to
be found in all the well-known books on nervous diseases,
and if asylum-physicians are not familiar with them, they
should be ; and we can strongly recommend Dr. Drum¬
mond’s book for anyone anxious to learn what is known
about them.
An admirable feature is the copious index. It has been
said that a good book cannot be too concise in its substance,
nor too full in the table of contents. In both these respects
Dr. Drummond’s book is to be commended. It need only be
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added that a chapter, written by a specialist, on General
Paralysis of the Insane, has been inserted. This is as it
should be, as general practitioners have few opportunities,
either at college or in text-books, of learning anything of
this most important disease.
A Manual of Psychological Medicine and Allied Nervous
Diseases . By Edward C. Mann, M.D. Philadelphia:
Blakiston. 1883. London : J. and A. Churchill.
This ponderous book does not call for a lengthened notice.
Though there is a good deal of valuable work in it (mainly
extracts from other writers), the author has failed to give it
scientific form. Undigested lumps, so to speak, of the most
diverse qualities are mixed up with a menstruum so thin as
to be devoid of solvent action. In an appendix there is a
carefully prepared abstract of the laws relating to the care
of the insane in the various states of the Union by the
author’s brother. We had almost forgotten to thank Dr.
Mann for one original statement. At least we confess that
it is quite new to us. “ Pyschological Medicine ” is, he
informs us, a u Nervous Disease.” W. E. H.
Insanity Considered in its Medico-Legal Relations . By T. E.
Buckham, A.M., M.D. Philadelphia: Lippincott. 1883.
Such is the anomalous state of the law in regard to in¬
sanity both in this country and in America, and so generally
are these imperfections recognized that any author dealing
with the subject can hardly fail to make a number of irrefu¬
table criticisms and of useful suggestions. It may further
be said that law is so rebellious to amendment, and custom
is so sturdily opposed to reform, that any fair attempt to
bring them into conformity with science deserves a hearty
welcome. The work before us, whatever may be its de¬
merits, is at least such an attempt. The chief objects the
author had in view “ were to point out the pernicious uncer¬
tainty of verdicts in insanity trials, with the hope that by
arousing attention to the magnitude of the evil, at least
some of the more objectionable features of our medical
jurisprudence may be removed; to faithfully call attention
to the more prominent causes of that uncertainty;” “and
with the most friendly feelings for both my own and the
legal profession, to criticize severely, and to censure when
necessary, not the individuals, but the system which has
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made insanity trials a reproach to courts, lawyers, and the
medical profession.”
The work consists of five chapters and an appendix. The
first chapter is introductory, and is intended to clear the
ground more or less. The next three chapters expound
different theories of insanity. The fifth and last chapter,
and perhaps also the most important, is upon experts. The
appendix gives a large number of extracts from judges*
speeches.
At the outset Dr. Buckham has little difficulty in showing
that “ underlying the whole subject of the jurisprudence of
insanity, as a potent cause of the uncertainty of verdicts, is
the fact that the real premises are imperfectly understood.
At every trial the question, ‘ What is insanity ? * is reiterated,
and no definition has yet been furnished that commands
general credence and acceptance. The opinions of the
courts as expressed in their rulings and charges to juries
are contradictory one of another, and physicians called to
testify as experts exhibit in their evidence anything but
uniformity of opinion.”
The author’s efforts towards a better state of things in
this direction do not appear to have much value except for
the antiquary of generations to come. The gist of Dr. Buck-
ham’s exposition is this : There are three prominent theories
of insanity, namely, the psychical or metaphysical theory;
the somatic or materialistic theory; and the intermediate
theory of Messrs. Wharton and Stille. But these theories
are all either imperfect or absolutely wrong; and the only
theory in accordance with all the facts is the author’s own,
the “ physical media ” theory. This theory might be described
shortly as the somatic or materialistic view with a saving
clause for the u freedom of the will.” Like the metaphysical
theory, however, it u regards the mind as a distinct, in¬
tangible, incorporeal entity, not dependent upon the body for
its existence; but, unlike the £ Metaphysical Theory,’ it recog¬
nises the most intimate relations between mind and body,
and holds that in this life the mind is wholly dependent for the
manifestations of its operations on certain organs of the
body which we designate c physical media” It treats in¬
sanity as a physical disease; “ hence in that most important
respect, in their ‘ medico-legal relations,’ there is no prac¬
tical difference between ” it and the somatic theory. The
mind, according to the author’s showing, is on much more
intimate terms with the body in his theory than in the inter¬
mediate theory; nevertheless the “freedom of the will,”
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1884.]
dragged in by machinery, is introduced to avert the “ abso¬
lute irresponsibility” that would flow from the somatic view.
Whereas had the author rightly understood the doctrine
he attempts to controvert he would have perceived that
his machinery was unnecessary.
A definition of insanity is given :—“ A diseased or dis¬
ordered CONDITION OB MALFORMATION OF THE PHYSICAL
ORGANS THROUGH WHICH THE MIND RECEIVES IMPRESSIONS,
OR MANIFESTS ITS OPERATIONS, BY WHICH THE WILL AND
JUDGMENT ARE IMPAIRED AND THE CONDUCT RENDERED IRRA¬
TIONAL. And as a corollary we offer : Insanity being the re¬
sult of physical disease , it is a matter of fact to be deter¬
mined by medical experts not a matter of law to be decided
by legal tests and maxims”
In the chapter on experts, it is suggested that super¬
intendents of asylums and assistant superintendents should,
as a condition of appointment, pass an examination in law,
medicine, and psychology before a specially constituted
Board. That only such men after a certain number of years’
experience should act as experts in insanity trials, and that
it should be part of their duty to do so without payment
and only on behalf of the Court; that the fact of insanity
should be held to be proved by the testimony of the expert
without being subject to legal tests.
The appendix contains an array of judges’ opinions ;
from which it will be seen that there is hardly a theory of
insanity that has not been upheld by some luminary of
justice.
The size of the book is somewhat disproportionate to the
amount of matter contained therein. If the type and the
spaces between the lines were reduced to ordinary dimensions
the volume would be smaller by one half. Italics and capi¬
tals are used with a frequency, not only far from elegant,
but to an extent which almost deprives them of emphasis.
W. R. H.
Clinical Lectures on Mental Diseases. By T. S. Clouston,
M.D., F.R.C.P.Ed. J. and A. Churchill, London.
We shall defer till our next number a full review of this
most important book, and at the present time desire only to
call the attention of our readers to the fact that an un¬
doubtedly good book has appeared bearing the characters of
a clinical guide. It is easier in many respects to write a
series of clinical lectures than to prepare a manual, and in
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many ways the writer of the former has the pleasanter task,
as he is bound by no hard and fast lines, and can divide
his subject as he pleases.
Dr. Clouston has been a lecturer on disorders of the mind
for years, and has won a high position from his eminently
practical and useful teaching; and both old students at Edin¬
burgh and others will be glad to have so pleasantly placed
before them the ripe experience of a practised teacher.
The book is handy in shape, clear in type, pleasant in
style, and characteristic of the author. It consists of
nineteen lectures, which range from the clinical study of
“mental diseases ” to the legal and social relationship of
both patient and doctor.
We shall later discuss the subjects handled and the general
divisions followed. And we shall not be altogether satisfied
with the introduction of new terms, which cannot be con¬
sidered as final expressions of the knowledge of insanity,
and add, we think, still more to the burdens of psychological
terminology. Tn the meantime, we trust our readers will
study the book arid compare their judgment with ours.
The Extra Pharmacopoeia of Unofficial Drugs and Chemical
and Pharmaceutical Preparations . By William Mar-
tindale, F.C.S. With References to their Use Abstracted
from the Medical Journals and a Therapeutic Index of
Diseases and Symptoms . By W. Wynn Westcott, M.B.
2nd Ed. London: H. K. Lewis, 1884.
One of the chief features of the progress of medicine in
recent years has been the advance in therapeutics. Not
merely is there a constant in-pour of new drugs, but owing
to experimental investigation, their actions are more pre¬
cisely known than were the actions of the most frequently
used medicines twenty years ago. To those who wish for a
very concise account of what lias been done of late in this
department the little book before us is a treasure.
The arrangement is alphabetical. All the new drugs and
nearly all the old ones are to be found with terse statements
of pharmaceutical and medicinal properties and non-officinal
formulae. The very brief abstracts from medical journals,
which represent an enormous amount of work, are well done,
and are valuable besides for reference.
The first edition was exhausted in a few weeks. We
advise all our readers to possess themselves of a copy.
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1884.] Reviews. 113
Ueber die Gesetze dee Periodischen Irreseins und Verwandter
Nervmzustande. Von Sanitatsbath Db. Kosteb,
Director der Provincial Irrenanstalt, St. Johannes
Hospital, zu Marsberg. Bonn, 1882.
Periodicity is an undoubted fact, both in healthy and in
morbid processes, in epidemics as well as in chronic diseases;
and many experienced physicians have noticed the simul¬
taneous or periodical appearance of rare diseases or states
of health. The regular recurrence of fits of excitement and
calm has been used to mark and give a name to a periodical
form of insanity. Dr. Koster, who has for years made a
study of periodicity in insanity, and accumulated a number
of careful observations, has observed the recurrence of
regular periods even in chronic insanity. He has dili¬
gently noted the length of the remissions or lucid intervals in
mania, melancholia, epileptic insanity, and other recurrent
forms, and finds that the number of days is generally divi¬
sible by seven. This is because the return of the perigee
when the moon is nearest the earth, generally takes place in
28 days, and if one multiplies seven by four no candid reader
will deny that the product is 28. It is true that in dividing
his periods of calm and excitement by seven there is often a
remainder of one or two days, but this is because the moon
sometimes takes a day or two longer between its perigee and
apogee, and if that satellite will not observe a due regard to
regularity, can one expect more of the behaviour of the
lunatics under its influence ? Dr. Koster thinks that the
moon acts indirectly upon the insane by modifying the
magnetism of the earth, and quotes a number of astrono¬
mers, whose opinions are somewhat carefully worded, but
who evidently regard it as possible that the moon and also the
sun may have an influence upon the paroxysms and relapses
of human feeling and passion. No doubt the cyclical,
physiological, and pathological variations in the human con¬
stitution are dependent upon causes which act at regular
periods. These are possibly owing to changes in the great
masses of matter which revolve through space in cycles of
such astonishing regularity, and it may be that in time we
shall be able to make out connections of cause and effect less
fanciful than those of the astrologers, who so laboriously
constructed a system of influences which remain recorded
in old parchment-bound volumes.
In the meantime we think the principal value of the
xxx. 8
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114
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studies of the learned Sanitatsrath consists in his careful
observations on the prevalence of periodicity in all forms of
mental derangement. However, it is likely enough that a
new means of inquiry and analysis may give us the clue
which the astrologers failed to find.
The Relations of Mind and Brain . By Henry Calderwood,
LL.D., Professor of Moral Philosophy, University of
Edinburgh. 2nd edition, 1884. London: Macmillan
and Co.
We reviewed the first edition of this work in the Journal
for April, 1880, at some length, and while unable to follow
the author in all his contentions, we accorded him praise
for many valuable qualities. This edition has been care¬
fully revised, and a new chapter has been added on
“ Animal Intelligence.” Altogether this volume is aug¬
mented to the extent of seventy pages. The author’s
conclusion, expressed in the new chapter, is that “ Animal
Intelligence is only a higher form of sensori-motor
activity, in which the action of the special senses operates
in conjunction with co-ordinated cerebral centres communi¬
cating with the muscular system. . . . All that is con¬
cerned with a higher intelligence, whose natural function it
is to seek the interpretation of sensory impressions, and to
govern activity on principles of conduct superior to the im¬
pulses of the sensory apparatus, lies quite beyond the region
of investigation now explored. To some physiologists it
appears as if it were a comparatively narrow and insignifi¬
cant region of inquiry which lies beyond the line to which
we have now advanced. But human history is against this
representation. . . . All that is grandest in human life
remains unaccounted for by physiological science. The
animal life of man is explained; but resting on this ex¬
planation, human life itself stands unexplained—a physio¬
logical mystery ” (p. 288).
We refer our readers to Dr. Calderwood’s work to decide
for themselves how far the author supports his position with
success in the ably marshalled arguments with which this
edition is fortified. The general position taken by the
writer is, of course, the same as before, and to that the
observations we formerly made still apply. We need not
repeat them. We would now only say that nothing but
good can result from the fair and lucid way in which the
views advocated in this volume are set forth, whether they
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1884.]
produce conviction or not. It is no better for the physio¬
logical than for the theological mind to have dogmas pre¬
sented to it in only one aspect.
TraitS des NSvroses. Par A. Axenfeld, Professeur de Patho-
logie, Interne 4 la Faculty de Medecine de Paris. 2me
Edit. Par Henri Huchard, Laur^at de l’Acad6mie et
de la Faculty de MMecine de Paris. Paris: Germer
Baillidre et Cie. 1883.
This edition, increased in size by 700 pages, extends now
to nearly 2,000. We cannot do more than commend the
care which has been taken with this work. The amount of
labour expended in the bibliography alone is enormous.
The chapters on epilepsy, chorea and hysteria, especially
the last named, are very complete, and will be found very
instructive. There is a considerable amount of matter
in reference to hypnotism and catalepsy, but we are sur¬
prised to find nothing in this connection about spontaneous
somnambulism.
M. Huchard has edited the work of his late master, who
died in 1876, with conscientious and constant regard to
the advance made in the knowledge of nervous affections
since the former edition appeared.
Record of Family Faculties, Consisting of Tabular Forms and
Directions for entering Data, with an Explanatory
Preface. By Francis GAlton, F.E.S. London: Mac¬
millan and Co. 1884.
The zealous perseverance which marks Mr. Gal ton’s
labours is again exemplified in this publication. We bring
it under the notice of our readers, who ought to be specially
interested in a book “ designed for those who care to fore¬
cast the mental and bodily faculties of their children, and
to further the science of heredity,” and hope that they will
aid its circulation by every means within their power.
Mr. Galton offers £500 in prizes to British subjects in the
United Kingdom who shall furnish him before May 15,
1884, with the best records from their own Family Ke-
cords.
We cannot do more than re-echo his wish that his efforts
to draw the attention of the public to the utility of family
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[April,
records, and to collect materials for a really scientific study,
will be taken in good part, and in the spirit in which Mr.
Galton has made them.
Lemons sur lee Maladies Mentales . Par B. Ball, Professeur
k la Faculte de Medecine de Paris. Paris: Asselin et
Cie. 1883.
To the earlier portion of this volume, which appeared as
a separate fasciculus, we have had occasion to refer in a
former number. The complete work is quite worthy of the
ability of the author, and the style is at once forcible and
graceful. There are many passages which we should gladly
transfer to our pages, but the space at our command will not
allow us to do more than praise the book much and cite
from it little.
Dr. Ball gives, like everyone else, his own classification of
mental diseases, and this we append. Following Morel, he
bases it upon aetiolo gy.
Mental Disorders .
1. Vesaniae.* No lesion discovered. “Essential.”
(Types —Circular Insanity; Partial Insanity.)
2. Neuro-pathic.
3. Diathetic
4. Sympathetic,
5. Toxic
C Hysterical Insanity
< Epileptic Insanity
(.Choreic Insanity
Gouty Insanity
Rheumatic Insanity
Tubercular Insanity
Cancerous Insanity
.Anaemic Insanity
Genital Insanity
Cardiac Insanity
Gastro-intestinal Insanity
.Pulmonary Insanity
(Alcoholic Insanity
I Saturnine Insanity
I Morphinic Insanity
L Etc.
* Insanities properly so called.
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6. Organic or cerebro¬
spinal .
General Paralysis
Aphasia
< Acute delirious mania
Hemiplegic dementia
L Etc.
7.
Congenital or morpho¬
logical.
C Idiocy
s Imbecility
C Cretinism
It would be easy to criticise, and we have little doubt that
were we to do so, the Professor would be the first to assent
to our criticisms.
The author gives unqualified adhesion to the Moral In¬
sanity of Prichard as “ un veritable delire”
It is to be regretted that there is no alphabetical index to
the book—an essential condition of a book of nearly 900
pages. We have given up in despair the attempt to find
some passages which had struck us on first reading the
book, and which we wished to recall.
A Practical Introduction to Medical Electricity . By A. de
Watteville, M.A., M.D., B.Sc.Lond. 2nd edition.
London: H. K. Lewis. 1884.
We are glad to see that this excellent introduction to
Medical Electricity has reached a second edition. The work
is thoroughly practical, and well deserves the success it has
achieved. It has been much enlarged, and very useful plates
have been added, illustrating the localities of the chief
nerve trunks and motor points of muscles accessible to
electrical excitement. In the chapter on Electrotherapeutics,
Dr. de Watteville has eliminated the translation of the por¬
tion written by Dr. Onimus and substituted his.
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118
[April,
PART III.—PSYCHOLOGICAL RETROSPECT.
1. English Retrospect.
Asylum Reports for 1882.
To write a good asylum report appears to be a really difficult task
for the average superintendent. It should not be so. He is favoured
by his brother superintendents in this and other countries with their
efforts in the same line, and if he has not the literary qualifications to
write a neat, concise and grammatical report, he might obtain useful
bints from them. The old-fashioned report was in many cases a
most able essay, but perhaps wasted or nearly so, as reports once read
are apt to be forgotten, and the facts and observations, often of great
value, are unavailable for the instruction of a rising generation.
If essay8 on asylum management, or records of interesting cases, are of
transient value when they appear in an annual report, they can be pub¬
lished in our own or some other medical journal, where they will be
available for reference when the present generation of asylum super¬
intendents has disappeared. Whilst we are against the too elaborate
essay of former days, we are more hostile to some of the crude pro¬
ductions of the present time. When the Visitors have read a few
bald sentences containing nothing beyond what any intelligent person
can understand by a cursory perusal of the statistical tables, these
gentlemen are apt to conclude that their medical officer can write no
better than a schoolboy, or that he considers it not worth his while
to exert himself—either conclusion being most damaging to his
position and reputation. What is worth doing is worth doing well;
and any trouble taken in the production of a readable and instructive
report, is well spent and is amply repaid by the approval of those to
whom it is addressed. A neatly turned sentence has sometimes
secured a good friend.
In preparing this notice, we have been in the habit of commenting
on only those passages which struck us as specially deserving atten¬
tion. Much to our surprise, we learn that some of our members feel
that to be exempted from criticism or notice is nothing short of de¬
liberate neglect. Now, we are above everything careful not to hurt
anyone’s feelings, and so in an attempt to please everybody we have
set ourselves the task of saying something about every report which
has been forwarded to us. Now this we have found really hard work,
in some cases extremely so, but a determination to be conciliatory has
overcome all difficulties ; and even where we have felt compelled to
mark a fault, how delicately has it been done, how gentle has been
the criticism!
Aberdeen .—It is reported that “ The Institution is at present
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1884.] Psychological Retrospect.
119
suffering from two serious disadvantages. The main building is
greatly overcrowded, and the extent of land attached to the asylum
is much too limited. These evils have now existed for a considerable
time. Attempts have been made to relieve the overcrowding by
successive additions to the building ; but these have scarcely been
sufficient to keep pace with the increasing demand for accommodation
for pauper lunatics, and the present condition of the establishment
has only been prevented from becoming much worse by the number of
private patients having been reduced during the past three years from
171 to 147. No addition has recently been made to the amount of
land attached to the asylum, and it is evident the insufficiency of its
amount must have been aggravated with every addition to the number
of inmates and the size of the buildings.”
Argyll and Bute .—A determined effort was made in 1882 to keep
down the accumulation of patients in the asylum by the discharge of 42
unrecovered cases. These were all sent to reside in private dwellings
and very few were sent back as unsuitable. In spite of this the
buildings are much overcrowded, and the additions are not ready for
occupation.
One source of trouble has disappeared at Lochgilphead. It is re¬
ported by one of the Commissioners that i( An important and very
desirable change is about to be made in the relations of the farm to
the asylum. It seems impossible that the existing arrangements
could have long continued, but they have been brought to an end by
the resignation of the Farm Manager. No further observations on
this subject are deemed necessary, as the views of the General Board
are well known as to the difficulty of obtaining a successful manage¬
ment with a divided responsibility.” An asylum superintendent need
not be a farm manager, but no person should reside on an asylum
property who is not under his authority.
At Dr. Sibbald’s visit the clothing of four men and four women,
and also the bed coverings of three bed3 on the male side and three
beds on the female side were weighed.
The following were the weights ascertained :—
Men's clothing
Women’s „
Male Bed coverings ...
Female „
741b., 841b., 941b., 1041b.
e!„ 6?„ 8|„ 10 „
15 „ 16 „ 17 „
16 „ 16 „ 16^ „
In Table III there are several mistakes in the percentages of
deaths on the average numbers resident for 1882. They are so
obvious that one is at a loss to account for them.
Bamwood House Hospital .—The management continues to be
marked by great energy and enterprise.
The asylum farm has been taken over by the Committee and the
results are already good. The additional accommodation provided for
female patients is full, and applications for admission have frequently
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[April,
to be refused. A villa with four acres of grouud adjoining the
asylum has been purchased, and can be readily made suitable for the
reception of patients of the better class.
It is exceedingly satisfactory to learn that the Committee have
continued to keep constantly in view the charitable and benevolent
objects of the Institution. Fifty-five patients have been maintained
at reduced rates throughout the year, most of them for payments
largely below the actual cost of their maintenance. Many of them
have also been supplied with clothes, wine, and other extras at the
charge of the Institution.
The rules were revised and the Visitors took advantage of the
opportunity to insert one for the pensioning of old and faithful de¬
pendents. They thought it would be wise to follow the principle
laid down in the statutory regulations of county asylums.
Dr. Needham in his report deals somewhat in detail with the sani¬
tary arrangements of the building. He also refers to a case in which
a gentleman, seized by a sudden impulse, threw himself from a
window and sustained injuries from which he recovered, but which
might have been fatal.
Bedjord , Hertford and Huntingdon .—An attendant sustained
almost fatal injuries in an attack by a patient. As he is likely to be a
confirmed invalid and quite unfit for further duty, the Committee
granted him an annuity of £26.
Unless a very good reason can be given to the contrary, we are of
opinion that the entry by the Commissioners should form a part of
every annual report.
Berkshire , $c .—The attendants and nurses are now allowed uniform
in addition to their wages.
Dr. Gilland reports that there is a growing tendency to pass pauper
patients through workhouses on their way to the asylum. Thirty-six
were so treated during the year. He adds, however, that it is so far
satisfactory that fully one third of the number were detained in the
union for a few days only, and were removed to the asylum within a
week.
Out of the total admissions for the year, 138, no fewer than 27
refused food so persistently that they required artificial feeding.
This must be considered an unusually high proportion.
Bethlem Hospital .— For the first time this report appears without
the documents referring to the King Edward’s School, a charity ad¬
ministered by the same Governors.
There is continued evidence that every effort is made to render the
hospital as beneficial as possible to the poorer middle classes.
Apropos of feeding, Dr. Savage remarks :—“ Some superintendents
say they never use the stomach pump or the nose tube ; 1 can believe
them, but I question whether they may not be sacrificing something
to this hobby of non-feeding. 1 feel with forcible feeding as I do
about restraint that I should never use it as a mere saver of trouble ;
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but if patients are likely to suffer by being held down, or if they
would suffer from not taking enough food, or if they would be more
harassed by spoon-feeding than by the use of the stomach-pump or
nasal tube, I should in the one case restrain, and in the other feed.
Forcible feeding has not, in my experience, the dangers or evils
which have been credited to it. I have never seen a case in which
food was sent into the air-passages instead of into the stomach. I
have not found patients lose any self-respect after feeding; and
though there is some danger of getting persons into the habit of
being fed, I have myself never found this a danger which could not be
avoided. I make it a rule, that if patients are not taking as much
food as I think they should, and if they are losing flesh, to have them
fed artificially for a time; by this means one can judge if the wasting
is due to physical disease or simple 8tarvation. ,,
Dr. Savage is averse to the removal of Bethlem to a rural situa¬
tion.
When the Commissioners visited in September, there were ten
patients paying £2 2s. each per week.
Birmingham , Winson Green .—Many important structural improve¬
ments have been effected during the year, but they need not be de -
tailed though some of them were urgently required. Asylum
chaplains will be greatly alarmed to hear that “voluntary services
have been given on Sunday afternoons by ministers of different de¬
nominations, and have been much appreciated by the patients.”
Conservative clergymen will think this inserting the thin edge of the
wedge and they can have no difficulty in foreseeing the disestablish¬
ment and disendowment of their Church. Ah, Birmingham is
certainly a terrible place.
Till we read it we did not believe that any asylum church was so
far behind as to have in it a barrel organ. What can the services
have been like, accompanied by such an instrument of torture. An
American organ is bad, a harmonium is worse, but a barrel organ I
Ruhery Hill .—This new asylum seems to be getting into thorough
working order. From Dr. Lyle’s report it is evident that he is
adopting all the most approved methods of administration. The pro¬
portion of epileptics is large.
We would point out that in Table III tho average number of
women resident is given as 117, instead of 177 as in Table I.
No report by the Commissioners on the condition of the Birming¬
ham asylums is given.
A clinical clerk is in residence at Winson Green, and it is proposed,
at least the Visitors are quite agreeable, that the students attending
the Birmingham medical school, should be instructed clinically in
mental diseases in the wards of the borough asylums.
Beer is no longer an article of diet.
Bnstol .—If additional land could be acquired, this asylum would
be immediately enlarged, as it is now overcrowded.
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122 Psychological Retrospect. [April,
Dr. Thompson holds oat against the recommendation of the Com¬
missioners that the epileptics should be under supervision at night.
In thus refusing to do what is generally approved, we think he is, for
his own comfort, wrong. “We can only repeat the remarks made by
our colleagues in the previous entry, that should any patient die un¬
attended from suffocation during an epileptic fit the Medical Super¬
intendent will be directly responsible for a death which might have
been prevented.” When the Commissioners express such an opinion,
we advise Dr. Thompson to give way. There is no use in presenting
your adversary with a cudgel wherewith to break your own head.
Broadmoor , (1881).—The total admissions for the year were 64.
and of these no fewer than 15 men and 6 women had taken life.
Commenting on this fact, Dr. Orange says:—
“ The first question that naturally arises in the mind is whether,
out of so large a number, it would not have been possible to take
measures beforehand, in some of the cases at least, to avert some
portion of this serious loss of life. The majority of these 21 persons,
who had committed homicide, had given indications of being mentally
deranged, and of being, in consequence, dangerous persons to remain
at large ; and yet, either because of mistaken kindness, or through
disinclination to run the risk of incurring the inconveniences which
sometimes attend the adoption of the statutory means for placing
persons in asylums, matters were allowed to run their course, and
innocent lives were thus sacrificed. Another point of interest lies in
determining the degree or extent to which these homicidal acts were
the result of inebriety. But, interesting as this point undoubtedly is,
it is one that is by no means easy of accurate settlement; and, in any
investigation into this matter, It is necessary not to confound sequence
with effect. That intemperance plays an important part in the pro¬
duction of insanity, either in the persons themselves who give way to
this vice, or in their descendants, there can be no room whatever to
doubt; but that it does not account for every case of insanity is
certainly equally clear. Considering, first, the cases of the six women
included in the list of homicides, it appears that there is no evidence
of inebriety on the part of any of them ; but that, on the other hand,
causes, which appear to be adequate, and which were of an entirely
different character, were found to have existed. With respect, how¬
ever, to the 15 men, there was a clear history of intemperance in the
cases of five; but it must be added that in the cases of four out of
this number, there existed also insanity arising from other causes,
such as hereditary predisposition, cranial injuries, or harassing and
exhausting circumstances. One instance, therefore, only remains, of
the 15 men, in which, apparently, the homicidal act was to be ascribed
to a mental condition resulting from inebriety and from that alone.
But, with respect to the four cases in which inebriety existed in com¬
bination with previous insanity, of different degrees of severity, re¬
sulting from other causes, it might be asked whether the homicidal
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1884.] Psychological Retrospect .
acts would have been committed if the perpetrators of them, although
more or less insane even when sober, had not added the delirium of
intoxication to the previously existing state of things. Whether
this question could, or could not, be answered with a decided nega¬
tive, it may, at any rate, be safely affirmed that whenever anyone,
whose conduct has already given ground for suspecting the existence
of mental derangement, begins to drink to excess, the danger to the
community is, thereby, most certainly increased ; and, therefore, all
the greater promptitude should be used in placing such a one under
restraint, without waiting to give him the opportunity of being ar¬
raigned on a charge of murder. The principle of respect for the
liberty of the subject is a good one ; but it is capable of being pushed
too far, and it would certainly appear that this is done when it is
carried to the point of non-interference with insane persons who have
also become in temperate.* *
The report from which the above is an extract was delayed in its
preparation by the serious assault committed on Dr. Orange. We
can never think of this outrage without recalling the correspondence
which appeared in the London papers as to the mental condition of
the assailant. Perhaps those who so loudly declared their belief in
his sanity, and, if we recollect rightly, offered to champion his case in
the law courts, are now thoroughly convinced that they were mistaken
in their diagnosis. It is greatly to be desjred that such subjects
should be discussed in the medical press alone, nor can it be doubted
that the blunder which was made in this case, and which was so
thoroughly advertised in the daily papers, must have done great
damage by further shaking public confidence in the opinions of experts
in mental cases.
Cambridgeshire , &c.—It is satisfactory to learn that improvements
of various kinds continue to be carried out. The patients have so
much increased in number that it has been necessary to transfer eight
males to Northampton.
The rate of maintenance continues high—11s. 2£d. per week.
It is impossible to read this report without regret that Dr. Bacon
was not spared to see the fruits of his labours. We all know how he
struggled to establish a rational system of management at Fulbourne ;
and just as his efforts were beginning to bear much fruit, death removed
him from the 6cene of his labours.
Carmarthen .—It is a perpetual puzzle to most superintendents to
discover the secret of maintaining an asylum in creditable order and
the patients in sufficient comfort at a weekly cost of 7s. 10£d. The
Commissioners state that the dietary is low, but that it is not danger¬
ously so is shown by the low death-rate which has existed for the
past six years.
A second assistant medical officer has been appointed.
It is exceeding satisfactory to learn that every woman who can
walk goes beyond the courts for exercise.
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Psychological Retrospect.
Dr. Hoarder is in favour of discharging patients on probation. We
see no advantage in the method. If a patient can be sent away from
the asylum, he may as well be discharged outright. If the asylum
authorities had any control over the patient during the period of pro¬
bation, some benefit might possibly result, but as things are at present
managed they are responsible for the patient and for the folly and
ignorance of the relatives, and that is a burden quite unnecessary to
be borne.
“ An official inquiry has been made during the past year as to the
working of the capitation grant, which was made in 1874. In several
counties it has apparently had the effect of causing the removal to
asylums of many cases which might, and would otherwise, have been
cared for in workhouses. But it does not appear to have in any way
influenced the character of the admissions from your district. Thus
we find, that while in 1868 there were 25 lunatics in the workhouses
of the three counties, in 1874 this number had increased only to 29.
By January, 1875, however, immediately after the grant took effect,
the number in workhouses rose to 46 ; and we further find that there
has been since 1875 a continuous increase up to January, 1882, the
latest date for which we have returns, when the number in workhouses
was 95. During the same period the cases received here which
might properly have been treated in a workhouse have been very few,
as almost every case admitted into your asylum has been sent on
account of violent or suicidal tendencies which have rendered special
care an absolute necessity. During the fifteen years now under con¬
sideration the number of lunatics chargeable to unions within the
three counties, including the boroughs of Carmarthen and Haver¬
fordwest, has increased from 626 in 1868 to 905 in 1882. The
number in your asylum has grown from 190 to 450, while the number
residing with relatives and others has slightly decreased, having been
400 in 1868, it was 397 in 1882. Thus while less than 9 per cent,
of the total lunatics of England and Wales are resident with relatives
or others, in your district the proportion still amounts to over 40 per
cent.”
Cheshire . Chester .—The proportion of unfavourable cases is high.
Of 75 deaths no fewer than 25 were due to general paralysis, five
being women. Of 197 cases admitted no fewer than 45 died within
the twelve months, while as many as 14 of these succumbed within
one month.
Cumberland. —Dr. Campbell reviews his statistics for the past 10
years, and arranges his remarks under the following heads :—Is
insanity increasing in the district ? Is the type of insanity changing?
Is it possible to diminish insanity in the district ? We must content
ourselves by remarking that he clearly shows that sudden prosperity
in a district increases the cases of lunacy, especially amongst the
uneducated and previously destitute.
Denbigh .—A large portion of the drains has been reconstructed on
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1884.] Psychological Retrospect .
an improved system. A hot-water heating apparatus has been intro¬
duced and works well, adding materially to the comfort of the
patients.
Two members of the staff resigned on account of age and infirmity,
and were granted superannuation allowances for life.
Since this report was written Dr. Williams has resigned, and has
been succeeded by Dr. Llewelyn F. Cox.
Derby .—There are several subjects in this excellent report to which
we would gladly refer did space permit; but it is enough to say that
they all indicate thorough efficiency and a determination to keep up
with the times. To obtain room for recent cases, several imbeciles
and dements were sent to workhouses, but Dr. Lindsay reports that
several have been sent back to the asylum on the ground that they
were too troublesome in the workhouses, and required more super¬
vision than the limited arrangements of the workhouse enabled them
to get. The experience of the past year only tends to confirm his
opinion that workhouses, as at present conducted, with their inade¬
quately paid nursing staff, deficient arrangements and insufficient
supervision, are not the most suitable places for the care and treat¬
ment of even harmless chronic and imbecile asylum patients, who often
deteriorate in mental and physical condition, habits and conduct when
removed from the better diet, exercise, discipline, more frequent
supervision and better surroundings of the asylum to the workhouse.
Dr. Lindsay again returns to the subject of asylum provision for
the poorer middle classes. He seems to favour middle class asylums
rather than the admission of such cases to county asylums. This is
of minor importance, accommodation somewhere is wanted, and we wish
Dr. Lindsay all success in his efforts to interest his visitors and others
in this most important subject.
Devon .—Beer has been given up as an article of ordinary diet, with
satisfactory results.
Four charts have been prepared by Dr. Saunders, and they indicate
by the graphic method various subjects of interest. By appealing to
the eye they certainly show more readily the rise and fall in numbers
than does the old method of figures. No. 1 shows the number of
patients in the asylum at the end of each year from the opening.
No. 2 shows the percentage of deaths on the average number resi¬
dent. No. 3 gives the percentage of recoveries on the admissions
from 1847 to 1882. No. 4 shows the weekly cost of maintenance.
Little success appears to have attended the efforts made by the Visi¬
tors to get rid of chronic and harmless cases, and thus to make room
for the recent and curable. The asylum is full, and the question of
providing further accommodation is under consideration.
Among the admissions there were no fewer than seven who were
found “ not insane.”
Dundee .—It is to be regretted that the Directors find themselves in
serious financial difficulties. This is the more unfortunate as, during
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126 Psychological Retrospect . [April,
the year, all the patients were transferred from the old to the new
asylum, in proposing to raise the rate of board as the only means of
escaping their present difficulties, the Directors give a short account
of the weekly charges, going back so far as 1820.
As might be expected, Dr. Rorie has much to say anent the change
of residence, the new buildings, and so forth. All his remarks are in
praise of the change, though he has to report the occurrence of a few
rather severe cases of erysipelas, and an outbreak of diarrhoea.
Edinburgh ( Royal ).—There are many paragraphs in this report
which we would reproduce did space permit, for they contain valuable
trnths clearly and forcibly expressed. It is an essay on some points
of insanity and its treatment, for lay readers. As such, it is an ad¬
mirable production, and sure to excite the interest of the intelligent
portion of the public. Were it not that no Board of a Scotch or
English county asylum would care to print such a lengthy paper, we
would recommend Dr. Clouston’s report as one of the best we have
over seen, and one well worthy of imitation. There are a go and
vigour about it which are usually conspicuous by their absence in the
average asylum report.
Concerning the causation of insanity, Dr. Clouston writes :—
“ Turning to the physical and bodily causes of the disease, the usual
enormous predominance of these is found. Drink alone upset 44
cases; accidents or injuries, 15 ; child-bearing, 16; the periods of
puberty, the climacteric, and old age, 39 ; and various bodily diseases
and disorders, 68. But we must always remember that there are
some brains so unfortunately constituted that very slight causes
indeed, from within or from without, will upset them. Such brains
are from the beginning so formed that they are bound to lose their
balance some time in life. If one thing does not produce this effect
on them another will. And between such unstable organs and the
tough brains in which no cause whatever, no matter how disturbing,
will upset the reasoning and controlling power, there are every variety.
There can be no doubt that, as at present constituted, there are only
a small minority of the human race who can be made insane in the
ordinary sense. By starvation, or poison, or fever, they can be made
temporarily delirious, and their mental functions may be destroyed by
organic brain disease, but true insanity cannot be produced in them by
any cause known to us. Some sort of direct or indirect predisposition
or peculiarity of brain constitution, is needed for this. One of the
great problems—as yet unsolved—for medical men is, how this pre¬
disposition to insanity can be avoided, and, when present, how it can
be got rid of. The preventive aspect of medicine in all its depart¬
ments is perhaps the most hopeful of good to humanity. Beyond lay¬
ing down general maxims as to living according to the laws of Nature
—cultivating bone, muscle, and fat and letting brain lie fallow, making
the educational process one of true natural development on physiological
lines, going back to Nature, in fact, in all directions—we are as yet un-
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127
1884 .] Psychological Retrospect .
able to do very much in preventing the development of insanity with
scientific certainty. There is not the least use denying, however, that
this liability is one of the penalties of a high brain development,
especially if this is continued for several generations. There are few
families who have produced more than their share of very extraordi¬
nary men or women that have not also produced more than their share
of insane members. This seems to be one of the penalties of great¬
ness. It is not the fools alone who become insane. But neither a
sound physiology nor a scientific sociology can accept such a fact as a
necessary part of Nature’s laws. Both the one and the other must
necessarily conclude that the fact is a demonstration that Nature’s
laws have been broken in some way in the lines of the ancestry of
those families, and one of the aims of both will be in the future to
find out how the bad result has come about, as well as the good.
No doubt we shall in time solve the problem for humanity, how
to combine the greatest mental strength with the greatest speed.”
As is well known, Dr. Clouston is a great advocate of fattening up
as a method of cure, in melancholia especially. It is possible that he
may overdo it, but his results encourage him to continue. He says—
“ The great importance of proper diet and abundant exercise in the
fresh air in certain cases, to which I last year alluded, has been more
and more impressed on me this year of my experience. It is very
surprising the effect of putting some nervous patients on a diet con¬
taining what would have seemed to me formerly an excess of milk and
eggs. The gain in weight that is possible, when a previously thin and
highly nervous patient is put on about a dozen eggs a-day and six or
seven pints of milk, with plenty of walking exercise in the fresh air,
is most surprising ; a gain of two or three stone is quite common, and
usually there is an immense advance along with this in nervous stability,
in contentment and in self-control, even if a complete recovery does
not take place. I think such good results even make up for the in¬
creased cost, and compensate for the £56 worth of eggs which, in one
quarter of this year alone, we got through, as compared with the same
quarter of a year before, and which naturally surprised our Finance
Committee when they came across it. I admit that at present one has
to apply dietetic rules in a somewhat haphazard way ; we cannot as
yet tell the exact cases in which certain diets are good and curative.
But this can only be ascertained by experiment; and I don’t suppose
anyone will object to such 4 experiments on living beings * on any
ground but the cost.”
Glasgow District .—This is a new asylum under the charge of Dr. A.
Campbell Clark. The report is satisfactory in every respect but one,
that exception being in regard to post-mortem examinations. In an
entry by one of the Commissioners the following occurs :—“ Of only
two of the seven patients who died was a post-mortem examination
made. This is probably due to a resolution of the Asylum Com¬
mittee, that no such examination of the body of any patient shall be
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128 Psychological Retrospect . [April,
made without the written consent of the nearest known relative
of the deceased, and the written authority of the Committee or
Convener. It is clearly right that the consent of relatives should
always be obtained, but it seems impossible that the authority of the
Committee could be obtained, and it is difficult to see how the Com¬
mittee or Convener could possess any knowledge which would qualify
them or him either to authorise or forbid such an examination. It
seems only reasonable that such a matter should be left to the
discretion of the Medical Superintendent, who is in a better position
to judge of what it is desirable to do in the circumstances than any
other person can be. In suggesting that the Committee should re¬
consider this resolution, it is perhaps right to point out that post¬
mortem examinations do more thau advance our knowledge of the
nature and causes of insanity. If they did nothing else this would
surely be a sufficient reason for making them, but they frequently lead
to the discovery of injuries which patients have sustained, and the
inquiries following such discoveries often prove practically beneficial
to the patients.”
In answer to these remarks, the Committee published the following
minute :—“ The Committee further, on the motion of the Chairman,
agree to record that they do not consider it necessary to recall their
resolution as to post-mortem examinations. It was passed after full
inquiry, attention having been directed to the matter by the Commis¬
sioner reporting, in September, 1881, that the number of deaths had
been large, and that 4 in the case of every patient who died a post¬
mortem examination was made.’ The Lunacy Acts provide for the
care and treatment of lunatics, and for the establishment and main¬
tenance of the necessary buildings. On the death of a lunatic the
Medical Superintendent closes his professional duty by making
an entry of the death in the register, and sending a copy of such
entry to the person or parish interested. The Committee have
no power to 4 authorise' or to ‘forbid’ properly authorised post¬
mortem examinations, but it appears to be their duty to guard
against such irregularities as have occurred in other places, and
to know that in every case of death, the body of the patient will
be dealt with in a becoming manner and according to the ordinary
usages of society.”
The folly of such a minute is so palpable that no comment is
necessary.
Glasgow (Gartnavel ).—In such an asylum as Dr. Yellowlees
has under his care, where there is a large number of private patients,
it must always be a difficulty to secure the services of properly
qualified attendants. We, therefore, sympathise with him when
he writes:—“There is always difficulty in getting exactly the
right persons for attendants. Their duties are very trying and
difficult, and to discharge them well requires high qualities of head
and heart. 'The power of influencing others against their wish,
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1884.] Psychological Retrospect . 129
and without the familiar argument of favours bestowed or expected,
is, in truth, a rare gift, but it is the true test of a good attendant.
This power may be gained in some degree though experience,
but never thoroughly; it is a gift, not an acquirement; a true
attendant, not less than a poet, is born, not made. Many excellent
servants never acquire this faculty at all; while they do their
own specified duty admirably, they are useless in getting others
to do theirs, and are therefore unsuited for asylum work.”
The asylum is evidently in a highly satisfactory condition.
Gloucester .—The perusal of this report makes it evident that
the new Medical Superintendent, Mr. Craddock, has many difficulties
to encounter in his work, and we will content ourselves by wishing
him every success, and that peace of mind which comes of honest
work.
Hereford .—A laundry block has been completed at a cost of
£1,248. No patient who can walk is now confined to the airing
courts. Dr. Chapman is to be congratulated on the death rate,
which was unusually low—4*98 per cent, on the average number
resident. Only three women died, and for more than eight months
there was no death on the female side. Such an occurrence is,
unfortunately, very rare.
(To be continued.)
2. American Retrospect .
By D. Hack Tuke, M.D.
American Journal of Insanity , July and October, 1888.
The numerous journals devoted to Psychological Medicine in the
United States defy the attempt to retrospect them with any approach
to regularity or completeness, regard being had to the corresponding
literature emanating from the European Continent. It is not possible
then, with the space at our command, to do more than touch in the
briefest manner upon the articles which appear, although many
deserve discussion and citation to a large extent.
Dr. Callender contributes to the July number of the above Journal
an interesting record of the Association of Medical Superintendents
of American Asylums in the form of a Presidential Address. It is
a history of forty years, the same period which the writer of the
Retrospect had occasion to review on a similar occasion at the annual
meeting of our own Association in 1881.
We find that it originated in a conference, in the year 1844, be¬
tween Dr. Samuel B. Woodward, of Worcester (Mass.), and Dr.
Francis T. Stribling, of Staunton (Virginia), both Superintendents
9
XXX.
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130 Psychological Retrospect . [April,
of Asylums. Our Association originated, it will be remembered, in
1841, in a circular letter addressed to all concerned, signed by Dr.
Hitch, of the Gloucester Asylum.
The consultation between the two American doctors was communi¬
cated to Dr. Kirkbride and Dr. William M. Awl, of Columbus
(Ohio), and through their zealous co-operation, a meeting of Superin¬
tendents was held at Philadelphia, October 16th, 1844. Of these,
three survived when Dr. Callender delivered his address ; now we
regret to add there are only two, consequent upon the recent death
of Dr. Kirkbride. The survivors are Dr. Pliny Earle and Dr. John
S. Butler. A deserved tribute is paid to those who were more
especially distinguished, namely, Dr. Luther Y. Bell (Mass.), Dr.
Amariah Brigham (New York), and Dr. Ray, whose name is justly
venerated on both sides of the Atlantic by those devoted to the de¬
partment of medicine he so much adorned. Dr. Bell was for twenty
years the Superintendent of the McLean Asylum ; a brilliant man in
various lines of thought and work, as well as in his special sphere.
To him we owe the first and best description of mania with extreme
exhaustion and delirium, often called after him, “ Bell's disease/*
Dr. Brigham founded the American Journal of Insanity, and was the
first Superintendent of the New York State Lunatic Asylum at
Utica. Of Dr. Ray, appointed Superintendent of the Maine Hos¬
pital for the Insane in 1841, it is unnecessary to say more in this
place. Passing reference is made to the names of Galt, Awl, Foner-
den, Benedict, Booth, Cutler, Waddell, Landor, Chipley, Green, Tyler,
Ranney, and Walker, among those, who, having passed away, deserve
honourable mention. Although not a member of the Association, the
well-known name of Miss Dix is very warmly alluded to, one who has
consecrated a life to the welfare of the insane, and has been the means
of establishing a number of excellent institutions for their care and treat¬
ment, Of the subjects discussed at the early meetings of the Asso¬
ciation, Dr. Callender remarks that in their scope they leave little if
anything to be added after the lapse of forty years, “ in which science
in all departments, and all forms of skill and appliance, have made
unexampled progress/' This observation is open to possible miscon¬
struction, for although all that is intended, is, we presume, that the
object in view, and the humane feeling and good 6ense brought to bear
upon it, were the same then as now, and have never been exceeded in
earnestness of purpose (which is quite true), it will very likely be in¬
terpreted to mean that these early pioneers 6aw adequately the true
scientific bearings of medical psychology. That they took a broad
view, however, of the direct and collateral questions to be discussed
under this head, is shown by the subjects enumerated by Dr. Callen¬
der as having claimed attention and elicited reports.
The relations of the Association to Canada possess an interest for
us, and we find that at the second meeting held at Washington, in
1846, the Dominion was represented by a delegate named Dr. Walter
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Psychological Retrospect.
131
1884 .]
Telfer, Superintendent of the Toronto Asylum. We are told that
from that time the specialty in our Colonies in Canada u has been
thoroughly incorporated in the work of the Association. Its long
line of representatives, some of whom have retired from active duty,
and others who have passed from the scene of life, are remembered
for the zeal, ability and erudition they displayed in the debates of the
body, and those now in service are always greeted warmly and cherished
for similar qualities. Eminent among these, the venerable Joseph
Workman, of Toronto, stands yet among us by long service, large
learning and wise counsel, one of the members of the body at whose
meetings he is frequently present. Thrice in its history the Associa¬
tion has held its sittings in the capitals of the Canadian provinces, and
had the privilege of inspecting some of their admirable institutions
and enjoying intercourse with that refined and hospitable people.”
The tone of much of this address is apologetic, and is intended as a
reply to criticisms which have been freely launched of late against
the elder generation of American Alienists and the proceedings of the
Association. It is to be hoped, and judging from parallel events in
the course of other movements, we should say it is to be expected that
critical reformers, however unfair and injudicious they may be in their
philippics, will ultimately be of service, precisely as in the English
Parliament, an Opposition however carping and hypercritical it may
be— and injurious as it may to that extent prove—is regarded as, on
the whole, a necessary and by no means unmitigated evil. But, at
the same time, it surely becomes a younger generation of men, while
infusing new blood into the scientific study of insanity and the treat¬
ment of the insane, to tread lightly on the shortcomings and faults of
their predecessors, and to avoid placing themselves in violent an¬
tagonism to them. We are not quite sure that the Rabbi was right,
who, in commenting upon the passage, “ Your young men shall see
visions, and your old men shall dream dreams,” inferred that the
former are admitted nearer to the Divinity than the latter, because
vision is a clearer revelation than a dream. If, as Bacon says, men
of age object too much, consult too long, adventure too little, and
young men in the conduct and management of actions embrace more
than they can hold, and fly to the end without consideration of the
means and degrees, it is equally certain that the compound of the
two is good, because the virtues of either may correct the defects of
both*
The October number contains the report of a case of Moral Insanity,
by Dr. W. B. Goldsmith, the Superintendent of the Danvers Lunatic
Hospital (Mass.). The patient was a girl of 18, whose father laboured
under melancholia, and committed suicide. She was a healthy child
* It appears that while there were only 20 asylnms in the American States
and Canada in 1844, there are now in the United States and Canada 130 (ac¬
commodating 41,000 patients), and the 13 members of the original Association
are now represented by 115.
!
Digitized by {jOoq le
182 Psychological Retrospect [-A-pril,
until seven, when she had scarlet fever, severely attended with convul¬
sions and delirium, which continued several weeks. From the time
of this illness a mental change was observed. She could no longer be
made to obey, and was easily excited. About this time her father’s
suicide occurred, and on seeing the corpse, she became hysterical and
lost her self-control. Shortly after she went to school, but she was
sent back as she caused so much trouble : “ There must be a screw
loose somewhere ” said her teacher. At home she displayed violent
paroxysms of temper and violence. She told lies and erotic feeling
was early developed. Medical advice was obtained then and subse¬
quently, with the result that she was sent to an asylum from the age
of 9 to 18. Dr. Godding, who was then the Superintendent, failed to
detect any intellectual defect, and regarded her case as one of true
moral insanity. Her morbid peculiarities developed as she grew older,
and 6he was next placed in the Worcester Asylum for twenty months,
under Dr. Quimby, who deemed it best to treat her as a wilful child,
and whipped her with the mother’s consent. The effect at first
was excellent, but on repetition it lost its effect. Still self-control
somewhat increased. Dr. Quimby, “after repeated and careful ex¬
amination, was unable to discover any intellectual impairment.” She
was, on the contrary, “ especially bright.” She keenly distinguished
right from wrong, and “ only seemed lacking in the power or will to
control herself.” For four months she remained at home, exercising
self-control admirably. Then, about a week after scanty catamenia
and dysmenorrhcea, she began to complain of her head, and was
nervous. A few days after, in consequence of chagrin, she jumped from
the roof of the verandah, and was found on the walk below scream¬
ing and maniacal, a mental condition which continued in an intense
form for two days. She was removed in consequence to the Danvers
Asylum (Oct. 14, 1880), where 6he has remained, and “ engaged the
sympathy and exhausted the resources of treatment, mental and
moral, of everyone who has come in contact with her.” The attacks
not unfrequently occur during menstruation; she complains of dull
pains in the iliac regions, especially the right, and also of head¬
ache. She is at first distressed and apprehensive, then violent, and
screams till she is hoarse. Mostly the attacks are excited by moral
causes, as disappointment, or she apparently desires by her conduct
to attract attention and sympathy. She rarely uses bad language, or
is obscene, but a tendency to eroticism manifests itself. With the
exception of ovarian tenderness, nothing abnormal was discovered on
examination.
Such a case may be set down as one of hysterical mania, but with
this peculiarity, that although mentally affected before nine years of
age, and almost always requiring asylum care, “ there is an unusual
symmetry and completeness in the development of her intellectual
faculties, and her mental capacity is markedly above the average.
She never has shown a semblance of a delusion or hallucination, has
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1884.] Psychological Retrospect . 133
no peculiarities in her likes, dislikes, habits of life or tastes ; when
calm, is generous and affectionate to her attendants. . . . She is
capable of giving judicious advice to them concerning their hospital
duties or private affairs, and is much relied on by them. She reads a
great deal, mostly light literature, and excels in neatness and despatch
in accomplishing all kinds of work with which her life has allowed
her to become familiar.” Curiously enough, she admits her responsi¬
bility at the beginning of the attack, but says she cannot control
herself when once started. Dr. Callender administered bromides,
hyoscyamine, chloral, &c., without benefit. A padded-room appeared
to be the best palliation. Various forms of mechanical restraint were
applied and demolished. In 6hort, force proved to be no remedy.
Finally, in despair, and as a last resort, the ovaries were removed
(August 12, 1883), the patient recovering well from the operation.
Here the case ends for the present, and we look with interest to a
future report. The apparent connection of the attacks with ovarian
excitement certainly justified the experiment. The change of charac¬
ter, however, consequent upon scarlet fever, and the unfortunate
heredity, present a complication anything but favourable in consider¬
ing the prognosis.
The Journal of Nervous and Mental Disease y October, 1883.
The first article in this Journal is an important one by Dr. G. L.
Walton, of Boston, on the “ Neglect of Ear-symptoms in the Diagnosis
of Diseases of the Nervous Symptoms.” Dr. Walton has enjoyed excel¬
lent opportunities for observation of nervous affections in the hospitals
of Paris, Berlin, &c., and has availed himself of them in a way calcu¬
lated to advance our knowledge of diagnosis by concentrating his
attention on special points of interest rather than by diffusing it over
many. It is, indeed, a remarkable fact that aural symptoms are almost
entirely passed over by neurologists and psychologists. From time
to time, however, our attention is forcibly directed to the close rela¬
tion existing between ear and cerebro-mental disorders by the rapid
recovery of insane patients after the removal of obstructions in the
meatus. Auditory hallucinations, again, not unfrequently stand in
important relation to deafness, and, on the other hand, patients will
sometimes describe their sense of hearing as preternaturally acute.
Fiirstner has reported cases in which auditory hallucinations, ap¬
parently due to anaemia, induced mental depression. Dr. Walton has
done well, then, to 6tudy otology in connection with neurology, and to
place his researches on record. As hysterical blindness has been
rescued by Charcot from vague generalities, so hysterical deafness
has been found to be no less marked by regular characters and
definite laws. Thus, for example, audition through the bone dis¬
appears in hysterical and senile deafness before that through the
meatus, and high tones are lost before middle tones. Dr. Walton
has found such knowledge useful in diagnosing functional anaesthesia.
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134
Psychological Retrospect . [April,
It is usual to explain loss of hearing in advancing life by impaired
bone-conduction, but as the like defect occurs in young women, the
explanation has to be sought, in both instances, in the fact that the
auditory centres themselves are less tenacious of high tones and of
sounds passing through bone. Other examples of the importance
of studying ear-symptoms are seen in lesions of the pons, medulla-
oblongata, and cerebellum, as also in Meniere’s disease and loco¬
motor ataxy. We cannot doubt that in future much more accurate
observations will be made upon the auditory sense in nervous and
in mental affections; in short, that “ reports of cerebral disease
ignoring the condition of the hearing and the examination of the ears
will be considered as incomplete as they are at present without record
of the condition of the eye8. ,,
A discriminative tribute to the memory of Dr. Wilbur is written in
a kindly tone by “ W. W. G.,” who thus expresses himself :—
We felt that hie criticisms of onr methods were certainly not generous,
hardly just; bat the trouble was, there was too much truth in them. It was
good, wholesome troth for os to hear, at any rate, for the Association of
Medical Superintendents of Institutions for the Insane had become too much of
a mental admiration society for healthy growth. More than thirty years ago
he had been introduced to the Association by one of its founders and welcomed
by it, had amicably co-operated with us for many years, attending most of
onr meetings; and then becoming exclusive, we unwisely and rudely, it
seems to me, drove the superintendent of idiot asylums out of our synagogue
Was it to be expected that he would be very indulgent to our methods after
that ? . . . Perhaps, after all, we were a little too sensitive of comparison
with the English, fearing that our methods might not be properly appreciated,
by any outsider, and so too easily we took offence where only fair criticism was
meant. I at least am convinced by my correspondence with him that his
convictions were honestly held, and much as I may regret that he could not
see some things differently, now that I can no longer join issues with him—
standing uncovered in the presence of that silence which has fallen over all our
strivings—I feel it is due to him to say that he was more sinned against than
sinning.
Death has a wonderful influence in softening the bitter feelings and
rivalries arising during life between fellow-workers in the same field.
The American Journal of Neurology and Psychiatry , August, 1883.
This number contains an article by Dr. Spitzka on u The-Alleged
Relation Between the Speech-disturbance and the Tendon-reflex in
Paretic Dementia,” elicited by a paper read before the American
Neurological Association, by Dr. Shaw, on the tendon-reflex in
general paralysis, in which he advocated a direct connection between
difficulties of speech and exaggerated tendon-reflex, as also hemi-
paretic attacks, 6uch relation being demonstrable by pathology. It
is hardly necessary to say that the presumption is against any such
connection. Dr. Spitzka has, however, tabulated cases of general
paralysis in which the speech-disturbance and the tendon-reflex were
noted, and so far as eighteen cases prove anything, they prove that
clinical observation does not bear out Dr. Shaw’s conclusions. Thus out
of eight instances in which the knee-jerk was exaggerated, the speech
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1884.]
Psychological Retrospect .
135
was markedly affected in only one instance, whereas, in two instances
in which the reflex was abolished, the speech was much affected. It
is a pity that similarly careful observations are not instituted in all
cases in which statements of this description are made.
The simulation of insanity by lunatics is a very important practical
subject, and to its elucidation Dr. Bluthardt contributes an article.
He cites a considerable number of examples, and reports a striking case.
An elaborate article by Dr. Hoffmann, on the normal and pathological
anatomy of the grey substance of the brain does not admit of con¬
densation. Fifty pages would seem rather a disproportionate allow¬
ance for one paper in a single number.
The consulting physician to the Inebriate Asylum, Fort Hamilton
(L.I.), Dr. Mason, contributes an article on Alcoholic Insanity. He
makes the usual division into acute and chronic; the sub-divisions of
the form being:—(1) Acute alcoholic mania (mania a-potu). (2)
Acute alcoholic delirium (delirium tremens). (3) Alcoholic epilepti¬
form mania ; and the sub-divisions of the latter being :—(1) Chronic
alcoholic mania—maniacal type—homicidal tendencies. (2) Chronic
alcholic melancholia—suicidal tendencies. (3) Alcoholic dementia.
(4) Dipsomania or oinomania.
In the first form, the paroxysm occurs in the midst of a debauch,
and is not common in the habitual drunkard. It usually lasts only a
few hours, but if febrile action is set up, may last for some days. An
alcoholic maniac may commit any crime in the calendar. Unlike other
forms, it is not preceded by delusions. Imbeciles and epileptics, as
everyone knows, become fearfully dangerous.
Acute alcoholic delirium (D.T.), is divided by Dr. Mason (who
criticizes the reference to tremor in the popular term) into three
forms, the simple, non-febrile one, in which convalescence quickly
follows; the second, in which recovery is slow, the delusions persis¬
tent and the relapses common ; while in the third, “ Febrile delirium
tremens,*' the pulse and temperature are high, and death frequently
occurs in a few days. A good analysis is given of the symptoms in
acute alcoholic insanity, including the pantomimic state in which a
tailor for instance will thread an imaginary needle, and stitch an im¬
aginary cloth, like Sir Jacob Kilmansegg washing his hands with
invisible soap and imperceptible water. Two divisions suffice for
the chronic form, the maniacal and homicidal, and the melancholic
or suicidal. In both the suspicions and dread of persecution are
prominent symptoms. Marital unfaithfulness is a particularly com¬
mon delusion. Some striking cases illustrate Dr. Mason's paper,
which is very clearly expressed.
Dr. Mason dwells on the points of diagnosis between chronic
alcoholic mania and the acute forms, general paralysis, syphilitic in¬
sanity and traumatic insanity associated with intemperance. No
difficulty is experienced in recognising the beery delirium,insomnia and
restlessness of the acute form as separating it from chronic alcoholism,
in which the sleep may not be disturbed, and the delusions become
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186 Psychological Retrospect . [April,
fixed and monomaniacal. More difficulty is felt in cases of general
paralysis in an early stage, complicated as they often are by fits of
intemperance. The general rale, no doubt, holds good that there is
here exaltation, but the diagnosis may be wrong when depression
and hypochondriasis exceptionally take its place. Further, alcoholic
insanity may merge into true general paralysis, and there may be a
stage during which no physician can speak positively as to the nature
and future course of the affection ; at any rate, if he does diagnose
in haste, he is as likely as not to repent at leisure. No doubt, as
pointed out, grandiose ideas are more logical and plausible in the
alcoholic than in the paretic patient.
Regarding syphilitic and traumatic insanity, Dr. Mason refers to re¬
ports of cases of alcoholism, in which the history was obtained, and it
was found that one case in four had syphilis, and one case in six had
received injury to the head. To determine the real cause of the
attack, it is absolutely necessary to examine minutely into the history
of the case, so as to avoid confoundingcausation and a mere symptom.
Dipsomania is defined as an irresistible impulse, “ driving a person
to get drunk at stated or irregular periods preceded by melancholia,
insomnia and restlessness, the debauch itself causing hallucinations,
tremors and gastric derangement. Dr. Mason does not dwell further
upon oinomania, but passes on to the symptoms of chronic alcohol¬
ism or the effects of chronic poisoning by alcohol, which may co-exist
with any type of alcoholic insanity. We need not, however, refer to
these well-known symptoms.
On prognosis, Dr. Mason does not speak more hopefully as to a
radical cure than we should expect. It is the old story of frequent
recovery from the particular attack for which he comes under care,
and no end of relapses. The treatment recommended by the writer,
inebriates must be glad to learn, does not necessarily exclude alcoholic
drinks. “ The method of treatment will include the use of alcoholic
stimulants. Whether or not these shall be used, will depend much
on each individual case; some may be very much benefited by the
use of stimulants, and others positively harmed [an apparently un¬
expected resultI] As a rule, I have found that when stimulants are
indicated, the malt liquors are preferable to spirituous liquor—Bass’s
ale, Guinness’s stout, or lager-beer when a milder form is required.
The quantity as well as the form of the stimulant used, and whether
or not it is to be used, each case must determine for itself.’’ This
might mean that each patient is at liberty to decide the quantity as
well as the form of alcohol consumed, but even taking the alternative
and narrower meaning of the paragraph, we must say that Dr.
Mason would be a very charming physician to be under, and that the
Inebriate Asylum at Fort Hamilton, must in the eyes of a dipso¬
maniac, be robbed of the terrors with which he might not unnaturally
have regarded it before admission. We should rather like to know
whether the Doctor’s generous board is at all exceptional in the
American inebriate asylums, and if it is, and answers well, whether
Digitized by <^.ooQLe
1884.] Psychological Retrospect. 137
the Dalrymple House, whose opening we recorded last quarter, ought
not to follow suit. Dr. Norman Kerr, however, might have some¬
thing to say on this matter, and suggest unpleasant doubts about the
danger of keeping up the drink craving, and might possibly prog¬
nosticate that asylums for inebriates would, under such circumstances
become but too truly inebriate asylums—especially as Dr. Mason
observes, when speaking of patients who have left the asylums, that,
‘‘even that which might in a healthy person be regarded as a
moderate use of alcohol, will undoubtedly bring on a relapse.”
3. Colonial Retrospect.
By Frederick Needham, M.D.
Annual Report of the Inspector General of the Insane. New South
Wales. 1882.
In Dr. Manning’s interesting report we are presented with another
year’s record of the operations of the Lunacy Department, over
which he presides with so much energy and ability.
It appears that the burden of insanity which has so heavy an in¬
cidence in this country, presses with little less severity upon one of the
largest and most important of its colonial dependencies.
The number of insane persons in the various asylums, and other¬
wise on the registers, on December 31st, 1882, was 2,307 as com¬
pared with 2,218 at the same date in 1881, giving a percentage of
2*82 per thousand of population, or 1 in every 354, as against 1 in
every 353 in England.
The gradual rate of increase in the proportion of insane to
population in New South Wales and this country respectively is
shown in the following table :—
Year.
Population of
New South
Wales.
Total Number
of Insane in
New South
Wales on 31
December.
Proportion of Insane
to Population in New
South Wales.
Proportion of Insane
to Population in
England.
1873
560,275
1,526
Per M.
1 in 367 or 2*72
Per M.
1 in 381 or 2*62
1874
584,278
1,588
1 in 367 or 2*72
1 in 375 or 2 66
1875
606,652
1,697
1 in 357 or 2*80
1 in 373 or 2*68
1876
629,776
1,740
1 in 361 or 2-77
1 in 368 or 2*71
1877
662,212
1,829
1 in 362 or 276
1 in 363 or 2 75
1878
693,743
1,916
1 in 362 or 2*76
1 in 360 or 277
1879
734,282
2,011
1 in 365 or 2 74
1 in 357 or 2 80
1880
770,524
2,099
1 in 367 or 2*72
1 in 353 or 2 83
1881
781,265
2,218
2,307
1 in 352 or 2*84
1 in 352 or 2 84
1883
817,468
1 in 354 or 2*82
1 in 353 or 2 83
The general movements of cases and the results of treatment in the
Colony are set forth in the following table which gives the admis¬
sions, re-admissions, discharges and deaths, with the mean annual
mortality and the proportion of recoveries, &c., per cent, in the
Digitized by <^.ooQLe
188 Psychological Retrospect [April,
hospitals for the insane, for the years 1876 to 1882 inclusive, and in¬
cluding the licensed house from the year 1882.
Digitized by boogie
1884.] Psychological Retrospect. 139
The percentages of recoveries to admissions, and of death's to the
average numbers resident, were for the seven years which ended in
1882, 42 and 67 respectively. From the table which gives the ap¬
parent or assigned causes of insanity in the admissions during the
year under review, it appears that intemperance in drink was credited
with the causation of the mental attacks in 67 of the 473 admissions,
while hereditary predisposition was ascertained in 37 instances only ;
this being probably due to the fact that of the 2,743 patients under
care in 1882 only 711 were natives of New South Wales—the pre¬
vious history of the remainder being presumably unascertainable.
Dr. Manning is able, with reference to his own sphere of work, to
confirm the opinion of the English Commissioners as to this country
—that the proportion of persons attacked with insanity is at present
not on the increase.
The recent publication of the census returns has enabled him to
give a series of interesting tables with reference to the nationality
and ages of the insane in the Colony under care in 1881.
It is not necessary to give the tables themselves here, but the
conclusions which he has drawn from them are both curious and
interesting. He says “The proportion of insane men under care in
1881 to every 1,000 of population was 3*98, whilst the proportion of
insane women was only 2-95, whereas in England the proportion
of insane men was during the year 1881 2*38, and of women 2 52 to
the population. The difference may be accounted for partly by
the fact that for many years the proportion of males in this Colony
was largely in excess of the females, and during all these years
contributed a large annual quota to the number of insane now
accumulated as chronic cases in the asylum, and partly from the
stress of climate and of occupation falling more heavily on the male
than on the female population. The drinking habits of a large part
of the male population may also account in part for the difference.
The proportion of insane to population born in New South Wales is
only 1*40, and in other Australian Colonies 1*23 per 1,000, whilst
the proportion born in Great Britain is 7*97 per 1,000, and in foreign
countries 8*69 per 1,000 of the population. It appears that the
number of insane born in England and Wales is 6*36 per 1,000
of population; in Scotland, 6*18 per 1,000 ; in Ireland, 11*63 per
1,000; in France, 12*06; in Germany, 8 37 ; in China, 6*46; and in
other countries, 10*40.
“ The very small percentage of Australian-born population is to be
accounted for by the fact that insanity is a disease most common in
middle and old age, and is rare in childhood and youth, to which
period of life one-third of the population mainly, if not entirely, of
Australian birth belong. The high proportion of foreign-born
patients appears due partly to the admission of the waifs and strays of
all nations to our hospitals, the ports of other Australian Colonies
being to a large extent closed to them, and partly to the peculiar
isolation of foreigners in an English-speaking community, an isola-
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140
[April,
Psychological Retrospect.
tion which tends to mental disturbance. The very large proportion
of persons born in Ireland, which is twice as large as the proportion
born in England and Scotland, is perhaps the most remarkable fact
shown by these returns. The total number of insane persons of
Irish birth under care in 1881 was 804, or nearly one-third of the
total number, whilst the proportion of persons of Irish birth to
the general population was only about one-eleventh.”
The existence in New South Wales of an institution for the insane
of a peculiar, and almost an unique kind, is recorded in the following
suggestive remarks:—
Reception House for the Insane , Darlinghurst.
The Lunacy Act Amendment Act, which was assented to in
December, 1881, opened the doors of this Institution to the many
doubtful cases of insanity which are taken before the Police
Magistrates sitting in Sydney, and remanded for medical treat¬
ment and further inquiry, and the patients now admitted to this
Institution are of two classes —
1st. Those for whom either one or two medical certificates have
been signed, and who are awaiting transfer to a Hospital for the
Insane, and
2nd. Those who are under remand under section 1 of the Amend¬
ing Lunacy Act.
Of the first class, three patients remained on 81st December,
1881, and 810 were admitted during the year ; making a total
of 318 under care and treatment. Of these, 24 recovered and were
discharged; 285 were sent on to hospital, and one died and three
remained on 31st December, 1882. Of the patients forwarded to
hospital, 246 went to Gladesville, 37 to Callan Park, and one
to Newcastle.
Of the second class, 227 were admitted, and of these 153 were
found, after treatment varying from 6even to twenty-eight days
in duration, fit to be at large ; 61 were certified as insane, and
returned to the Reception House for transfer to hospital; four died,
and nine remained at the close of the year.
Taking the two classes together, and deducting the 61 patients
who appear in both classes, first under remand and second under
certificate, the number of cases treated has been 479, and of
these 177 were discharged recovered.
The work done by the Institution has therefore been large and
important. It enables scientific treatment to be applied under
favourable conditions at an early 6tage of the malady, and so stops
a number of cases from passing into a more advanced stage, and
affords a temporary refuge of the most fitting kind for cases
which from their nature must go on to hospital for further and
more lengthened treatment.
Digitized by <^.ooQLe
1884 .]
Psychological Retrospect.
141
At present this Institution is all but unique; the only similar
Institution of which I am aware being at Paris, near the large
Asylum of St. Anne, and receiving all the cases from the Depart¬
ment of the Seine. In England the wards of the poor-houses have,
up to this time, done part of the work carried out here by this
Institution, but the want of a separate Institution is much felt,
and Sir H. W. Gordon, a Justice of the Peace for the County
of Middlesex and Visiting Magistrate for one of the largest County
Asylums, in a letter published in the Lancet of the 21st October,
1882, recommends the establishment of a Receiving House for
the County, and urges that all lunatics should first be sent to
this Institution and detained there under supervision until each
individual case has developed itself, when the patient would be
either discharged or drafted to such Asylum as the Medical Officer
might consider best suited for the particular case ; and the “ Lancet,”
in commenting on this letter, points out that this is identical
with a proposal made by the “ Lancet ” Commission on Lunatic
Asylums, in 1876-7, as “ likely to effect a solution of the difficulty
of dealing with doubtful cases.”
This Colony is in this particular very decidedly in advance
of the Mother Country, and the establishment at Darlinghurst,
as well as the work done in it, may be viewed with satisfaction.
I have had particular pleasure, both during the past and former
years, in showing the Institution to visitors from other Colonies
interested in the treatment of insanity.
Dr. Manning gives at length the entries which he has made
on the occasions of hi6 frequent visits to the several Asylums
which he inspects. And it is obvious that, although there are
some overcrowding and other defects resulting chiefly from the
transitional state of the buildings, their general condition is satis¬
factory, and the treatment of the insane in the Colony credit¬
able to those who are responsible for their care.
We are, unfortunately, unable to give so satisfactory an account of
the treatment of the insane in another Colonial possession of this
country, the report of whose Asylum is now before us.
The Colonial and Criminal Asylum of Trinidad, on the 31st
December, 1882, contained 39 patients in excess of the accommoda¬
tion.
The average number resident during the year was 292; 112
patients were admitted, 40 discharged, and 51 died I
The recoveries were at the rate of 33’9 per cent., while the deaths
amounted to 17*4 per cent, on the average numbers resident, the death-
rate of the last 10 years having averaged 15 per cent.
That Mr. Seccombe, the Medical Superintendent, who was for¬
merly at Caterham, fully realizes the defects of the asylum of which
he has recently assumed the control, is obvious from the resumi of
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142 Psychological Retrospect . [April,
them which he places before the Colonial Secretary in the following
indictment:—
“ I take this opportunity whilst making my first report to draw
His Excellency’s attention to the points in which this Asylum from
various causes fails in its object, namely, the care and cure of the In¬
sane.
'* The site, unhappily chosen on the side of a steep hill, comprises
some six acres, and on this confined space are dotted about various
blocks which immediately suggest to one’s mind the difficulties that
must attend the administration of the Asylum. Of course this irre¬
gular arrangement of the blocks is, in a measure, due to the attempts
which have been made at various times to meet the ever-increasing
demand for extra accommodation.
“ Nearly all the blocks, which have both internally and externally a
prison-like appearance, are unsecure, many positively rotten, offering
to the patients facilities for their escape, and in addition the blocks,
from their faulty construction, afford the inmates ready means for
their self-destruction. This I need not remark is undesirable ; com¬
munication from one block to another is carried on in some cases over
steep, dangerous declivities, rendered more difficult and dangerous
during the rainy season.
“ The two sexes are not sufficiently kept apart. Some of the Male
patients sleep in a block on the Female portion of the Asylum, and
six of the Male Attendants have accommodation provided on the
same section of the Institution. I need not enlarge on the unplea¬
sant results which might follow these faulty arrangements.
“ The Water Supply, which is never abundant, seldom sufficient, is
often so scanty that for days we have not enough water in the Asylum
for cooking purposes. This necessitates water being carried from a
ravine on the mountain side, distant over half-a-mile from the Asylum.
When this dearth of water exists, the daily bathing of the patients,
which is so necessary in this climate, is prevented, and the work in
the Laundry is at a standstill. I may add the same baths and the
same water are used for bathing and laundry purposes. The source
of our Water Supply is situated on the lowest point in the Asylum
premises, the Cook and Bakehouses on one of the highest. It is un¬
necessary to detail the extra labour, &c., thus resulting.
“ The Closet accommodation is most meagre. On the Male side
we have two Closets on the earth and charcoal system for the use of
185 patients ; the Females are equally unprovided for. This I would
simply note as among the very many difficulties with which one has
to contend in administering the Asylum.
“ On the Male 6ide there is Day-room accommodation for about
two-thirds of the patients, on the Female side we have no Day-room.
The meals are served to the Females in a small confined Gallery,
where they while away the tedious monotony of their every-day exis-
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1884.] Psychological Retrospect . 148
tence in ceaseless quarrelling, the result of overcrowding; I have
been speaking of able-bodied. In the Infirmaries, both Male and
Female, the patients are in even a worse condition ; the wards are so
overcrowded as not to admit of tables being used on which to serve
the food ; the patients take their meals in anything but an orderly
manner, and the spectacle presented is not such as one cares to wit¬
ness, so different from what is seen in the well-regulated Asylums in
the United Kingdom.
11 This overcrowding, which has been steadily increasing during the
past year, is now taxing our resources to the utmost; we have 39
patients over our number, and we ought to consider the future, as,
with an increasing population, we must expect an increase of the In¬
sane. I am sorry to report that the overcrowding is affecting the
health of the patients, causing an increase of disease and death, and
we must still further expect an increase of our mortality whilst the
numbers exceed the accommodation.
“We have no airing Courts; in the Home Asylums every section
has its own airing Court, where, under the supervision of the atten¬
dant, a patient may roam at will within its limits. With us patients
are necessarily confined to a certain position, on a certain bench, to
wander from which means to wander from the view of the attendants.
Patients naturally resent being kept in a fixed position, and unseemly
struggles between the attendants and patients frequently ensue, to the
detriment of the patients.
“ When I first took over the charge of this Asylum, scarcely a
patient was employed beyond a few women in the Laundry, and those
of both sexes told off to clean the respective blocks and carry
water. This year I hope, partially, to remedy this state of affairs,
by employing patients at several trades, # such as Tailors, Boot¬
makers, Carpenters, &c.—in fact to make the Institution, as far
as possible, self-supporting. It is by employment, and by employ¬
ment chiefly, that we may hope to render these patients useful mem¬
bers of society. In this direction one’s efforts are unfortunately
limited, owing to the confined site on which the Asylum is erected;
we have a large number of Coolies, both male and female, the
majority of whom might, with advantage, be employed in the culti¬
vation of the land, rearing stock, &c., all of which means of employ¬
ment have been long recognised in the Home Asylums as potent
agents in the cure of Insanity.
“We have little or no amusements for the patients, and dances,
musical entertainments, &c., are almost out of the question, as we
have no suitable building in which such forms of recreation could be
held.
“ One would have to go back forty years in the History of the
Insane to find another such Asylum at Home. I would call His Ex¬
cellency’s serious attention to the pressing necessity for the immediate
construction of a suitable Asylum on a suitable site. To further
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144 Psychological Retrospect . [April,
delay means simply to increase the expenses of construction whenever
it is taken in hand, as our numbers are daily increasing, and, instead
of the Asylum being a Hospital for the treatment of the Insane, it
is rapidly becoming a Refuge for the chronic Insane, the patients
lapsing, owing to the want of means for their cure, into hopeless
forms of Insanity, in which state they will be life-long sources of ex¬
pense to the Colony.”
It is to be hoped that Mr. Seccombe’s energy will overcome the
obstacles which now exist to the proper care and treatment of the
insane under his charge. In this connexion it is unfortunate that
the income of the Colony is at present exceeded by its expendi¬
ture, but he has our best wishes for his success.
4. Oerman Retrospect .
By William W. Ireland, M.D.
Hypertrophy and Sclerosis of the Brain in Idiots. —Dr. Oscar
Bruckner (“ Archiv.,” xii. Band, 3 Heft) has made a curious study
of the symptoms and pathological appearances found in the brain of
an imbecile woman who died in the asylum at Halle. She came of a
family visited by phthisis, but free from any neurosis. She was weak-
minded from birth, began to speak at two years of age, and to walk
about four. She was sent to school at seven years of age, but it was
found that she could not learn. There were no epileptic fits till the
ninth year, when she experienced a very severe one. After this she
had frequent spasms of one or other of the extremities, like the
motions of chorea, accompanied by momentary loss of consciousness.
There was also a jerking character about her ordinary movements,
which had not been noticed before. Her mental powers at the same
time became duller. She was more apathetic and indolent. In a
few years the convulsions ceased, and the mental faculties became
brighter. In September, 1876, after being teased by some children,
she passed into a state of maniacal fury, which necessitated her en¬
trance into the asylum. In a short time she passed into a state of
dementia. She spoke little, would not dress herself or comb her hair,
and was sometimes dirty in her habits. After a year the epileptic
movements returned, and she was shifted into the poor-house as in¬
curable, where she died of phthisis in 1880.
On examination there were found general hypertrophy of the brain
and numerous hard masses of hypertrophy of the neuroglia scattered
over the surface of the cortex, and also affecting the corpora 6triata,
the optic thalami, and the cerebellum. The sclerosed matter was
found to be composed of the connective tissue at the expense of the
nervous elements. Very few vessels were seen traversing the sclerosed
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Psychological Retrospect.
145
1884.]
patches. The fact that this adventitious matter was more abundant
in the frontal gyri (the first and third) and the lower part of the
median and neighbouring frontal convolutions seems to explain both
the diminished mental power and the motor disturbances.
Dr. Bruckner cites a somewhat similar case of Bourne ville’s. This
was an idiot girl, who did not speak, and was paralysed on the right
side. She had frequent convulsions, which commenced with move¬
ments of the muscles of the eyes at the age of fourteen months. At
the end of the second year she had a complete epileptic attack. She
died in the status epilepticus when fifteen years old.
On examination there were found little rounded, whitish, opaque
masses of a greater density than the nervous matter of the cortex,
amongst which they lay, somewhat bulging above the surface—as M.
Bourneville expresses it, a sort of hypertrophic sclerosis of portions
of the convolutions. The left side of the brain was more affected than
the right. The gyri most infiltrated were the first and third frontal,
the two median and the lobulus paracentralis on the right hemi¬
sphere. The second and third frontal and the anterior median gyrus
were the most affected.
Cysticercus in the Brain (“ Neurologisches Centralblatt,” 15th
November, 1882).—Zenker, in a treatise on this subject, has collected
fifteen cases of cysticercus racemosus since the first case was de¬
scribed by Virchow in 1860. Five of them were noticed in the brains
of patients who had died of other diseases, and seven died of the
effects of the parasite, four of these quite suddenly. What the other
three died of is not mentioned. Some of the cysts wanted the head.
These remain sterile. The wall of the bladder is without vessels, and
structureless. In five of the fifteen cases, in which the cysts were
small, there were no cerebral symptoms ; in eight, such symptoms
were marked, though variable in character. In the more decided
cases chronic arachnitis, and following upon that, chronic hydroce¬
phalus. The duration of the disease varies much. In one case the
parasite seems to have remained in the brain for seventeen years. As
long as the cysticercus racemosus remains small its effects may be
unnoticed, but when it increases in size it produces severe functional
disturbances of the brain, sometimes complete amentia, and often
sudden death.
Cysticercus has been found in the spinal cord by Walton, pro¬
ducing symptoms such as appear towards the close of tabes dorsalis.
Cysticercus in the Brain with Insanity. — “ The Irrenfreund,” Nos. 7-8,
1881, contains a description of a patient affected with this rare form
of disease. Miss N., 57 years old, had a hereditary neurosis both on her
father’s and mother's side. She had suffered from hysterical attacks
when young, and when about forty-five from mental derangement for
several years from which she recovered. About two months before
the second attack she was troubled with headache, sleeplessness, and
startings in the limbs, which her medical attendant attributed to
xxx. 10
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146 Psychological Retrospect. [April,
hyperaemia of tlie brain. The appearance of melancholia with delu¬
sions of persecution and hallucinations, and an attempt at suicide led
to her being put under the care of Dr. Claus in the asylum of
Sachensberg.
On admission she was found to have trembling in the arms, and
the right pupil was dilated. There was a moderate degree of ptosis
of the right eye, and hypermetropia of both eyes. The patient saw
a great variety of objects such as threads, pearls, sparks, white bodies
like flakes of snow, and coloured streaks flying here and there. She
often thought she saw a beam which she felt to descend and lie upon
her head. She complained of weakness and giddiness, and was in a
state of deep melancholy fearing for her life. The appetite and sleep
were good ; the bodily functions normal. Hallucinations of bearing
and of touch were soon added. She thought she heard threats and
reproaches from the people around, and held her companions to be
witches. She sometimes said that she tasted poison in her food.
After four months she was sent out of the asylum, but soon had
again to return. It was noticed that the hallucinations were stronger
by lamplight, and were seen more distinctly by the right eye which
was sometimes troubled with nystagmus and with the spasmodic
closure of the eyelid. She described what she felt in the following
manner:—
A pain began in her right eye, the eye ball moved about, then
there was numbness in the head, in the fingers and in the whole body,
with a distressing and indescribable feeling in the head as if she were
losir^ her senses. At another time she felt as if she had got a blow
on the right eye, or as if it would fall out, and there was tenderness
at the point of exit of the supra-orbital and the supra-trochlear nerves.
Coloured forms floated before the eye like balls of flame, generally of
a blue colour. These appearances were sometimes not apparent to
the left eye, though sometimes they were visible to it along with the
right one. Towards the close of her time in the asylum a right
lateral hemiopia was observed. Her intelligence remained good. She
had at an early period of her illness lost the power of writing
correctly; the words came in wrong order, and she could not keep
the lines straight. There was slight paralysis of the face on the
right side. The startings in the muscles of the arms and legs
gradually got worse, passing into clonic spasms which continued for
half-an-hour at a time, so that she would stand up in bed which she
found caused them to cease. At last they passed into regular epileptic
fits with loss of consciousness.
About four months after her first admission there was partial
paralysis of the right arm with diminution of sensibility which lasted
seven weeks. Eight months after, following three epileptic fits, there
was paresis of the left arm lasting several days. The epileptic fits
became very frequent, and she died nearly two years after her admis¬
sion. The brain was found to weigh 1,350 grammes. Scattered over
Digitized by v^ooQle
1884.] Psychological Retrospect . 147
the encephalon were found as many as from three to four hundred
cysts from the size of a pinhead to that of a bean. They were found
to be the cysticercus cellulosus of the taenia solium with four suckers,
and double set of hooklets. Some of them seemed to be undergoing a
process of degeneration. These parasites covered the convexity of
both hemispheres, but were most numerous on the right side. More
than a hundred of them lay on the frontal, parietal and temporal
lobes. On the right floor of the orbital portion of the brain there were
twelve cysts ; on the left there were five. The optic nerves were free ;
but one cyst lay in front of the chiasma. The cerebellum, and outer
surface of the pons, medulla, and spinal cord were unaffected. Some
of the cysts were found imbedded in the grey substance of the hemi¬
sphere, and even a few in the white matter. The parts around the
cysts were hyperaemic, and there was some formation of nuclei ob¬
served through the microscope. There was a cyst in the anterior left
corpus quadrigeminum. Apparently the brain tissue was not much
affected, even in the immediate neighbourhood of the cysts. Dr. Claus
observes that though there were a much larger number of cysticerci
on the right side of the brain, it was not on the crossed side that the
convulsions or paralysis were most marked.
Melancholia, Induced by a Sound in the Ear .—Tuczek has
described (“ Zeitschrift,” Band, xxxviii., Supplement Heft) a case
observed in the clinique at Marburg in which melancholia seemed
to have been induced by a peculiar sound in the ear. The patient
was a lady of twenty-nine who had suffered an abortion with
great loss of blood. The melancholy disappeared after the cause
ceased. The noise in the ear came on suddenly. The patient com¬
pared it to the ticking of a watch or crackling of the finger nails. It
was twice as frequent as the pulse and was synchronous with an un¬
dulation of the external jugular, but was not influenced by the re¬
spiration. The hearing power was not diminished, and the auditory
meatus was found free from any foreign body. The tympanum was
normal. The patient was unquiet and anxious and sought to attract
attention to the distress in the ear. She believed that something was
wrong in her head and slept badly. It being noticed that pressure of
the tympanum against its posterior wall made the noise cease, the
meatus was stuffed, and the sound did not come back when the pad¬
ding was removed. The mental condition straightway improved,
the patient became cheerful and hopeful, sleep returned and her
general health became good. In six weeks she was discharged as
recovered.
I once observed a case of the same kind in a man wounded in the
temporal bone. The sound was like that of the beating of an artery
in the ear, or like the heart’s sounds applied close to the ear. It used
to come on suddenly, sometimes four or five times a day, when the
patient would lie on the opposite side till it went away. It caused
him great distress, and he much feared its coming on ; but there was
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148 Psychological Retrospect . [April,
no melancholia or symptoms of mental aberration. At last he dis¬
covered that it coaid be stopped at once by closing the nostrils and
suddenly taking a deep breath, so as to bring a stream of air through
the meatns to strike against the tympanum. In the same way,
closing the nostrils and making a forcible expiration would bring it
on. It thus appeared to be in some way connected with the con¬
vexity of the tympanum being directed outwards.
Census of the Insane in Prussia (“ Centralblatt fiir Nervenlieil-
kunde,” 15 Sept., 1882).—By the census of 1880, there were found to
be in Prussia 34,309 insane persons of the male sex, and 32,036
females ; 66,345 in all. By the census of 1871, there were found to
be 28,002 males, and 27,041 females; in all 55,043 insane. During
these nine years the number of the insane had increased by 20 per
cent., and the deaf and dumb 18 per cent., while the sane population
had only increased 10*6 per cent. Out of 10,000 persons there
were found to be insane —
Males.
Females.
Total.
1871.
. 23
22
22
1880.
. 25
23
24
Or one insane person—
In 1871 oat of
443
462
448
In 1880 „
391
432
411
This is a much surer way of knowing whether the number of the
insane is increasing than from counting the number of lunatics in
asylums, which is influenced by causes quite apart from the increase
or diminution of the insane in the population at large ; 28*6 of male
lunatics, and 28*3 of female ones were in asylums in 1880. The
number cared for in these establishments seems to have a connection
with the material well-being of the different districts.
It was found in the census that 9,809 males and 7,827 females
were born insane, 17,636 in all; and 16,088 males and 16,277
females, 32,365 in all, had become insane afterwards, while this
point could not be determined in 8,412 males and in 7,932 females
=16,344. The reporter does not tell us whether idiocy in Prussia is
increasing or not, though he leaves the inference that it is increasing.
As regards the age of those affected with insanity, there were in
1880:—
Males. Females. Total. In 10,000. In 1871.
Under 15 years . 4,038 3,110 7,148 7 3 per cent. 7*7 per cent.
15_60 years . 22,485 19,601 42,086 31*2 „ 29*9 „
Over 60 years. 7,313 8,686 15,999 38 6 „ 310 „
Unknown. 473 639 1,112
Of 10,000 persons professing the Evangelical religion, 24*1 per
cent, were insane ; of the Catholics, 23*7; of the Jews, 38*9 ; and
of members of other religions, 18 per cent. Of 10,000 persons the
Evangelists counted 9*80 per cent, deaf and dumb, the Catholics 10*39
per cent., and the Jews 14*38. Hereditary neuroses seem thus to
be commoner with the Israelites.
Digitized by <^.ooQLe
1884.] Psychological Retrospect . 149
Statistics of Epileptics in the Rhine Provinces .—A statistical table
has been made, which is interesting, as it distinguishes the number
of the sane and insane among epileptics. It is as follows :—
Department.
.8
.2
p*
W
(h £
© 3
T3 ©
p *
.
mB
> ©
6 *
si
P<
4
&
1
„ a
1 I
d
Mental state
deranged.
Aix.
687
78
609
87
600
528
159
Coblenz...
635
72
563
179
m
478
157
Cologne.
560
94
466
74
486
425
135
Diisseldorf .
1,048
136
912
209
839
808
240
Tr&ves ..
530
83
447
79
116
Total number of epi- J
leptics . j
3,460
463
2,997
628
2,832
2,653
or 76*7
per cent.
807
or 23*3
per cent.
Agricultural Colonies for the Insane .—At a meeting of the Medico-
Psychological Society at Carls ruhe (“ Zeitschrift, ,, Band xxxix., Heft
1), Dr. Landerer, of Goppingen, gave an account of the colony of
Freihof which has now lasted fifteen years. Those lunatics thought
fit and able to work lived in a separate house not quite a mile from the
asylum, and under the same management. They cultivated 90 hectares
of ground. He had from 30 to 36 labourers out of 350 lunatics, a
small proportion. He calculated that 200 lunatics were worth 50
sound labourers. Acute and troublesome cases of lunacy were not
employed. The care of cattle was found the best and most profitable
occupation. He recommends a hop garden as giving a profitable em¬
ployment to many hands. After the discussion on Dr. Landerer’s paper
Dr. Riegen gave an account of what he had seen of the insane colony
at Fitzjames, at Clermont (Oise).
Hyoscyamine in Insanity (“ Zeitschrift,” Band xxxix., Heft).—Dr.
Kretz has used this drug, originally brought into notice by Dr. Lawson,
in many cases at the Asylum of Illenau. Merk’s Crystalline prepara-
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150 Psychological Retrospect . [April,
tion was the form employed; the dose 0 01 of a gramme twice a day.
The highest daily dose was 0 03, the highest dose given was 0*05. It
was sometimes given in the form of subcutaneous injection. Dr. Kretz
finds the following symptoms accompany the administration of hyo-
scyamine: A feeling of tightness and oppression in the chest, with
difficulty of breathing, a diminution in the powers of vision so that
they are less able to read or do fine work, and an unpleasant feeling of
itchiness in the skin and dryness in the throat accompanied with numb¬
ness, giddiness and tendency to stumble. On observing the patient
closely it is found that the frequency of respiration is diminished ; but
from five to ten minutes after the dose the respiration becomes more
frequent and slowly returns to the normal standard. In like manner
the pulse becomes slower, weaker and smaller, then it becomes more
frequent, returning after several hours to its usual rate. The dila¬
tion of the pupil becomes visible in about ten minutes. In some
cases there was a haze before the eyes ; in one the patient saw red and
yellow ; in another the haze took the form of spectres and devils on
which account the hyoseyamine was stopped.
Dr. Kretz thinks that it should not be used when there are hallu¬
cinations. He has given it continuously for five months in doses of
0*01 without injury to the general health. He points out that hyo-
scyamine has both a hypnotic and a calmative effect. It acts both
upon the sensorium and on the motor and sensory nerves. The
danger of over-doses of the drug consists in failure of the heart’s
action. Dr. Kretz considers that it acts most favourably where the
symptoms of motor restlessness are prominent. It is also useful in
soothing maniacal excitement, in chronic mania, and in fits of periodic
and circular exaltation.
5. French Retrospect .
By Dr. T. W. Me Do wall and Dr. D. Hack Tuke.
{Concluded from Yol. xxix., p. 598.)
Compulsory Feeding . By Dr. E. R^gis.
The author appears to be excessively afraid of the dangers attend¬
ing the passage of the oesophageal tube. To obviate the risk of
pouring broth into the trachea and lungs he has invented a tube so
arranged that, if by any chance it did get into the wrong passage, the
operator would discover his mistake by producing temporary asphyxia.
To anyone as nervously anxious as Dr. Regis we would recommend a
trial of the instrument, though we are honestly of the opinion that
an ordinary tube can always be passed with perfect safety if proper
care be taken.
In many cases of refusal of food there is marked derangement of
digestion. To cure this condition Dr. Regis recommends the washing
out of the stomach with water or some alkaline fluid, such as Vichy
Digitized by <^.ooQLe
1884.] Psychological Retrospect. 151
water. It is quite possible that in some cases such treatment may be
found useful. As to the method in which it should be performed, we
would not advise anyone to follow exactly the author’s method. He
begins by withdrawing the acid fluid from the stomach. It would be
much safer to inject some tepid water first. All risk of injuring the
mucous membrane is then avoided ; for should the pump be used
when there is no fluid in the stomach, the mucous surface can scarcely
escape being injured.
As to the substances which should be used in artificial feeding, the
author believes that the addition of peptones to those ordinarily used
will be of great value. His experience leads him to believe that
these highly nitrogenous matters will be readily absorbed by even the
most disordered stomachs.
Clinical Cases .
I. General Paralysis in an Imbecile, The symptoms observed
during life, and the lesions found post-mortem, leave no room to
doubt that it was a genuine case of general paralysis. It is not by
any means as clear that he was an imbecile. The patient’s mother was
insane. He was born in 1824, became maniacal in 1855, and re¬
mained at Charenton till 1860. In 1856 he had a single attack of
cerebral congestion. In 1878 he again became excited. He had re¬
peated attacks of cerebral congestion and died of well-marked general
paralysis. During the whole of his asylum life he was described as
weak-minded.
II. General Paralysis. Recovery ? The author, M. Mabille, con¬
fesses that the case is one of remission of the symptoms, not of
genuine recovery. Benefit seems to have followed the use of pro¬
longed baths and setons.
III. Hallucinations in an Old Blind Man who had been Operated on
Twice for Cataract .
The patient is an old man, 83 years of age, in good health. He is
quite aware of the nature of his attacks, which as ju.rule last about
two days and a night, during which time he cannot sleep.
During the attacks he sees himself surrounded by figures which
approach him armed with daggers, but they never strike or lay hold of
him. Sometimes he seizes the daggers and easily breaks them. One
day he fell asleep after an attack with five daggers close to his throat,
but without feeling anything. He often sees his bed filled with men,
and this explains why he refuses to go to bed when he is suffering
from his hallucinations. He has also seen himself surrounded by
precipices.
In the intervals between these attacks he has sometimes hallucina¬
tions of a different character. He sees, for example, a table on his
bed, and several people about to dine at it; he takes cakes and carries
them to his mouth, but in doing so he feels nothing in his hand and
tastes nothing. T. W. McD.
Digitized by v^ooQle
152 Psychological Retrospect. [April,
Archives de Neurologic; sous la direction de M. Charcot, 1888.
This excellent journal continues to be conducted with the same spirit
which characterised its first appearance. It is frequently enriched
with finely executed plates representing pathological changes, as in
the number for May, 1883, in which a case of tubercular meningitis
of the ascending frontal and parietal is represented, illustrative of
the motor centres of the brain. In the same number is a continua¬
tion of the series of articles by MM. Charcot and Paul Richer (of
which we have given a summary in a previous number) on the study
of Hypnotism in Hysteria, with especial reference to the phenomenon
of neuro-muscular hyper-excitability. Three propositions are main¬
tained in this paper, viz.: 1. This phenomenon is reflex in character.
2. Its nature is founded upon a special modification of the activity of
the central nervous system. 3. The centripetal course of the reflex
arc differs from that of the cutaneous sensitive nerves. It is in the
subjacent parts that these nerves must be found. It has been
proved by Sacs and others that there exist in the tendons and the
aponeuroses of the muscles, centripetal nerves which play a special
rSle in muscular tonus and the functions of the muscular system. The
authors think it rational to suppose that these are the special sensi¬
tive nerves through which the afferent influence is conveyed. Thus,
when a tendon is tapped, its own nerves are directly involved ; if a
muscle is struck, the sensitive nerves of its aponeurosis or the muscle
itself are excited to action. When pressure on the ulnar nerve causes
in the lethargic stage of hypnotism contraction of the hand and fore¬
arm, this is not due to the direct mechanical excitation of the motor
filaments of the ulnar, but to its sensory filaments, through which the
action is transmitted to the medullary centre and thence reflected
along the motor filaments to the muscles it supplies.
L'Encephale ; sous la direction de MM. Ball et Luys. 1883. Many
articles of interest appear from time to time in L'Encephale, among
which, in the number for August, 1883, is a paper by MM. Ball and
R£gis on the Families of the Insane, being a contribution to the
Study of Heredity. Great labour has been bestowed on this investi¬
gation, and with valuable results. We summarise what the authors
say about general paralysis. These statistics demonstrate that it is
not an insanity, and ought not to be classed among mental affections,
for it does not originate like them in insanity, and does not engender
it. On the contrary, like cerebral disorders not involving insanity, it
arises from and propagates these cerebral disorders. It results that
general paralytics belong, not to insane families, but to families prone
to cerebral affections other than mental; that general paralysis, when
hereditary, is not so quoad the insane element, but the cerebral one,
or, as M. Doutrebente says, there is an hereditary tendency to (cerebral)
congestions; that consequently general paralytics do not transmit in¬
sanity to their offspring, but head affections of various kinds ; and
that hence the family of a general paralytic would be prone to the
Digitized by <^.ooQLe
1884 .] Psychological Retrospect. 153
cerebral disorders of childhood and advanced life. Passed the critical
period of infancy, such children manifest cerebral excitement in the
form of extraordinary intelligence, and, if they survive to maturity,
astonish the world by their brilliancy.
Bulletin de la Societe de Medicine Mentale de Belgique. 1883.
This journal, and the Society, maintain their activity. Number 31
contains an important article of 43 pages on the Classification of
Mental Disorders, by M. Jul. Morel, the President of the Associa¬
tion. He passes in review a large number of classifications, and
ends in adopting, with certain modifications and additions, the prin¬
ciples followed by Guislain in his well-known nosology. Dr. Morel’s
article should be read by all interested in the classification of mental
disorders.
Rapport d VAcaddmie de Medicine sur les Projets de Rdforme Relatifs
d, la Legislation sur les Alienes au nom d'une Commission , com¬
posed de MM. Baillarger , Brouardel , Lunier , Lugs, Mesnet , et
Blanche , rapporteur. 1884.
This u Rapport” was read by Dr. Blanche to the Academy of
Medicine on the 22nd of January. Among other matter it contains
a flattering reference to Broadmoor, and the hope is expressed that
France will soon have its Broadmoor also. Ten propositions close
this carefully prepared address, which, coming from a mental phy¬
sician of Dr. Blanche’s experience, will no doubt exert much influence
in the deliberations of the Senate on the important question of a
change in the French Lunacy Law, which now excites so much in¬
terest across the Channel.
D. H. T.
PART IV.—NOTES AND NEWS.
THE MEDICO-PSYCHOLOGICAL ASSOCIATION.
The Quarterly Meeting of the Association was held February 5th, 1884, at
Bethlem Hospital, at 4 p.m., Dr. Orange, President of the Association, in the
chair. There were present—Drs. S. H. Agar, A. J. Boys, R. Baker, P. E.
Campbell, Fletcher Beach, J. E. M. Finch, J. R. Gasquet, W. R. Huggard,
H. Lewis, H. Rooke Ley, C. Mercier, G. E. Miles, P. W. Macdonald, W. J.
Mickle, J. H. Paul, H. Rayner, J. B. Spence, H. Sutherland, A. H. Stocker,
D. Hack Tuke, D. G. Thomson, L. A. Weatherly, E. S. Willett, T. 0. Wood,
&o., &o.
At the commencement of the proceedings, the President referred to the
death of Dr. Parsey, Medical Superintendent of the Warwick County Asylum
at Hatton, remarking that Dr. Parsey had been President of the Association in
1876; and also that he had completed a longer term of service at one asylum
than would probably fall to the lot of many then present. Dr. Parsey went to
Hatton in 1852, being the first superintendent of that asylum, and everyone
who had visited that asylum knew to what a reputation it had deservedly
attained under Dr. Parsey’s management. There was one respect especially in
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154
Notes and News.
[April,
which the good work done by Dr. Parsey had often come prominently under hi*
(the President's) notioe, and that was in regard to persons charged with offences
who were suspected to be of unsound mind. In a recent contribution to the
Journal, Dr. Hack Take, in mentioning the various places where things were
satisfactorily done, had occasion very particularly to mention Dr Parsey’s
county, recognising that the County of Warwick was especially fortunate
in possessing an officer who made his experience available for the county
magistrates and others in connection with the gaol. The President then
proposed that a resolution of condolenoe should be oommunicated by the
Secretary to the family of Dr. Parsey.
Dr. Micxlk, in seconding the motion, said that he had been under Dr. Parsey
for some time, and had had the opportunity of becoming acquainted with his
great ability and his very great kindness. He had learnt from that gentleman
much that was now of great advantage to him, and he oould testify as to the
thorough manner in which Dr. Parsey had attended to his duties and the kind¬
ness he had always shown to his patients.
The resolution was unanimously adopted.
The following gentlemen were elected members of the Association, viz.:—E.
B. C. Walker. M.B., C.M.Edin., Assist. Medl. Officer, County Asylum, Hay¬
wards Heath; Dr. Thomas Draper, District Asylum, Enniscarthy, Ireland;
Dr. 0. Theodore Ewart, ALB.Aber., C.M., Assist. Medical Officer, Fisherton
House, near Salisbury; Wm. Milsted Harmer, F.R.C.P.Ed. Physician Supt.,
North Grove House Asylum, Hawkhurst, Kent.
Dr. Savage read a paper on “ Constant Watching of Suicidal Cases.’ 1 (See
Original Articles, p. 17).
Dr. Rayner said that the question introduced by Dr. Savage was a very
interesting one, both theoretically and practically. He agreed with Dr. Savage
in a very great measure in regard to the watching of suicidal patients. He
thought that they should not look at the mere prevention of suicide. If they
were fortunate enough to escape suicides they ought to make themselves very
happy in their good luck, but it was not a thing to pride themselves upon.
Greater results would be obtained by treating the mental state upon which
suicide depended, rather than the suioidal impulse. It was quite possible to
deyelope and encourage a suicidal impulse. By too much attention this might
be developed and cultivated just in the same way as refusal of food. In cases
of simple melancholia, with suicidal tendency, he had found frequently that it
had subsided with rest, just os in the case of refusal of food. When the
patients had well rested and had begun to gain flesh he tried to get them up
and out, and he relied a great deal upon the effect of fresh air. As regards
the watching, the less the patient was irritated by the means adopted the
better. In quiet cases he (Dr. Rayner) simply put the patient into a small
dormitory of four beds in the Infirmary, which was not under constant but
under frequent supervision. Beyond that, Dr. Rayner had no very special
provision for suicidal cases, and yet he had been very fortunate.
Dr. Ley said that he thought that the majority of suicides did not occur from
actively suicidal patients, but from those who had not been suspected. Patients
could be as well watched in a single room with an opening through which the
night attendant could see in as in an associated dormitory. Probably the
reason why the Commissioners in Lunacy laid so much stress upon patients
being watched at night was that they thought— and, he thought, very justly—
that all patients should be watched at night, and that the number of night atten¬
dants should be increased much more than they were at the present time. A
great deal was done in the daytime, but very little in regard to night super¬
vision. Many bad practices might be remedied by a better supervision at
night. With regard to the use of associated dormitories, there might be some
difficulty in the case of a male patient, but women did not mind them half so
much as men.
Dr. Hack Tuke enquired of Dr. Ley whether the bright light thrown into the
Digitized by v^ooQle
Notes and News.
155
1884.]
room through the slit referred to had been found to interfere with the patients
comfort or sleep.
Dr. Let said not at all.
Dr. Finch referred to the fact that the Commissioners , Report usually con¬
tained some reprimand that such and such a case had committed suicide, although
he was to be “ constantly watched.” If what was thus implied by the Com¬
missioners were actually carried out, it would make life perfectly miserable.
With respect to light cast into a room through a slit in the door, he might quote
the case of a suicide occurring where there was a very careful night-nurse, who
went into the room every half-hour, and, although the patient had committed
suicide, the nurse thought her still asleep. The patient had strangled herBelf
with a portion of her night-dress, and when he (the speaker) saw her, although
she had then been dead more than an hour, she had still every appearance of
being asleep.
Dr. Huggakd enquired as to the means of restraint referred toby Dr. Savage.
He also referred to one of the answers to the CommissionerB , circular, which
stated that, in the experience of the correspondent, suicides were invariably at
night. Was that the experience of most of the members ? No doubt a great
deal of watching did harm ; at the same time little watching might be as ob¬
jectionable, and might lead to suicides.
The President said that the object of any well-regulated system was that
there should be adequate supervision without making the patient unpleasantly
aware thereof. It was unquestionably desirable that the treatment should not
impair the chances of cure, but a patient could not be cured if not kept alive.
He was glad to hear Dr. Rayner say that he treated suicidal patients in bed.
He had done that himself for many years, and his infirmary wards were, as
much as possible, like hospital wards. So far from objecting to the recommen¬
dations made by the Commissioners in Lunacy in the direction of increasing the
number of attendants on duty by night, he always hailed their recommendations
with unfeigned delight, for he felt sure that enough had not been done in regard
to night supervision. The patients who were sent to the asylum with which he
was connected, were patients who required special watching, and, therefore, a
larger staff was required. They had, therefore, at all times, twelve attendants
upon duty during the whole of the night, those attendants doing no work during
the day. They patrolled the ordinary wards at frequent intervals, whilst the
infirmary wards were never left either night or day without someone on duty.
The patients, therefore, did not think they were especially placed there to
be watched as suicides. Any kind of watching which tended to impress this
upon the patient was, as Dr. Savage had so well pointed out, injurious.
Dr. Savage, in reply, said as to night supervision, of course the most perfect
asylum would be that where watching was so automatic and well arranged as
to be unobserved by the patient. He approved of the infirmary treatment if
it could be a combination of the infirmary treatment with the single room treat¬
ment, and, at all events, he should be happy to try the effect of putting suicidal
people to bed. The strong clothing to which Dr. Huggard referred was not a
“ straight jacket.” The garment was—well, it was a combined garment,buttoned
down behind—without gloves, which were not usually put on unless the patient
endeavoured to gouge out his eyes or otherwise maltreat himself. The sheets
were of the same strong material, so that, except with the aid of his teeth, the
patient could not tear it. He had had several patients who had attempted to
commit suicide just as they were beginning to mend, and there were many
cases where suicide was not suspected until it took place. It was a question
whether the more determined suicidal cases would not be more dangerous by
day if as strictly watched by night.
Dr. Gasquet read a paper on “ Some of the Mental Symptoms of Ordinary
Brain Disease.” (See Clinical Notes and Cases.)
The President asked in how many cases there had been a post-mortem ex¬
amination P
Digitized by <^.ooQLe
156 Notes and News. [April,
Dr. Gasquet replied in three of them ; he had mentioned that in whioh it waa
omitted.
The President enquired whether there were adhesions of the membranes ?
Dr. Gasquet said there was an absence of adhesion or the nsnal physical signs
of what was known as general paralysis. In reply to Dr. Savage, he said that
the case of disseminated sclerosis was 52 years of age.
Dr. Savage said that it struck him that that was rather an advanced
age. The only case he had seen at Bethlem was that of quite a lad. The points
were of great importance. Were they to have any touchstone which would
enable them to say—“ That is not a case of general paralysis ? ” In regard to
exaltation of ideas, where the patients had a feeling of well-being, they seemed
to live from moment to moment—he believed they had no memory of what
they had been—but Dr. Mercier would, he hoped, give his view of what the basis
of exaltation was in the two cases—the one who was degenerating and losing
self-control, and the other who, with a sudden blow, as it were apoplectic, was
at once reduced to that condition of restless exaltation. There was one patient
then at Bethlem about whom they had doubts. Dr. Hack Tuke said—•“ Well,
what right have you to consider this case one of general paralysis rather than
one connected with arterial changes." My opinion was given in favour of
general paralysis because of the rapid and complete recovery after each fit.
I have had one general paralytic who, for a long time, although he was a doctor,
did not appreciate that he was in any way paralysed, but when later he got dis¬
tinct signs of paralysis, he shook his head and said—“Well, I am paralysed
now 1 ” and recognized the fact, although he did not do so before. At present
they had been taking hold of the two ends of a stick and attempting to bring
them together.
Dr. Mercier said that in regard to delusions of grandeur associated with
brain disease he might say that so far as he knew they were not able to give
any explanation, but there was a clinical entity which they termed general
paralysis, and in that clinical entity several definite symptoms were associated,
but here and there they found cases in which one symptom or other was absent,
and then there was another set in which the remaining (exaltation) was absent.
Probably the cases quoted by Dr. Gaequet were cases of what the French called
megalomania, and in ordinary cases of megalomania they would often find gross
lesion of brain substance similar to what Dr. Gasquet mentioned.
Dr. Hack Tuke said that he could not help thinking that ideas of grandeur
might be associated with some morbid condition of one part of the brain rather
than another and not be merely a consequence of the loss of control exercised
by the supreme centres in health. Inability to compare the present condition
with the past—loss of memory—arose in cases of ordinary dementia ; but there
was something special in cases of general paralysis with exaltation and of
megalomania, and he thought that common to them all there might be some
lesion locally different from that which took place in other cases.
Dr. Mickle said he thought that the question raised by Dr. Gasquet as to the
existence of delusions of grandeur had been decided in the affirmative. The
existence of delusions of grandeur, simply defined as delusions of grandeur,
would apply to a very large number of cases of insanity which had nothing
whatever to do with general paralysis; and even if they left out the systema¬
tized delusions of grandeur—even if they took into consideration only the
delusions of grandeur of the same kinds as were found in general paralysis—
they found them in a great many forms of brain disease. The very first case
mentioned by Dr. Gasquet (multiple sclerosis), was, as regards its mental
symptoms, the same as one of the very first cases of multiple sclerosis
described in medical literature, which case had delusions of grandeur very
much like those described. As regards the second case described, it struck
him that the case, after all, was perhaps one of general paralysis, but of course
in the absence of a post-mortem a definite conclusion could not be come to.
With reference to the second question, as to whether delusions of muscular
Digitized by <^.ooQLe
Notes and Nens.
157
1884.]
strength were to be associated with general paralysis, he thought they might
answer that in the negative. Many cases had not only no delusions of muscular
strength, but they had delusions of muscular feebleness. Many general paralytics
had the idea that they were extremely small and feeble, and that their muscular
power was less than it really was, and this sometimes with exalted delusions
on other subjects.
The President adverted to the double sort of nomenclature running through
the matter under discussion. In one case megalomania was spoken of, and in
another general paralysis. One referred to mental symptoms and the other to
bodily symptoms; and it must always be open to doubt whether the term
“ general paralysis ” ought to be used to describe a definite form of mental
disease.
Dr. Gasquet said that he did not think that Dr. Mickle had quite apprehended
his second question, which was not whether general paralytics had no delusions
of strength, but rather whether other cases, not general paralytics, who had
delusions of grandeur usually exhibited no delusions of strength.
In the absence of Dr. Major, Dr. Hack Tuke read a paper which had been
forwarded by that gentleman : “ The Results of the Collective Record of the
Causation of Insanity.” (See Original Articles.)
The President said that they all regretted that Dr. Major was not able to be
present. He had no doubt that some useful and interesting observations would
be made. In discussing this paper, upon which Dr. Major had bestowed great
industry, much might be said upon each individual point; but looking at the
matter broadly, it was obvious that there were two distinct modes in which the
preparation of the table might be undertaken. One method consisted in ascer¬
taining as far as possible the number of instances in which any particular factor
which might be regarded as a cause of insanity had occurred ; then tabulating
the results, then adding up at the end the number of cases treated, and then
showing in how many cases certain factors were present. This might be termed
the mechanical or self-registering method. The other method might be termed
(as opposed to the first) the “ human ” method, and in pursuing this method it
was intended that each person who made an observation should bring his own
judgment to bear upon it. He supposed that was the method chiefly adopted,
and he was sure it was one from which an immense amount of good might be
expected. If no cause could be assigned one must say so: but if each individual
observer would weigh all the facts and then record what he thought was the
probable cause he felt perfectly certain, that taking into consideration the
number of highly skilled observers, there must be a good result.
Dr. Huggard said that he mn$t confess that he could not altogether agree
with some of the conclusions which were drawn from the tables in question.
Although the facts stated by the Commissioners were extremely interesting,
he thought that drawing an inference was a much more complicated matter
than appeared at first sight. The figures which Dr. Major laid before them in
his appeal to the sceptic, did not appear to him to possess any cogency at all,
and his conclusions from the frequency of the so-called causes, were open to
question; in faot it would seem that the whole paper was really lodged upon
fallacy, regarding the post hoc for the propter hoc . Causation must be arrived
at from comparison and not from simple observation, otherwise, it was im¬
possible to say which was the cause and which only an ordinary antecedent.
He did not think the table could be called a collective record of causation ; at
the same tin\e the paper was a very interesting one, and there was a good deal
of suggestion in it, although it did not proceed upon a record which was cal¬
culated to lead to altogether trustworthy results.
Dr. Mercier said that he could quite agree with what the President had
said as to the industry bestowed upon the paper, but he must also agree with
Dr. Huggard as to its value. He believed the conclusions given in the paper to
be absolutely worthless, being founded upon data that were utterly untrust¬
worthy, unreliable and invalid. To set down causes of insanity as they were
Digitized by <^.ooQLe
158
Notes and News.
[April,
set down in the table of the Association appeared to him an unwarranted
assumption. “ Antecedent circumstances ” were as much as we could dare
to say; contributory circumstances even we might venture to speak of, but
certainly not of causes. What were the sources of the statements found in
the tables? They were got from the statements of relieving officers, of
patients’ relatives and of the patients themselves. What was the value of a
scientific conclusion founded on the statements of lunatics ? All the state¬
ments as to cause were obtained from people who were unintelligent, unedu¬
cated, and had received no scientific training. It was characteristic of such
people that they would find some cause or other for every occurrence, quite
apart from any evidence of the existence of a causal relationship. Even
educated people of some intelligence attributed changes in the weather to
changes in the moon, when the most superficial observation would show that
there was no connection between them. They had all heard of the gentleman
who noticed an unusually large number of snails in his back garden in the same
year that York Minster was on fire, and who discerned a causal relationship
between the two events. He thought that the statements as to the causes of
insanity found in their tables had a validity about equal to that of the case he
had mentioned. The speaker then went seriatim through the table, showing
the sources of fallacy that, in his opinion, vitiated each of the statements
therein; pressing with special insistance upon the headings of Drink, Epilepsy
and Previous Attacks. Dr. Major had laid stress upon the greater frequency
of drink as a cause of insanity in males than in females. It might be so, but
we could not safely infer it from the tables. One source of fallacy was the
freedom with which men admitted the charge of intemperance as against
the reticence of women. He referred to a case in which a woman, the keeper
of a station restaurant, was admitted suffering from what was manifestly and
unquestionably delirium tremens. She denied that she ever touched liquor;
her husband denied it; her brother denied it; her sisters, and her cousins, and
her aunts denied it; yet the woman was unquestionably and indisputably a
drunkard. If pregnancy, lactation, and the puerperal state were true causes of
insanity, how were they to account for the millions and millions of women who
underwent their experiences without becoming insane. If epilepsy was a
cause of insanity, what were we to say of those numerous cases in which the
insanity precedes the epilepsy. When previous attacks were alleged as a cause
of insanity, it was only the respect he entertained for the gentleman who drew
up the table, that withheld him from calling the statement absurd. He might
as well call yesterday’s dinner the cause of to-day’s. If a previous attack was
the cause of a present attack, it would be equally reasonable to say that an
initial attack was the cause of a relapse, or that an outbreak of insanity a
fortnight ago was the cause of the patient getting worse now. In his opinion
the proper treatment of this table of causes would be to convert it into a
tabula rasa f and that they should substitute for it a table of antecedeut
causes probably contributing to the attack; but that they should not arrogate
to themselves a knowledge of causes of insanity of which, as yet, they were
almost wholly ignorant.
Dr. Savage quoted Griesinger as an authority for the use of the word
cause, although perhaps it could only be considered so in a slight sense
of the word; and he thought it would be a good thing if they took Dr.
Mercier’s advice, and were more cautious in the use of the language they used
in their tables. Possibly the tables might be improved. The word “ cause *
might be a mistake as it was at present used, and it might be better if they
used the word “ condition,” but the word 44 cause ” in a certain sense would
have to come in. Even Dr. Mercier made use of it before he sat down, saying
44 antecedent causes.”
Dr. Hack Turk explained that the setiolcgical table adopted by the
Association, was simply that already in use by the Lunacy Commissioners in
their Annual Report. The Statistical Committee, while aware of its imperfec-
Digitized by <^.ooQLe
Notes and Nervs.
150
1884.]
tion, could not agree upon one so much better as to justify them in giving
Superintendents of Asylums the trouble of preparing two tables, where
one would suffice. In regard to the general question, he thought they were
constantly confounding two things which were totally distinct. Take intem¬
perance for instance. One question was, if a hundred males and a hundred
females were subjected to the action of alcohol, in excess, would one sex be
more liable to become insane under its influence than the other P The other
question was (and the object in asking it was entirely different) were men or
women more frequently made insane through intemperance P Their statistics
showed that many more men went insane from this cause, or he supposed he
must say, “ contributory circumstance” or ** antecedent condition,” for they need
not quarrel about the particular term used. But though men were more fre¬
quently made insane by drink than women, it by no means followed that this
indicated the relative liability of the male and female brain to alcoholio in¬
sanity. It might only show that one sex was more exposed to the tempta¬
tion to drink to excess than the other. He (Dr. Tuke) only mentioned this as
one instance of the confusion of thought constantly fallen into. Both ques¬
tions were important. If our tables Bhould show in the future an increase of
alcoholic insanity among women, it would be an important fact, having a prac¬
tical bearing upon intemperance, for they would strive to remove as much as
possible the antecedent condition. He (Dr. Tuke) had himself made some in¬
vestigations on a tolerably large scale in 1857, as to the influence of
intemperance on insanity, and he had placed it at about 13 per cent.,
at a time when 50 per cent, was frequently spoken of as the proportion. The
tables of the Commissioners placed it at about 14 per cent., and some enquiries
carried on at Wakefield, pointed to 15 per cent. Such an amount of uniformity
in the results when independent and careful researches were made, showed that
valuable and approximately correct conclusions were possible, and that was all
he contended for. The other day, a patient was admitted into Bethlem
Hospital, the canse of insanity assigned being the change in the weather.
But do we find this cause put down in 14 per cent, of the admissions into our
asylums ? There is then a limit to absurd statements as to causes, and we
must look to the broad results. When Dr. Mercier argued that in consequence
of the loose statements about the influence of puerperal conditions in relation
to insanity, they could not be accepted, this seemed, if he might say so, a re-
ductio ad absurdum , for it was carrying scepticism to such an extent, that we
were led to ignore one of the most certain causes of insanity. No doubt some
of the criticisms made by Dr. Huggard and Dr. Mercier had force, and es¬
pecially would it be desirable to collect statistics showing the degree in which
the causes of insanity might be in full force without any of their supposed
effects being witnessed, so as to avoid the post hoc fallacy. Still he (Dr. Tuke)
was strongly of opinion that there was a great gain from this setiological
enquiry, and he had hoped that the sceptics would have been more convinced
than they had been by Dr. Major’s valuable paper.
The Pbesfdent congratulated the meeting upon the interesting discussion
that had been provoked by Dr. Major’s paper. They were especially indebted
to Dr. Mercier for the spirit and life that he had infused into the discussion.
Dr. Mercier had been very clear and decided in the judgment passed by him.
He (Dr. Meroier) had no doubt at all that the table of causes should be
a tabula rasa . The fact that the table provided under the heading “ un¬
known,” a haven of refuge for cases of insuperable difficulty, did not propitiate
Dr. Mercier. Nothing would suffice short of an absolutely clear sheet. But
when Dr. Mercier came to give his reasons, in some detail, for the heroic
treatment recommended by him, it became clear that Dr. Mercier would
himself become, in future, a most trustworthy contributor to the table. After
enumerating the difficulties besetting the path of the observer, he gave us
an instance, that had occurred in his own practice, in which the most ingenious
attempts had been made by the relatives of his patient to deceive him as to
Digitized by <^.ooQLe
160
Notes and Nms,
[April,
the cause of her malady, but, in which, his skill and acumen enabled him to
expose the intended deception, and to fasten securely upon a very definite
cause. It was the case of the keeper of the station restaurant. Her sisters
and her cousins, and her aunts had all protested that from the day of her
birth she had never touched anything but the purest filtered water; and yet,
when Dr. Mercier set himself to examine into the case, he tells that he had
not a shadow of a doubt that the woman’s condition was caused by drink. Now
here was at least one good and thoroughly trustworthy observation. Let not,
therefore, Dr. Mercier leave his table an entirely blank sheet. Let him, if he
feels constrained so to do, place all his other cases under the heading “un¬
known,” but let him at least place this one well observed case, boldly down in
the centre of the sheet under the cause brought to light by his careful
inquiries. By degrees other equally well observed oases will accumulate
around this nucleus. The number of cases under the heading “ unknown ”
will gradually diminish; and the table, instead of being a tabula rasa , will
become, on leaving Dr. Mercier’s hands, a valuable contribution to science. By
the care taken in proving that one case that he had related, Dr. Mercier had
shown himself to be largely endowed with the qualities of a good observer,
able to draw a sound conclusion from the facts presented to him. Let not,
therefore, his diffidence prevent him from recording his conclusions in the
table for the benefit of others (laughter and applause).
The President then proposed a vote of thanks to the Treasurer and
Governors of Bethlem Hospital for kindly allowing the use of the room,
and begged Dr. Savage to favour the Association by conveying the vote.
The proceedings then terminated.
A Quarterly Meeting of the Medico-Psychological Association was held at
the Royal College of Physicians, Edinburgh, on Friday, 16th November, 1883.
Present: Drs. Rorie (chairman), Blumer (New York), Clouston, Urquhart,
Turnbull, Yellowlees, Ronaldson, Clark, McPhail, Mitchell, Ireland, Johnstone,
Rutherford, Ac.
Dr. Campbell Clark read a paper on “ The Special Training of Asylum
Attendants.” (See Original Articles, Jan., 1884).
The Chairman stated that this was not a new departure. It was begun by
Dr. Browne when physician to the Crichton Royal Institution nearly 40 years
ago. He delivered courses of lectures to his attendants which were still well
worthy of study by members of the specialty. Dr. Mackintosh at Gartnavel
many years ago also instructed his attendants to take notes of cases, to observe
the state of the tongue and pulse, to pass the catheter, Ac.
Dr. Clouston said that Dr. Clark in his able paper had awarded him too
much praise. Dr. Browne was undoubtedly the first who moved in the im¬
portant direction of giving systematic training to attendants. He however
had written a paper on the subject, and had sent circulars to the Royal
Asylums, which, having funds at their own disposal, were better able to
initiate a scheme for the training of attendants, but it came to nothing. It
had been reserved to Dr. Clark, a former member of his staff, to solve the
problem by putting into practical form a scheme of which all must approve in
principle, and many doubtless would put into practice. Dr. Clark had done
him the honour to ask him to look over the papers written by his attendants,
and he had seldom been more surprised than to find ordinary asylum attendants
giving almost as good an account of cases of hallucinations and delusions and
arriving at conclusions as sound as any ordinary medical attendant could have
done. These papers were not speculative in character, but correct statements
of actual fact. He mentioned as supplementary to Dr. Clark’s paper that when
reorganizing the female hospital at Morningside, he determined that all new
attendants should pass through it, and be taught the nursing of the sick. For
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161
1884.]
the first three months they were taught the nursing of bodily ailments and of
acute mental diseases. The arrangement had worked well. It had now been
in operation for a year and a half. It was found difficult to get the attendants
to leave the hospital, the duties were so much more interesting that they
thought it almost a hardship to go to the ordinary wards. The training of
attendants he thought should begin in the hospital where they wonld learn to
realize the individual necessities of the patients, by attendance on oases such
as general paralysis, puerperal mania, acute mania, and other forms of insanity
with obvious bodily symptoms—such as sleeplessness, deranged digestion, &o.
They thus learned to recognize what was important to observe and to reoord.
Dr. Ronaldson said that he had recently given a lecture on “ What to do
in Emergencies,” which was attended by many of his staff, and was followed
by good results.
Dr. Ireland said that he had read the essays written by Dr. Clark’s attend¬
ants and had been much struck by the acuteness of observation they displayed.
In practice it must be admitted that we all were benefited by hints from
attendants, they often might observe things which the Medical Superintendent
could otherwise know nothing of. General Washington, who was a man of
sense and sound judgment, used to consult his staff as to what should be done
in the exigencies of war, indeed he seldom originated his plans, but took
the best advice and acted accordingly. Much benefit he was sure would
result from the training of attendants. It had been begun by Dr. Browne,
and continued by Dr. Mackintosh and other gentlemen, but never hitherto
put into systematic form. This should now be done, and he thought that
attendants should be encouraged to study, to answer questions, and to
obtain certificates. Dr. Clark’s suggestion that a manual or text-book be
prepared was a good one, and should be set a-going.
Dr. Urquhart said that this question had been forced upon him owing to
the copies of his asylum-rules having become exhausted. He had always felt
that asylum-rules were unsatisfactory, so much so that he had commenced to
write a short manual for the use of his staff. There was a question he might
ask. Should the attendants be expected to study when off duty P Of one
thing he was certain, that the old system of going round the wards with the
matron and ignoring the attendant was becoming obsolete. Good attend¬
ants were much more valued and taken into the Superintendent’s confidence
than they used to be.
Dr. Yellowlees, though much impressed with the importance of the
subjeot, was not so enthusiastic as Dr. Clark. He had tried lecturing and
had not got such good results; true, he had not aimed so high. He con¬
sidered that the best attendants were those who in the wards were open
to instruction, and that very little good resulted from lectures. Direct
personal, individual teaching afforded instruction more valuable. He had
recently drawn up a code of instructions for his attendants. All who really
cared for instruction studied them, and tried to work up to them; to those
who did not, lectures would be of little avail. As a rule the attendants,
like the whole asylum, took their tone from the Medical Superintendent.
He was certain that most of the gentlemen present would rather train their
own attendants than take them from other asylums, however highly trained
they may profess to be. He agreed with Dr. Clouston in thinking that
attendants should be trained in the infirmary, and that this gave them a
medical idea which was of value, but he didn’t think that any grand scheme
of teaching and examinations would succeed. Each Superintendent would
continue to work his asylum in the way best suited to himself. It was an
important matter to have a staff of good nurses for outside cases, if it
could be done without injustice to the institution.
Dr. Howden said that he endorsed all that Dr. Yellowlees had said. He
would not, if he could help it, take attendants, however highly trained and
certified, from other asylums.
XXX. 11
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162
Note* and Newt,
[April,
Dr. Rutherford war of the same opinion.
Dr. Turnbull said that when the idea was first started he was not
enamoured of it ( but the more he thought of it, and haring seen the papers,
the more he was in favour of the carrying out of Dr. Clark's scheme.
Dr. Clouston then moved, and Dr. Urquhart seconded, “That a com¬
mittee of the medical officers of the asylums of Scotland be appointed by this
meeting for the purpose of considering the questions of<1) The special
training and instruction of asylum-attendants, and the best modes of doing so.
(2) The preparation of a manual of instructions for nursing and attendance
on the insane,” which was carried.
A Committee was then nominated, consisting of all the gentlemen present,
and of any member of the Association in Scotland who desired to join it.
Dr. Clark to be convener.
Dr. J. Bruce Ronaldson read a paper on “ Murder during Homicidal
Impulse.”
Dr. Yellowlees said that although such. cases were called impulsive, the
acts were often prompted by delusions, and the result of them. When
asylum-officials were attacked, there were generally motives. Doubtless if we
could look into the minds of those patients we should see that there were
delusions which overpowered them, and when we hear of patients asking that
their hands might be tied to prevent them from doing injury, we have a proof
of this. The risks which asylum-officers run are not folly realised.
Dr. Howden said that he had a case recently transferred to the Criminal
Asylum at Perth by appeal to the Home Secretary. He had attacked an
attendant and fractured his skull, and had made several attempts on himself.
Several of the members mentioned similar cases.
Dr. Howden read a paper, “ Precautions against fire in Lunatic Asylums **
(see Original Articles), which was followed by an interesting discussion.
The members afterwards dined together at the Royal Edinburgh Hotel.
A Quarterly Meeting of the Medico-Psychological Association was held in
the Hall of the Faculty of Physicians and Surgeons, Glasgow, on Tuesday, 21st
February. Present: Drs. Clouston (chair), Clarke, Robertson, Turnbull, Drqu-
hart, Ireland, Yellowlees, Rutherford, Rorie, Love, Ac.
George S. Pullen, M.B., Edinburgh, and John Love, M.B., Glasgow, were
elected members of the Association.
The report of the Committee on the special training of asylum attendants
was read as follows :—
“ At a meeting of the Committee appointed at last Quarterly Meeting to
consider the best means of training asylum attendants, it was resolved that a
short manual of instructions be prepared, comprising :—(1) Simple physiology
in its practical bearing on the insane. (2) The symptoms of bodily and
mental diseases, which should be observed and reported. (3) The nursing of
the sick. (4) The management and care of the insane. (5) The duties of
attendants as servants of the institution.
“ The following gentlemen were appointed an editorial Sub-Committee :—
Drs. Urquhart, Turnbull, Clark, and Maciver Campbell, with instructions to
prepare and submit proofs of a short manual of instructions to asylum atten¬
dants to the Committee.
“ Convinced of the importance of the special training of attendants, the
Committee hope that the manual may be useful as a means to that end, and
invite reports of the results of such instruction as may have been given.”
Dr. Robertson moved, and Dr. Ireland seconded, that the report be
adopted and the Committee reappointed, which was carried.
A discussion on “Thought-reading” followed, and the meeting was ad¬
journed, to meet in Perth at an early date.
The members afterwards dined at the Bath Hotel.
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1884.]
Notes and News .
163
A CORRECTION.
[It is requested that the following Table may be substituted for the Table
printed at the foot of page 92 of the Thirty-seventh Report of the Commis¬
sioners in Lunacy to the Lord Chancellor.]
The following are the details of the average weekly cost:—
County
Asylums.
Borough
Asylums.
£ s. d.
£ s. d.
Provisions (including malt liquor in ordinary diet) ...
0 4 4|
0 4 74
Clothing
0 0 8?
0 0 9}
Salaries and wages
0 2 2}
0 2 6}
Necessaries (e.g., fuel, light, washing, &c.) ...
0 0 10#
0 13}
Surgery and dispensary ...
0 0 o|
0 0 o|
Wines, spirits, porter
0 0 0}
0 0 0#
Charged to Maintenance Account:
Furniture and bedding
0 0 4}
0 0 5}
Garden and farm
0 0 6*
o o 6*
Miscellaneous
0 0 3J
0 0 71
Less moneys received for articles, goods, and produce
sold (exclusive of those consumed in the Asylum)
0 9 6i
0 10 10J
o o 8}
0 0 2}
Total Average Weekly Cost per Head
£0 9 3}
0 10 7}
Mem. —The errors in this Table as published arose from displacement of type
after return of a correct proof.—C.8.P.
MEDICAL JOURNALISM.
Development in this direction indicates no abatement of enterprise or ability.
Dr. Richardson has shown that, in spite of increasing years and total abstinence,
his natural force has not abated. “Animus hominis semper appetit agere
aliquid,” as Cicero says, and when the “ something ” is worth doing, it is a happy
thing that such is the law of life. He has resumed a publication long since laid
aside, and we have before us a new series of “ The Asc^p^d,” a quarterly journal
devoted to original research and observation in the science, art, and literature
of Medicine. The remarkable feature of this serial is that all the contributions
are by the same hand. This is laborious work. There is certainly the compen¬
sating advantage, however, that the Editor will never fall out with his contri¬
butors; will never wound their feelings by rejecting an article, and will never
give offence by giving precedence of position to one article over another. Not
the less, however, will he have to exercise judgment in the admission of his own
writings, to be a just judge in his own cause (a rather delicate position), and as
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Notes and Newt.
164
[April,
such he will merit condemnation, cum noceng absolvitur , or rather, when an in¬
ferior article is admitted.
The first number in no respects calls for condemnation ; on the contrary, the
papers are pleasant and instructive reading, and many freshly-thought and
freshly-expressed passages occur. In the article “ Morphia Habitues and Their
Treatment,” the writer confines himself to the subcutaneous injection of morphia.
It is a valuable essay, and were there no other than this and “ Felicity as a
Sanitary Research,*’ the current number would be worth its price. We hope
that the same interest will attach to future issues of “The Asclepiad/’which, we
trust, will meet with the encouragement and support the author so greatly
merits.
An old friend with a somewhat new face made its appearance with the present
year—the “ Medical Times and Gazette.** In wishing it success, we may cite
from the editorial article of the first number,“ that its first aim will be to make it
essentially a clinical journal.” Its small size is claimed as a recommendation, as
“it renders it a necessity to select only the best original articles and cases that are
offered to us; it makes padding superfluous, and it is a constant reminder to the
Editorial Staff to say all they have to say as tersely as possible.”
AFTER.CAEE.
EXTRACT FROM SERMON BY REV. H. -HAWKINS AT ST. MARY’S,
OXFORD, 29th JANUARY, 1884.
“ Is it allowable to avail myself of the present occasion to beg an interest in
your prayers, on behalf of a large class of grievously afflicted persona whose
visitation is that of mental rather than of bodily disease, though often physical
and mental ailments are in combination ?
“ Ministerial work, extending over many years, among the infirm in mind,
and carried on in a hospital containing more than 2,000 patients, may perhaps
justify or excuse me in requesting some special remembrance in prayer of the
large community of sufferers from mental disorders. It is very numerous. In
addition to those patients belonging to the higher ranks and wealthier classes of
society, there are probably not fewer than 60,000 in the various public hospitals
of this country.
“ Among these, though the great majority belong to the lower classes, are num¬
bered many men and women of education and refinement—members of profes¬
sions and literary vocations, teachers male and female, and others who, from
their position in society, have sunk, and so are most to be pitied, to a low
estate.
“ The causes of those mental maladies by which so many of our fellow crea¬
tures are afflicted are various. Numbers suffer the consequences of their
parents’ faults. In an enfeebled mental organization they bear the iniquity of
their fathers. Penury and privation prostrate others. Not a few are brought
from these causes to that hospital just referred to, from the vast region of East
London. Again, failure, disappointment, competition, and other anxieties of
business, perverted religious emotions, above all, intemperance and excess, are
contributories to that most grievous form of disease.
“ Among those afflicted ones are many whose morbid mental condition does
not lessen but rather enhances their capacity for profiting by the ministrations
of religion; many who, constant at daily and Sunday worship and Holy Com¬
munion, are regular remembrancers for others, and are comforted by the hope
that intercessions are offered by others on their behalf.
“ Some persons in quest of an interesting and novel field of labour might
find work to do on behalf of these afflicted ones, which would yield useful
results.
Digitized by <^.ooQLe
1884.]
Notes and News.
165
“ There are many lonely and friendless inmates of asylums appreciative of
sympathy and kindness, who might be comforted and cheered in ways which
cannot now be indicated by friends from ‘without;’ many who might be en¬
couraged and upheld on quitting their retreat, and renewing life’s struggle, by
seasonable 1 After-care* exercised on their behalf ; nor would such ministries be
least among those which help to stablish Christ’s Church, and make His name a
praise.
“ In another communion there exists a society which specially devotes itself to
the interests of the infirm in mind. Perhaps in due time some will be found
among ourselves to accept a similar charge as their own special work.”
[We desire to draw attention to the usefulness of the “ After-care Ladies
Working Society ” in aid of the association of the After-care of poor and friend¬
less female convalescents on leaving the asylums for the insane. The object of
this Society is to assist poor female convalescents, after leaving asylums, with
gifts of clothing according to the special requirements of each case. The annual
subscription is five shillings. Gifts of dresses, &c., are thankfully received. Com¬
munications on the business of the Society to be addressed to Mrs. Richabdson,
Parkwood House, Whetstone, N.; or Miss Hawkins, Chaplin’s House, Colney
Hatch, N.—Eds.]
FIRE AT HAYDOCK LODGE, ASHTON, LANCASHIRE.
About half-past nine on Wednesday evening, Feb. 20th, the drying-room ad¬
joining the laundry was discovered in flames. Mr. Beaman and Dr. Shaw were
at once told, and the fire bell rung to summon the Asylum Fire Brigade. In a
few moments after the discovery of the fire, extincteurs, hand-pumps, and water-
buckets were used in order to extinguish it, and the Fire Brigade having very
quickly assembled and fixed hose to the hydrants, jets of water were soon playing
on the burning part of the building. The wind was blowing almost a gale, and
as there was a lot of dry woodwork about the laundry and drying-room, and the
linen store adjoined them, the flames spread very rapidly, and gained ground in
spite of all endeavours to put it out. The engine was situated immediately
under the drying-room, and the floor of the latter soon fell in and stopped the
pumps, and thus partly cut off the supply of water. Almost immediately after
the discovery of fire, a messenger was despatched to Ashton and another to
Messrs. McCorquodale’s, of Newton Bridge, to summon the Fire Brigades, and
the latter fortunately had a manual engine, which, on its arrival, was at once
taken to the fish pond, where there is an abundant supply of water. By this
time the fire had made considerable progress, and the most combustible part of
the building was destroyed; and as there was now plenty of water the flames
were soon got under.
Soon after the fire began, it was thought there was some danger of it ex¬
tending to the front main block, and Mr. Beaman and Dr. Shaw ordered the
building connecting the main block with the part where the fire was, to be
knocked down. Dr. Shaw also saw that the patients in the front block were re¬
moved to another part of the Asylum, not in any way connected with the burning
portion. No excitement was observed amongst the patients, and they were never
in the slightest danger.
The laundry was situated in an old wing extending backwards from the main
front block, where Mr. Beaman resides, and this old wing, which is the ad¬
ministrative department, was all destroyed with the exception of the kitchen and
bakehouse, which were fortunately very little damaged.
Although the building destroyed was very old, considerable damage was done,
and it will take several thousand pounds to put up and furnish modern buildings.
In the meantime temporary places have been fitted up, and though agreatincon-
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Notes and Newt.
166
[April,
venienoe to the staff of the Asylum, the work of the institution has gone on
almost as usual.
The origin of the fire is still a mystery. The flames could be seen for miles
around, and soon after the fire began several hundreds of people assembled out¬
side the building.
The damage is partly covered by insurance.
A. F. M.
Obituary .
JOHN DALE HEWSON, L.R.C.P. Lond.
In recording in this Journal the death of a well-known member of our As¬
sociation, the late Medical Superintendent of the Coton Hill Asylum, Stafford,
we cannot express the sentiments of those who knew him, better than in the
following brief notice which appeared in the “ Staffordshire Advertiser ” :—
The Late Dr. Hewson. —To a wide circle of friends in thiB county, and
also in the oounty of Wilts, the death of Dr. Hewson, the Medical Superinten¬
dent of Coton Hill Asylum, which took place on the 10th inst., has brought deep
sorrow and a sense of irreparable loss. He was appointed to his office in 1863,
and had just entered upon his 31st year of service. When he first came to
Stafford the building at Coton Hill was not completed, but early in 1854 he was
prepared to receive his first instalment of patients. He very soon won the
entire confidence of his committee, and well did he vindicate that confidence.
His skill and devotion brought the place rapidly abreast with the foremost of its
class; and now that unfinished pile of brick and mortar which they entrusted
to him thirty years ago, hiB dead hand yields back to them, a full and well-
organised institution, second to none in the kingdom. Coton Hill is, in part, a
charitable institution, and Charity herself could not have chosen a kinder hand
to dispense her delicate and, in such association, her necessarily secret succour
than that of Dr. Hewson. He had for many years a most able, devoted, and
considerate coadjutor in his wife. He never thoroughly rallied after the shock
of her illness and death, which happened about three years ago, but gradually
gave way before the inroad of the disease which finally proved fatal to him. He
bore the lassitude aDd utter helplessness of the closing weeks of his life with
much placid and often cheerful resignation, and at the last he passed very peace¬
fully away. Dr. Hewson was one of the most genial, generous, and open-
hearted of men, and inspired all who were conversant with him with no common
degree of attachment to him. He possessed in a wonderful manner the real,
though often unconscious, confidence of those under his charge; and if a sym¬
pathy which never faltered under the hardening influence of constant famili¬
arity with one of the saddest and most inscrutable of human maladies deserved
such confidence, well was he worthy of it.—“ The Staffordshire Advertiser/’
Nov. 19th, 1883.
WILLIAM HENRY PARSEY, M.D., B.A. Lond., F.R.O.P. Lond.
At the County Lunatic Asylum, Hatton, near Warwick, on the 10th of Jan.
last, died Dr. W. H. Parsey, for more than thirty years the Medical Superinten¬
dent of that Institution. During his superintendency the asylum had doubled
or trebled in numbers and size, notably by the erection, some thirteen years
ago, as an annexe to the lunatic asylum, of a large separate building for the
reception of the idiot and imbecile poor of the county.
Dr. Parsey held the degree of M.D. of the University of London, the Fellow-
Digitized by ^ooQle
1884.]
Notes and News.
167
ship of the Royal College of Physicians, London; and in 1876 was President of
the Medioo-Psychological Association, and gave an address at its annual meet¬
ing. Dealing with the question of the provision for the insane poor, and offer¬
ing several important suggestions and reasonings in support, his Presidential
Address will long be remembered by those who heard or read it.
To one who had the good fortune to work under him for a time, it is a
sad privilege to have the opportunity of writing a few words of him by whose
death our Association now suffers a heavy loss.
Dr. Parsey's scientific acquirements were of a high order. When a student,
and in early professional life, he laid the foundations of, and built up, a wide
and accurate knowledge of his profession; he maintained this throughout life
by careful reading and observation, and by a deep interest in, and use of all the
advances of medical science. But his tone of mind was judicial. He did not
too hastily adopt any new theory or method of practice, but carefully tested it
by comparison with the established in science, and by practical trial. Select¬
ing the best in newer and older, he combined and harmonized them in a body of
sound scientific knowledge. That he did not place much on permanent record
in the literature of the subject in which he was so well skilled, was a loss to all
his contemporaries. But he was always ready to impart to his professional
brethren the results and teachings of his experience. In pathology his interest
was lively ; he was shrewd and accurate in diagnosis, quick and skilful to devise
and apply remedial measures.
Similar high qualities of mind were evinced also by Dr. Parsey in his
administrative functions. The long and successful management of the large
asylum in which he passed most of his professional life is evidence of this. And
what was true here of the general was true of the particular also; for in deal¬
ing with details he was ever of ready resource, skilful in adaptation, judicious
in selection.
With his patients, his relations were of a cordial nature, his kindness and
goodness of heart conspicuous j and great were his forbearance and tact in
dealing with many difficult cases, and never-wearying his thoughtfulness and
assiduity in making provision for their better interests and care and cure.
To those who worked under him in any capacity he showed a generous kind¬
ness and benevolence of disposition, mingled with a firmness, which made his
rule at once successful and agreeable. A considerate or indulgent bearing to¬
wards the various members of the staff, however, never relaxed into looseness
of control, or permitted of carelessness in duty.
He will long live in the memories and affections of all those who were privi¬
leged to know him. His friendships were intimate and cordial. They who
knew him best loved him best.
This is scarcely the place to dwell upon his family relations. Yet it is per¬
missible to say how loving and tender were the ties that bound him, in life, to
the wife, the daughter, and the son, now left to deplore his loss.
W. J. M.
DR. THOMAS S. KIRKBRIDE.
The long and honourable career of this distinguished mental physician—an
Honorary Member of our Association—has at last been brought to a close, and,
appropriately, on the spot where he has so long laboured.
The proper place for man to die
Is where man works for man.
It is melancholy to think that we shall no more receive the familiar Annual
Report which, with such undeviating regularity made its appearance year after
year. These reports were a true reflex of the unceasing care, the unflagging zeal,
and the stem devotion to duty which for nearly forty-four years marked the cha-
Digitized by <^.ooQLe
168
Notes and News,
[April,
racter of " the man at the helm.” Never were superintendent and asylum more
completely one. It was impossible to think of the Pennsylvania Hospital for
the Insane without thinking of Dr. Kirkbride; it was equally impossible to
think of Dr. Kirkbride without thinking of the Pennsylvania Hospital.
Several years ago when in our American Retrospect we referred to one of Dr.
Kirkbride’8 Reports in which he suggested the propriety of a statue being erected
to Dr. Franklin in the grounds of the Asylum, we ventured to express a hope
that another would be erected to mark the Committee’s appreciation of the pro¬
longed and faithful services of the Superintendent himself. Since his death we
have observed the suggestion made that statues should be erected to the memory
of both Kirkbride and Ray in Philadelphia. To this proposition we cordially
respond, and we should hope that those who in other lands appreciate unselfish
worth and a life-long devotion to humanity, will be allowed to unite in this
public tribute to two great and good men, intimate friends during life, and not
long separated by death.
We have been favoured with the following sketch of Dr. Kirkbride's life,
written mainly by Dr. Curwen, of the Warren Asylum, Pennsylvania:—
Dr. Thomas S. Kirkbride, Physician-in-Chief and Superintendent of the
Pennsylvania Hospital for the Insane, died on Sunday night, December 16th,
after a protracted illness, at his residence, within the grounds of the Institu¬
tion which, for over forty years, he had faithfully served.
Dr. Kirk bride’s habitually vigorous health sustained a severe shock four
years ago in a prolonged illness, from the effects of which he only partially
recovered. About two years ago he had a second illness, from which again he
rallied, and last winter he was able to resume a considerable portion of his
ordinary duties. In the spring he was again, however, prostrated, and never
rallied to any hopeful extent. During the last few weeks there have been
periods of temporary improvement, and he has even been able to drive in the
Hospital grounds. On December 14th he had a severe chill, and gradually re¬
lapsed into coma, from which he never rallied.
Dr. Kirkbride was born on July 31, 1809, near Morrisville, Bucks County,
Pennsylvania. His ancestor, Joseph Kirkbride, came to this coantry from
the parish of Kirkbride, County of Cumberland, England, with William Penn,
being connected with the Society of Friends, as have been his descendants
down to the present generation. He received his academical education at
Trenton, N.J., and graduated from the Medical Department of the University
of Pennsylvania in March, 1832, the subject of his thesis being “ Neuralgia.”
In the following April he was appointed resident physician to the Friends'
Asylum for the Insane, in which position he served for one year, when, in
March, 1833, he was elected resident physician to the Pennsylvania Hospital,
where he remained two years, after which, settling in Philadelphia, he engaged
in private practice, devoting himself principally to surgery, and at this time he
was physician to the House of Refuge, the Institution for the Blind, and the
Magdalen Asylum.
In October, 1840, without solicitation on his part, Dr. Kirkbride was elected
Physician-in-Chief and Superintendent of the Pennsylvania Hospital for the
Insane, a new institution on the west side of the Schuylkill River, then nearly
completed, and to which it was intended to remove the insane from the old
hospital at Eighth and Pine Streets. The new hospital was opened on the 1st
day of January, 1841, since which time he has had the care and management
of it. By constant improvements and additions to the original building, this
institution, which was then only capable of receiving a hundred inmates, now
accommodates upwards of five hundred. In 1854, the original building having
become crowded, Dr. Kirkbride recommended the erection of a new one on the
grounds of the institution, which comprised a tract of one hundred and
thirteen acres, and he urged the complete separation of the sexes as if in two
distinct institutions. He further recommended that the building proposed
should be erected through an appeal to the public, which, accordingly, was
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Notes and News.
169
made, and with entire success, the building being completed wholly with
private contributions, exceeding in the aggregate $355,000. This new building
was a third of a mile distant from the other. It was erected in accordance
with his own carefully-prepared plans, and is so admirably adapted to the
purposes for which it was intended, that it has been a model for similar build¬
ings which have been subsequently erected. The new building was opened in
October, 1859, and since that time the Pennsylvania Hospital for the Insane
has consisted of two separate departments—one for men and one for women—
each having a capacity for two hundred and fifty patients, and entirely distinct
from each other in all their arrangements, though with the same physician-in¬
chief and the same Board of managers. The success of this experiment,
which he inaugurated, has been complete, and has led to the adoption of the
plan in other institutions.
As an authority in mental disease, Dr. Kirkbride enjoyed the highest repu¬
tation, and his name was so identified with the great institution of which he
was the physician-in-chief, that “ Kirkbride’s ” has become in this country the
popularly-used synonym of the English “ Bedlam.” He was a careful student,
and possessed marked executive ability. His faithful devotion to the interests
of the institution confided to his care has frequently elicited the admiration of
its managers.
Dr. Kirkbride was of square build and medium height, with a firm mouth,
penetrating eye, and a charmingly benevolent face, which was expressive of his
great modesty, spotless integrity, and rare virtue. He was endowed with a
wonderful tact in the management of the insane, and he was able quickly
to win the affections of even his most wayward patients, and his forbearing
gentleness and wise firmness enabled him to exert the best influences upon all
who came under his care.
His writings have given him a high reputation. His “ Propositions Relative
to the Construction of Hospitals for the Insane,” first adopted by the Asso¬
ciation of Medical Superintendents of American Institutions for the Insane,
has been repeatedly re-affirmed by them, and were published in 1854, with
notes and additions, under the title of “ The Construction, Organization, and
General Arrangement of Hospitals for the Insane,” of which a second edition
was called for in 1880. In his annual reports Dr. Kirkbride, year by year,
discussed at length nearly every subject connected with the treatment and
care of the insane, and they constitute a series of great value to the student
of mental diseases.
No man in the United States has devoted himself more entirely to the care
of the insane than Dr. Kirkbride. From the day of his appointment to the
superintendency of the Pennsylvania Hospital for the Insane, his whole
thought was given to whatever would tend to relieve the mental disorder of
those placed in his care, and everything which could in any way assist in that
work was laid under tribute from the firm belief he entertained that nothing
should be overlooked, for a reason clear to everyone, that small things often
have a great influence in turning the current of thought and diverting to
happier or more gloomy thoughts, as the incident may itself determine. No
one can read the very able, conscientious, and practical reports which have
emanated from him during more than forty years without being fully con¬
vinced that his whole energy was given to his work ; and the results of that
work are shown in those reports, and in his work on the “ Construction of
Hospitals for the Insane,” which places the reader in possession of practical
conclusions and sound deductions from long experience which can be relied on,
while the shifting sands of theory are blown away.
The wonderful changes which have been effected in the last forty years in
the treatment of the insane in America may, in great part, be attributed to his
labours and his influence on his brethren connected with the different institu¬
tions. The amount of restraint used at that early date was greater than even
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those who write so much on the subject know, and Dr. Kirkbride’s efforts to
change that condition of things were earnest and persistent, and while not a
believer in absolute non-restraint, he yet held firmly to the opinion, as he did
to all that he had formed cautiously and deliberately, that restraint should be
used only when the condition of the case, and the benefit of his fellow-patients,
really demanded it, or, in other words, on the same principle that a surgeon
would apply a splint to a broken limb; and the truth was strongly expressed
by Dr. Bucknill, of England, that while Dr. Kirkbride believed in restraint, he
rarely used it.
Dr. Kirkbride was one of the founders of u The Association of Medical
Superintendents of American Institutions for the Insane,” and for eight
consecutive years was its President. He was also a .Fellow of the College of
Physicians of Philadelphia, an Honorary Member of the British Medioo-
Psychological Association, and a member of the American Philosophical
Society.
Correspondence.
To the Editors of The Journal or Mental Science.
Gentlemen, —In Prof. Cleland’s rejoinder to my reply, which appeared in
the last number of the Journal, he refers the reader to his paper in the July
number, and to his previous memoir which it supplements j and he goes on to
say that he “ suspects that those who pursue this course will have a great
advantage over Dr. Mercier.” I do not for a moment impute to Dr. Cleland
any intentional discourtesy, but the passage I have quoted might mislead a
hasty reader into the belief that Dr. Cleland accuses me of the dishonourable
course of criticising a paper that I have never read. Against such an inter¬
pretation of this passage I am bound to protect myself. My reply concerned
only Dr. Cleland’s paper in the July number of this Journal; it was not
intended as, nor did it pretend to be, an answer to any other paper. As hia
article was written, as he avows, with the intention of explaining “ more
fully*’ his views on the relations of the nervous system to the operations of
consciousness, I was under no obligation to go back to his previous utterances.
As a matter of fact, I tried to procure a copy of the paper which he read
before the British Association in 1870, but as it was not published in the
“ Report of the Association,’* I was unable to do so. Had I read that paper,
however, I should certainly not have thought it fair to nail a writer to opinions
expressed by him thirteen years before. That I read the article to which I
did reply, and read it pretty carefully, is, I think, apparent not only from the
detailed nature of my reply, but from the fact that in nine pages I have
quoted Dr. Cleland’s own words no less than twenty times. I feel sure that
most of his readers will disagree with Dr. Cleland’s opinion that no advantage
to science would result from another contribution by him to the controversy ;
but as to this he is, perhaps, the best judge.
Will you allow me to make another explanation ? Dr. Huggard, in his very
interesting article on “ Definitions of Insanity,” quotes my definition as “ a
failure of the organisation to adjust itself to its environment,” and proceeds to
demolish it. This, however, is not my definition. I have defined insanity as
“ a failure of the process of adjustment of the organism to its environment,”
an expression which carries, to my mind, a meaning quite different from the
• one that Dr. Huggard ascribes to me. I should now substitute the term
“ disorder ” for “failure.”
Yours truly,
Feb. 15. Chas. Mercier.
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Notes and News.
171
DE. MERCIER’S DEFINITION OF INSANITY—A COERECTION.
To the Editors of The Journal of Mental Science.
Gentlemen, —I find that in my “ Definitions of Insanity ” in the last number
of this Journal I have not given Dr. Mercier’s definition precisely as he states it.
Dr. Mercier’s words are: “ From whatever point of view it is regarded, insanity
is then found to be a failure in the process of adjustment of the organism to
its environment,” whereas the definition I ascribed to him was that insanity
is “ a failure of the organism to adjust itself to its environment ” (“ Journal,”
Jan., 1882, p. 526). I need hardly say that the first form of words is, equally
with the second, open to the objections I have pointed out. I may add, more¬
over, that it gives prominence to an element that renders the definition self¬
destructive. In the paragraph preceding the one I have quoted from, Dr. Mer-
cier says : “To say that the organism is adjusted to the environment is to say
that it is in definite relation with the environment, and for a relation between
two terms to be definite it is necessary that the terms themselves between
which the relation subsists should also be definite ” (p. 525). Now, as “ environ¬
ment ” is not a definite term, there can not (from Dr. Mercier’s premises) be
any definite relation between the organism and it, and therefore the organism
cannot be adjusted to the environment. Dr. Mercier’s only escape from this
position would be to say that “environment” is a definite term. He has,
however, himself cut off his retreat. He says: “ Now, the definition of
insanity is a failure in the process of adjustment, and the onus of failure lies in
the process itself only when the terms are capable of adjustment. If the condi¬
tion of the organism on the one hand, or the condition of the environment on
the other, is such that they are either of them incapable of being definitely re¬
presented in consciousness, then the failure is in the representation of the terms
in consciousness, and not in the process of adjustment of the one to the other ”
( l . c.). Dr. Mercier then gives examples where special portions of the environ¬
ment were not definite. The addition of the remoter and more general por¬
tions would hardly increase the definiteness. We thus see that Dr. Mercier
cannot consistently admit either that the organism is ever adjusted to the en¬
vironment, or that the failure in adjustment is ever in the process.
Yours truly,
Sussex House, Hammersmith, William E. Huggard.
March, 1.
INDEX MEDICO-PSYCHOLOGICUS.
(For the Tear 1883.)
Acute Delirium. Ueber den Nachweis der anatomischen Ursache des Delirium
Acutum idiopathicum. Allg. Zeitschr. fur Psychiatrie, 1883, part xxxix.,
page 796.
Alcoholism, Chronic. Die klinischen und anatomischen Beziehungen des
Alcoholismus Chronicus. Dr. Wille. Allg. Wien. Med. Zeitung, 1883,
xxviii., 447.
Alcoholic Insanity. Dr. Mason. Amer. Journ. of Neurol, and Psychiatry,
New York, 1883, ii., 453.
-Inebriety, from a medical standpoint, with illustrative cases. Dr. Par¬
rish. Philadelphia, 1883.
Alcoholism. Dr. Boulet. Deutsche Verteljahrschrift fur offent. Gesund-
heitspflege, 1883, part xv., page 242.
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Notes and News.
172
[April,
Alcohol (Clinical Studies of Inebriety and its treatment by moral means). Med.
and Surg. Rep. Philadelphia, 1883, part xviii., page 88.
-(L* App^tit de la soif; la soif de rAloool). Semaine Med. Paris,
1883, part iii., page 9.
Alcoholism. Les Alcoolis6s, action toxique de l’alcool, troubles de l’intelligence
et des sens ; actes criminels. Dr. Legrand du Saulle in Gaz. des Hopitaux,
1883, lvi., 258.
Alienism (Data of). By Charles Mercier, M.B. Joum. of Ment. Science, Jan.,
1883, page 496.
Alternating Insanity. Zur casuistik des inducirten Jrreseins. Dr. Lehman.
Arch f. Psychiatric, 1883, xiv., 145.
Ambidextrism in the Insane and Criminal. Dre. Marro and Lombroso. Archiv.
de Psychiatrie, Turin, 1883, iv., 229.
Anatomy. Researches in the normal and pathological Anatomy of the gray
substance of the Brain, with remarks on methods of examination. Dr.
Hoffman. Amer. Journ. of Neurol, and Psychiat., New York, 1883, ii.,
403.
Asylums (Small and large). Dr. Claye Shaw. Journ. Ment. Science, July, 1883,
page 205.
Asylum Management. Dr. J. A. Campbell. Journ. Ment. Science, Oct., 1883,
page 373.
-Medical Officers, Forensic bearing of attacks on. By Dr. Kiernan.
Amer. Journ. of Neurology, 1883, part ii., page 67.
-Statistics (Recovery—and Death-rates). Dr. Chapman. Journ. Ment.
Science, April, 1883, page 4.
Asylums (Relative cost of large and small). Dr. Rayner. Journ. Ment.
Science, April, 1883, page 1.
Atrophy of Brain (Case of). Fletcher Beach, M.B. Journ. Ment Science,
Jan., 1883, page 535. ,
Anthropometry of Criminals, Lunatics, etc. Etudes de Tanthropometrie sur
les criminels, les fous, et les hommes normaux. Dr. Ferri. Archiv. Ital. de
biologie, Turin, 1883, iii., 368.
Beer-Dietary (in Asylums). Journ. Ment. Science, July, 1883, page 248.
Bone-Degeneration in the Insane. Dr. Wiglesworth. Brit. Med. Journ., 1883,
ii., 628.
Borderlands of Insanity. Dr. Ball in l’Enc^phale, 1883, part iii., page 5.
Brain-Diseases, Book on, for Physicians and Students. Dr. Wernicke. 3 vols.
Kassel, 1881—1883.
Brain-Disease (Demonstration von drei Fallen von Gehirnkrankheiten). Dr.
Nothnagel in Wiener Med. Presse, 1883, part xxiv., page 276.
Brain-Diseases, Treatise on, for Practitioners and Students. Lehrbuch der
Gehirnkrankheiten fur Aerzte und Studirende. 3rd vol., 8vo. Berlin,
1883.
Brain-Mischief (Cases of, without organic lesion). New York Med. Journ.,
1883, part xxxvii., page 91.
Brain-Weight (Comparative, of boys and girls). Bulletin Soc. d’Anthro¬
pologic de Paris, part iii., page 524.
-On the unequal weight of the cerebral hemispheres. Revista Speriment.
di Freniat. Regio Emilia, 1882, viii., 450.
Brain, The removal and preservation of the. Dr. Wilder. Journ. Nerv. and
Ment. Diseases, New York, 1883, x., 529.
Brain-tumour, Two cases of. Dr. R. B. Mitchell. Edin. Med. Journ., 1883,
xxix., 430.
Broca (Psychology and Works of). By Dr. Zaborowski. Revue Internat. des
Sciences Biolog., Paris, 1882, x., page 141.
Caffeine. Dr. Bevan Lewie. Journ. Ment. Science, July, 1883, page 167.
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1884.]
Cannabis Indies and Syphilis as causes of Insanity in Turkey. Dr. Davidson.
Journ. of Ment. Science, Jan., 1883, page 493.
Cerebellar Cortex, The. By Dr. O. E. Beevor. In Brain, 1883, xxiii., 419.
Cerebral Anatomy. Method of demonstrating the Connections of the Brain.
By Prof. D. J. Hamilton, in Brain, 1883, xxii., page 212.
- Congestion and Excitement (La congestion edrdbrale et la folie con¬
gestive). Dr. Legrand du Saulle. Gaz. d’ h6p., Par., 1883, lvi., 601.
- Sclerosis, in Dementia Paralytica. Dr. Tuczek. Neurolog. Central-
blatt, Leipzig, 1883, ii., 147.
- Tumour, Case of. By Dr. Bruce, in Brain, 1883, xxii., page 239.
- Tumours, Clinical Remarks on. By Dr. Bristowe, F.R.S., in Brain, 1883,
xxii., page 167.
-Tumours (at base of brain). Dr. Strahan. Journ. Ment. Science, July,
1883, page 246.
- Disease (Cases of, involving the medulla oblongata). Dr. Mackenzie,
in Brit. Med. Journal, 1883, Yol. i., page 408.
- Tumour (Case of). By Dr. A. Hughes Bennet. Brain, part xx., January,
1883, page 650.
- Disease. (Case of obscure brain disease in an infant.) Dr. Donkin, in
Med. Times and Gaz., 1883., Yol. i., page 240.
- Disease (Interesting case of, with grave symptoms, ending in recovery).
By Dr. A. H. Bennet, in the Lancet, 1883, Yol. i., page 267.
Chemical Diseases of the Brain and Spinal Cord as conditioned by the chemical
constitution of these organs. Dr. Thudichum. Brit. Med. Journ., London,
1883, ii., 624.
Chloral Hydrate, Use of interrupted doses. (Ueber dieWirkung gebrochener
Dosen von Chloralhydrat bei Aufregungs-Zustanden). Dr. von Rinecker.
Allg. Zeitschr fur Psychiatrie, Berlin, 1883, xl., 272.
- Hydrate in the Psychoses. Dr. Kieman. Journ. of Nerv. and Mental
Diseases, New York, 1883, 239.
Chorea (Some statistics of). By Angel Money, M.D. Brain, part xx., January,
1883, page 611.
Chronic Insane (Care of). Dr. Agnew, in New York Med. Record, 1883, part
xxiii., page 138.
Clinical and therapeutic researches in Epilepsy, Hysteria, and Idiocy. Drs.
Bourneville, Bonnaire and Wuillami^, Compte rendu du service des Epiiep-
tiques et des enfants idiots et arri6r6s di Bicetre, pendant l’annde 1881.
Paris, 1883. 8vo.
Comity-Asylums and County-Boards. By the Editors Journ. Ment. Science,
January, 1883, page 552.
Conium in Acute Mania. Dr. Kiernan, in Journ. Nerv. and Ment. Diseases,
New York, 1883, viii., 234.
Consciousness (On the seat of). Dr. John Cleland. Journ. Ment. Science, July,
1883, page 147.
Concealed Insanity, as illustrated by the case of Mark Gray. Dr. Brower,
Alienist and Neurologist, St. Louis, 1883, iv., 461.
Craniology of Epileptics. Sulla Craniologia degli Epilettici. Dr. Amadei, in
Archiv. per Antropologia, Florence, 1882, xii., 185.
Cranium-Caparity. La capacita del Cranio negli Alienati. Archiv. per l’Antro-
pologia, Firenze, 1882, xii., 185.
Cranio-Maxillary Angle, in the Insane and Criminals. Archiv. per l’Antro-
pclogia, Firenze, 1882, xii., 273.
Criminal Psychology (its relationship to states of society). Dr. David Nicolson.
Journ. of Ment. Science, Jan., 1883, page 510.
Criminals' Brains (Regarding). Dr. Benedikt Wiener. Med. Presse, 1883, part
xxiv., page 119.
Criminal Asylums (Discussion on). Annales Med. Psch., Paris, 1882, part viii.,
page 259.
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174 Notes and News . [April,
Criminal Anthropology. Dr. Puglia, in Archiv. di Psichiatria, Lorino, 1888, iy.,
126.
Crime committed during unconscious states. (Verbreohen in bewusstlosem
Zustande begangen). Dr. Franckel. Allg. Zeitschr. f. Psychiatric, Berlin,
1883, xl M 244.
Criminal Skulls. Crani d f Assassin! e considerazioni di craniologia psichiatrico-
criminale. Arch de Psichiatria, Lorino, 1883, iy., 98.
— Brains, Ueber sogenannte Verbrechergehirne. Dr. Von Bardeleben, in
Breslau. Aerztliche Zeitschrift, 1883, v., 60.
Criminal Lunatics. (Beitrage zur Kentniss der criminellen Irren). Ibid, page 88.
Criminals’ Brains, Ueber sogenannte Verbrechergehirne. Dr. Bardeleben.
Deutsche Bey., Berlin, 1883, viii., 209.
Drink-craving, its causes, nature, treatment, and curability. Dr. Harris,
London, 3rd ed. London, 1883, 12mo., 2s.
Drunkards (Management of Chronic Inebriates and Insane). Alienist and
Neurologist, St. Louis, 1883, part iv., page 36.
Electrical Excitability of the Cerebrum (The influence of Anaemia on the). By
Dr. Orschansky. Archiv. fur Physiologie, Leipzig, 1883, page 126.
Electrical Treatment. Behandlung der Psychosen mit Elektricitat. Dr. Tigges,
in Allg. Zeitschr. f. Psychiatrie, xxxix., 697.
Electrisation (Therapeutic value of spinal and cephalic). Alienist and Neurolo¬
gist, part iv., page 77.
Employment of Insane. Zur landwirthschaftliche Besch&ftigung der Irren.
Dr. Schroeter, in Zeitschr. f. Psychiatrie, 1883, part xxxix., page 818.
Epilepsy. Ueber epileptiforme Hallucinationen. Dr. Kuhn. Berl. Clin.
Wochenschrift, 1883, xx., 253.
— ■ Trephining in. By Dr. Yandel, in Medical News, Philadelphia, 1883,
xlii., 448. ,
-• Le 9 ons cliniques but l’Epilepsie. By Dr. Magnan. Paris, Delahaye and
Lecrosnier.
-(Ein Fall von langjahriger Reflexepilepsie, in Folge von Oxyuris ver-
micularis). Dr. Windelschmidt. Allg. Med. Central. Zeitung, Berlin, 1883,
iii., 605.
- and its relation to Ear Disease. Dr. Ormerod, in Brain, 1883, xxi., 20.
- Case of. By Dr. Mercier, in Brain, 1883, xxiii., page 372.
-study of a case of. By Chas. Mercier, M.B., in Brain, 1883, xxii., page
191.
Epileptic imbecility, atrophy and sclerosis of cerebellum in a case of, Dr.
Major, Journ. Ment. Science, Jan. 1883, p. 532.
Epilepsy, treatment of 17 cases by sodium nitrite. Dr. Balfe. Proc. Boy. Med.
and Chir. Soc. London, part i., page 23.
-Trephining in Traumatic, with remarks, Dr. S. N. Leo, in Amer. Journ.
of Neurology and Psychiatry, 1883, part ii., page 36.
■- clinical lecture on, by Dr. Hammond, in New York Med. Jour. 1883,
part xxxvii., page 337.
- contribution a l*6tude des Pseudo-epilepsies, convulsions epileptiformes
d’origine gastrointestinale, Paris, 1883.
-Presentation of patients trephined for. Dr. Leo. Jour, of Nerv.
and Mental Diseases, New York, 1883, viii., 270.
-- considerations on the Pathology and Therapeutics of Epilepsy. Dr.
Corning. Journ. of Nerv. and Mental Diseases, New York, 1883, viii.,243.
--La cura chirurgica dell’epilessia. Dr. Musso. Gazz. d’osp, Milano,
1883, iv., 393.
Epileptiform convulsions. Recherches experimentales et critiques sur les con¬
vulsions epileptiformes d’origine corticale. Drs. Franck et Pitres, Archiv.
de Physiologie, Norm, et Path, Paris, 1883, ii., 1.
Epilepsy, fits of an unusual kind, Lancet, London, 1883, ii., 257.
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1884.]
Epilepsy, Bromide of sodium in the treatment of. Dr. Coming. Med. Bee.,
New York, 1883, xxiv., 345.
- Case of, obliviousness of dangerous acts, medico-legal bearings; value
of percussion of the skull. Dr. Robertson. Lancet, London, 1883, ii., 492.
- experimental and clinical researches on epilepsy. Experimentelle und
klinische Untersuchungen iiber die Epilepsie. Dr. Unverricht. Archiv. f.
Psychiatrie, Berlin, 1883, xiv., 175.
-remedies in use prior to introduction of Bromides. Dr. Russel. Practi¬
tioner, 1883, part xxx., page 81. Treatment. Dr. Saundby. Practitioner,
part xxx., page, 105.
Erotomania, De 1’ Erotomanie ou Folie drotique, by Dr. Ball. EncSphale, 1883,
, part iii., page 129.
E’tude clinique sur le ddlire de persecution, Semaine Med., Paris, iii., 1, 1883,
par Dr. Ball.
Examination of the insane, how to examine the insane. Dr. Spitzka^ New
York Med. Gaz., 1883, x., 267.
Feigned insanity by a criminal lunatic. Dr. Bluthardt. Amer. Joum. Neurol,
and Psych. N. Y., 1883, ii., 380.
- Zur Frage der Similation von Seelenstorung. Dr. Siemens in Archiv.
f. Psychiatrie, 1883, xiv., 40.
-Simulirter Wahnsinn. Dr. Krauss, Friedreich’s Blatt f. gerichtl. Med.
Nurnberg, 1883, xxxiv., 315.
-Case of. Dr. Alex. Robertson. Joum. Men. Science, April, 1883, p. 81
Folie a deux, its forensic aspects. Dr. Kiernan, Alienist and Neurologist, St.
Louis, 1883, iv., 285.
Folie aveo conscience, recherches cliniques sur la. Dr. Marandon de Montyel.
Arch, de Neurol., Paris, 1883, vi., 34.
Fracture of skull and abscess of frontal lobes, case of, by J. M’Carthy, F.R.C.S.
Brain, part xx., January, 1883, p. 559.
Fright, sudden death from. Dr. Cooney. Lancet, Lond., 1883, ii., 388.
Gapje smokers, chronic mania. Asylum Joum., Berbice, British Guiana, 1883,
60.
General paralysis of the insane. Buffalo Med. and Surg. Joum., 1882-3, xxii.,
537.
- LaParalysie G£n6rale des Ali6n6s. Dr. Legrand du Saulle. Gaz. d hop.,
Paris, 1883, lvi., 777, 801, 825, 849, 873. Speech disturbance and tendon
reflex, relationship between, in general paralysis. Dr. Spitzka. Amer.
Jour. Neurol, and Psychiat., New York, 1883, ii., 373.
-Case of, in a young man of 19. Note sur la paralysie g6n5rale pre-
maturee, a propos d’un cas remarquable observe chez un jeune homme de
dixneuf ans. Dr. Regis. Encephale, Paris, 1883, iii., 433.
-Case of, in girl aged 15. Dr. Wiglesworth. Joum. Men. Science, July,
1883, p. 241.
-Ueber Hirabefunde bei der Progressiven Paralyse der Irren, by Dr.
Mendel. Berl. Klin. Wochenschrift, 1883, xx., p. 249.
- from cranial injury. Dr. Mickle. Journ. Men. Science, Jan. 1883,
page 544.
- De la Paralysie g4n5rale au point de vue des assurances sur la vie. Dr.
Hanot. Annales d’Hygiene, Paris, 1883, part ix., page 60.
-its early symptoms. Dr. Goldsmith. Arch. Med., New York, 1883, x.,
47.
- Arthropathies in gen. paral. of insane. Dr. Shaw. New York Med.
Archives, 1883, ix., 144.
-Cas de migraine ophthalmique au d6but d’une paralysie gendrale. Dr.
Parimand. Archiv. de Neurol, Paris, 1883, part v., page 57.
- from cranial injury. Dr. W. J. Mickle. Med. Press and Circ., London,
1883, part xxxv., page 25.
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176
Notes and News.
[April,
General Paralysis, and ite relation to syphilis. Dr. Kiernan. Alien, and Neurol.,
— Sreselver Paralysie dor Irren. AUg. Zeitschr. f.
^ P r 8periment *
Fre ptmona^% E oC a ’of^ Dr. Crichton Browne, F.B.S., in Brain,
1882, xxiii., 317.
Pathology of.
Dr. Wiglesworth. Journ. of Hent. Science, Jan., 1888,
p. 475.
Qouty insanity, a historical case of. Dr. Kieman, in J. Nerv. and Ment Die..
N. York, 1883, viii., 26. .
Guiteau, autopsy on, Journ. Men. Science, Jan., 1883, p. b53.
Hallucinations, on the Pathogeny Ac. of Alienist and Neurologist, 1883, part iv.,
Hallucination' Des erreurs de nos sensations, contribution i Y 6 tude de I’illueion
“ de ^ll^inatton. Archives des Sciences Phys. et nat, Geneva, 1883,
Hall^na i tionrD 1 es 8 hallucinations de la vue, Ac., by Dr. Ball, Practicien,
_haUuofnations. Dr. Gaultier de Beauvallon. Paris, 1883.
Hereditary ^transmission of insanity, Ac. Becherches cliniques sur 1* hferMitt
He ^a y foUeda“sses rapports av’eo la ffcondite des dpoux etlamortal-bb
des enfants. Dr. Marandon de Montyel, Enclphale, Paris, 1883, ill., 449.
Home-treatment of insanity. Dr. Urquhart. Trans. Perthshire Med. Assoc.a-
Hospi'tal’s for^the i^ane, general hospitals and Dr. Rogers, Brit Med. Journ.,
Hydrobromic Kid, on the use of, in nerv. affections. Dr. Dana. Med. News,
_Note^’use 8 ^’ to'nl^ous affections. Dr. Dana, Journ. of Nerv. and
Hyos^yamine, 86 Der' Werth°dea ^Hy’osc’yamin fur die Psychiatrische Praxis.
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Hyp^hUrU^ Zeitschrift f.
Hypnotom Utr Dr X Sylanf 3 'Tr. Med. et Chir. Assoc. Maryland, Balt, 1883.
Contribution k I’dtude de l’hypnotisme chez les hystenques, etc. Dr. Charcot
Compt. rend. Soc. de Biologic. Paris, 1882> 7 . s. 111 ., 13o. # -DV'io/ioirtViia
Hypnotism, personal experiences in, by Dr. Leffmann. Polyclinic, Phil P >
* 1883 i 41 •
- (Une Malade chez laquelle on provoque facilement le sommeil
hypnotique). Dr. Pitres. Journ. de. Med. Bordeaux, 1882-8, xn., 501.
_-Contribuzioni alio studio sperimentale dell’ ipnotiamo. DrTamburim
in Rivista Speriment di Freniatria. Reggio Emilia, 1882, vui., 99 •
_Contribution a l’etude de rhypnotisme chez les hystenques, eto. Prot.
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_ (Mental state in). Dr. Hack Tuke. .Journ. Ment. Science, Apnl,
HystermEpilepsy (some cases of), by Dr. S. K. Jackson. Tr. Med. Soo. Virg.
U.S.A., 1883, vol. iii., part iv., page 492. .
—— Epilepsy (de l’Hystero-dpilepsie chez l’homme). Gaz. d. Hop, Paris,
1882, p. 1188.
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Notes and Nervs.
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Montpellier, 1883, vol. xxviii., p. 49.
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by W. C. Kesteven, M.D. Brain part xx., January, 1883, p. 662.
Hysterical Hemi-anaesthesia (Deafness in), by Dr. Walton, Boston, U.S.A. Brain
part xx., January, 1883, p. 468.
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Baillidre et fils, 1883.
Hystero-Epilepsy (Notes on). Dr. Richer. Archiv. de Neurol. Paris, 1883,
page 66-80. ,
Hysterical Insanity, Etude M6dioo-16gale sur la Folie liystdrique. Dr. Pastroit.
Montauban, 1883.
Hysteria and its treatment by hypnotism. Dr. Schleicher. Annales de la
Soci6t6 de Med. d’Anvers, 1883, xliv., 61.
' Idiosyncrasy. Dr. Allen. Mind. London, 1883, viii., 487.
Idiocy. A manual for the training and educating of the feeble-minded, imbecile
and idiotic. Dr. Buckham. New York, 1883.
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Montpellier, 1883, 86 pp. 4to.
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Doct. Coll., 1882, part viii., pp. 201, 221, 237, 249.
- Tagesordnung und Lektionsplan fur Idiotenanstalten, Zeitschrift f. d.
Idiotenwesen, Dresden, 1882-3, part i., p. 1.
Impulsive Insanity. Gerichtsarztlicher Bericht fiber 'einen Fall von primaren
Schwachsin. Casuistischer Beitrag zur Lehre von dem sogenannten im-
pulsiven Irresein. Dr. Fritsch. Jahrb. ffir Psychiatrie, Wien, 1883, iv.,
184.
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Oct., 1883, p. 387.
Inability to distinguish right from wrong, illustrated in cases of brain-disorders
from Alcoholism. Dr. Wright. Med. Rec., New York, 1883, xxiv., 31.
Incendiarism by an Epileptic. Gerichtsarztlicher Fall der einen der Brand-
stiftung beschuldigten Epileptiker betraf. Dr. Schultz in Allg. Zeitschr, f.
Psychiatrie, part xxxix., p. 791.
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Index Medico.Psychologies for 1883. Journ. Ment. Science, April, 1883,
page 139.
Inebriety. Inebriates’ Home, Fort Hamilton, New York, Annual Report for
the year 1881, Statistical Report of 600 cases of Inebriety treated in the
Home, by Lewis D. Mason. Fort Hamilton, 1882, 27 pp. 8vo.
Inebriates, remedial treatment of. Dr. Kerr. Quart. Journ. of Inebriety,
Hartford, U.S.A., 1883, partv., page 77.
Insanity, Suicide and Civilisation, G. H. Mullhal. Contemp. Review, London,
1883, xliii., 901.
Insane Delusion. Dr. Spitzka, in American Journ. of Neurol, and Psychiatry,
New York, 1883, ii., 167.
Insanity, its cause, prevention and treatment. London, 1882. Dr. Wm. Harris.
-with delusions of persecution, etc. Dr. Legrand du Saulle. Gaz.
des hdp., Paris, 1883, lvi., 929.
-plea of, in criminal cases. Med. Press and Circ., 1883, xxxv., 279.
- (case of, after Alcoholic excess and Lead-poisoning). Mr. A. Campbell
Clark. Journal Mental Science, Oct., 1883, p. 394.
- (the curability of, new observations). Dr. Pliny Earle, in Alienist and
Neurologist, 1883, partiv., page 61.
--— a Treatise on in its Medical Relations. Dr. Hammond. New York,
1883.
-its cause and prevention. Dr. Stearns. New York, 1883, 260 pages.
Digitized by <^.ooQLe
178 Botes and News.
Insanity, its classification, Diagnosis and Treatment. Dr. Spitzka. New York,
1883, 415 pp. 8vo.
-and Nervous Diseases (Clinical lectures on), by Dr. Auguste Yoisin.
Paris, Bailli&re et fils, 1883.
Intemperance and Insanity, the relations between. Dr. N. Kerr, in Amer.
Psych. Joum., Philad., 1883, i., 53.
Iodoform (Die Anwendung des Anwendung des Geisteskrankheits bei Iodo¬
form). Dr. Eckelman, Allg. Zeitschr. f. Psychiatrie, 1883, xl„ 258.
Joan of Arc (Hallucinations, etc., of). Dr. Ireland. Jonrn. of Ment. Science,
Jan., 1883, p. 483.
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Pelizaens. Archiv. f. Psychiatrie, Berlin. 1883, xiv., 402.
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ii., 255.
Localisation of Brain-Functions in the cerebral hemispheres in Man and in
Animals, by Dr. Nathan. R6vue Internationale des Sciences Biolog., Paris,
1883, part xi., page 1.
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Polyclinic, Philadelphia, 1883, i., 5.
Lunacy-Legislation (in Holland). Dr. F. M. Cowan. Journ. Ment. Science,
July, 1883, p. 158.
(To he continued,)
Appointments,
Deshon, F. P., M.R.C.S., appointed Medical Superintendent of the Metro¬
politan Lunatic Asylum, Kew, Victoria.
Godson, Edwin, M.R.C.S., appointed Medical Superintendent of the Hospital
for the Insane, Paramatta, New South Wales.
Lee, G. T., M.R.C.S., L.S.A.Lond., appointed Assistant Surgeon at Fisherton
House Asylum, Salisbury.
Mickle, Arthur Fflintoff, M.B., appointed Medical Superintendent of
Haydock Lodge Asylum, wee James Shaw, M.D., resigned.
Richardson, William, M.B., C.M.Edin. (Senior Assistant at the Crichton
Royal Institution, Dumfries), appointed Medical Superintendent of the Isle of
Man General Lunatic Asylum, Douglas.
Sankey, H. R. 0., M.B.Lond., appointed Medical Superintendent of the War¬
wick County Lunatic Asylum, Hatton, vice Dr. Parsey, deceased.
Scott, John Walter, M.R.C.S. and L.S.A., appointed to be Assistant Medical
Officer at the Hants County Asylum, Fareham.
Sinclair, Eric, M.B., C.M.Glasg., appointed Medical Superintendent of the
Hospital for the Insane, Gladesville, New South Wales.
NEW YORK MEDICO-LEGAL ASSOCIATION.
Among the Honorary Members recently elected are the names of Professor
Ball and M. Motet, Paris; Dr. Ireland, Prestonpans, near Edinburgh ; and Dr.
Hack Tuke, London.
Digitized by v^ooQle
THE JOURNAL OF MENTAL SCIENCE.
[Published by Authority of the Medico-Psychological Association]
No. 130. NEw^ERres. JULY, 1884. Vol. XXX.
PART 1.—ORIGINAL ARTICLES.
The Physical Conditions of Consciousness. By A. Herzen,
Professor of Physiology, Lausanne. Translated by Db.
T. W. McDowall.
(Concluded from p. 53.)
IV.
Before approaching the next subject I wish to avoid
the reproach of departing from the rules of the inductive
method by drawing conclusions from the complex to the
simple; that is to say, in this case, by applying to the
lower centres a conclusion drawn from the observation of the
higher centres, instead of proceeding in the opposite way. I
am obliged to proceed in this manner by the very nature of
the problem which really cannot be treated any other way.
As we have to deal with the subjectivity of central phenomena
it is impossible to seek its conditions when we have no
direct means of proving its presence or absence. Now in
respect to the subordinate centres we are reduced exclusively
to objective observation, which in no way can teach us any¬
thing of the subjectivity of the changes which take place in
them; therefore, whatever conjectures we may make in
regard to the consciousness or unconsciousness of the motor
reactions furnished by the lower centres, they can have
only a certain degree of probability when we study these
reactions by the aid of what subjective observation teaches
ns relative to the consciousness or unconsciousness of the
cortical centres. It is because they have not followed this
method that writers disagree so completely as to the pre¬
sence or absence of subjectivity in the sensori-motor centres,
and especially in the spinal cord. Let us begin with the
latter.
Whereas some adopt the doctrine of Marshall Hall, ac-
xxx. 13
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180 The Physical Conditions of Consciousness , [July,
cording to which the activity of the cord is essentially
different from that of the brain, absolutely unconscious and
purely mechanical, Maudsley and Lewes maintain, on the
contrary, that the activity of all the nervous centres is
essentially identical; but, as we know, with this radical
difference, that according to Maudsley consciousness is in
every case an accessory phenomenon generally absent;
whereas, according to Lewes, it is a necessary phenomenon,
constantly present. The facts under discussion are the fol¬
lowing :—
If we place a drop of the acid on the skin of the lumbar
region of a decapitated frog we immediately see the foot on
the corresponding side lifted to scratch and rub the spot
irritated by the acid; if we repeat the experiment after
having amputated the foot, the application of the acid
puts the frog into an evident state of agitation, it makes
fruitless efforts with the stump, hesitates, stops, seems
to reflect, and ends by employing the other foot to wipe
off the acid. Pfliiger was so struck by this phenomenon
that he attributed not only consciousness but even intelli¬
gence and will to the medullary reflexes. These opinions
were adopted by Auerbach in Germany and Lewes in Eng¬
land. But since 1858 Schiff expressed himself opposed to
this interpretation. He has the merit of having recognised,
on the one hand, that the facts observed in man in con¬
sequence of traumatic lesions of the cord do not permit
us to conclude the unconsciousness of the spinal cord. For
in these cases the nervous communication between the cord
and brain being interrupted, the latter can in no way
perceive what takes place in the cord: it is exactly as
though these two organs belonged to two individuals—the
brain of Paul does not know what occurs in the cord of
Peter. On the other hand, the visible reactions being the
only objective sign which reveals to us the presence of
a conscious sensation in any organism, except our own, we
have no right to refuse all trace of consciousness to the spinal
cord. But whatever may be the degree of consciousness
it possesses, we can by the following reasoning refuse the
property of intention and will to the spinal reactions;
in fact, we give this name to movements of which we
have an anticipated representation, of which we foresee
the form, the energy, the succession, and the effect; but
the spinal cord of a decapitated animal cannot have these
representations, because the destruction of every sensory
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181
1884.] by Professor A. Herzen,
centre necessitates the abolition of the corresponding re¬
presentations, and because decapitation is the simultaneous
destruction of all these centres ; the cord is therefore
deprived of the psychical materials which, combined into
a whole, confer on any given movement the special char¬
acter which we indicate by the word voluntary. So true
is this that we do nob give this name to movements which,
notwithstanding the integrity of the nervous centres, are
accomplished in the absence of all this combination of
representations, without prevision and without conscious¬
ness : we then call them automatic. I would further say:
the examples of unconscious movements accomplished by
ourselves seem to me the only facts favouring the possi¬
bility of any unconscious nervous reaction.
This reasoning is perfectly applicable to the sensori¬
motor centres; they are accessible to the multiplicity of
impressions which the organism can receive from the
external world by the organs of sense, and they con¬
sequently react by series or groups of movements to
the series or groups of impressions which stimulate them.
Thus, for example, a pigeon deprived of the hemispheres
stands on the ground or perches on a stick, maintains its
equilibrium when the stick is rotated, rises if placed on
its back, flies if thrown into the air, and does not fall down
after having flown, but perches on any object, and so on ; in
some favourable cases, it even ends by learning to eat and
-drink by itself; it then continues to live and behaves almost
like a normal pigeon, the only difference being that it is
more apathetic, that it manifests less initiative ness, that
it seems to “want spontaneity,” as A. Bain would say.
Seeing that the analogy between sensori-motor and ideo¬
motor acts is much greater than that between the first and
the spinal reactions, we may a fortiori conclude that the
opinion is not maintainable according to which the
activity of these centres is also unconscious.
Now what is the degree of consciousness which we can
attribute to the spinal cord and to the sensori-motor ganglia ?
By degree I mean simultaneously the quantity and quality
of consciousness, that is, its intensity and the psychical dignity
of its contents.
On this subject accident has furnished me with informa¬
tion which I think important. During a certain period of
my life I suffered from frequent syncope, and I had the oppor¬
tunity of observing on myself the psychical phenomenology
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182
The Physical Conditions of Consciousness , [July,
of the return to consciousness. During syncope there is
absolute psychical non-existence, total absence of all con¬
sciousness; then one begins to have a vague, unlimited,
infinite feeling, a feeling of existence in general without any
delimitation of one’s own individuality, without the least
trace of any distinction between the ego and the non-ego:
one is then “ an organic part of nature,” having the con¬
sciousness of the fact of one’s existence, but having none of the
fact of his organic unity; one has, in a word, an impersonal
consciousness. This feeling may be agreeable if the syncope
is not due to violent pain, ana very disagreeable if it is:
this is the only possible distinction: one feels that he is
living and enjoying or living and suffering, without knowing
why he enjoys or suffers and without knowing the seat of
this sentiment. A great number of facts make it probable
that in this phase of return to consciousness, the extremities
may execute the spinal reflexes in response to tactile or pain¬
ful irritations; although the cephalic centres are certainly
still incapable of becoming active. As a result of this first
observation I believe that the spinal marrow, suddenly
separated from the cephalic centres by decapitation, is re¬
duced to this elementary form of sensation, without any
discrimination, without localisation, without knowledge of
the different parts of the ego, or the ego itself, and accom¬
panied only by a vague, diffuse, impersonal consciousness.
Such no doubt is the only form of consciousness which we
can admit in the minute beings which are wanting in special
organs; it is also the only one which savants unanimously
attribute to the newly-born child, before he has had time to
learn, by the education of his senses and the association of im¬
pressions, the topography of the surface of his body, and to
distinguish its different parts from one another and from
the objects which do not belong to it. I think, con¬
sequently, that the spinal cord of a decapitated animal would
react to any impression indifferently by any movement, per¬
haps by a series of irregular contractions of all the muscles
(as it really often does in the newly-born), if it did not
contain a great number of direct communications from the
afferent to the efferent nerves, communications previously
developed during the infinitely long evolution of living beings
and become hereditary, or else acquired by the individual
himself; but in every case preformed, that is to say, ready to
re-act immediately in a given manner to a given irritation. I
believe that in relatively simple cases, those in which the
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18S
1884.] by Professor A. Herzen.
cord gives an immediate and limited reaction to a particular
stimulus, by means of a preformed mechanism, the spinal
consciousness is reduced to the minimum of intensity or to
zero; because then the transmission of the stimulus is
accomplished with the maximum of rapidity and facility by
nervous paths perfectly adapted thereto; on the contrary,
in relatively complicated cases, like that of the decapitated
frog whose leg we amputate to oblige it to execute less
automatic reactions, or like that of the tritons of Flourens
whose posterior extremities, after total section of the cord,
gradually learned to co-ordinate their irregular reaction with
the movements of locomotion; in these cases, I say, the
spinal consciousness attains its maximum of intensity,
because in these cases the central elements offer a con¬
siderable resistance to the stimulus which, not finding a
means of escape close at hand, radiates and produces an ex¬
tended, profound and lasting disintegration up to the
moment when it succeeds in making new paths duly adapted
to the unusual circumstances ; these paths once sufficiently
elaborated, every act is accomplished more quickly, more
easily, more automatically, less consciously.
But it must not be forgotten that we have always spoken
of decapitated animals; in the normal animal it is not quite
the same; if an excitation which affects the spinal cord is
not immediately and entirely transmitted and discharged in
the shape of automatic reaction, nothing obliges it to remain
in the cord, and there to effect the adaptation of new central
tracks; on the contrary, it passes directly to the cephalic
centres ; it thus follows that in the non-mutilated animal
the spinal consciousness will never be called upon to mani¬
fest itself except in some exceptional cases, as that of animals
who have no cephalic centres—the amphiozus for example.
It is evident that in such animals the cord must accomplish
all the functions devolving upon the nervous centres. But
during the course of the evolution of living beings, the anterior
portion of the cord undergoes an extraordinary development
and becomes cephalic; the central attributes follow the same
course; they gradually abandon the spinal centres which
become more and more subordinate, and end by being only
organs of transmission and of some definitely organised reflex
acts: the central attributes gradually become the more and
more exclusive privilege of the new cephalic organs which
alone exhibit a complexity and specialisation of structure
capable of corresponding to the more and more varied neces-
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184
The Physical Conditions of Consciousness, [July,
sities of a more and more complicated organism. It follows
that the spinal consciousness must be more intense in the
inferior vertebrates and less intense in the superior: it must
be at its maximum in the amphioxus and its minimum in
man.
Let us now proceed to the sensori-motor centres at the
base of the brain. I have already said that the observation
of animals deprived of their cerebral lobes leads us, in the
majority of cases, to the conclusion that the movements
which they execute apparently without intelligence and with¬
out will, are yet not unconscious; on the contrary, analogy,
and especially the arguments which we have quoted in sup¬
port of spinal consciousness, oblige us to consider them as
habitually conscious reactions. Maudsley himself, so inclined
to deny consciousness wherever it is possible to deny it, and
so disposed to consider animals as unconscious machines, is
obliged to recognize, notwithstanding some contradictions
to which I will refer later on, that in regard at least to the
superior vertebrates the sensori-motor centres enjoy a
certain degree of consciousness:—
“ For it may well be that organs which are only a little lower in
dignity than the supreme cerebral centres, which are essential to the
development of their function, and which are in such intimate
functional relation with them throughout life that a functional
separation appears to be a pure abstraction, do possess that property
which is most highly, but not exclusively, developed in the higher
centres ”—(“ Physiology of Mind,” p. 242).
For the same reason he grants them, though unwillingly,
what he calls a kind of sensory 'perception, which he considers
the germ or rudiment of intellectual perception, the exclu¬
sive privilege of the cortical centres. So it is no longer the
fact of consciousness which is placed in doubt; we have to deal
with a more subtile distinction, relative to the quality of the
contents of consciousness. Let us see if the study of the
further progress of return to consciousness after syncope
permits us to determine this quality.
From the chaos of the first phase which is characterised,
as you remember, by a confused, impersonal consciousness,
without any trace of localisation, without discrimination of
definite sensations, vague and obscure differences gradually
take shape; one begins to see and hear; but, what is very
curious, the sounds and colours seem to arise within one’s self,
without one having the least idea of their external origin $
Digitized by Google
1884]
by Professor A. Herzen.
185
further, there is no connection between the different sounds
and the different colours ; each of these sensations is felt by
itself; thence results an inexpressible confusion, accom¬
panied by a complete stupefaction of the individual; at this
moment the sensory centres have regained sensibility, but
they are so only to the impressions which come directly from
the exterior , each centre for itself. The intercentral reflex
action is not yet re-established, the different sensations do
not combine with one another; there thus results the total
want of localisation, of distinction between the ego and the
non-ego, and of projection beyond the origin of the impres¬
sions ; one has stupid sensations, if I may express myself so,
that is to say, sensations which, because they remain isolated,
cannot be known , but only felt. Next follows the re-establish-
ment of the intercentral reflexes ; their activity fuses into
what we call the sensorium commune; the different sen¬
sations begin to influence one another, and, consequently,
to become reciprocally determinate, defined and localised;
and there results the distinct appearance of the consciousness
of the unity of the ego; but this consciousness is at first
only an unintelligent feeling, which merely expresses the
fact of the organic unity of the subject, and from which
a clear notion of the relation of himself to his surroundings
is still entirely absent. In this stage of awaking I clearly felt
(p. 181-2) I was myself and that my auditory and visual sensa¬
tions came from objects which did not form a part of myself;
but I did not understand what was happening, nor what had
happened, why I was there, stretched on the ground or on
a sofa, nor why the persons present surrounded me eagerly,
unbuttoned my shirt, threw cold water on my face; that was
because these are complex perceptions of a higher order,
genuine intellectual perceptions resulting from the synergic
action of the cortical centres; they can only, therefore, re¬
appear with the complete re-establishment of these centres,
which are the first to suffer and the last to recover their
functional integrity. Later on, at a given moment, at the
end of a variable but always appreciable interval, filled by
the strange stupor already described, the cortical centres are
suddenly re-established, their nutrition having resumed its
normal course; at the same moment the mind is traversed,
like a flash of lightning, by the following thought: “Ah,
that was another fainting fit.” From this moment intelli¬
gence is completely re-established, it seizes the complicated
relations of the situation, and resumes the command which
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186 The Physical Conditions oj Consciousness , [July,
a temporary insufficiency of cerebral nutrition had deprived
it of.
Now, what conclusions can we draw from these observa¬
tions ? In the first place it seems evident that the sensory
centres, taken individually, can be conscious each in its par¬
ticular mode of sensation, but only, as I have said, in a
stupid manner, that is to say, without combination or cor¬
relation between the different sensations, consequently with¬
out their localisation—without projection of their origin
beyond the ego—and, consequently, finally, without dis¬
tinction between the ego and the non-ego. In the second
place, it is evident that the sensory centres, combined in the
sensorium commune (if not anatomically, at least functionally,
as the mechanism of inter-central reflex action, of the
synthesis of the different specific sensations of external
origin, and of the internal induction of reflex sensations
producing each other) may be conscious in an elementarily
rational manner. Not only can they feel, but they can
know that what feels is not what produces sensation; they
can consequently have individual consciousness in its most
elementary form, i.e., as a mere sentiment of the unity of
the ego, but- cannot form a notion of the relations of this ego
with what surrounds it, nor understand the circumstances in
which it finds itself.
We see in all this a great analogy to what occurs in the
spinal cord of a decapitated animal; very probably, in an
animal deprived only of the cerebral hemispheres, the sen-
sori-motor centres can at first accomplish only the acts,
however complex they may seem to us, which are due to a pre¬
formed mechanism, hereditary or acquired; their reactions
would consequently, in the majority of cases, be automatic,
and slightly or not at all conscious. Just as the spinal cord
in certain favourable cases, for example in the salamanders of
Flourens, may learn to execute reactions which at first were
impossible, so the sensori-motor centres learn in certain cases
(to tell the truth, very rare ones, for example in the pigeons
deprived of their hemispheres) to execute all the co-ordinate
movements necessary for the maintenance of the life of the
individual ; and we cannot doubt that during the period of
learning, their consciousness must be carried to the maximum
intensity of which it is capable, to diminish afterwards
gradually and in proportion as the new associations, by
repetition and habit, adapt the nervous paths and render the
intercentral transmission rapid and easy.
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187
1884.] by Professor A. Herzen.
On reflection you will see that I do not make an improper
use of the word learn ; it suffices, in fact, to recall the per¬
fect analogy which exists between the genesis of a motor
association and that of an association of ideas. In both
cases we have to do with intercentral reflexes in process of
organisation. Once organised they constitute a faculty;
this faculty, by habit, may at last act unconsciously. The
process is identical in both cases. Maudsley is quite right
in insisting on this analogy; he draws the following parallel
between the acquisition of a series or group of co-ordinate
movements, and the acquisition of a series or group of reflex
cortical sensations—that is to say, of ideas; ideas, like co¬
ordinate movements, are the “ constitutional 99 result of the
surroundings, exercise, education. The ideas of a child are,
like his movements, instantaneous, undecided, transient, dis¬
orderly. Ideas, like movements, are combined in groups or
series the more indissoluble the oftener they are exercised;
once combined, they are not produced separately without diffi¬
culty, and indeed generally become absolutely inseparable.
Ideas, like movements, become more and more easily evoked
by exercise, and end by appearing unconsciously. Finally,
ideas by being repeated several times running, fatigue the
organs concerned in their production, exactly as too pro¬
longed movements fatigue the muscles. The sensori-motor
centres being capable of perfecting their motor reactions,
should be capable also of perfecting their rudimentary intel¬
ligence ; but it is probable that, as in the spinal cord, this
intelligence, as well as the consciousness itself of the senso -
rium commune , is very rarely called upon to act in the
normal animal, as, whenever all the energy of any stimulus
is not immediately and automatically restored entirely to the
external world in the form of muscular movement, it does
not stop in the subordinate centres to force new paths, but
goes directly to the cortex. This preponderance of the cor¬
tical centres corresponds with the zoological position of the
animal, and, as it increases, those exceptional cases for which
there exists no mechanism ready to act immediately, and
which demand reflection, pass more and more to the exclu¬
sive domain of the cortical centres. It follows that Con¬
sciousness, Intelligence, and Will abandon more and more the
subordinate centres, and concentrate themselves in the supe¬
rior ones; consequently the activity of the sensori-motor
centres has its maximum of Consciousness, Intelligence, and
Will in the inferior vertebrates, or in the animals entirely,
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The Physical Conditions of Consciousness, [July,
or almost entirely, deprived of cerebral hemispheres, and
these faculties are, contrary to Maudsley’s opinion, reduced to
their minimum in the superior vertebrates, especially in man.
It is easily seen that the relation between consciousness
and the functional disintegration of the nervous elements
such as I have already indicated, holds good for the sensori¬
motor centres as well as for the cortical centres and the
spinal cord. By neglecting this relation the clearest minds
inevitably fall into contradiction.
We have seen that Maudsley considers the sensory centres
as organs of a dignity almost equal to that of the cortical
centres; elsewhere he says that the fact of animals artifi¬
cially deprived of their hemispheres crying when irritated,
does not prove that these animals feel pain, but only that
they cry as if they felt it. To this I answer that Maudsley’s
reasoning proves still less that these animals do not feel pain,
for cries, or anv other external expression, are the only ob¬
jective signs which reveal to us pain or any other internal
sensation in any organism except our own ; so that in all pro¬
bability they indicate consciousness and not unconsciousness.
We might as well doubt, in fact, that an animal in full pos¬
session of its hemispheres feels when it cries. In this case,
as in the other, we have in favour of sensation only analogy.
We might even doubt the consciousness of a man who
says that he has a sensation, for, strictly speaking, each of
us can decide the question only for himself, and can by no
means have a proof that another individual feels anything.
We can simply state that he acts as though he feels, and then
remember that if we ourselves acted thus, we should do it
in consequence of such and such sensations, and should
finally conclude that probably the other individual had
similar sensations. Still the analogy of one man to another
is such that on this subject we have not the shadow of a
doubt. Certainty diminishes, it is true, according as the
organism is different from our own ; it further diminishes if
this organism is placed in abnormal conditions which permit
it no longer to manifest all the reactions which it would
manifest if it were not mutilated; but as long as there is
any reaction, however imperfect or partial, we never can say
with certainty that nothing has been felt. On the contrary,
the only proof we have that any reflex reactions may occur
unconsciously is furnished, I repeat, by subjective observa¬
tion, which teaches each of us individually that certain re¬
actions sometimes occur unconsciously in us.
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189
1884.] by Professor A. Herzek.
Further on, Maudsley questions if we ever have conscious¬
ness of a sensation unless it awakens a perception.
“ It is doubtful whether we ever are conscious of a sensation with¬
out perceiving, whether, in fact, we can have consciousness of a pure
sensation ; when we say we feel it, we feel it in a particular part of
the body; and what is that but to perform internally a sensori-motor
act, and to recognise more or less clearly its where —in other words, to
perceive it according to forms of space ? ”—(“ Physiology of Mind,”
p. 242).
So be it, but when we feel without saying it, without
knowing that it is we who feel, nor what we feel, as happens
in the second stage of awaking from syncope, have we not
simple sensations with absence of all judgment? Besides,
Maudsley himself destroys this argument by admitting, on
the one hand, that a new-born child has sensations, although
he does not localise them, and cannot do so, as everybody
agrees, until after the lapse of some time ; and, on the other
hand, that the confused sensations which accompany the
various organic activities are felt , although they do not pro¬
duce clear consciousness in us, or a perception of the causes
from which they originate.
“ In respect of our organic feeling, we are, in reality, on a level
with those humble animals that have a general sensibility without
any organs for special discrimination and comparison ; and if this
were the only feeling which an individual had, he would probably not
know that he was an ego ”—(“ Physiology of Mind,” p. 254).
This is certainly incontestable, and I have tried to show
that this is really so in the first stage of awaking from syn¬
cope ; but because the notion of the ego is then impossible it
by no means follows that impersonal consciousness does not
exist; Maudsley seems here to confound consciousness of
the ego with consciousness in general . It is with the latter
that we have to do at this moment, and we have seen that
we cannot exclude its- existence even in the spinal cord;
still more must we admit it in the sensory centres, but in
these centres it is no longer quite indistinct as in the spinal
cord, which has no special organs for discrimination and
comparison; it is differentiated, for to each sensory ganglion
there corresponds a particular quality of sensation, a specific
sensation. Further, owing to their mutual reflex relations
these ganglia, functionally united in the “ sensorium com¬
mune,” possess all they require for comparison and dis¬
crimination , that is to say, not only for unintelligent and
undetermined sensation, but for elementary perception , for a
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rudiment of intelligence, a first distinction between the ego
and the non-ego, sufficient to establish at least the sentiment
of the unity of the ego, in opposition to the plurality of ex¬
ternal objects. Elsewhere Maudsley observes that, from the
presence of a rudimentary intelligence in the sensory ganglia
of inferior animals, we must by no means conclude that it is
present in the sensory ganglia of man.
“ On the contrary, it might be argued that as higher nervous
centres are differentiated in the course of evolution, functions are
localized in them which were more generally diffused in the lower
animals; not otherwise than as the fore-limbs in man, which in the
ape and some other animals serve both for grasping and walking, are
specialized in structure and function as prehensile organs ” (p. 24).
There is no doubt of this, and withdrawal of attributes and
localisation of functions most certainly occur during the pro¬
gress of evolution ; indeed, evolution consists in this, and for
this reason the higher an animal is placed in the zoological
scale, and the more its cerebral hemispheres are developed,
the less can we observe conscious psychical functions in
its sensory centres ; sensori-motor acts are in fact to a great
extent automatic; we call them instinctive. For the same
reason, in Man, consciousness and intelligence of the sensory
centres are doubtless reduced to the minimum, exactly like
those of the spinal cord; consciousness and, consequently,
intelligence manifest themselves in those parts of the nervous
system where there is still something to be done, which are
not yet perfected mechanisms, and whose automatism leaves
something to be desired; for they are, as we know, the
subjective expression of one of the phases of the work of ac¬
quisition and organisation. Now to admit that consciousness
has completely abandoned these centres, and has become the
exclusive attribute of the cortical centres, we must first
allow that all possible and imaginable sensori-motor acts are
accomplished by means of a preformed mechanism, almost like
the direct and immediate spinal reactions in the superior
animals; but if it is probable that the spinal cord of these
animals, through reacting in a uniform manner to uniform
impressions, has arrived at the highest degree of unconscious
mechanism, this is not at all probable for the sensory centres
which are exposed to an infinite variety of impressions,
not only from all the external influences likely to call into
action the different forms of sensibility, but also from the
inexhaustible stream of internal influences, acting upon
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by Professor A. Herzen.
191
1884.]
each from all the others, and all being acted npon by the
cerebral hemispheres. So that, except the few automatic
acts which they accomplish in virtue of an organisation
definitely acquired by the species or by the individual, they
are every moment obliged to provide new adaptations, that
is to say, to do what the hemispheres do, though doubtless
in a much more restricted manner. It follows that if in the
superior animals the spinal cord, in which reflex sensation
does not exist, has been reduced by the preponderance of
the cephalic centres to an unconscious and automatic organ,
and especially to an organ of transmission, the sensory
ganglia are not so easily deprived of their attributes as in¬
dependent and conscious centres, for they are the seat of
reflex sensation , through which the simple organic sensibility
is transformed into genuine mental activity, or psychicity; so
that it is incorrect to say, as Maudsley does, that there is no
demarcation between the reflex actions of the cord and those
of the sensori-motor centres ; on the contrary, there is a very
marked difference between them—a difference which does not
exist between the reactions of the sensory centres and those
of the hemispheres; in fact, in the first case, the transition
is abrupt, whereas in the second it is gradual; in the first
we pass from a simple to a complex mode of activity; in the
second we only pass from a complex to a more complex; and
the complication which appears in the sensory centres, reflex
sensation , is really the rudimentary germ of intelligence,
which may be thus defined: an increasing complexity of re¬
flex cortical sensations produced under the influence of ex¬
ternal impressions ; so that the transition in this case does
not imply any new mode of activity, and is accomplished
without any appreciable line of demarcation between the less
and the more complicated; which justifies this other assertion
of Maudsley, that a separation between the sensory and
cortical centres must appear as a pure abstraction.
The result of this paper may be summarised as follows:—
I. In the spinal cord: Elementary, impersonal, unintelli¬
gent consciousness; maximum in inferior animals, minimum
in superior; in the latter in their normal state spinal con¬
sciousness is never called for, because all the reactions which
are within the capacity of the cord are accomplished auto¬
matically, and because the stimuli, not finding in the cord
any mechanism capable of discharging them, are directly
transmitted to the cephalic centres. It is only in cases of
experimental complications of conditions that this conscious-
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192
The Physical Conditions of Consciousness , [July,
ness is awakened through the extended and profound dis¬
integration which such complications produce ; it disappears
again according as new mechanisms are organised and con¬
solidated.
II. In the sensori-motor centres (functionally co-operating
as “sensorium et motorium comraunia”) : Individual con¬
sciousness, rudimentary perception, germ of intelligence;
intelligent and voluntary character of the reactions sub¬
mitted to conditions identical with those governing the
intensity of the spinal consciousness, but with this difference,
that owing to the infinite variety of external and internal
impressions which excite these centres to activity, the latter
is not reduced to a completely automatic mechanism like the
spinal cord, and consequently always participates more or less
in the paneesthesia of the individual by contributing thereto
its share of consciousness.
III. In the cortical centres (acting as “ intellectorium com¬
mune ”): Intelligent consciousness, clear notion of the
relations of the individual to external objects, and of these
objects to one another, whence results the intentional,
really voluntary character of the reactions. Conduct is
regulated by past, present, and future circumstances, such
as the individual can foresee by means of the experience he
has acquired; differing from the two former modes of con¬
sciousness, this one increases with the zoological status of
the animal, and reaches its maximum in man. The intensity
of this consciousness and the quality of its contents depend
on the same conditions as those which regulate the con¬
sciousness of the sensori-motor and spinal centres.
IY. Lastly, in the whole nervous system , considered as the
organ of the fundamental function of the whole life of rela¬
tion, of reflex action —consciousness or unconsciousness of its
activity, according to the physiological phase of this activity
and according to the following law:—Consciousness is ex¬
clusively connected with the functional disintegration of the
central nervous elements; its intensity is in direct proportion
to this disintegration, and simultaneously in an inverse pro¬
portion to the facility with which each of its elements trans¬
mits to others the disintegration which affects it, and with
which it returns to the phase of reintegration.
Y.
I may be wrong, but it seems to me that this explanation,
however incomplete it may be, proves that the physical law
of consciousness which I propose is justified by facts, and
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193
1884.] by Professor A. Herzen.
applies equally to the action of the different nervous centres.
Far be the thought from me that my law is a perfect and
complete expression of the true state of things, but it seems to
me that it is a better and more complete expression than any
hitherto offered, for it embraces at the same time the most
intensely-conscious and the most unconsciously-automatic
activity. Besides, it forms a bond between the apparently
irreconcilable opinions of Lewes and Maudsley, and this
not by adopting the juste milieu , but by amalgamating
the extremes in a conciliatory synthesis. Let us return for
a moment to the opposition between these two eminent
psychologists. Neither maintains an absolutely false thesis,
but each exaggerates what there is of truth in the thesis
which he maintains: Lewes, too much pre-occupied by the
phase of cerebro-psychical disintegration, by the resistance
of the central elements and by the difficulty of transmission,
sees consciousness everywhere; Maudsley, too much pre¬
occupied by the cerebro-psychical reintegration, by the rapid
action of the preformed mechanisms and by the facility of
transmission, sees it nowhere. It follows that Maudsley
thinks himself justified in enunciating this paradox: that
man would not be a less perfect intellectual machine with¬
out consciousness than with it, and that Lewes is indignant
at such an assertion:—
“ To suppose that they pass from the psychical to the physical by
frequent repetition would lead to the monstrous conclusion that when
n real naturalist has, by laborious study, become so far acquainted with
the specific marks of an animal or plant that he can recognise at a
glance a particular species, or recognize from a single character the
nature of the rest, the rapidity and certainty of this judgment proves
it to be a mechanical, not a mental act. The intuition with which a
mathematician sees the solution of a problem would then be a
mechanical process, while the slow and bungling hesitation of the
tyro in presence of the same problem would be a mental process : the
perfection of the organism would thus result in its degradation to the
level of a machine ”—(“ The Physical Basis of Mind,” p. 379, 1877).
I confess that in this I see no more a subject for indigna¬
tion than in the fact that a musician, who has painfully
learned the varied and delicate movements which he must
execute, with a lively consciousness of each one during
the period of learning, ends by playing the most difficult
pieces without his movements, the mechanism of which is
definitely organised, occupying his consciousness for a single
moment; this is a necessary consequence of his progress
and his “ virtuosity,” and without it he could never enjoy
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The Physical Conditions of Consciousness , [July,
music nor afford pleasure to others by it. The same must
hold good in relation to intellectual activity, and does so; in
fact, the conscious mental process betrays an imperfection of the
cerebral organisation , for it indicates, as Herbert Spencer has
so well understood and expressed, the presence of a new, un¬
usual activity, which deranges the equilibrium of the innate
or previously-acquired automatism, and which does not find
a preformed mechanism ready to discharge it. Active vibra¬
tions occur unconsciously until the moment when they meet
central elements which resist their transmission, and then
they become conscious ; but if the same activity is repeated
several times, if the resisting elements learn to transmit it
without delay to other elements, the limit between the con¬
scious and unconscious will ipso facto be displaced, thrown
back: the conscious proceeds from the unconscious and
returns to it; but consciousness does not thereby cease, it
only goes elsewhere, and continues; as combinations of an
inferior order escape from consciousness, combinations of a
superior order occupy it. The reduction of the simpler psy¬
chical processes to automatism is the absolute condition of
the mental development which would otherwise be impossible;
a naturalist would never recognise a plant or an animal at the
first glance, if he were obliged each time to have a vivid
consciousness of each separate characteristic; the mathe¬
matician would not even conceive of the existence of the
highest problems if he were obliged each time to have a
clear consciousness of the multiplication table. It is thus
with all our psychical acts. It follows, therefore, that the
conscious mental process is the transitory phase of an
inferior to a superior cerebral organisation; it expresses
novelty, incertitude, hesitation, groping, astonishment, an
imperfect association, an incomplete organisation, a want of
promptitude and exactness in transmission, a loss of time in
the production of reaction; it indicates that the nervous
paths are not sufficiently cleared or distinctly enough traced
to permit the stimulus to be transmitted without obstruc¬
tion, whatever may be the final effect, reflex movements or
reflex ideational sensations. It shows in short that physiology
has not yet become morphology, and as soon as it does so it
disappears. But it does not disappear completely and abso¬
lutely , it only disappears where the work of incarnation is
finished, to proceed to some other region where this work
has just begun; for consciousness always and necessarily ac¬
companies the clearing of the cerebral field , whilst it ignores the
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1884.]
by Professor A. Herzen.
195
rest unless there is some new combination to be formed. This
is what has escaped Lewes and Maudsley, when the latter
supposes that a man may be as good an intellectual machine
without consciousness as with it, and when the former is
indignant at the idea that the perfecting of the organ
coincides with its degradation to the level of a machine. The
reduction of the whole psychical activity to an unconscious
automatism would be possible only if organic evolution
had an unsurpassable limit, if all labour required to reach
this limit had been completed, if nature had exhausted its
resources and could no longer advance. But all our know¬
ledge of the evolution of living beings tells us, on the contrary,
that it has no limit. This is why the unconscious intellectual
machine of Maudsley is just as impossible as Lewes’s indig¬
nation is useless; for if the psychical processes which now
are conscious become automatic to-morrow, far from losing
all consciousness thereby, we should have a consciousness
more vivid than ever, but its contents would be different;
it would not abandon the psychical acts which it now ac¬
companies and which seem to us very complex, until they
had become simple to us, and in order to accompany more
complex acts, more abstract ideations, acquisitions of a
higher order. It would then accompany the formation of
new intercentral communications in the cortical layers, the
appearance of new layers on the convolutions, the elaboration
of new convolutions in the hemispheres and perhaps the de¬
velopment of new cerebral organs. The race would then do
what the individual now does, what in fact it has always
done, but in another sphere of functions. The school-boy is
conscious of the separate cyphers or the elementary opera¬
tions which he must perform, but he has no idea of the
higher mathematical problems; the student is no longer
conscious of these elementary operations, they are ac¬
complished instantaneously and automatically in his mind,
but he is conscious of the more complex calculations and pro¬
blems of arithmetic and algebra, which he is studying. He is
ignorant, however, of the existence of the problems of higher
mathematics, these are sealed books to him. Finally the
mathematician executes, in the twinkling of an eye, uncon¬
sciously, the most complex calculations, manipulates formulae
as the pianist the keys of an instrument, and his conscious¬
ness is awakened only by the most difficult problems of
higher mathematics; and according as the latter become
familiar, habitual to him, according as he comprehends
xxx. 14
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196
The Physical Conditions of Consciousness } [July,
them easily and solves them rapidly, they occupy his con¬
sciousness less and less. It gradually abandons them, pro¬
ceeding to their results, their consequences, their applications,
to new combinations, to unknown questions—in other words,
it manifests itself more and more elsewhere , where cerebro-
psychical evolution trenches upon uncultivated regions, and
the work of clearing begins, and there stakes out the roads
of the future. It is conditional upon abandoning the simple,
the acquired, that consciousness rises to the complex and
goes forth to conquer the unknown.
Such is the cerebral or intellectual progress which has
done so much in the past and which will do still more in
the future, and which has no limits other than the evolu¬
tional plasticity possessed by a race or individual. Progress
towards perfection necessarily stops when the conditions of
further development no longer exist, but it necessarily con¬
tinues where these conditions are found united. This is
why, on the one hand, the animals considered as inferior by
us, remain where they are; they have traversed the whole
extent of the development compatible with their particular
organisation, and the more simple the organo-psyehical cor¬
respondence which they represent is, the more unintelligent
and unconscious, i.e., the more instinctive and automatic
they are. This is why, on the other hand, of all the animals
we call superior , man has been able to develope in such a
surprising manner, that he has come to believe that he has
nothing in common with them, and has thought himself
justified in denying their relationship ; they have exhausted
the possibilities offered by their poorer organisation and are
henceforth condemned to revolve in the circle of a more or
less complete automatism, which he alone has been able to
break and enlarge. And he has enlarged it so much that he
has opened to himself an infinite horizon of new acquisitions
more and more complex, where his conscious activity may
exercise itself during endless periods without the risk of
being reduced to a state of an intellectual automaton. Two
conditions, however, might put an end to the proud excelsior
of the human species ; psychical progress must of necessity
stop some day, either through an absolute boundary between
the knowable and the unknowable, or through an equally
absolute limit to the organic perfectibility of the human
brain. In these two cases consciousness will, without doubt,
finish by abandoning more and more the cerebral activity,
which will gradually assume an instinctive, reflex, auto-
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1884.]
197
by Professor A. Herzen.
matic, mechanical character. Notwithstanding the increas¬
ingly intense, forced, giddy and feverish work to which our
race addicts itself, it is certain that long before this limit
will be reached, the gradual cooling of our solar system
will have put an end to the possibility of life on the surface
of the globe. This prospect is not encouraging to the race,
but it is not the less certain; to tell the truth, it affects us
very little as individuals.
Shall we therefore say, Apres nous le deluge ? No, we will
rather say, Fais ce que dois , advienne que pourra !
On Escapes , Liberty, Happiness , and u Unlocked Doors/ 9 as
they affect Patients in Asylums . By J. A. Campbell,
M.D., F.R.S.E.
During the year ending 1883, I had rather an unusual
number of escapes, and as two ended fatally from exposure,
I thought it only fitting to glance over the escape-book and
see the results of previous years. I may here mention that
the two patients who died were dements, that one had been
17 years in Garland’s Asylum, the other 15, that neither had
shown a disposition to escape previously, that one died after
two days’ exposure, he having been found alive, and that the
body of the other was found seven days after his escape; also
that all means likely to be of avail in retaking these patients
were made use of.
As I take it, our duty as medical officers of asylums stands
in the following relations:—1st. To preserve, and to do all
we can to lengthen the lives of our patients. 2nd. To pro¬
mote recovery by all reasonable and legal means. 3rd.
To do this in the most pleasant manner for our patients,
and with the greatest regard for their comfort and happiness.
I am thoroughly aware that different opinions are held
about the gravity or triviality of escapes. I have heard the
views expressed that a good lot of escapes show a healthy state
of an asylum, and that some people take too serious views
about the loss of a patient by his own act or accident after
his escape from the asylum. I think we must look at this
from the point of view of the individual patient. We can¬
not afford, it is against the first tenets of our profession, to
follow the example of nature in sacrificing the individual for
the best interests of the race. We must not, we should not,
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198
“ Unlocked Doors ” as they affect Patients, [July,
we dare not, get rid of or allow the suicidally or dangerously
inclined to get rid of themselves or others, for the good of
the asylum as a whole. We have to look at this question
from the standpoint of a doctor and of a relative, as well as
from that of a philosopher or an asylum-improver. Much
praise is due to the English Commissioners for the anxious
solicitude which they have displayed in getting a proper
system of night-nursing and watching introduced into the
English asylums, with the view of preventing the accidental
suffocation of epileptics during a fit (though to some the
question of the value of a confirmed epileptic dement’s life
may appear a small matter), and in insisting on watching by
night of the suicidally inclined and the sick. At page 182
of the 14th report of the General Board of Lunacy for Scot¬
land, the following sentence occurs :—“ The list of deaths
presents an unusual number from accidents, but it is satisfac¬
tory to be able to report that this unfortunate result is not
due to any laxity of management, but mainly to an unfor¬
tunate concatenation of events ” (!) One was a suicide on
probation, two were suicides from escapes, one of them
through an open door, and one was a death from drinking
carbolic acid, which had been left in an unlocked room, in an
asylum with 175 patients. If at Hanwell, now-a-days, between
two visits of the Commissioners, 42 deaths of this sort occurred,
which is in the same proportion, I am quite sure there would
be some further explanation necessary.
In the sister country north of this, there has been much stir
lately made as to increased liberty for asylum-patients and
its beneficial effects; and the review which appeared in our
Journal of the 1883 report of the General Board of Lunacy
for Scotland, penned ostensibly by a very friendly critic,
administers lavish praise to Commissioners, Deputy-Com¬
missioners, who are so enthusiastic that they believe a
“ boarded-out dement ” is better off than an asylum-patient,
and infinitely better off than a British working-man, or
that the nursing of an insane mother by a lately-recovered
daughter is prophylactic against a return of the malady to
the latter. “ Everywhere there seems to be activity, zeal,
a desire to try new ideas.*’
“ The Beports on Asylums by the Visiting Commissioners
are mostly laudatory.”
This is all very well, and we are glad to hear that such a
good state of matters exists. There has been, however, a ten¬
dency on all occasions of late years for the mode of treatment
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1884.] by J. A. Campbell, M.D. 199
of lunatics in Scotch asylums to be extolled rather at the
expense of that in force in England, and we have heard
a very great deal of the “ open-door system,” the farm-work
and the “ boarding-out system/’ As l remarked in a former
paper, why do we not have these matters all laid before us in
such a form that we can trace their actions on the prosperity
of the asylum as to recoveries, comfort, happiness and safety
of its inhabitants, as well as in its monetary aspect? It
should be borne in mind also that before the Scotch Com¬
mission was formed, two English Commissioners, Mr. Camp¬
bell and Mr. Gaskell, gave their assistance and labour in the
original Royal Commission. At the present moment the two
principal Royal asylums are superintended by physicians
who practically made their fame in charge of English county
asylums, while in two other Royal asylums, the physicians
acted as assistants in English asylums, and the same is the
case as regards three of the district asylum superintendents.
Now, with these facts before them, it does not look too well to
have an attempt made to elevate “ a Scotch system of lunacy
and its treatment ” into too high a position at the expense of
English confreres.
It is quite true that some of the Scotch asylums are most
admirable, that one of them has cost more per bed than any
asylum in Great Britain, but at my visits I have seen asylums
with grave defects, and within the last eleven years I have seen
in Scotch Asylums evidences of want of progress of a more
glaring character than I have noticed in any English asylum.
I do not think it profitable to enter on this subject in detail.
I believe that many misapprehensions are caused by writing
about and discussing modes of treatment and amount of
liberty which should be given, recovery and death-rates,
without really knowing whether the character of the material
dealt with is at all similar. I would respectfully suggest to
my fellow-superintendents the advisability of giving in their
reports a table such as is to be found in my report of this year,
which contains data concerning the inmates of this asylum on
December 31st—the nationality, numbers of those epileptic,
general paralytic, suicidal, above 70 years of age, under con¬
tinuous night-supervision, employed usefully,bed-ridden from
age or disease, probably curable, and the number and propor¬
tion of attendants. To anyone conversant with asylums and
asylum-management such a table will at once convey with com¬
parative accuracy a fair idea of the patients and the difficulties
of working the institution. In remarking on, reporting of, and
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200
“ Unlocked. Doors 99 as they affect Patients , [July,
deducing conclusions from, states of asylums, too little atten¬
tion has hitherto been given to the character of the patients
previous to admission, or to the different forms of insanity
from which they suffer. An asylum which contains the whole
of the lunatics of the parish or district for which it is built,
has probably a different class of patients from an asylum in
a county where a considerable proportion of lunatics are kept
in workhouses, and the forms of insanity occurring in quiet
rural districts are very different from those drawn from urban
or pit districts. The insane miner from Newcastle, Durham,
or the Whitehaven district in Cumberland, is a very different
patient from the Fife weaver or the Argyle shepherd.
I give here certain data concerning four English asylums
and four Scotch asylums ; the latter are worked partially or
wholly on the €t open-door ” principle. I heartily thank the
medical superintendents who have kindly furnished me with
the data contained in the table on opposite page. A glance
at it will show the different character of the patients in
these asylums, and the greater proportion of escapes in the
four Scotch asylums.
Many escapes really are of little consequence, being those
of patients unlikely to injure themselves or others, and quite
fit to take care of themselves for a short period.
A large proportion of the escapes at Garlands have been of
this nature. Then patients on parole at times walk off. I
have seen some extraordinary and unaccountable instances
in which harmless and demented patients, lacking in nerve-
energy, who for years have been trusted to do some simple
and regular work have some fine day walked off. I believe
this is really due to a slight attack of excitement.
But then comes another variety of escape, which we must
look at quite differently. The suicidal, the homicidal; the
young wife unfit for the time to protect her own person; the
erotic young girl anxious, owing to her state, to find a partner
who shares her feelings and will indulge them. These cases
exist. I think no one will gainsay this. The relatives, the
wife, the husband, the father, the brother consign them for
security as much as for recovery to the asylum; and it is
quite known to us that in many of such cases, time, the great
healer, is the only remedy, and that to safely tide the patient
over a given number of weeks or months is the sure road to
recovery.
I have been eighteen years in asylum practice, and have
not yet reached the stage that I can take certain escapes coolly.
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201
1884.] by J. A. Campbell, M.D.
Table giving Data concerning Inmates in Four North of
England Asylums and Four Scotch Asylums,* on De¬
cember 31st, 1883.
Asylum.
No. of Patients.
Epileptics.
General Paralytic.
Suioidal.
Above 70 years.
Bedridden.
No. of Escapes.
Carlisle .
511
53
12
35
31
48
14
Northumberland.
438
31
9
70
17
5
3
Newcastle (City).
286
36
13
14
8
5
5
Durham .
1109
112
71
75
38
50
20
Argyle District .
335
15
B
19
6
10
(Lenzie)
Barony Parochial.
522
H
14
16
(Rosewell)
Midlothian District
214
9
1
13
4
14
Fife and Kinross District...
327
15
, 8
11
11
15
32
■pgj
Totals in
/
4 English .
232
105
94
108
42
4 Scotch .
1398
85
31
39
72
. i
i
.9
t
/
4 English .
9*8
B
8'2
40
4*6
1-7
4 Scotch .
60
2*2
51
50
. 2-7
5*0
* Partially or wholly worked on the Open-Door System.
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“ Unlocked Doors ’* as they affect Patients , [July,
202
Until last year I had been specially fortunate, but many a
miserable hour certain escapes have cost me. I have known an
escaped patient fished out of the neighbouring river, another
1 ‘ust caught on the bank, and several other similar casualties
Lave been averted by a kind Providence. One patient told
me on his return that the sun was so beautifully out and
the day was so lovely that it had prevented him doing what he
purposed. I have been told by a medical superintendent of
a young female who escaped, telling that the night of her
escape she had connection several times with a man she met.
It is easy for an official who never has had charge of an
asylum to talk loosely in praise of extended freedom for the
insane, but an asylum-doctor who knows the forms of in¬
sanity practically, who is entrusted by relatives with their
insane, will have a bad time of it if a patieut, while he is
declared to be unfit to have care of himself, suffers in person
from want of ordinary care and precaution. I think any
unbiassed mind must consider the medical man very repre¬
hensible who gives entire freedom to those clearly unfit to
use it aright. In saying this I, of course, exclude errors of
judgment in individual cases where all reasonable precau¬
tionary measures have been adopted.
At page 33 of the twenty-third report of the Scotch Lunacy
Board the following sentence occurs : “ And in the Barony
Asylum at Lenzie, which accommodates upwards of 500
patients, there is free communication between all the wards
as well as free egress from each of them to the general
grounds of the establishment.” Is what is here stated
meant P Can any of the patients from any part of the asylum,
and labouring under any form of mental disorder, go as they
see fit out of the asylum at will to the grounds P If this is
so what security does the asylum-treatment offer? The
relatives should surely be aware that the lives and honour of
the insane sent to the asylum are so left to the guidance of
the individual whose mental state was deemed such as to
prevent his being dealt with at home. If, however, it
is intended only to convey that there is a possibility of
getting out, what the better are the patients off? If the door,
though open, is guarded, it is merely reproducing the suffer¬
ings of Tantalus, which may be good mental discipline for
some patients, but is, I know, detrimental to others.
I have seen restless melancholiacs, determined on self-
injury, who resisted everything, dressing, undressing, feed¬
ing, &c., who even in a day-room, with a door opening with
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203
1884.] by J. A. Campbell, M.D.
the ordinary handle (for at Garlands portions of the interior
of the asylum were worked without locks in 1867), would
struggle to get through, and when the door was locked would
at once subside and settle. And one of our chief authorities
on asylum-matters in the North told me lately that a private
case of this class under his treatment, who resisted every¬
thing, was walked about under the charge of two capable
attendants till, from her actions and the necessary restraint
of them, her hands and arms became seriously inflamed. In
this case by locking the patient in a large room with the two
attendants, she at once gave up some of her worst practices
and gradually improved, so that she could be more easily dealt
with. Now is it meant in the sentence quoted above that
such cases are allowed to roam through the woods and
grounds of Lenzie unattended or at their will?
Garland's asylum is not surrounded by a big wall, with
only one exit through a constantly guarded gate. It never
had walled-up airing courts, where on looking down from an
upper window one could see the patients walking about as if
at the bottom of a well; for many years, all, except those
physically unfit, have gone beyond the airing courts for exer¬
cise. Farm-labour and other industries were in use even
before the recent furore on the subject.
The patients likely to escape have neither been restrained
mechanically, nor have they had “ escaped from-asylum,"
printed in large black letters on the back of their white
trousers ; nor have they been dressed in yellow on one side
and black on the other.
So far as I can understand what is called the “ unlocked
door system" of working an asylum, it is merely substi¬
tuting human vigilance for the lock; the patient gains no
more liberty, and the wonderful thing is that it is applied to
all portions of the asylum, even where the patients are most
anxious to escape and least to be trusted. When I was
assistant at Durham asylum in 1866 patients on parole lived
in some cottages; but in their case they were trusted, and
went out and in of their own accord. This is what I would
call a true open-door system. Previous to the date that I
began asylum-practice, I am aware that at Morningside,
under the able, kindly, and progressive superintendence of
Dr. Skae, patients lived in two houses in the grounds, which
during the day, were open, but at night had the out-door
locked. The patients were of course carefully selected and
were considered trustworthy.
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204
“ Unlocked Doors '* as they affect Patients, [July,
The mode of treatment in the Fife asylum is a more full
development of what has been long in use, while the dan¬
gerous and suicidal, few in number in that asylum, are care¬
fully looked after and locked up.
In this asylum there are so many doors opening to the
outside that it would certainly cause an increase of attendants
if I had to place one as a Cerberus at each outside door; and
though the comforts of the asylum are fair, and I think will
quite bear comparison with those of most of the Scotch
asylums, yet I have many misguided patients who still have
the feeling that home-life is preferable to life in an asylum,
and would put their views into practice if they got the oppor¬
tunity. We know that in the heart of all there exists an
instinctive love of personal liberty, and few can entirely
repress some inclination even for the moment, to sym¬
pathise with attempts to escape. So far as I can learn, the
open-door system has not been adopted either in the Royal
Edinburgh or Glasgow asylums, whose medical heads—lec¬
turers at their Universities—are justly held to be the
authorities on asylum-treatment in Scotland. Nor by the
following named superintendents whose sagacity, knowledge,
practical experience in the treatment of insanity and success in
asylum-management is unquestioned, and must command our
respect, and whose example must necessarily be looked up to
with reverence by those who, like myself, younger in years,
are less ripe in experience and knowledge. I refer to Drs.
Jamieson of Aberdeen, Howden of Montrose, Rorie of Dundee,
Grierson of Melrose.
Dr. Sibbald is the only one of the five members who at
present constitute the General Board of Commissioners
in Lunacy for Scotland who has had the advantage of study¬
ing insanity and its treatment practically as a medical
assistant, and afterwards superintendent of an asylum for
the insane. In the latter capacity he was well known as
careful and cautious, as well as kindly and skilful; and that
he kept the individuality of patients and the special character
of cases prominently before him in treatment (as all rightly
constituted medical minds should do) and evidently held
very strongly the views I advocate in this paper, while he
was responsible, as medical superintendent, for the lives of the
patients under his charge in the Argyll asylum is, I think,
clearly proved by the following. I quote from his report for
the year 1866, at page 9, where at considerable length he
details the case of a patient who had very suicidal propensi-
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1884.]
205
by J. A. Campbell, M.D.
ties. “ She would bite herself or others, or attempt to
commit suicide by strangling, or by beating her head against
the floor or wall. 55 “The case is particularly worthy of
notice, however, as being one in which the medical superin¬
tendent did not consider himself justified in refraining from
the use of mechanical restraint. 55 “ The superintendent,
while cordially recognising the advantage of the general
abolition of such restraints, considers that in such excep¬
tional cases as this it would be pedantic adherence to a rule
and not the preservation of a principle, which would dictate
the refusal to employ them. 55 The daily average of patients
in the Argyll asylum for this year was 118. In large asylums
such cases are frequent.
The proper medical aspect of the treatment of the indi¬
vidual with the view to probable recovery, if the suicidal
paroxyms were safely tided over, was clearly present to the
writer when this was indited. The life of a lunatic is as valu¬
able now as it was then, and insane patients now are as suici-
dally inclined as they were then. While writing this paper a
Scotch patient of mine put his head deliberately in the fire
and kept it there till he was pulled out. If facilities were
offered him he would not be long a patient. At page 13 of the
twenty-fourth report of the Scotch Commissioners a table is
given of the escapes per 1,000 patients in asylums. I have
made use of it for purposes of comparison, and I find that from
1871 to 1881, inclusive, the escapes in Scotland have been at
the rate of 3*8, while the escapes from Garlands have been
at the rate of only 1*7 per cent. I know that it may be
easily said that you house your patients up so tightly they
have no chance of escape, but this tells upon your recovery
rate, and your patients are not nearly so happy as they might
otherwise be.
Now happiness is a difficult question to estimate, so I do
not propose to discuss it at any length. However, patients
during lucid intervals have told me that the feeling of happi¬
ness experienced by them during attacks of excitement was
most intense. We know that many of those capable, from
mental constitution of states of exhilaration and excessive
happiness, also experience from slight causes intense misery.
Exaggerated happiness and contentment are the prominent
features in several forms of mental disorder. To expect
great happiness in patients in an asylum, away from rela¬
tives, from home, from all the struggles which make life in¬
teresting and the successes which make it enjoyable, shows
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206 “ Unlocked Doors ” as they affect Patients , [July,
a want of knowledge of tlie human mind. When great
happiness and contentment exist among the patients of an
asylum, there must be something far wrong.
If patients were happy and content in an asylum, why
should they wish to leave it and face the world. A patient
recovering with the hope of discharge kept before his eyes
may for the time be content and cheerful. Patients who
realize that they have recurrent attacks of mental disorder
may have the sense to become resigned to life in an asylum
and try to make the best of it. And some old broken-down
patients, friendless and homeless, may in time look on the
asylum as their home and the officials as their best friends.
Certain patients exist whose mental calibre is so small,
whose powers of enjoyment are so limited, that the mere
satisfying of their creature-comforts produces a sort of con¬
tentment which to them probably constitutes happiness.
Most of the asylums in Great Britain now afford the creature-
comforts required by this class. Many patients in asylums,
like other people outside, are unhappy and miserable from
the ever present recollection of former misdeeds, and their
memory of the past causes unhappiness and fearful forebod¬
ings for the future. The absence or presence of locks on the
doors may interest them only as offering a greater chance of
escape from the asylum and the world, it affects not their
happiness—for them a draught of the waters of Lethe would
be treatment at once efficacious and pleasant. To many
patients, however, an asylum is really a place of detention.
You may employ, you may amuse for the time, but you can
never get them to rid themselves of this feeling.
But with recoveries it is quite a different matter. We
have sent our patients out as recovered, fit to take care of
themselves, presumably fit in most instances to maintain
themselves; and, taking it over a period of years, I should,
after examination of the re-admissions and the number of in¬
dividuals discharged in one year, be satisfied of the honesty
of intention in registering recoveries in most public asylums.
I compare the returns of this asylum which, of course, I
know best, (possibly many other English asylums might show
a better record if I had time to reckon up their results) with
those of the three Scotch asylums where the open-door
system is in part or entirely in use. Where the individual
asylum has not been the ten years at work, I give the number
of years for which the calculation is made. I have to end
the period at 1881 as I have not later reports in my posses-
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1884.]
207
by J. A. Campbell, M.D.
sion, and owing to the form of table adopted in the Rosewell
asylum I am unable to include the return from this asylum.
RECOVERY-RATE CALCULATED ON ADMISSIONS, VIZ. :-
Name of Asylum.
Length of Time.
Percentage of
Recoveries.
Fife and Kinross.
10 years, ending 1881.
439
Argyll and Bute.
10 years, ending 1881.
320
Lenzie (Parochial) .
5 years, ending 1881.
46*5
Garlands .
10 years, ending 1881.
47-7
The presence of locks does not seem to have had any evil
influence on the recovery rate at Garlands, and I may here
say that the report of 1882 of this asylum shows an average
recovery rate of 47’3 per cent., a death rate of 8*1 per cent.,
with one suicide and one accidental death occurring in the
asylum during the ten years ending 1882, and that during
that time only one patient who escaped was not recovered
within the time the order was in force, and that this was
entirely due to assistance of relatives who, if they had stated
their wish, would at once have got the charge of the patient
in the proper manner; they subsequently, I believe, deeply
regretted their action.
At page 111 of appendix B of the twenty-fourth report of
the Scotch Commissioners the following sentences occur in the
report on the Lenzie Asylum:—“ Eleven escapes are regis¬
tered, the patients being absent for at least one night. They
all either came back or were brought back. For some of
them no search was made, as it was believed they were in
safety with friends, and that they would return. This indeed
was the case as regards four of the eleven who escaped.
They went to friends in or about Glasgow, and after a short
absence voluntarily returned to the asylum.”
We, of course, understand that as no fault is found with
this mode of dealing with escapes it is officially approved of.
Certainly it is not what was taught me when I was an
assistant, or what I have practised as a superintendent, or
inculcated on those who have medically assisted me, and
though patients may at times come back or be brought back.
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208
“ Unlocked. Doors ” as they affect Patients 9 [July,
they may quite well cause injury at home to relatives or even
be au annoyance to the public ; and, when they do not come
back alive, I for one think it does not look well, even in print,
that it should be the recognised thing not to send after
escapes. I quote the following which must, of course, be
authentic, as it is an editorial note from page 456 of the
October number of the “ Journal of Mental Science,” 1883:
“ In May last a female patient escaped from the Lenzie
Asylum, Glasgow, through an unlocked door, and was killed
—whether suicidally or not is unknown—on the railway
near the asylum.
“ The Public Prosecutor for the county has intimated to the
asylum-authorities that if such an accident occurs again it
may be his duty to institute an investigation as to whether
there has not been culpable negligence in the custody of the
lunatic; and the husband of the deceased woman has, we
observe, raised an action against the managers of the asylum
for damages for the loss of his wife. The managers have
compromised the action by a payment of £50 to the husband.
A very serious question is thus raised, and one which in¬
volves the increase of the already sufficiently heavy risks and
anxieties of asylum-physicians. We believe that during the
last year the number of suicides in Scotch Asylums has been
unusually large. Is this a mere coincidence, or is it as¬
sociated with the granting of a greater amount of liberty? ”
I quote the following from the late Sir James Cox’s
pamphlet on “ Lunacy in its Relations to the State,” pub¬
lished in 1878. “ When a man becomes insane it is held to
be the duty of the State, in modern civilised communities,
to provide for the protection of the public against risk from
his actions; and also to provide for the care and safety of
the insane person himself, and the protection of his estate,
whether imperilled by his own acts or the acts of others.”
Fashions change. Men’s views change, and have done so
since time began, and it may be that as time goes on we
shall change our views completely as to the proper mode of
dealing with insanity, and as to the higher meaning of the
word philanthropy so far as insanity is concerned. In some
quarters, to judge from articles which have appeared on
treatment, great changes seem taking place in the views held
and expressed by some members of our department, though
such expressions are just the logical outcome of the indica¬
tory expressions of some official authorities. A most able
article on the “ Punishment of the Insane ” appeared in the
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209
1884.] by J. A. Campbell, M.D.
April number of our Journal for 1883, which deals with cer¬
tain matters of treatment, and most excellently describes the
essential elements of the recognised modem treatment of the
insane, “kindly care and sympathy, careful medical treat¬
ment, as much freedom as possible, and as little as practic¬
able of the feeling or the appearance of restraint, safety
being the only limit of freedom/’
Some asylum-officials and others clearly have so advanced
in their views as to consider it reasonable that entire per¬
sonal freedom should be given to patients dangerous to them¬
selves. In a short time an advance in education and views
may also prevent our interfering with those presumably
dangerous to others until they have proved themselves to
be so distinctly.
We may have asylums in the future divided up into
classes, viz., asylums for recovery, with precautions and
safety to life, asylums for recovery with moderate risks ;
asylums for recovery at any risk, freedom and excitement,
shooting, boating, and ballooning, the true aids to recovery
open to all!
The determination of the character of the asylum to which
a patient is to be sent will present some nice points of in¬
terest, and we may expect to see quite a run of paying
patients to the latter-mentioned class of asylums when the
expectant heirs of an insane patient, or husband, or wife,
anxious to remarry, et hoc genus omne , have the matter pro¬
perly before them.
Can it be that some of the younger members of our depart¬
ment are striving to excel each other in carrying out notions
so belauded by the Scotch Board of Lunacy ? It would be
well gravely to consider whether the discovery that lunatics
should be punished like ordinary men is not the natural de¬
velopment of such fancies.
Is there no apostle of this new gospel capable of putting
pen to paper and expounding to us its blessings P Are we to
trust alone to official laudation as our only source of informa¬
tion as to the glowing results obtained ? Can we not have
the matter brought before us “ in a true, full, and parti¬
cular manner,” dealing at length with the statistics of
recoveries, escapes, and deaths from suicide and accident,
and, if possible, by the superintendent who has had the
longest and most varied experience of this much-extolled
mode of treatment?
If we were convinced that the open-door system of treat-
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210
“ Unlocked Doors 99 as they affect Patients . [July,
ment increased the recoveries, reduced suicides and accidents,
and promoted happiness, we should be very wrong, almost
culpable, if we did not at once adopt it. We should have the
facts put before us so that we may judge of the matter dis¬
passionately, and at leisure. To visit an asylum where even
open sesame is uncalled for during the walk through, in the
middle or visiting part of the day, is not the way to get an
idea of the efficacy of the treatment. At Garlands during
the forenoon, and for two hours in the afternoon, the wards
are empty, and the doors for the most part open in all but
the sick wards. Let us, if possible, get a true and full ac¬
count. Such a communication will be of the highest value.
Ovariotomy once decried now saves the lives of hundreds, and
if we could elucidate, as I am endeavouring to do, the true
facts of the open-door system, it is possible that we may in¬
crease our recoveries and the happiness of our charges, and
do so perhaps at only a monetary expense, without additional
risk or anxiety, or perhaps with a diminution of all. But on
the other hand, when the whole truth is known it may turn
out that what is possibly is not actually the fact.
An Inquiry into the Value to be Attached to the Different
Recovery Rates of Different Asylums as Tests of Efficiency.
By T. A. Chapman, M.D., Hereford.
In the “Journal of Mental Science” for April, 1883, I
presented some statistics as to the recovery and death-rates
of asylums, especially directed to the question of the effect
of the size of the asylum upon them. In that communica¬
tion I stated an opinion (p. 9) that the dominant element
governing the different rates of recovery in different asylums
was to be found in the different classes of cases admitted
into different asylums, and expressed a hope of some day
being abl e to make a further research in this direction.
Table YU. of the tables of the Association obviously afforded
the most hopeful available means of doing so, but how much
could not be seen until a laborious abstract of its contents
for a number of asylums over a series of years was made.
This I have at length worked out, and find that certain
definite conclusions can be derived from it.
This Table VII. is the Table E. of Dr. Thurnam, and
divides the admissions into four classes according to the dura¬
tion of the disorder, and though it is a somewhat bare and
Digitized by Google
1884.] An Inquiry into Recovery-Rates of Asylums . 211
meagre classification, not according to the nature of the
disease, but merely as to its duration, it does give four
classes of very different prognosis, as may be shown by the
recovery-rates of the different classes.
Recovery-Rates of the Different Classes in Table VII., ex¬
tracted from “ Journal of Mental Science,” July, 1877.
Both sexes.
Duration on Admission.
Thuraam,
Table E.
County Asylums
for year 1876.
Hereford Asylum,
up to July, 1876.
Class I.
First attack and within
three months .
78*18
460
620
Class 11.
First attack above three
and within 12 months
46-00
29-0
17*0
Class HI.
Not first attack and
within 12 months...
60-96
600
720
Class IV.
Over 12 months. First
or otherwise .
1916
10-0
1-0
In collating this table I have simply taken the largest
supply of material available, and having a tolerably complete
set of asylum-reports for the past eleven years, I have in
most instances taken that period. I have omitted the tables
of asylums within a few years of opening. In some cases
the tables are not given, and in others for only a part of the
time; in others the tables have been made out in an ob¬
viously erroneous manner, so as to be utterly useless, as, for
instance, in the Norfolk Asylum Reports.
In making such an analysis of the admissions, imperfect
though it is, we expect to find that if an asylum has a high
recovery-rate due to efficiency it will also have a high re¬
covery-rate in each of the classes into which we have divided
the admissions. If we find that such an asylum has high
rates in some classes and low in others, we must conclude that
these classes have in themselves further peculiarities that will
account for the differences, as it would be absurd to conclude
that an asylum has a high rate in one class due to efficiency,
and in another a low rate due to inefficiency. It is further
xxx. 15
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212
An Inquiry into Recovery •Rates of Asylums , [July,
obvious that an asylum with a high general recovery-rate
may have low rates in each of the classes, the high general
rate being due to the proportion of the more favourable
classes being above the average, whilst equally an asylum
with good recovery-rates in all the classes may have a bad
general recovery-rate owing to an excess of the unfavourable
classes. An asylum with a large proportion of Classes I. and
HE. among its admissions will have a good general recovery-
rate, one with an excess of Class II., and especially of Class
IV. will have a low general recovery-rate. For example,
Carmarthen, with a general recovery-rate of 22*8, and Mac¬
clesfield with 88*2, have better rates in the three most
important classes, I., II., and III., than Essex at 40*6 (ex¬
cept as compared with Carmarthen in Class I.) and Leicester
Borough at 41*4; but then the former have only 35*4 and
55 # 7 per cent, of Classes I. and II. in their admissions, the
latter 79*8 and 84 0.
In comparing the recovery-rates of different asylums in
the several classes, 1 attach much the most importance to
Class I., because, since it contains much the most curable
patients, efficiency must be most clearly observable in the
results here. Class III. does indeed present a larger ratio
of recoveries than Class I., but their variation in dif¬
ferent asylums probably depends more than anything else on
the existence of a larger or smaller number of recurrent
cases, or on a different practice as to discharging such cases
during remissions. In only one or two instances does a
high general recovery-rate appear to depend on some such
circumstance, as, perhaps, the cases of Lancaster and
Cumberland, which have high general rates, not accounted
for by high rates in Class I., nor by large proportions of
curable admissions, but have bigh recovery-rates in Class
HE. Similar remarks as to individual asylums might be
made in other directions, but a short study of the tables
given will suggest most of these.
I give here a table summing up the whole of the materials
examined (omitting several of the least trustworthy asylums),
giving the results for 93,443 cases classified as in Table VII.,
much the largest number that has, so far as I know, been
collected into such a table. The percentages differ appre¬
ciably from those founded on the year 1875 only, which I
gave in the Journal for July, 1877, in Class I. (F.), Class III.
(M.), and Class IV. (F.), being larger in each instance. This
is accounted for probably by reasons stated by me at that
time, and especially, perhaps, because I was not then able to
Digitized by v^ooQle
by T. A. Chapman, M.D.
1884.]
213
detect and reject doubtful statistics, as I am to some extent
able to do here.
The Admissions and Recoveries, and Percentages of the
latter on the former, arranged in Classes as per “Table
VII.,” of 46 English County and Borough Asylums and
the Edinburgh and Glasgow Royal Asylums for (in most
instances) 11 years, 1872 to 1882 inclusive.
Classes.
Total Admissions.
Total Becoveries.
Percentage of
Eecoyeries
on Admissions.
| M.
F.
Total,
M.
F.
Total.
M.
F.
Total.
Class I.
18786
19497
38283
18654
44*77
52-53
Class IL ...
6155
6971
12126
1997
3421
22-99
33-44
Class III. ...
8701
10878
19574
4368
6126
56-34
Class IV. J
1
10424
9873
20297
1275
2456
11-33
12-92
i
Total*
1
46300
47143
93443
15892
19676
35468
34-32
41-52
37-95
There is one point in the abstracts I have made in which
they are not strictly comparable owing to a mistake of my
own in first making the abstracts. Some asylums separate,
as a Class V., VI., &c., congenital cases, unknown, unascer¬
tained, &c.; others lump these together in Class IV. I began
by omitting these where omitted, but finding I could not
always do so, afterwards lumped them. This makes a varia¬
tion in the figures, which is, however, of small amount, and
in a comparatively unimportant portion of the figures.
The full abstract involves a large array of figures with
which I do not like to burden this paper.
It may enable me to somewhat abbreviate the remainder
of this paper, without sacrifice of perspicuity, if I state at
once the largest conclusion at which I arrive after a study
of these figures. It is customary in asylum-reports (I have
done it myself, and may probably do it again) to state the
recovery-rate for the year to be satisfactory, &c., clearly
* This total does not agree with the additions, owing to the circumstance alluded to in
the text.
Digitized by Google
214
An Inquiry into Recovery-Rates of Asylums , [July,
suggesting a belief that a high rate of recovery is a proof of
the efficiency of the asylum. There can, of course, be no
doubt that efficiency is proved if it can be shown that the re¬
covery-rate is higher than the average for the class of patients
treated ; but then no clear measure of the class of patients,
and what would be an average recovery-rate for them, is ever
indicated.
The conclusion at which I arrive, broadly stated, is that
these statements, as usually made, are without meaning.
That the different rates of recovery obtaining in different
asylums, whether we take Carmarthen with 22 # 8, or Cumber¬
land with 47 # 4, appear within so narrow a margin to de¬
pend on the different classes of patients admitted to different
asylums, that we may feel certain that had the classification
of patients available for our analysis been of a less general
character, the differences would have been fully accounted
for. Indeed, it is remarkable that the outstanding variations
should be so small.
This conclusion is not, I think, disturbed by the occurrence
of such anomalous cases as those of, for instance, Bumtwood
and Banstead, where the recoveries in Class I. are less than
half the average, or of Bristol, where they are nearly double
the average.
The cases that are most disturbing can usually be ac¬
counted for by carelessness, or other error, in the compila¬
tion of the tables. I have already alluded to one or two
instances where the figures given are obvious nonsense; but
there are a few other instances that, whilst not outrageously
absurd, are still so contrary to the general drift of the figures
as to suggest some error. For instance, nothing can be
clearer than that the proportion of recoveries in Class I.
should exceed those in Class II., usually by from 50 to 60
per cent. Yet Burntwood cures 33*3 per cent, in Class II.,
which is a very fair figure, and only 23*4 in Class I., which
is a very low one. Somerset gives 51*4 in Class II., which is
far too high—only one other asylum exceeding 40—and only
42*4 in Class I.; Sussex gives 35*3 in Class II. and 32*6 in
Class I., and the City of London brings these figures too
close, viz., 37’8 and 38*5. Then again, Prestwich claims to
cure 30*7 per cent, of Class IV., but since in the other three
classes Prestwich takes a high but by no means a first place,
and since only one other asylum cures more than 20* per cent,
in Class IV., there can be little doubt that cases properly
belonging to the other classes have been here included in
Class IV.
Digitized by C^ooQle
215
1884.J by T. A. Chapman, M.D.
Possibly, indeed, the circumstance, which I think has ap¬
peared to be suggested by other statistics of Prestwich, that
cases are selected in the sense that a large proportion of un¬
favourable cases are kept in the workhouses, especially affects
the statistics of Class IV. Since, however, a similar selection,
though perhaps less marked, takes place in regard to other
asylums, one would not have expected Prestwieh to stand
forward so prominently if this is the true meaning of this
figure.
With regard to Class IV. especially, the result of errors in
tabulating so varies the rate of recovery that any comparisons
between different asylums in this class are probably wholly
fallacious; a few instances of Class III. are very apt to get
into it, and even perhaps of Class I., and the true recovery-
rate of Class IV. is so low that a very few extraneous re¬
coveries added to it seriously affect the percentage. In most
asylums Class IV. contains so many imbeciles, cases of
advanced brain disease, of senile dementia, and other
chronic and incurable forms of disease, that I feel consider¬
able doubt of the accuracy of the figures wherever the
recovery-rate much exceeds 10 per cent. At the same time,
since a small inclusion of extraneous recoveries has a large
effect here, this figure may be rendered worthless by an
amount of error that does not very materially affect the
figures in the other classes.
I am unable to refrain from stating my impression that, in
not a few of these cases, also when Class I. presents a low
rate, it is not due to inefficiency in treatment, nor to an un¬
favourable class of cases having to be treated, but to want of
care in tabulating ; not a few cases that ought to be in Class
n. or Class IV. being in Class L, chiefly because the dura¬
tion stated by the relieving officer has been accepted. It
is still, unfortunately, the practice in some asylums to let
the facts (?) of the “ statement” be slavishly copied into the
admission-book as possessing an official sacredness, and then
to tabulate from these without further care or thought.
This practice will tell on our figures in two ways: first,
it will depress the recovery-rate in Class I., and, secondly, it
will increase the stated proportion of curable cases. Thus,
in several asylums having a gross recovery-rate of about 35*0,
a lower rate of recoveries in Class I. is accompanied by a
higher rate of curable admissions, but if some of the incurable
cases in Class I. could be relegated to Class IV., the recovery-
rate of Class I. would be improved, and the stated proportion
of curable cases would be diminished. The tendency of the
Digitized by A^ooQle
216
An Inquiry into Recovery-Rates of Asylums, [July,
statement always is to abbreviate the duration, cases of
senile insanity of several years’ duration, and utterly hopeless
as regards recovery, being often entered as having lasted “ a
week,” “ten days,” and so on. This grievous flaw in the
value of these statistics has several times nearly led me to
give up the whole -inquiry as seriously vitiating the results,
and preventing the real meaning of the figures from ap¬
pearing. On the whole, however, though thus vitiated, there
is a sufficient mass of trustworthy matter to indicate in what
direction the truth lies, and to afford a useful amount of
valuable meaning.
When we go into details as to individual asylums, there
are very few that do not present some anomaly requiring ex¬
planation, whether by errors in tabulating, or by some special
local characteristics of certain classes of the admissions.
Not only broadly, however, but also with considerable de¬
tail, the figures show that those asylums that habitually give
a low rate of recovery might claim a high one; thus, for
instance, Carmarthen, at 22*8, cures 52*3 percent, of Class I.,
which is above the average. On the other hand, those in higher
positions might be lowered; Leicester Borough, for instance,
with 41*4, might be put in a low place as curing only 42*9
per cent, in Class I., if judgment is based, not on the gross
recovery-rate, but on the rate in the different classes.
I tabulated also the proportion which the deaths from
general paralysis and from cerebral diseases bore to the
total admissions, but have not been able to throw much light
on the other figures by their means. It is, however, no
doubt more than a coincidence that the two asylums with
the lowest general recovery-rates, 21*1 and 21*4, and the
lowest recovery-rates in Class I., 23*4 and 30*3, have also the
highest death-rates from cerebral disease, viz., 31*0 and 38*1,
the next highest being 27*7, and only three exceeding 25*0.
Whilst the only three asylums with a lower rate than 14, viz.,
Prestwich 11*2, Cumberland 12*7, and Hereford 13 # 4 (omit¬
ting London and Somerset, whose figures cannot be trusted),
have high rates of recovery in Class I., viz., 53*9, 54*6, and
69*6 respectively.
If we take the six asylums with the lowest recoveries in
Class I.—omitting Sussex and London as untrustworthy—
and the nine with the highest, the ratios of deaths from cere¬
bral diseases are respectively 25*0 and 16*0. The inter¬
mediate figures are less marked, but these results are
sufficient to show what is very important, that a higher or
lower rate of recovery in Class I. may, and probably usually
Digitized by Google
217
1884.] by T. A. Chapman, M.D.
does, depend on a difference in the nature of the cases in¬
cluded in it rather than on the efficiency of the asylum in
treating them. This may be further illustrated by the case
of Bristol, where no less than 77*8 of the cases in Class I.
recover. Now two circumstances show that this cannot be
due to any unusual efficiency in the treatment pursued at
Bristol. One is that in Classes II., m., and IV. the results
at Bristol are very poor, especially in Class II. (Banstead
12*0, Bristol 12*4, only one other under 20*0), and Bristol
cannot be at once both the most and the least efficient
asylum. And secondly, an analysis of Hereford cases shows
that, did every case in Class I. recover, in which recovery
was in the slightest degree possible, the recoveries would not
amount to 77*8 per cent. Probably there is a habit in
Bristol of sending to the asylum an unusual proportion of
transient cases.
The following analysis of the admissions in Class I. for two
years at the Bumtwood Asylum, for which I am indebted to
Dr. Spence, compared with a similar analysis of Hereford
cases, further illustrates the different character of the cases
dealt with in different asylums, and shows that whilst Bristol,
for instance, deals with a class of cases under Class I., much
more favourable than Hereford (taken as nearly an average),
so Bumtwood has a much less favourable class.
ANALYSIS OF CLASS I. OF ADMISSIONS 1881 AND 1882.
BURNTWOOD.
M.
F.
Tl.
p.o.
Incurable from
General Paralysis
Other Brain-Disease
Epilepsy
Old Age
Advanced Bodily Disease _
-
29
22
51
42*5
Did not recover for other reasons
12
18
30
Recovered
Iff
16
23
39
32-5
57
63
120
SAME ANALYSIS,
HEREFORD -1880-81-82.
M.
F.
Tl.
p.c.
Incurable from above well -1
defined causes J
f 12
3
15
24-0
Did not recover, including 8 }
\ 8
5
13
discharged convalescent
J
Recovered
18
15
33
64*1
38
23
61
In Table 1.1 have placed the asylums in the order of the
percentage of total recoveries to total admissions, and show
Digitized by <^.ooQLe
218
An Inquiry into Recovery-Rates of Asylums , [July,
in it the number of years dealt with, the percentage on the
admissions of the total recoveries, and of the recoveries in
each of the four classes in Table VII., the percentage of the
total admissions that Glasses L and 1IL form, and the per¬
centages to the total admissions which the deaths from
general paralysis and from cerebral diseases constitute.
TABLE L
|
Gross
on
Beod.
Beod. in Classes
19 3 4
p.c.
Prop, of
1 A3
to Total
Admns.
Prop.
G.P.
Deaths
to Total
Admns.
Prop.
Deaths
from
Cer.
Dis.
Barntwood
11
91‘1
93*4
33*8
93*9
8*1
62*0
9*9
31*0
Ban steed
6
91*4
80*3
19*0
82*8
9*9
53*0
19*6
38*1
Carmarthen
11
99*8
69*3
93*7
47*3
6*2
36*4
2*4
mm
Oxford
4
98*9
46*5
15*4
39*3
6*8
69*0
2*0
B.X1
Bridgend
11
99*5
38*7
91*6
46*6
8*3
67*0
6*6
Hereford
10
99*5
69*6
97*7
62*4
4*8
45*0
6*8
lil
London
10
99*6
38*5
37*8
64*8
18*9
41*0
6*0
III
Chartham
6
80-0
48*7
97*6
62*6
9*0
44*0
6*0
16*7
Hants
10
30*8
46*6
91*8
64*1
7*7
49*0
6*3
25*1
Berks
11
81*0
43*3
96*0
61*3
6*0
65*0
4*3
mti
Beds
11
81*9
45*4
93*8
61*8
4*9
60*0
mtWm
I’ll
Northampton
6
89*0
40*9
37*3
41*9
6*9
66*0
Sussex
11
89*9
83*6
35*3
48*0
14*4
67*6
6*1
mk J
Ipswich
11
89*6
63*0
99*6
47*0
11*6
64*0
Maoclesfleld
11
88*9
60*7
80*7
66*8
7*0
65*7
7*6
18*0
Bucks
11
33*5
48*3
36*7
66*6
7*6
62*0
9*6
18*9
Wilts
11
83*8
49*6
91 3
47*2
13*3
61*0
3*1
16*4
Warwick
10
84*1
64*4
33*8
69*1
11*9
48*0
11*0
23*0
Denbigh
8
34*9
49*0
99*0
47*2
8*4
69*0
4*6
14*0
Cornwall
11
34*3
66*8
99*6
44*9
6 7
66*0
3*9
18*6
Beverley
10
84*6
48*8
99A
68*3
8*8
64*0
8*7
93*1
(jambs
11
35*0
43*8
90*0
69*9
6*8
66*9
mSM
16*7
Abergavenny
11
35*1
60*1
94*0
61*9
7*0
66*6
16*2
Hanwell
11
35*5
47*6
30*3
61*2
18*0
49*0
88
17*1
Notts
11
35*6
41*6
31*0
49*0
10*2
72*0
8*2
24*0
Stafford
11
35*6
41*0
94*8
60*1
13*2
62*0
8*7
23*0
Worcester
11
35*8
49*3
30*0
64*9
8*7
68*0
10*2
27*7
Wadsley
9
36*1
45*4
95*6
48*3
9*5
61*0
Brookwood
10
36*5
44*7
91*3
47*3
11*2
70*5
11*4
26*0
Northumberland
11
37*9
49*7
93*8
68*2
15*9
64*0
6*0
15*6
Oolnev Hatch
11
37*3
46*9
98*0
60*1
12*5
82*0
8*1
24*2
Lincoln
11
37*5
47*0
32*1
62*9
11*8
60*0
7*0
21*6
Somerset
11
38*1
49*4
61*4
42*1
16*2
66*1
3*8
13*8
Dorset
11
38*5
45*3
96*5
49*1
14*6
67*0
■si
Ohester
11
38*6
46*9
98*3
68*8
10*0
66*4
EH
Newcastle
11
38*9
61*1
98*9
47*2
18*4
61*0
HIS
Bristol
11
39*3
77*8
19*4
66*4
2*1
62*0
Em
Shrewsbury
11
40*0
61*1
944
60*1
12*1
69*4
KSfl
Devon
11
* 40*4
61*8
32*9
66*5
16*2
52*4
9*0
16*5
Essex
10
40*6
45*6
26*3
63*3
12*3
79*3
3*6
18*9
Birmingham
11
40*6
47*7
38*0
68*8
11*3
66*2
9*0
92*0
Banning Heath
8
40*7
48*3
30*3
65*9
19*9
66*0
6*2
23*4
Derby
10
40*9
60*1
37*9
64*6
14*0
63*0
7*1
20*8
11
41*4
49*9
22*3
51*8
16*1
84*0
6*8
15*7
l r r |HT r i!■
10
49*3
54*4
42*8
43*8
9*6
68*0
4*8
17*8
Lancaster
7
49*9
68*8
28*3
68*8
6*0
69*0
9*0
14*4
Wandsworth
10
43*0
48*0
30*0
64*4
20*2
72*4
5*1
14*8
North Biding
11
43*3
60*0
39*1
69*2
14*8
65*0
7*3
21*0
Wakefield
9
46*1
60*9
37*6
63*7
11*7
64*0
6*4
16*5
Cumberland
10
47*4
54*6
33*5
68*0
16*1
67*0
6*3
12*7
Prestwich
10
48*1
53*9
30*1
66*6
30*7
75*0
5*7
11*2
Glasgow, Gartnavel
11
37*4
46*8
22*9
46*6
11*0
75*7
5*0
17*6
Edinburgh, Moraingslde
10
47*1
65*9
33*9
66*7
19*5
69*0
4*6
10*6
Digitized by Google
1884.] by T. A. Chapman, M.D. 21§
A glance at this table will show that the recoveries in the
several classes are not parallel with the total recoveries;
though, if we select Class 1. as the most important, and, if
efficiency is to he judged by the fact that the proportion of re¬
coveries presents a much better figure for this purpose than
the gross recoveries, we find that the asylums with a high
recovery-rate do not, invariably, have a good recovery-rate in
Class I., whilst a good rate in Class I. is to be found in not
a few asylums with poor general recovery-rates; but such
asylums will be found to have a very low ratio of Classes I.
and TIT. to their total admissions (Class III. having an even
higher rate of recovery than Class I.). By compressing this
table, and taking groups of asylums, advancing by 5*0 per
cent, in the total or gross recoveries, we get—
TABLE II.
Percentage of
Percentage Deaths from
Gross
of
Cferebral Disease
No. of
Recoveries
Recoveries
Class
to
Asylums in
on
in
I. and III. of Total
Group.
Admissions.
Class I.
Total Admissions. Admissions.
8
21-1—300
422
48-6
200
14
30-0—360
46-0
670
19-1
17
361—400
46-2
68-4
18-6
10
40-4—43-3
60-7
67-4
18-6
3
46-1-48-1
66-7
68-7
13-4
It might appear from this that the gross recoveries being
parallel to those in Class I., either of these may be accepted
as proof of efficiency ; but in the first place the recoveries
in Class I. vary much less than those of the total admissions,
only from 42 to 56, the total recoveries varying from 21*1 to
48*1, and secondly, the last column shows that in those with
lower rates in Class I. the admissions are of a less favour¬
able class.
The following two tables show the same facts tabulated in
the one case according to the recoveries in Class I., and in the
other according to the proportion which the curable Classes
I. and III. bear to the total admissions. These show that
the recoveries in Class I. influence the total recoveries to
almost the same extent as the proportion of curable admis¬
sions, and point to the same conclusion that appeared to
result from Table II.—that efficiency as gauged by Class I.
tended to show itself in the total recovery-rate. And I must
allow that the figures admit of this interpretation to some
slight extent. But it must be observed that we have, in the
Digitized by <^.ooQLe
220
An Inquiry into Recovery-Rates of Asylums, [July,
first place, reduced by more than half the value of the total
recovery-rate as a gauge of efficiency by showing that it is
rather more governed by the ratio of the curable cases than
by the recoveries in Class I. Then we observe still further
that those asylums with a low rate in Class I. have a worse
type of cases to deal with, though our means of grasping
and gauging this circumstance is somewhat slender.
TABLE HI.
ARRANGED IN ORDER Of RICO TIBI 18 IK CLASS I.
Beooreriea in
Class I.
2S-4-38-7
No. of
Asylums.
“t ?
Per cent.
Curable Admissions.
41-63
67-67
Gross Recoveries.
24*0 1 26*7
30*8
402-44-7
66-66
67-84
3S7\*k.a
37-li 364
46-2470
»!!
49-61
66-82
m} 36 ' 6
47-6.49-7
■«!!
44-64
68-72
38-9 1 36-6
600-64-6
»fi
36-4-66-6
61*0-76
sa«
66-8-77-8
’{!
46-62
66-64
364 1 38-9
408 J 38 "
TABLE IV.
ARRANGED IN ORDRB Of PIRCINTAGI Of CURABLE CLASSES IN THE ADMISSIONS.
Per oenfc. of
Curable Glasses.
36-49
No. of
Asylums.
'SI!
Recoveries in
Class I.
(38*6-48*7
162-3-69-6
Gross Recoveries.
ill 30 - 3
62-66
»l l\
( 23-443-3
148-8-778
83«
66-60
»5fl
(38-7-49-3
1601-61-1
61-66
11 5*1
(410-46-6
146-9-60*2
aai««
66-70
»5il
(32-2-44*7
(46-3-64*6
S3} 8 ®-*
72-84
(41*6-46*2
146*5-63-9
S#}"- 0 -
If, instead of taking Classes I. and IIL together, as giving
a ratio of curable cases, we take Class IV. by itself as a
measure of incurable cases, we find the result to be as
follows:—
Digitized by Google
1884.]
221
by T. A. Chapman, M.D.
astlums arranged in
TABLE V.
ORDER OB PROPORTION
OF CLASS IV. TO TOTAL
Proportion per cent.
ADMISSIONS.
Gross Recoveries
of Class IV.
No. of Asylums.
per cent.
7-9
3
384
10-19
- 9
40*3
20-29
24
360
30-38
12
32-9
42-46
2
29*6
64
1
22-8
which accords entirely with the results of Tables III. and IV.
If we use these figures to push a little further the inquiry
into the effect of size or efficiency, we obtain the following
table. The asylums under each class are those so placed by
Dr. Eayner in his paper in the Journal of April 1883:—
TABLE VI.
astlums tabulated according to size.
Size of Asylum.
Gross Recoveries Recoveries in Proportion of
Under 460.
11 years.
Class 1.
Classes I. and III.
11 Asylums (Suffolk omitted) )
(no tables) j
34*3
48*9
665
460 to 600.
11 Asylums.
34-8
45*6
69*4
(10 without Burntwood.
38*1
48*1
601)
600-800.
9 Asylums (Rainhill omitted)
36-9
48*5
69*9
Over 800.
10 Asylums (Durham and 7
38*8
48*2
66*0
Whittingham omitted.) S
In this table 450-600 looks bad, but it has the misfortune
to contain Burntwood, with nothing to balance it. With
Bumtwood omitted, it would liave ranged fairly with the
others, and the whole table would have distinctly indicated
that size was on the whole prejudicial, but hardly to an
appreciable extent, the recoveries in Class I. slightly
diminishing with increase of size, whilst the gross recoveries
increased, because the proportion of curable cases increased.
But there is an item still to score against the large asylums,
viz., that Whittingham is omitted, and its statistics, were
they available, would probably be unfavourable, since from
my last paper it appeared that just as Banstead gave bad
figures to benefit those of Colney Hatch and Hanwell, so
Whittingham appeared to suffer, though not so severely, for
the benefit of the other Lancashire asylums, and especially of
Prestwich. Lancaster and Prestwich are both in this group.
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222
An Inquiry into Recovery-Rates of Asylums . [July,
Could this omission be remedied, I think this table would
tell appreciably, instead of inappreciably, against the large
asylums.
It may be desirable here to correct an error in the paper
just referred to (“ Journal Mental Science,” April 1883, p. 6,
Table B). The per cent, admission of average number
resident for over 700 should be 25*8 instead of 39*0. This
is repeated on p. 15, Table N., the result of the error being
to present large asylums in too favourable a light.
Looking at the main conclusion at which I arrive in this
paper, it may be said that such a comparison of asylums of
different sizes must be of no value, but this is hardly so. It
may be that the gross recovery-rate is of no avail to compare
individual asylums, and the rate in Class I. of but doubtful
value for such a purpose; but when a number of asylums
can be grouped together and treated as units (that is, adding
the percentages together and dividing, not adding the admis¬
sions and recoveries and calculating a new percentage), the
varying characters of cases are liable to be eliminated, and
any balance due to efficiency might then appear.
In conclusion it may be safely asserted that —
I. The gross recovery-rate is quite useless as a gauge of
the efficiency of an asylum, because:
II. The gross recove ry- rate varies directly as the propor¬
tion of Classes I. and III. (Table VII.) in the admissions;
and
III. The recoveries in Class I. vary directly (in such
instances as can be analysed) as the curability of the cases
included in it; and
IV. These results, based though they are on a very general
analysis of cases and masked by some obvious, and many
suspected errors in the figures supplied, account for so large
a proportion of the variations in the gross recovery-rate, that
a complete analysis might be expected so fully to explain
them, that there would be but a very narrow margin left due
to efficiency.
V. That there is an appreciable presumption (not at all
amounting to proof or demonstration) against the efficiency
of large asylums.
VI. That if there is not an absolute uniformity in the
results obtained in different asylums in view of the different
classes of patients treated, the results are much closer to
such uniformity than the usually stated recovery-rates sug¬
gest.
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1884.]
223
/
Unverified Prognosis . By H. Hates Newington, M.R.C.P.
(Read at the Quarterly Meeting of the Association, held at Bethlem Hospital,
May 6th, 1884.)
In none of the more practical aspects of insanity, with
the exception perhaps of that of pathology, does the alienist
stand at so much disadvantage with the other members of
the medical profession as in the matter of prognosis. In
diagnosis we have, as a rule, an easy task, though now and
then cases arise in which it requires much thought to come
to a determination whether some unhappy event is due to
insanity or to crime. Again, in treatment we fairly hold
our own, taking into consideration the complex nature of
the organs and functions that are affected, coupled with the
impossibility of direct examination and treatment of them.
But in prognosis we are distinctly less sure of our footing,
and it is unfortunate that this uncertainty is accompanied
by a most pressing demand for accurate forecasts from the
relatives of those who are placed under our charge. This
pressure, no doubt, arises in chief from the necessity in nearly
every case for modifying, either temporarily or for good,
those circumstances, domestic, official, and pecuniary, from
which the patient has been removed ; but there is this fur¬
ther difficulty, that while in cases of general disease, other
than insanity, the friends have some sort of knowledge and
opinion of their own as to the probable result, gained from
insight into similar cases, in insanity such clinical ex¬
perience is denied them by the necessity for withdrawing
patients from the observation of the public. They are thus
almost entirely without guides of their own, and in conse¬
quence they come to lean more heavily on the doctor. The
strain and responsibility for error thus cast on us would
be intolerable were there only the two eventualities of abso¬
lute recovery and absolute loss of mind; but, fortunately,
there are many stages to fill up the huge gap between these
two extremes, stages of partial recovery which allow of the
restoration of the patient to various degrees of liberty and
usefulness in the world. It is not too much to say that the
problem of the future of the patient has to be faced never
less often, generally more frequently, than that of treatment.
To prognosis, therefore, much attention has been paid in
treatises systematic and clinical, and in detached papers, such
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224 Unverified Prognosis , [July,
as the able one of Dr. Thomson, which appeared in the
“ Journal of Mental Science ” of 1882. The author of the
latter rightly states that general rules of prognosis are
arrived at from statistics, plus the results of individual cases.
I venture to add that the results of these general rules have
further to be refined and adapted to practice in detail, by a
close study of each case that refuses to conform to rule,
and that a knowledge of what is normal must be comple¬
mented by experience gained from a search for the causes
of abnormality. Such search into each case is most instruc¬
tive, and tends to lift experience into a far higher sphere
than that of a mere knowledge of figures. Prognosis, as a
term, covers a large field, too large for the present purpose,
and, therefore, it must be limited by cutting off all con¬
sideration of cases before they come to, and after they leave,
the asylum. I shall deal only with what we are called upon
to say about the prospects of those patients that we have
under our charge as medical superintendents. Further, my
object is to draw attention to some of what appear to me to
be the principal causes of erroneous prognosis, and to illus¬
trate them by cases as well as I can; and I shall assume
that the errors do not arise from carelessness or bungling,
but are such as everyone might be expected to fall into
blamelessly.
If we take 100 cases consecutively, whether of all classes
indiscriminately, or of some selected class, we know by
statistics that a certain proportion will recover and that the
remainder will not. If, again, we take the same 100 cases,
and having made a prognosis of each individual one, follow
it to the end, we shall find that our forecasts are not in
keeping with the gross results; we shall find that a con¬
siderable number that we set down to the credit have passed
over to the debit, the balance being made good to some ex¬
tent by unexpected recoveries. In some cases it is possible
to demonstrate a reason for failure, in others it can only be
guessed at by analogy with these successful demonstrations,
while in the remainder neither demonstration nor analogy
will afford a clue.
To bring as much order as possible into the treatment of
such a wide subject, I shall follow the course of a case, com¬
mencing with the history and tracing it onwards; for in
every stage there are opportunities for the introduction of
errors, which will contribute materially both to the wrong
formation and the non-fulfilment of prognosis.
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1884.] by H. Hayes Newington, M.B.C.P.
The history-stage of a case abounds with pitfalls, so much
so that one is never surprised at some untoward and hitherto
unknown fact turning up in the course of it, which would
obviously have modified the opinion formed at the outset.
We have to contend with intentional suppression, misappre-
ciation, forgetfulness of, and non-acquaintance with, material
facts ; we are never sure what more is behind that which is
told us, and we have to place a liberal discount on most
statements.
Hereditary predisposition is peculiarly open to these diffi¬
culties. But very few relatives have either the moral
courage or the necessary knowledge to fully supply what is
admittedly a most important item. We know from statistics
that heredity by itself is slightly in favour of recovery from
any first, second, or even third attacks; but we also know
from experience and reasoning that on the closeness or
directness of that predisposition much depends, and that in
doubtful caseB the scale would be turned the wrong way, in
our opinion, by a knowledge that a parent had laboured
under insanity, while we might not take much notice of an
insane cousin.
Some time ago a young lady, particularly bright and in¬
telligent, consulted me about her brother. I asked the pre¬
scribed question as to heredity, and, as usual, I was told
that she knew of none, and that she wondered where it
could have come from. In the course of further conversa¬
tion on indifferent subjects, she quite artlessly told me that
their father had committed suicide abroad ; but the act was
due, she said, to a fever from which he had suffered. Fur¬
ther questioning convinced me that he had suffered from
melancholia as well. The patient himself was paralytic,
though only 30 years of age. As from a distinct history of
syphilis and a blow on the head, it was possible that the
insanity was acquired, the case, though grave, was not
without hope on its own merits; but the history as revealed,
adding predisposition to acquisition, reduced the hope to a
minimum, which the subsequent course has justified.
More important than mere directness is a history of the
actual existence of insanity in either parent at the time of
the procreation of the patient. It is difficult to arrive at
this knowledge, but when it has been obtained it is of great
value. In a case of the insanity of adolescence, in which
form heredity is an usual factor, while close heredity is a
grave element, I was told that there was no predisposition.
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Unverified Prognosis , [July,
From the course of the case, I was for a time quite hopeful
of recovery, but further on it became known to me that at
the time of the conception of the patient the very parent
who had given me the history had been “ peculiar,” and had
several epileptic fits. The real nature of the affection,
which was onlv of short duration, was never realized by my
informant, ana it was brought to my knowledge by accident.
But it completely reversed my opinion, and the patient died
insane.
I have lately been able to work out a family history,
which, as usual, notwithstanding its importance, was con¬
cealed from me at first. As it is interesting from other
points of view beyond the one that I am dealing with now,
I give it at some length. The patient is a lady, 58 years of
age; a suicidal, querulous melancholiac, who has at times been
violent and has given much trouble. Her father was an only
child. He drank hard, and died of apoplexy; aged 65.
The paternal grandfather died of softening of the brain, and
this grandfather’s brothers were fast and rackety, one com¬
mitting suicide while insane. We get three elements of
predisposition here: one indirect of insanity, the other two
—drink, and neuroses other than insanity—more direct.
The patient’s mother was also an only child, as, indeed, was
the mother’s mother. There was consumption in the
mother’s family, though she was not phthisical herself.
Here was a fourth element to start with. The father and
mother, being both only children, proceeded to restore the
balance by having 17 themselves, two of whom were still¬
born, the patient being the youngest of all. In these 15 living
children the drink-element showed itself in six of the seven
sons; the tendency to neurosis declared itself by two sons
dying with paralysis, one facial, the other creeping; while
the consumption was carried on in three of the daughters,
the patient herself being phthisical. But all the elder 14
escaped the insanity, and it seemed as if our patient would
also have escaped. In her case, however, fresh direct predis¬
position came into play; for while she was in utero y her
mother, being 47 years of age, became seriously insane,
having homicidal impulses and pyromania, though after some
years she recovered, and died sane. It is possible that the
patient might have followed her mother’s footsteps to re¬
covery, were it not for the difference in their respective gesta¬
tions, and the opinion that I formed turned mostly on that.
I should add that though the 14 brothers and sisters have all
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1884.] by H. Hayes Newington, M.R.O.P.
themselves escaped the indirect predisposition to insanity,
yet it has reasserted itself in their children, two of whom
are insane. Yet, again, the tendency to extinction of the
race, shown by the father, mother, and grandmother being
only children, retarded, as it was for the time, by the
numerous family, comes to the front again in the next genera¬
tion, for of the 11 who married there have only 28 children
been born, and of these no less than 18 are already dead.
Hardly second in importance to the history of heredity is
that of a group including the temperament , disposition , in¬
stincts, and habits of the patient as he was before he became
insane. Correct information as to this is very essential in
making a prognosis; not only as supplying often a key to
the causation and nature of the attack, but as also affording
some means of estimating how far the brain mischief has
gone. And, again, it is often of service in judging as to
how far recovery has taken place. It is very hard to get
this information truly; for relatives frequently fail to see
important points that are patent to all others, and they are
prone to suppress, minimise, or explain away what is dis¬
agreeable to themselves. For instance, we may be told, as
I have been told, that a man had a sweet disposition, and
was never angry unless he was put out, which may have
been true ; but it may also be the case that the man was for
ever being put out by trifles, and was really in a chronic
state of ill-temper. Again, we may hear that he has been
a model husband and father, while he has been keeping up
another establishment in secret.
But in any case we expect to find, and do find, more or less,
alteration in many respects when mental trouble comes on.
We must not accept the fact of an alteration without look¬
ing well beneath the surface to see how far it is real. I use
the word alteration rather than change, for what we do find
may be less of a real change than an alteration by way of
diminution or exaggeration of the previous habit of mind.
And this is important; for without going so far a& to say
that complete change of disposition, etc., is invariably a
more hopeful sign than a morbid exaggeration, I will say
that it is far less easy to bring back a patient from exaggera¬
tion than to lead him to give up what is only a recent acqui¬
sition. And I think that reasoning supports this view.
Exaggeration can be brought about only by the lessening of
control and reflection, and can be remedied only by a corres¬
ponding restoration of these, which are just the two ele-
xxx. 16
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228 Unverified Prognosis , [July,
ments that are most wanting when the disease is estab¬
lished. Again, if a patient’s disposition has been completely
changed, it is probable that this has occurred more or less
rapidly: he may have the recollection of a former happy
state, with which he can compare his present one. And,
still more important, if he can be brought near the edge of
the pit into which he has fallen, and be induced to endeavour
to extricate himself, he finds sound ground on which to step
out. On the other hand, where the insane is merely an ex¬
aggeration of the sane habit, the reverse is the case. Most
probably considerable time has been taken to effect this; the
reflection on the past offers but little help, and the patient
has beforehand destroyed that sound foothold without which
he cannot hope to drag himself out of his trouble. Alco¬
holism in ordinary life, and religious insanity in our domain,
afford good examples of what I mean. The latter I will
therefore take as an illustration.
I have two patients in view. Both have been actively
suicidal, and in both religious despair has been the chief
element. The first has been brought up from her childhood
in the very gloomiest views, in that form of so-called re¬
ligion which allows the holders of it to ascend to jtheir
heaven only over the lost souls of other beings. She herself
has been so tinged with this morbid conviction that when
misgivings as to her own future safety entered her mind she
lost heart, and has gradually tumbled back into that place of
torment which, in preparing it for others, she has made a
fearful reality for herself.
The second has, during her illness, been more actively sui¬
cidal, and more self-accusing than the previous lady. But as
the daughter of a clergyman, she has been brought up in a
brighter faith, and her trouble, which in itself is a direct
change to her, has come more rapidly. She has the recollec¬
tion of what was previously a happy time, the hope of re¬
gaining which affords a healthy stimulus. No one can
doubt which of these two has the better chance of recovery.
I have another patient in view, who had paid great atten¬
tion, so I was told, to religion, and in whose early symptoms
were evidences of this. She saw visions, heavenly and the
reverse, and she raved Scripture. However, I found out that
she had married a clergyman a year or two before, and that
her devoutness was then assumed, so really her religion and
its manifestations were merely passing elements in, and not
factors of, the insanity.
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1884.] by H. Hayes Newington, M.K.C.P.
In some cases a direct change of habit, etc., on the inva¬
sion of insanity is followed so quickly by restoration, that it
appears to be the direct antidote to a previous condition
which had become morbid. Such is the case of a lady who
for several years past has come to us for about three weeks
soon after Easter. She is very advanced in her religious
views, praying through Lent, and fasting also in season and
out of season. She then breaks down, and has an evanes¬
cent, though sharp attack of acute mania, in which she
rushes about laughing and chattering, wild as a hawk, and
the very reverse of devout. This passes off, and leaves her
in her normal condition. I have but little doubt that this is
the true medicine, sharp though it be, for the effects of the
strain that she puts on herself, and that were it not for these
attacks she would probably pass into obstinate melancholia.
Sometimes we are left in ignorance of previous attacks of
insanity. These have, of course, a considerable bearing on
a present attack, giving, as it were, the line of prognosis.
But it is a more serious thing not to have information of
the pre-existence of some of the graver bodily diseases. This
remark applies especially to the various neuroses other than
insanity.
Some years ago a lady was admitted suffering from melan¬
cholia of the ordinary religious type. She was very gloomy,
thin and yellow, and had made two serious attempts at
suicide. Ordinary treatment improved her, and she seemed
to be in a fair way to recovery, her friends being led to be¬
lieve so. But after getting to a certain point she seemed to
become stationary, and remained so for some years. One
day she had a severe epileptic seizure, followed shortly by
another. Careful inquiry revealed the fact that nine years
before, while she was standing on a friend’s doorstep, she fell
insensible, and must evidently have had an epileptic fit then,
though the relatives had never recognised its nature, and had
indeed forgotten the fact until it was recalled to their re¬
collection by the later seizure. One or two more fits have
followed at lengthened intervals, and the cause of the non¬
recovery stands declared.
The causation of an attack affords quite as many oppor¬
tunities for error as any of the foregoing. In fact, it is not
too much to say that, as regards some of the assignments
of cause in the admission papers, we had far better be with¬
out them. No assignment is better than a wrong one, so
easily can we be put on the wrong track. Without doubt,
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280 Unverified Prognosis, [July,
unless we have accuracy here, we cannot approach accuracy
in forecast. As an instance of this, a gentleman was
brought to us in the following condition He was gloomy,
reserved, and silent, somewhat vacant in expression, with the
appearance of being beaten down by trouble. He was ob¬
stinate, disinclined to eat or move, quite heedless of the calls
of nature, and weak in body. Trouble was given as the
cause, and there was a history of a fall on the head. He
improved slowly up to a certain point, but never lost his
gloom. The prognosis, though guarded, was not altogether
a bad one. But in a little time it came to my knowledge
that not only had he had the trial of losing his worldly
goods, but that he had done so under shameful circum¬
stances. He had the misery of seeing his family brought
near to penury by his own misconduct, and was altogether
deprived of any hope of being able to rehabilitate them by
his future exertions. In my opinion it was just this addition
of shame and self-recrimination that made his case a hope¬
less one.
Having got as near the probable cause as we can, we have
to consider both the validity and the nature of it. It is
obvious that if a given cause produces mental disturbance
out of proportion to its importance, then we must look
farther again and expect to find contributing elements such
as heredity, mental worry, bodily disease, drink, etc. And
we can go so far as to say that an inadequate cause is in¬
sufficient in itself to form a foundation of prognosis. But
when we do get an adequate and true cause we obtain from
it substantial aid. It is to be remembered that a cause does
not exhaust itself in the work of developing insanity. It
may be destined to last out the patient’s existence. For
instance, if a person loses a relative, that loss may be very
sharp for the time, but in the natural order of things it tends
to wear itself out. Again, if a person becomes insane
through bankruptcy or loss of money, the same occurs; but
there will probably be difficulty in healing up the wound in
proportion to the difficulty in remedying the misfortune.
But if, as in the last case, the cause be an ever present one,
then the chances are much against the patient. I will give
an instance of this: A lady came to us labouring under
melancholia. There was no particular religious element about
the case, the chief symptom being a beaten, cowed condition
associated with the digestive derangements usually seen.
The history that I had with her was that she had been in-
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1884.] by H. Hates Newington, M.R.C.P.
sane twenty years before, from which she completely re¬
covered, and had been quite well up to forty, her age at the
time of admission. It was supposed that she had worried
herself into this condition, but no particular cause of worry
was suggested. The prognosis was good, and, indeed, she im¬
proved a little. Later on I got further information from a
private source. It appears that her present husband courted
her when she was quite young, and she returned his affection.
But her father, evidently with good cause, refused his sanc¬
tion, and the pair were separated, the lady thereupon be¬
coming insane. Some years afterwards the father died, and
she being a free agent, married her former suitor, who held
a very good position. But his principles were anything but
desirable, and he turned out to be a confirmed drunkard, so
much so, that in the midst of comparative opulence it was
necessary that she should keep the purse so strictly that he
had to come to her for money to get shaved with, for which
operation he had not sufficient steadiness himself. Here we
have a powerful cause, slow but sure in its action, and quite
likely to outlast the patient’s chance of getting well. She
continued for some time further under our care, but made
no more advance to recovery.
The duration of insanity before admission has such a well-
known influence on prognosis that it is an element that has
to be carefully inquired into. It fortunately can be deter¬
mined with a fair amount of accuracy, though occasionally
there is some difficulty in separating the prodromata from the
overt symptoms. But one or two cautions are necessary.
Firstly, when we consult statistics, such as are afforded by
No. VII. of this Society’s tables, we see that the duration is
calculated up to the admission into the asylum. But in apply¬
ing these tables to individual cases of our own, we must not
render the term admission too strictly. The admission into
the asylum may only be a phase in the treatment which
has been begun most actively elsewhere. To take a not un¬
common case : Last year a young lady was admitted by us who
was suffering from acute mania; the duration between her
first seizure and her coming to us was six weeks, but within
one week of the symptoms showing themselves she was at
home under very energetic treatment, with competent advice,
consisting of nurses, strong sedatives, restraint, and seclu¬
sion. The real duration before treatment was therefore one
week, not six. Of course, in such a short case, much difference
would not be made, but in a long case of melancholia a con-
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Unverified Prognosis , [July,
siderable misapprehension might arise. Secondly, it is not
sufficient to ascertain the duration of the disease as a whole.
It is necessary to find out how long symptoms, or sets of
symptoms, have existed in relation to each other. This ne¬
cessity has pressed itself on me recently. A young married
lady, who on admission had no very urgent symptoms, had
done some foolish and dangerous things, and had therefore
to come under care. It was a puerperal case originally, the
first symptoms of excitement coming on a few weeks after
her child was bora. She suffered from severe metritis. The
excitement passed off, and she began to regain strength.
But she did these silly things, and for no very good reason.
It soon appeared to us that she had aural and other hallu¬
cinations. The prognosis then very much turned on the
question of whether these grave symptoms were part of
the acute disease, or whether they had been developed when
the acuteness was receding and the bodily health was being
re-established. Had the latter been the case, I should un¬
hesitatingly give but a poor opinion. As it is, there is clear
evidence that they have been present from the first, and
therefore I look on her case much more hopefully.
In the history of the attack itself no very special risk
suggests itself to me beyond that of having the mind over¬
loaded by a mass of useless facts. The informants have a
great knack of telling one a long story, the whole of which
perhaps establishes one real fact only, while valuable infor¬
mation may be thus excluded.
In passing from this division of the subject, I must men¬
tion that occasionally a correct history is a source of positive
embarrassment. The history may contra-indicate a con¬
dition which is sufficiently apparent clinically. As an in¬
stance : A patient was with us last year who was clearly a
general paralytic, and condemned as such by several com¬
petent judges. The leading symptoms were busy activity
and great earnestness, much talk of riches and lucrative
speculations, dirty habits, somewhat unsteady gait, and
marked inequality of the pupils. The speech was not much
affected, and there was but slight fibrillar unsteadiness of
the tongue. The facial muscles, though unsteady, were not
so to the usual extent. He improved, and eventually left us
for domestic treatment, under which he continues in a most
satisfactory condition. Nevertheless, there is only too much
ground for being certain that it is a case of general paralysis,
Whether it be of syphilitic origin or idiopathic. But the
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1884.] by H. Hayes Newington, M.R.C.P.
history does not tally with this at all, for it appears that
twenty-five years ago the patient had an undefined attack of
mental trouble, which his father, a medical man, feared would
go on to insanity then. Again, some four or five years ago
he was excited over business matters, and of late years has
never been of the same calibre as before. The inequality of
the pupils has apparently but little to do with his present
disease, for it was noticed years ago, and he has worn glasses
of different powers to accommodate this condition. Again,
his mental state is only an exaggeration of what it was
formerly. He has good right to talk of his riches, which are
considerable, and activity in scheming has been his forte
and the source of his wealth. His habits, especially of late
years, have not been very tidy ; he has allowed his food to
drop about his clothes, and a long-standing looseness of the
bowels has contributed to other sources of uncleanliness. In
fact, there is not one of the leading symptoms that can not
be traced far back into the past; too far to be consistent with
what is accepted to be the ordinary history of the disease.
(To be continued .)
Exaltation in Chronic Alcoholism . By Bonville Bbadley -
Pox, M.A., M.D. (Oxon), Brislington House, near
Bristol.
(Read before the Medico‘Psychological Association, May 6th, 1884.J
During the last four years, as medical officer in an asylum
sufficiently populous to offer a fairly wide field for study, but
not too large to prevent each individual case from receiving
its own share of investigation, no subject has attracted me
more than the occurrence of delusions of exaltation and
optimism in the Insanity of Chronic Alcoholism. And this
mainly for two reasons, viz., the divergence of opinion of
good authorities as to the frequency of the association of such
ideas with this particular class of insanity, and the difficulty
which not seldom attends the accurate recognition of their
true character and import. If in this paper I can report the
salient features of these cases, they may, perhaps, have an
interest to others to whom they present no difficulties in
diagnosis; and if the inferences that are drawn from them
seem occasionally to deviate from those of writers of experi¬
ence, it must be remembered that the cases are too few to
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234
Exaltation in Chronic Alcoholism , [July,
admit of any but tentative statements, and that such will be
put forward as suggestions and not as dogmas, though at the
same time the accuracy of the facts and descriptions from
which they are deduced can be guaranteed.
Attention should be drawn at the outset to the fact that
the subject of this paper is not Alcoholic Insanity as a whole,
but merely one group of symptoms occasionally conspicuous
in the course of this disorder, and this generally when it has
assumed a chronic form. Within these limits the following
remarks will, as far as possible, be restricted, and an attempt
will be made to treat of them as distinctly as may be ; firstly,
as regards the frequency of their occurrence; secondly, as
regards their diagnosis and characteristics; thirdly, in rela¬
tion to their significance, and as aids in prognosis ; while, in
conclusion, some speculations will be ventured upon as to
their origin, and the morbid changes in the organism with
which they may be associated.
First as regards frequency of occurrence .
On this point considerable divergence is to be found in
writers on insanity. Blandford* states distinctly that he
“has not found the exalted delusions that characterise
general paralysis in patients suffering from chronic
alcoholism. . . . Their delusions have been mainly due
to the almost complete obliteration of memory ; 99 but at the
same time he admits that some cases are almost impossible
to decide upon one inspection.
Bucknill and Tuke,+ while not denying the occurrence of
such exaltation, often combined with paralysis in chronic
alcoholics, go on to say, “ Such cases may proceed further
and become examples of general paralysis, but in general the
muscular tremors and loss of power (in chronic alcoholism)
without ideas of grandeur, constitute a group of symptoms
quite distinct from this disorder.” (The Italics are mine.)
Griesinger,t on the other hand, admits the occurrence of
exaltation in the insanity of alcohol, and draws attention to
the fact that the diagnosis between it and general paralysis
is not very easy, citing as authorities on the same side
Lasagne and Bayle, who have made the subject a special
study.
Dr. Batty Tuke, in a paper published in the “ Edinburgh
Medical Journal,” for April, 1877, lays great stress upon the
♦ “ Insanity and its Treatment. M 2nd Edition, p. 288.
t Bucknill and Tuke’s “ Psychological Medicine.’* 4th Edition, p. 893.
I “ Mental Pathology and Therapeutics,” translated from the German, p. 403.
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1884.] by Bonyille Bradley Fox, M.A., M.D.
frequency of the occurrence of ideas of grandeur, and of the
feeling of bien-etre, often in combination with motorial and
sensorial derangements, in the victims of chronic alcoholism,
and adduces various instances to show how difficult it some¬
times is to distinguish this disease from general paralysis,
and how in some patients this can be done only by watching
the course of the case.
My own experience, and the investigation of the case¬
books of this asylum, certainly suggest that optimism and
exaltation are to be found very frequently indeed in chronic
alcoholism, or rather, to be more precise, in the chronic in¬
sanity of alcoholism, and occasionally, though rarely, in its
earlier and more acute phase. During the last 13 years, 18
patients have been admitted into Brislington House labour¬
ing under one form or other of alcoholic insanity, all of them
cases in which the disease was clearly due to intemperance.
Of these 18, 7 displayed very exaggerated delusions of
grandeur and importance; 3 others that placid contentment
and satisfaction with themselves and their surroundings
which are closely allied to the foregoing, and often are their
vestiges when all ideas appear to have vanished, and the
mental faculties no longer possess even an erratic and dis¬
torted activity, but are overwhelmed and lost in the desert of
dementia, the frequent termination of continuous alcoholic
poisoning. Thus in 10 out of 18, or in more than fifty per
cent, of a fair number of cases of alcoholism in patients of
the upper class, and as it happens, with one exception, all of
the male sex, these delusions appeared in greater or less
degree; and it should be remarked that of these 10 only 1
was a recent case, and this, though of but three days’ dura¬
tion, was a second attack. *
Secondly —Characteristics and Symptoms .
It may be both simpler and clearer at once to give an
epitome of the cases of alcoholic insanity in which these ideas
occurred, before proceeding to describe their characteristics,
and the means whereby such cases are to be identified and
distinguished from other varieties of insanity, in which
similar exalted delusions predominate.
Case I.— J. 0. M., a male, aet. 27. Admitted June, 1871.
Second attack of three days* duration—loquacious and irritable.
* Of these 18, 7 ended in recovery. Their insanity took the form of the
mania of suspicion and persecution in 4 ; of melancholia with suicidal tenden¬
cies in 3 j and of exaltation in 1.
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236 Exaltation in Chronic Alcoholism , [Jnly,
Says that he is God Almighty and king ; also Mr. Gladstone and the
Prince of Wales. Bodily powers good. No sign of paralysis.
Recovered in ten weeks.
Case II.—8. W., a male, let. 88. Admitted May, 1872. Second
attack of seven weeks’ duration. Has been a hard drinker for many
years. Is irritable and impulsive, but generally very contented. Says
“ he has palaces in the New Forest and at Winchester, and that all
England is his; that he owns quantities of carriages and horses, and
can ennoble anybody, or, if he chooses, kill anyone by breathing on
them.” Believes this asylum to be Buckingham Palace. Physical
powers fair.
Discharged not improved in two months’ time.
Case III.—K., a male, aet. 50. Admitted May, 1875. First
attack, of at least one year’s duration. Has drunk for years, and had
D.T. Marked heredity. Cachectic appearance. Chronic gastritis.
Pupils sluggish, right more so than left. Paretic debility of lower
extremities. Utterance slow, at times impeded. No tremor of
tongue, or of muscles generally. Impulsive if contradicted. Com¬
plete loss of memory for recent events ; recollection does not serve
him for ten minutes. For some years after admission thought he was
a physician, and had two stomachs, one inserted per anum after
having been taken from a corpse ; but in the fourth year of residence
here these entirely disappeared and were forgotten, and were replaced
by ideas of grandeur, which have never since varied, and are expressed
in exactly the same words every day, and in rhyme, constituting a good
instance of "rhyming delirium” (Griesinger). For example, he
states that the following gift and blessing has been pronounced on him
from Heaven:—
The whole world, a wife, and never to die,
These three things from the Trinity ;
To stop in my world till my unborn son
By my unseen wife is twenty-one.
Says that he is king and owner of the world, and therefore that all
that he can see is his, but at the same time asks for certain pictures,
and other articles of trifling value, to be given to him. Is perfectly
happy and satisfied, and says he must be well as he is never to die ;
but in the next breath demands brandy, as “ quite lately all food
comes up without brandy; though formerly the most temperate man in
the whole world, it has suddenly become a necessity.”
At the present time his physical powers are rather feeble, but with
no definite paralysis, and are no worse than on admission nine years
ago. His utterance is clearer, but he is.otherwise in statu quo.
Case IV.—C. H. C., set. 31, a male. Admitted October, 1871.
First attack of four days’ duration, but has had D.T., and has drunk
for years. At first he suffered from the mania of suspicion and per¬
secution, goaded by which, and by terrifying hallucinations, he had
cut his throat, and arrived here extremely collapsed and anaemic. His
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1884.] by Bonyille Bradley Fox, M.A., M.D.
bodily powers were otherwise perfect, and now are very good. This
mental condition continued for nine months, then gradually ideas of
exaltation appeared, which absorbed all others. Now believes that he is
engaged to the Princess Beatrice. That he is king of England. That
“ he has died and risen again after having been crucified at Jerusalem,
and is now Salvator Mundi, King of Kings, Lord of Lords, and an Im¬
mortality, possessing the Sacred Heart inside him.” Not serenely con¬
tented as he wants to join the Princess, and is constantly trying to
make his escape. Very impulsive and dangerous. Memory bad, and
getting worse. Hears <l voices.” Continued headache, and congestion
of face. No sign of paralysis.
Case V.—C. T. C.,a male, set. 44. Admitted March, 1869. First
attack of at least one year’s duration. Has drunk for years. On
arriving craved for sherry. At first delusions of persecution and
conspiracy, but these were soon submerged in exaltation. Says that
he is descendant and heir to the Plantagenets, and related to the
Queen through the Lord of the Isles. That he has thirteen peerages,
and is at the same time Duke of Rothesay, Marquis of Lothian, Earl
of Baltimore, and Baron Glenbay. Is at once King of the Two
Sicilies, the Pope and the Sultan, and has been eighteen times Lord
Chancellor. Is worth £500,000 a year. Believes this asylum to be
the Herald’s College, and his property. Suffers from hallucinations
of hearing. Memory defective. Very good-tempered and happy.
Extremely obese, but no paralysis. Delusions never varied for twelve
years, when he died of cerebral haemorrhage.
Case VI.—W. S. R., a male, aet. 48. Admitted October, 1880.
Second attack of long standing, as are the habits of intemperance.
Conspicuous heredity. Mother died of abscess of brain, father of
drink ; aunt, cousin, and grandmother also intemperate. Said to
have had a stroke of paralysis and D.T.
Appearance prematurely aged, shrunken, and stooping. Tremor
on exertion of hands and fingers, to less extent of tongue. Speech
drawling. Gait somewhat slow and halting. Pupils equal. Exalta¬
tion commenced about five years before admission, and has continued
unchanged in expression. Says that he is the eldest son of the
Queen and the Heir Apparent, and is going to do all sorts of grand
things when he ascends the throne, to which the Prince of Wales has
acknowledged his right. That Prince Leopold has given him a
carriage and horses. That he has only to ask the Government for
money to get it. Memory unreliable. Perfectly contented and
happy, and extremely patient and good tempered. Getting more
weak-minded now.
Case VII.—W. B., a male, aet. 60. Admitted April, 1878. First
attack of several months’ duration. Drinking habits of some stand¬
ing. Hereditary taint. Considerable muscular tremor; feeble,
shuffling gait; tongue tremulous ; utterance indistinct, the words
run into one another. Pupils contracted and sluggish ; sight good.
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Exaltation in Chronic Alcoholism , [July,
Decided impairment of sensation, especially in the lower extremities.
Emaciating rapidly. Destructive and dirty in his habits, strips off
his clothes; smears his body with his faeces, which he declares to be
the ointment of life. Says that he is King of England and Emperor
of the world, and Jesus Christ. That Prince Albert was the second
person of the Trinity, and himself the third. That he is worth 100
millions. Has appointed one of the staff physicians royal with a salary
of £10,000 per annum. Shall pay off the National Debt. Can give
eternal life by transfusion of blood. That revelations are made to
him. (Hallucinations of hearing.) Is irritable, abusive, and
emotional, occasionally bursting into tears. His delusions have
developed, and varied from time to time, but have always maintained
their extravagant character. Says he is very well and happy, and is
in a state of “ overflowing contentment.” At the present date his
memory has almost gone, and his mind is altogether far sunk in
dementia, but he €t still attempts vaguely to establish a great omni¬
presence, to show that he is everything, which, indeed, is in accordance
with his exalted state of mind " (Griesinger). His bodily powers are
at least as good as on admission.
Thede cases have been detailed at some length, because it
was thought desirable that the physical and mental points
of resemblance and difference between them and those occur¬
ring in other forms of insanity should, if possible, be brought
out. In attempting to draw such distinction their charac¬
teristics must incidentally be discussed, and will not, there¬
fore, be noticed more particularly by themselves.
It may be stated broadly that there is no form of delusion
common to a greater number of clinical varieties of insanity
than are these of exaltation. They are to be found in general
paralysis, in epileptic insanity, in that of masturbation, in
chronic mania not owning an alcoholic origin (and this more
frequently when its subjects are governesses, and persons
in similar positions), and in chronic alcoholism. Everyone
would assent to the truth of Dr. JBlandford’s * words in the
new “ Dictionary of Medicine,” that “ Accuracy of diagnosis
is specially important in insanity owing to the legal and
social results which flow from it; ” and, this being so, it is
not a little astonishing to find that from the opinions with
which patients arrive at the asylums, there are at least some
practitioners who appear to imagine that exaltation at once
marks the general paralytic, more particularly if there is
actual or threatening physical degeneration. That an accu¬
rate opinion is sometimes very difficult —nay, almost impos¬
sible—to form, it would be absurd to deny; and for other
* Quain’s “ Dictionary of Medicine.” Article, “ Insanity,” p. 715.
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239
1884.] by Bonville Bradley Fox, M.A., M.D.
reasons tlian that of mortal fallibility. The cases recorded
by Dr. Batty Tuke are alone sufficient proof of this, and
within the last three years a Commission of Lunacy has been
held, at which four medical men, all of them of considerable
experience in lunacy, expressed their opinions, more or less
strongly, that the subject of the inquiry was a general
paralytic in an early stage of the disease, an opinion that
has been entirely refuted by the subsequent course of the
case.
Before entering upon the points of resemblance and diver¬
gence between chronic alcoholism and general paralysis, the
exaltation of the insanities of epilepsy and masturbation may
be dismissed in a few words.
In epileptic insanity the exaltation is often paroxysmal.
There is not a fixed, stationary delusion that never varies,
though the same delusion may be reproduced again and
again at intervals. It more commonly, too, takes a “ reli¬
gious •’ or “ spiritual ” tone. There is probably a history
of petit mal or haut mal, and possibly an increase in the
number of the fits at the time of the mental disturbance.
The mental and bodily powers surely, if slowly, decay, and in
most cases there is little resemblance between the epileptic
and chronic alcoholic by the time that middle life is reached.
It must not be forgotten, however, that alcoholic excess and
its concomitants not unfrequently produce epilepsy, and that
epileptic fits occur in alcoholic insanity, and did indeed
take place in two of the seven cases that were noted before
to have lately recovered in this asylum.
In the insanity of masturbation memory may be weakened,
but the exaltation is usually an exaggerated development
of spiritual pride, self-complacency, and perfect satisfaction
as to prospects in futurity rather than the wild fantasies of
chrouic alcoholism. Hypochondriasis rather than a feeling
of bien-btre is more frequently present. The youth of the
patient, and his languid, debilitated appearance, will gene¬
rally suggest the cause of the symptoms, and be sufficient
guide, even if the history and plainer evidence are wanting.
One point of distinction of many may be noticed in the appe¬
tite, generally poor in the alcoholic, often ravenous in the
masturbator. But there is really no likelihood of confusion
between these two varieties.
Before attempting to draw any comparison between the
exaltation of the chronic alcoholic and that of the general
paralytic it may simplify matters if, from the narration of
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240 Exaltation in Chronic Alcoholism , [July,
the above seven cases, any symptoms can be found common
to all, or occurring in a sufficiently large proportion to make
them characteristic of this class of insanity.
The age of the patients is worthy of notice. In only two
was it below 81, and one of these recovered. In the others
the ages were respectively 44, 48, 50, 58, and 60.
The exaltation and feeling of well-being is usually not
developed until the insanity has been marked for some time,
but once decidedly pronounced, is stationary. The delusions
are repeated from day to day, are fixed, constant, and inera¬
dicable, unless disappearing in the terminal stage of dementia.
There are no lucid periods in which they are forgotten and
repudiated. As a rule they are not accompanied by much
emotional instability, but rather by a placid calm. There
are not often times of depression, gusts of weeping, or storms
of mania, in which destructiveness and dirtiness predomi¬
nate. Dr. Sibbald,* in “Quain’s Dictionary/’ mentions
persistent mental depression as distinguishing chronic alco¬
holism from general paralysis. I can only say it was con¬
spicuous by its absence in the cases before mentioned.
There is sometimes considerable tremor and some paresis,
but under proper treatment these symptoms do not increase,
and may altogether subside.
The bodily health of the patient is usually well maintained,
or deteriorates but very gradually.
The foregoing statements appear to be true of the majority
of such cases, and were they constant, and did the signs of
paralysis never vary, there would be little difficulty in discri¬
minating between the two disorders.
Thus we find that the victims of general paralysis are
generally younger than those of chronic alcoholism, and the
exaltation appears earlier in the former than in the latter.
In general paralysis the delusions often vary daily. Though
maintaining their exaggerated character, their expression
and development differ, and the assertions of one day are
denied on the next. This is veiy unusual in chronic alco¬
holism. In general paralysis there not uncommonly occur
remissions, in which all or most delusions vanish, and it
seems as if the patient were recovering. In other cases the
exaltation is interrupted by emotional conditions of intense
despondency, often with passionate weeping, which may give
place to as furious mania, in which everything within reach
* Quain’s " Dictionary of Medicine.” Article, “ Alcoholic Insanity,” p. 723.
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241
1884.] by Bonville Bradley Fox, M.A., M.D.
is destroyed. This phenomenon is very rare in chronic alco¬
holism, though it was visible in Case VII.
Tremor, paralysis, and other physical signs, as a rule, tend
to increase, and to terminate before many years in death.
But the above points of distinction, though useful aids in
diagnosis, must sometimes prove quite insufficient and value¬
less, chiefly for two reasons—
(1) They presuppose that the physician is furnished with
a fair history of the patient, and has the opportunity of ob¬
serving him for some time, whereas it often happens that we
are asked to give a definite opinion on a patient seen for the
first time, whose history may be very incompletely or inaccu¬
rately furnished by his friends.
(2) The symptoms of general paralysis vary very consider¬
ably. When far advanced the disorder is easily recognised,
but in the earlier stages the difficulty of an assured diagnosis
is often extreme.
Are there, therefore, any other mental or physical signs
by which the two diseases may be distinguished ?
Taking mental symptoms into consideration first of all.
Dr. Blandford * lays considerable stress upon the follow¬
ing points as pathognomonic of general paralysis :—
(1) The general paralytic cannot argue in defence of, or
attempt rationally to account for, his delusions, but, on the
other hand, several of the subjects of the preceding cases
equally fail to do so.
(2) The exaltation of general paralysis is less reasonable,
and more inconsistent than that of other kinds of insanity.
“An ordinary maniac may think himself a duke, or may
purchase a carriage and horses which he cannot pay for, but
a paralytic that he is a duke, marquis, and king all at once,”
&c. This, no doubt, holds good in many cases, but that it
has not sufficiently universal application to constitute a law
reference to Cases I., III., IV., V., and VH. will prove.
(3) Impairment or loss of memory is very common in
general paralysis. But it appears to be almost equally so
in chronic alcoholism.
(4) Emotional storms, while very common in general
paralysis, are very rare in chronic alcoholism, but not abso¬
lutely unknown. (See Case VIE.)
The conclusion, therefore, appears inevitable that there is
no mental symptom whereby the exaltation of alcoholism
* “ Insanity and its Treatment.” 2nd Edition, p. 268, et . seq.
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242 Exaltation in Chronic Alcoholism , [July,
can be distinguished with absolute certainty from that of
general paralysis.
Are physical signs of more avail 9
These are in general paralysis —
(1) Tremor of tongue and other muscles; most certainly
found also in chronic alcoholism. (Cases YI. and VII.)
(2) Slurri ng o f speech. (Seen also in Cases tH., VL, and
markedly in VII.)
(3) Weakening or paresis of the whole or parts of the
muscular system. (Seen also in Cases III., VI., and markedly
in VIL)
(4) Contraction or irregularity of pupils, on which Dr.
Batty Tuke lays much stress. But this is by no means con¬
stant in general paralysis, though very common, and is
certainly not confined to it, occurring in other forms of in¬
sanity, and in some degree in chronic alcoholism. (See
Cases III. and VII.) It must also be remembered that
inequality of pupils exists in some individuals in perfect
health. It may De remarked that in none of the cases of
alcoholic insanity quoted above has there been any appear¬
ance of alcoholic amblyopia.
If the patient can be watched for some time, there will, I
think, be found one point of physical difference between
these two diseases. From the few observations I have
hitherto made, I am led to suspect that the temperature
of alcoholic patients is usually lower, and not subject to
as wide fluctuations as it is in general paralysis. And
another point of physical distinction exists in the sensory
paralysis, which is frequent in chronic alcoholism as com¬
pared with general paralysis, in which it is rare, though not
absolutely unknown.
The habits of alcoholics contrast favourably with those of
paralytics as a rule, for it is a matter of daily asylum expe¬
rience how soon and how persistently wet and dirty these
latter patients become, either from relaxation and loss of
power of sphincters, or from being too imbecile to exercise
any care of themselves in this respect, or from both causes
combined.
I hope from the foregoing remarks that it has been
made clear to some extent that neither are the mental or
physical signs usually ascribed to general paralysis—viz.,
the exaltation and forgetfulness, associated with tremor,
muscular weakening, and alteration of pupils, either singly
or even in combination—absolutely pathognomonic of that
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Google
243
1884.] by Bonville Bradley Fox, M.A., M.D.
disease, or quite trustworthy. They will all be found in
Case VII., which, I venture to think, could be accurately
diagnosed only by watching the course it has taken, by the
gradually increasing paralysis of mental power without any
corresponding physical decay during several years.
The age of the patient is no doubt a point of considerable
importance, but cases must not unfrequently occur to us in
which we must decline to be guided by apparently unmistak¬
able signs, and in which our decision should be reserved until
a full and accurate history of the patient and his malady has
been supplied. And there are some rare instances in which
our opinion should still be withheld until the case has been
for some time under careful observation.
With regard to the significance of such delusions and
their bearing on prognosis, it is beyond doubt most unfavour¬
able. Reference to the foregoing narrative shows that of the
18 cases of chronic alcoholism on which this paper is founded,
in only seven did recovery take place, and of these seven but
one was characterised by exaltation, and this of compara¬
tively brief duration-—little more than a month. Of the 11
who did not recover, and of whose recovery there appears to
be now no probability, in no less than nine did these idea,s
show themselves to greater or less degree. This dispropor¬
tion is too large to be merely accidental, and leads to the
conclusion that when once exaltation is firmly established
there is little hope of much mental improvement, almost
none of complete restoration. It would be a mistake to
speak too absolutely, or to leave other considerations out of
the question, such as the duration of the delusions, and the
concurrence with them of loss of memory, and other indi¬
cations of intellectual decay; but the statement as to the
ominous significance of exaltation will be found generally
true. I cannot do better than quote the opinion of Griesinger*
on the subject, both from the high authority with which he
npeaks, and because my short and narrow experience precisely
accords with his. He says—“As soon as such a condition
(i.e. } exaltation) accompanied by delirious conceptions arising
from inordinate self-conceit, has in any degree become fixed,
there is founded a state of mental derangement infinitely
more serious than that of simple mania. . . . Delirious
conceptions, false ideas, which arise from over-estimation of
* “ Mental Pathology and Therapeutics,” p. 274. He is speaking of
“ Monomania.”
XXX. 17
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244
Exaltation in Chronic Alcoholism ,
[July,
self, and therefore relate only to the special self of the
patient, appear, which immediately involve the ego itself, and
therefore the innermost part of the individuality becomes
alienated and falsified.” And again—* " A completely fixed
exalted delusion, when it has continued for more than half a
year, is not easily got rid of; nevertheless, cases sometimes
occur where the monomania gradually disappears after it has
lasted for several years : when this occurs other morbid 'pro¬
cesses are generally developed. All symptoms of commencing
mental weakness, loss of memory, recurrence of incoherence,
Ac., indicate that the patient is becoming incurable.”
Drs. Bucknill and Tukef state that the prognosis of in¬
sanity characterized by exaltation is unfavourable, and also
that caused by alcoholism. Very unfavourable, therefore,
must be the insanity due to alcohol, and exhibited in exalta¬
tion. Other writers express themselves to the same effect,
and there is indeed a general consensus of opinion on this
part of the subject.
Pathology .—The precise pathological conditions which de¬
termine this state of exaltation are, to some extent, matters
of conjecture. We know the action of alcohol on the vaso¬
motor system, and we believe that it has a special affinity for,
and directly injurious influence on, the nervous tissue, so that
its evil effects on the brain are double, one direct, the other in¬
direct, through its alteration in the vascular supply. It differs
too from opium, belladonna, and other poisons affecting the
nervous system, in that its effects remain after its administra¬
tion has ceased.
Professor CumowJ has lately stated broadly that the
“ autopsy in alcoholic insanity discloses no specific characters,”
and this no doubt is the fact, in so far that it would be
impossible to identify this particular species of insanity by
mere post-mortem examination. But there are certain ap¬
pearances which are usually to be discovered, though they are
not confined to the subjects of the insanity of intemperance.
They consist of signs of present or past cerebral hypersemia.
Even* apart from actual anatomical demonstration, the
analogies of other conditions of expansiveness and exalta¬
tion, in which the pathology is less obscure, would strongly
point to hypermmia. In epilepsy and general paralysis, more
particularly in the latter, cerebral congestion is plainly shown
* Griesinger, op. oit ., p. 310.
f “ Psychological Medicine.” 4th Edition, p. 137.
X Quain’s “ Dictionary of Medicine.” Article “ Alcoholism,” p. 28.
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245
1884.] by Bonville Bradley Fox, M.A., M.D.
both before and after death, and though this may not be so
in the insanity of masturbation, it can hardly be doubted
that the frequent intense stimulation to which the victims
of this degrading habit expose their brains, a stimulation
whose effect is expressed in an organic convulsion, presup¬
poses corresponding convulsion or excitement of nerve-cells,
and at the time being at least involves an increase of blood-
supply to those cells, and to the brain generally. Again, in
the early stage of drunkenness, when ideas flow with in¬
creased rapidity, and a feeling of expansiveness and well¬
being takes possession of the individual, there is a deter¬
mination of blood to the head.
It is worth noting that these transient hypersemias, viz.,
that of drunkenness and that of too frequent sexual excite¬
ment, which may be associated at first with nothing more
than molecular disturbance, by repetition occasionally lead
to coarser and more permanent changes in the brain, of
which one result is general paralysis. And when the con¬
gestion of habitual drunkenness fails to effect thi#,* and
merely vitiates the mental health without destroying the
life of the individual, it is not surprising that those sensa¬
tions, which resulted from the first poisoning of the cerebral
tissue, should remain, when that poison is withdrawn. This
is expressed more clearly by Dr. Maudsley.* “Temporary
irregularities in the supply of blood to the supreme centres
may, and often do, pass away without leaving any ill conse¬
quences behind them; but when they recur frequently, and
become more lasting, their disappearance is by no means the
disappearance of the entire evil; the effect has become a
cause, which continues in action after the original cause has
been removed, and permanent mental disorder may be thus
established. Once the habit of morbid action is fixed in a part,
it continues as naturally as, under better auspices, the normal
physiological action” And he proceeds to point out the close
analogy between the phases of drunkenness and of chronic
insanity, and shows that as in the former the expansiveness
and excitement pass into stupor, so, in the latter, the dis¬
traught activity of the brain, as displayed by fantastic delu¬
sions, often lapses, and becomes dulled for ever in dementia.
This is the natural end of many of such cases, and in con¬
nection with the varied and wild ideas which mark the period
preceding that in which almost all ideas vanish, Claud Ber¬
nard’s observation is appropriate, that “ when a histological
* « The Pathology of Mind.” 3rd Edition, p. 192.
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246 Exaltation in Chronic Alcoholism , [July,
element dies or tends to die, its irritability augments before
it is diminished.”
Admitting then, as is doubtless true, that cerebral hyper-
semia is the original basis of these delusions of exaltation, it
is not difficult to understand why they can be so rarely
removed, associated as they are with permanent organic
lesions in the brain. To quote Griesinger* once more—
“ Cerebral hyperemias may occasion the development of
exudations and their further transformations. The more
the disease is prolonged the less it is interrupted by lucid
intervals and remissions, and the more intense the hyper-
semia the more are these exudations to be feared.”
It may be pointed out that, apart from the mental disturb¬
ance caused Dy habitual abuse of alcohol, it sometimes be¬
queaths certain permanent physical derangements, identical
with those seen in temporary intoxication, viz., impairment
of co-ordination, blunting of cutaneous sensibility, and, as I
think, permanent reduction of temperature from injury to the
vaso-motor system.
The treatment applicable to persons labouring under these
delusions of exaltation may be very briefly dismissed. If the
foregoing statements are correct, it is at once apparent that
little can be done for them ; certainly we cannot hope to rid
them of their false ideas by any argument or train of reason¬
ing. Their physical health often requires attention; their
bad habits should be checked, and the gastritis or other dis¬
eases induced by their course of life, as far as possible alle¬
viated. All stimulants should be cut off, or administered
sparingly, and much diluted. I have never seen any ill
effects accrue from this last step, and have occasionally
noticed considerable improvement. I am aware that the
total withdrawal of accustomed stimulants is considered to
be too drastic a measure by some authorities, but as Mr.
Holmesf points out, when speaking of delirium tremens,
there is no ground of reason, or therapeutical experience, to
lead one to expect a cessation of the effect from a continu¬
ance of the very irritation which produced it.
It is necessary to place such patients under certificates
of lunacy, otherwise they cannot be legally and properly
restrained from indulgence in drink, and from the wild and
ruinous schemes to which their inordinate self-esteem and
* “ Mental Pathology and Therapeutics,” p. 92.
t “ Surgery, its Principles and Practice,” p. 61.
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1884.] by Bonyille Bradley Fox, M.A., M.D.
vanity prompt them. And while the control of an asylum
is not absolutely indispensable, it offers the advantages of
healthy routine and safe protection for the patient from him¬
self and his bad habits, which he will probably cease to
attempt to gratify when he perceives that attempt to be
hopeless, while at the same time his happy frame of mind
will prevent his regarding such a position as a painful one.
In conclusion, to briefly summarize the propositions of
this paper:—
1. The insanity of chronic alcoholism is very frequently
characterised by exaltation.
2. But these exalted delusions are common to various
types of insanity, and are not therefore reliable as deter¬
mining classification.
3. This exaltation in some cases possesses nothing to dis¬
tinguish it from that of general paralysis. Occasionally,
too, the physical signs of the two diseases so far resemble
one another that they can only be differentiated by the
history and other circumstances connected with the case,
and in some rare instances, only by watching the course
of the malady.
4. In chronic alcoholism delusions of exaltation are usually
fixed, constant, and ineradicable.
5. This is in consequence of their dependence upon cere¬
bral changes, the result of repeated hyperaemia.
6. Little or nothing can be done for their removal.
CLINICAL NOTES AND CASES.
Unexpected Recoveries. Two cases contributed by Dr.
Willett, Wyke House Asylum, Isleworth.
Case I.—A. B., aged 30. Admitted June 29th, 1852.
There was some remote family history of mental disease, but this
was patient's first attack, and all near relations are quite healthy.
Present illness came on suddenly, and when in otherwise good
health, seven months previous to admission. It was undoubtedly
caused by overwork and anxiety, the entire burden of a large London
parish devolving unexpectedly upon him. Patient became oppressed
by the idea that he was not doing his duty, and so worked harder
until the brain gave way, and delusions respecting sin and the Evil
One took possession of him. He felt he was lost eternally, became
careless as to his appearance, slovenly in his habits, and at one time
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Clinical Notea and Cases.
[July,
exhibited suicidal tendencies. Patient’s brother, a medical man, now
took charge of him, and though they travelled together and every¬
thing possible was done to divert his attention from his delusions and
to keep him amused, no change for the better occurred in his mental
condition.
On admission patient was not in good health, several pustules being
present on the hands and elsewhere, which were being constantly irri¬
tated by picking. He was a very fair man, with a narrow forehead,
the head widening greatly behind. His attitude was illustrative of
deep melancholy, but he could be roused, and would sometimes break
out singing or whistling. He took no care for his appearance, and
was very slovenly. Would sit for hours in the same position, and
seemed only anxious to be left to himself; indeed, he sometimes
«.v*d great irritability when attempts were made to rouse him. He
A many strange delusions—that the devil bad possession of him ;
that he had lost his voice and could not preach ; that he had mur¬
dered many people ; that various animals, such as the birds in the
Aviftr* and the cows in the field, were his relations. He sometimes
$ *ie was dead, and that the asylum was Hades. He always ob¬
jected to taking the usual exercise, and to have his bath.
Patient continued much the same until about the middle of August,
when his condition appeared to be changing for the worse, and it was
feared that he would pass into a state of dementia. He began to
refuse his food, became dirty, and went about with his clothes undone.
His favourite attitude was to sit with hands in pockets, head bent on
chest, and legs extended in front of him, the eyes being kept closed.
Sept. 2nd.—No change, but burst out crying on his father and
brothers visiting him.
Sept. 30th.—Relations, on again calling to see him, expressed it as
their opinion that patient was no better.
Oct. 2nd.—Has been induced to play the cornet once or twice.
Appears a little brighter, and is to take his meals with the more
rational class of patients. At this period an old friend of the
patient, also a clergyman, called upon him, and the two had a long
talk together, during which his delusions were not referred to. This
conversation, indeed, seems to have been the turning-point from
which his recovery dates. Patient afterwards told me that he felt
ashamed that his friend should see him in such a state, and he re¬
solved to “ pull himself together.”
Oct. 4th.—Is much more lively. Has walked out with the Assistant
Medical Officer, which he had always previously declined to do; and
he then stated that many of his late impressions he felt to have been
“ in great measure delusions.”
Oct. 7th.—Wished to be shaved and to take daily walks. This he
now does, and on such occasions talks almost constantly of his state
of mind of late, and laughs at his old delusions.
Oct. 10th.—After a rather exciting day, during which he had
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1884.]
played billiards, written several letters, sung a few songs, and been for
a long walk, he was restless at night, could not sleep, and said some
of his old fancies were returning. A draught of chloral and bromide
of potash was given. Patient then slept, and awoke as well as ever.
However, he was forbidden for the present to write many letters or
excite himself with the visits of friends. This course appeared to irri¬
tate him much, and he sometimes used bad language in consequence.
This he never used to do when in perfect health.
Oct. 25th—Patient’s friends now say he is as well as ever he was
in his life. He consequently left on a two months’ leave, and was dis¬
charged, cured, on Dec. 25th, after an illness of 12 months.
Cask II.— C. D. Admitted April 22nd, 1856. Mt. 20.
Presented the appearance of ordinary dementia. Was unaVa to
perform the most trivial offices for himself, was extremely dirty in i 1°
habits, and inattentive to the calls of nature. By the following June
he had so far recovered that he would converse, though foolishly,
attended to his own wants, and was again cleanly in all respects.
In May, 1857, there is a note made of an attack of acute n *
previous to which, the report says, he had been getting thinner;
on June 4th of the same year the first mention is made of his habit
of masturbation, which appears to afford the key-note to this case.
Thus an entry occurs, dated April, 1858, in which - another attack of
acute mania seems to have been traced to this practice as a cause ; and
again, on Nov. 27th, mention is made of this habit of self-abuse, and
is followed by a notice on the ensuing day of a fit of violent excite¬
ment and screaming. In addition, it may be mentioned that running
continuously through the report is the fact of frequent costiveness
noticed, though plenty of exercise was always taken and the diet an
ordinary one.
These more or less acute paroxysms of maniacal excitement
occurred at intervals during the following years, until the follow¬
ing note occurs, dated Sept., 1882:—“ Attendants say Mr. W.
masturbates frequently every night. Patient looks pale and ill.”
At this time, too, mention is first made of a complaint on his part of
a 44 feeling of soreness and stiffness in the stomach.” Bowels then
much confined.
On examination, Oct. 11th, the pain and tenderness were found to
be localized chiefly in the right iliac fossa, though the abdomen was
generally distended and tender on pressure. In the inguinal region,
on very slight pressure patient called out loudly, and then complained
of feeling sick and faint. A small soft tumour was discovered at the
upper part of the right inguinal canal, and as the scrotum was found
empty, and, indeed, undeveloped on the same side, the diagnosis was
made of undescended testicle incarcerated in the inguinal canal.
It may be mentioned that the symptoms at this time, as well as in
subsequent attacks of a similar character when vomiting was also pre¬
sent, very closely resembled those of hernia. The apparent obstruc-
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250
Clinical Notes and Cases.
[July,
tion of the bowels (no motion was passed for four days), the sickness
and tnmid belly, together with the anxious expression of countenance
and dorsal decubitus, all pointed to that possibility.
These attacks of congestion and inflammation occurred at irregular
intervals for a year, and could generally be traced to patient’s indul¬
gence in the old practice ; and though every effort was made to break
him of it, including blistering the penis, cold baths, &c., success was
only temporary.
The severer symptoms, as of obstruction, due, no doubt, to the
rigid immobility of the abdominal muscles, and the pain arising from
any effort at straining, were always relieved by blistering in the
region of the testicle; but this constant source of irritation, besides
giving rise to great excitement, amounting at times to severe attacks
of fccute mania (during which patient was most dangerous) was telling
seriously on his health, and an operation for the removal of the mis¬
placed organ became imperatively necessary. It was felt useless to wait
until Mr. W. became again quiet and tractable. The testicle was
accordingly removed by Mr. Marcus Beck on the 27th Oct., 1883,
patient undergoing the chloroform fairly well. The spermatic cord
was not tied as a whole, as this proceeding has been said to cause irri¬
tation, but the vessels were separately ligatured. The entire opera¬
tion was conducted on strictly antiseptic principles.
On recovery patient was extremely sick, and called out loudly that
he should die, but was not violent. At 10 p.m. same night, tempera¬
ture 99, pulse 90. Quiet.
Oct. 28th.—Temperature 98, pulse 70. Has slept a good deal.
Attendant watching lest he should tear off the bandages. There has
been some slight haemorrhage, but none now. Dressings not re¬
moved. Says he feels comfortable, and is quiet, only asking that he
should not be killed.
Oct. 81st.—Wound dressed. Union of edges fairly strong. No
suppuration. Drainage tube withdrawn. Bore the dressing very
well. Very foolish, but quiet.
Nov. 6th.—Wound healed with exception of one point in situation
of suture.
Nov. 12th.—To resume his exercise. Bowels now acting regu¬
larly. Appetite good. Quite quiet and tractable. Has shown no
further sign of violence since the operation, though for the four
months previous to it, patient had been affected with almost daily
paroxysms of an acutely maniacal character, and had been unable to
exert the least self-control.
Jan. 12th, 1884.—Patient continues quiet and well-behaved, though
still very foolish. Bowels now act regularly and well. In personal
appearance he has much improved.
Feb. 5th.—Still quiet and well.
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1884.]
Clinical Notes and Cases .
251
Cases contributed by S. A. K. Strahan, M.D., Assistant
Medical Officer, Northampton County Asylum.
I.
Acute Mania in a Boy of Thirteen Years .
Acute mania in the young—before the period of pubes¬
cence—is sufficiently rare to invest the following case with
some interest:—
Alfred P., aged 13, an agricultural labourer, was admitted on Feb.
26th, 1883, with the following history :—Mother and a brother have
been insane and confined in an asylum. About three weeks ago
patient seemed “strange/* and complained of wandering pains in
limbs ; he stayed from his work in consequence for a fortnight, and
then appearing better he returned, but in five days again gave up
work, complaining of giddiness and left frontal headache. On the
next day he was incoherent and violent.
On admission to the asylum he was described as a boy of average
development for 13 years. Hair brown, eyes blue, pupils unequal—
left dilated. Testes have not descended to scrotum. He tumbles
about the bed with his knees at his chin, holds his mouth full of saliva,
which is beaten to froth from his churning it through his teeth. If
anyone attracts his attention he becomes stationary for a time, and
uses all his energy in cursing the new-comer and using obscene lan¬
guage. His obscene vocabulary was limited, but that of condemna¬
tion was varied and vigorously applied.
He was kept in bed for the first few days, and did not improve much.
After a saline purge he ate well of milk and other slops, but refused
solids.
On the third day he became more restless and would not remain in
bed, and the weather being cold he was clothed and got up. At this
time he was lively and incoherent, would do nothing required of him,
and described himself as being “ damned well.*’ The pupils were now
equal, and the right shoulder was noticed somewhat lower than the
left. There was no facial paralysis, and he walked smartly. Next day
the “ sinking ” of shoulder was gone, and he was quieter and more
tractable.
On the twelfth day he relapsed and became almost as on admission.
Three days later he again improved, and became coherent and well-
mannered.
From this time he continued to improve, and on the thirty-fourth
day was sent to work in the garden, where he soon turned out to be an
intelligent little fellow and a capital workman.
A few weeks later, he being much improved bodily, and apparently
well mentally, he was discharged recovered on the eightieth.day from
the time of his admission.
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252 Clinical Notes and Cases . [July,
n.
Hypodermic Injection of Nitrite of Amyl for Lumbago, followed
by Epileptiform Convulsions.
The following case may prove interesting from more than
one point, and should, I think, be recorded. First, it accen¬
tuates the fact that amyl is not so constant in its action as is
generally supposed, and that its depressing, inhibiting, or
paralysing action on the heart is constantly to be borne in
mind. Dr. Sidney Riuger has noticed this occasional action
of the drug upon the heart, and also speaks of the strange
effect sometimes produced on the nervous centres. He says,
“ I have seen one case where a woman, immediately after a
drop-dose, turned deadly pale, felt very giddy, and then became
partially unconscious, remaining so for ten minutes.” And
again, “A delicate woman, after one-thirtieth of a drop,
passed in a few moments into a trance-like state.”
Secondly, it has a questionable bearing on the (what some
people consider doubtful) action of the heart during the onset
of epileptic or epileptiform attacks. The patient in the case
given below was admitted as a non-epileptic, had been more
than six years in the asylum without having any kind of fit,
and has been equally free from convulsive attacks since the
occurrence recorded.
Cask. —Charles C., aged 53, a chronic maniac in rude bodily health,
was seized with lumbago; for several days he was almost unable to
move, and the usual treatment—warm baths, saline aperients, &c.—
failed to give relief. On October 13th, 1882, when he had been ill
several days I administered hypodermically a ten minim dose of a ten
per cent, solution of nitrite of amyl in rectified spirit.
Immediately after the injection the pain disappeared; he got up
from the bed, and at my request stooped and touched the floor with
his fingers. In as nearly as could be guessed about a minute and a
half, he suddenly became deadly pale, and sank back upon the bed
without sigh or other noise. On assuming the horizontal position,
his face, head (bald) and neck became congested, and he was strongly
convulsed for about the period of half a minute. The convulsion
affected the face and upper extremities strongly; the lower limbs only
slightly, the legs being drawn up towards the body and retained in that
position. During the convulsion the eyes were open and rolled upward,
the mouth was drawn in a grin, and the breathing was suspended.
The hands were clenched, and they and the arms were strongly
shaken, while the teeth were ground. Immediately after the convul¬
sion the pupils did not appear to be affected. Before and during the
early part of the seizure I had my finger on the pulse ; it became weaker.
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1884.]
and I lost it altogether just before the muscular movements commenced.
As soon as the convulsive movements ceased the patient clambered to
the sitting posture, and began talking in an incoherent manner, as
was his custom, and although he looked “ lost ” he answered simple
questions.
In about two minutes or perhaps three after his recovery from the
first convulsion, he was again attacked in a similar manner. He
seemed to “ faint,” and immediately after rolling over he was con¬
vulsed as before, but more strongly. On this occasion I happened
to have my ear upon his naked chest listening to the heart sounds,
which became weaker, or more distant, and then suddenly ceased ; at
this instant an attendant standing by called out “ He has fainted
again.” The muscular movements continued for forty or fifty seconds
and wore appreciably stronger than on the first occasion. The re¬
spiration ceased with the stoppage of the heart’s action, and began
somewhat heavily on the cessation of the convulsive movements when
the patient once more sat up and talked as before.
He was now made to inhale some chloroform, some of which was
also applied to his bald scalp; this, he said, “made his head nice and
cool; ” “ but,” he added, “ it is warm inside.”
He soon regained his usual colour, and looked as if nothing had
happened, except that he had entirely lost his pain, and could walk
about and bend the spine with perfect ease. There was no return of
faintness, .and an hour later he made a hearty tea. He was kept under
supervision for four days, and as nothing strange occurred he was
allowed to go to work again out of doors, where he has been employed
daily up to the present time.
Case of Cerebellar Haemorrhage. Abnormalities of Cerebral
Arteries. By James Shaw, M.D.
J. P., aged 74, was admitted into Haydock Lodge Asylum, on the
26th August, 1880. This was said to be the first attack, and of twelve
months’ duration. Patient was described as suicidal.
The following information was obtained from the medical certifi¬
cates on which she was admitted :—
Conversation incoherent and irrational. Restless and excitable.
Noisy and violent; screaming, scratching, kicking, and biting when
she was being dressed. In constant fear that everyone wished to do
her some bodily injury, bleed her, remove her skin, cut her up, &c.,
&c. She also feared that they were attempting to take her money.
Disliked those about her.
Condition on 2nd September.—Circumference of head 21£ inches.
Left pupil larger than right. Gait staggering. Very talkative and
incoherent. Irascible. Restless and sleepless at night. Clean in
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254 Clinical Notes and Cases . [July,
her habits. Does not know where she is. Says she is “ going to be
chopped up into pieces/'
Sept. 28.—Wanders about aimlessly, and converses incoherently.
Has many changing delusions as to the identity of the people sur¬
rounding her. Suspicious, fancying people are talking about her.
Nov. 80.—Has had a transient attack of incomplete right hemi¬
plegia with defective speech, from which she has just recovered.
During this attack she articulated badly, but there was no true
amnesic aphasia, and the hemiplegia only amounted to slight feeble¬
ness and diminished power of co-ordination.
De C# go.—Gait unsteady, but no localized paralysis. Fancies the
Medical Officer is the king, and one of her fellow-patients the devil.
Slightly deaf. Very restless and childish.
1881, Oct. 8, 8 a.m.—Seized suddenly with an attack marked by
unconsciousness and frothing at the mouth. She partially recovered
from this seizure, and was then very weak, lying with her legs drawn
up to her body. The left side showed diminished cutaneous sensibility
as compared with the right; and the left arm and leg were weaker
than the right. She muttered, mumbled, screamed, and shouted, but
the word “damn” was the only articulate expression she succeeded in
emitting. When being examined she pulled, scratched, and pinched
with her right hand. Nausea and vomiting. Pulse 100, and very
feeble. Feet cold. Eyes shut, and patient resisted when the eyelids
were raised. Left pupil larger than right. Patient incapable of
understanding what was said to her, and inclined to be drowsy. Cold
affusions to head. Sinapisms to legs. Enem. terebinth, &c.
Became comatose in the evening. Stertor avoided by turning the
patient on her side.
4. —Still comatose. Face flushed. Conjunctiv® insensible to
touch, and pupils to light. Both pupils contracted, left more than
right. Pulse 78. Respiration 24. Temperature 99° in left axilla.
5. —Coma continues. Pulse 104. Nutrient enemata after enem.
cathart. Died on the morning of the 6th.
Autopsy .—Dura-mater adherent to calvarium. Arteries of brain
atheromatous. Venous congestion of pia-mater. Right posterior
cerebral artery given off by internal carotid. The basilar artery gave
off, after the right superior cerebellar, a small branch from its right
side, which wound round the crus cerebri, and then a small posterior
communicating branch which joined the right posterior cerebral
anteriorly. The arteries given off to the left by the basilar were
normal as to their origin and distribution.
The right posterior cerebral divided near its origin from the internal
carotid into two branches ; one running posteriorly and terminating
in the parieto-occipital sulcus, supplying on its way the gyrus
lingualis, the inferior margin of the precuneus, and the superior of
the cuneus ; the other, and larger, passing outwards and backwards,
sending one terminal branchlct into the calcarine fissure, and supplying
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1884.]
the gyrus uncinatus, lobulus fusiformis, third temporal convolution,
and the occipital convolutions, including lower border of cuneus ;
this larger branch wound round the gyrus uncinatus close to the hook,
and then passed over the lobulus fusiformis. The cerebral cortex was
apparently healthy.
In the external capsule and external division of the lenticular
nucleus in both hemispheres, and in the inner and middle portions of
the right lenticular nucleus, there were several small lacunae which
were free from colour as to their walls.
Cerebellum .—The right lobe looked dark, inferiorly, and felt soft,
and on cutting into it a clot weighing 5*248 grammes was discovered.
The clot was fresh, close to the surface inferiorly and internally, and
pressed on the pons and medulla. The fourth ventricle contained
some dark fluid blood. The whole of the cerebellum was congested,
and the portion of the right lobe immediately surrounding the clot
was softened.
The posterior root zones (columns of Burdach) of the spinal cord
were slightly sclerosed. Columns of Goll apparently normal.
Remarks .—The motor troubles which occurred in Novem¬
ber, *80, probably arose from embolism of one of the arterial
branches supplying the right lobe of the cerebellum, or from
a slight haemorrhage into that lobe, the traces of which were
obliterated by the fatal attack nearly a year afterwards.
Lesion of the right lobe would be accompanied by weakness
of the limbs of the same side, in accordance with the opinion
held of the direct instead of cross action of the cerebellum
from its anatomical relation to the cerebrum, and patho¬
logical experience.*
The motor and sensory symptoms were much more marked
on the side opposite to the lesion in the second and fatal
attack, but this was manifestly owing to the pressure of a
comparatively large clot on the cerebral fibres of the right
side of the pons and medulla.
The unsteady gait, nausea, and vomiting pointed to the
seat of lesion; and the defective hearing after the first
attack (although, unfortunately, no examination of the ear
was made) is noteworthy, taken in conjunction with Mey-
nert’s description of the root of the acoustic nerve, most of
the fibres of which, as demonstrated by his preparations,
run into the cerebellum.
* See Bastian’s “ Brain as an Organ of Mind,” pp. 393, 507-8. Also “ Case
of Atrophy of the Left Hemisphere of the Brain,” Ac., by S. van der Kolk.
New Sydenham Soc., 1861, p. 144; and Andral’s “ Cliniqne m6dicale,” 1833,
Vol. v, p. 679.—[Eds.]
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Clinical Notes and Cases.
[July,
Post-Hemiplegic Hemi-Chorea Associated with Insanity. By
W. Bevan Lewis, L.R.C.P., West Riding Asylum.
(Illustrated.)
The clinical history of the following case, whether regarded
from its subjective or objective side, together with the
pathological aspects presented, embraces features of interest
which I believe are worthy of perusal s—
A. M., 8Bt 61. Patient is married and the mother of twelve
children; has been an active, intelligent, and fairly-ednested woman,
of temperate habits. She has been subjected to much ill-usage by her
husband and greatly neglected in her late illness. Her family history
appears free from any predisposing neurotic element, bat her sister is
SAid to have had a “ stroke.'’ Patient has suffered from rheumatic
fever, but her present illness dates two years back, at which period she
had a paralytic seizure affecting the right side of face , right arm , and
depriving her of the faculty of speech , but in no way implicating the
right leg; she did not lose consciousness. Bed-ridden for the past
eighteen months, with chronic ulcers on the legs, negleoted and half-
starved, she had become wretchedly enfeebled and emaciated. Six
months ago she began to lose control over the movements of the right
leg t and about the same time the right arm, which had regained much
of its former power , beeame the seat of the restless choreic move¬
ments present upon admission. Her speech, which she had never
fully regained since the “ stroke,” became more difficult and much
impeded at this time, and coincidently with the onset of choreic
spasms mental derangement supervened.
Upon admission patient endeavoured to give a detailed account of
her past history; could recall correctly the events of the last few
days ; knew where she was and why she had been brought to an
asylum ; said she had had much trouble of late. She talked in a
rambling strain about her husband ; said he was dead, but had come
to life again ; declared a few moments afterwards that he was killed,
her son shot and a daughter drowned lately—all delusional statements.
She exhibited beyond simple depression a notably peevish, querulous
humour, a distrust of those around her, and an obstinacy associated
with childish inattentiveness and apparent utter inability for the
slightest mental exertion at times.
Her speech was notably choreic, broken, spasmodic, the last word or
syllable emphasized in a breathless manner ; articulation at times
much blurred; naming and propositionising good, but both appeared to
cause unnatural effort. The auditory and visual elements of written
and spoken language were fully appreciated. The movements of the
lips were very inco-ordinate ; there were clonic spasms of the facial
muscles of the right side amounting to contortion and grimace ; the
tongue was frequently thrust forward during speech, the angle of the
mouth was slightly drawn to the left side ; tried to whistle, but failed,
thrusting the tongue out. There was no dysphagia.
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1884.]
During the whole period of examination there were restless move¬
ments of the limbs, involving the right arm chiefly, and to a much less
extent the right leg. The right arm, as a rule, lies perfectly flaccid
and helpless, but during conversation, upon making any voluntary
efforts, and especially during excitement and emotional disturbance,
the limb was thrown about in disorderly, choreic movements; tossed
into positions of flexion or extension with alternate pronation and
supination of the fore-arm. The muscles of the hand, extrinsic and
intrinsic, were not affected ; the left arm was unaffected by paralysis
or spasm. The dynamometer registered for the right hand a pres¬
sure of 8 kilos. ; the left hand 10 kilos. Upon a second trial—for
the right 7 kilos.; and for the left 11 kilos.
Galvanic reactions .—On the right side the biceps alone gave evi¬
dence of the reaction of degeneration, the Anodal closure pro¬
ductive of a minimum-contraction being caused by 18 cells; the
Kathodal closing-current giving the same with 15 cells. The reac¬
tion of three muscles of the arm gave the following results:—
KSo. ASo. KOc. AOc.
Pectoralis Major . 14 26 Nil at 50 Nil at 50
Deltoid . 16 28 do. do.
Biceps.. 15 18 do. do.
Faradaic currents gave similar indications.
The limbs were extremely emaciated; the right and left arms at
thickest part of biceps measured 5-J- inches; the right and left
thighs 8£ and 8-| inches respectively; the right and left calf to 6£
inches respectively.
The triceps-reflex was absent from left arm, but unusually brisk in
the right; the patellar tendon-reflex was almost abolished in both legs ;
there was no ankle clonus; the superficial reflexes, however, es¬
pecially the plantar, were extremely brisk. The quadriceps responded
sluggishly to percussion. As regards muscular power, she could only
support herself upon the left leg—locomotion was impossible, and
upon attempting it with great timidity, the right foot was jerked
forwards, sideways, or backwards—movements which she endeavoured
to control by standing on the left leg with the right leg twined
around its fellow. Lying in bed, she could draw up both legs briskly,
there appeared to be no great loss of power in the right member, but
merely an extreme inco-ordination which prevented her attempting to
use it in progression.
Muscular sense was intact; she was fully conscious of the position
of her limbs, appreciated the difference in weights, and by other tests
proved its retention. There was no marked cutaneous anaesthesia ;
tactile appreciation was very slightly disturbed upon the right side,
as seen by the following results of the aesthesiometer test.—
Tip of Finger . Bight side *1 inch. Left side T inch.
Ball of Thumb. „ *4 „ „ -3 „
Back of Forearm. „ *8 „ „ *7 „
Plantar aspect of Great Toe „ *3 „ „ *2 „
»» » Foot. » *5 „ ,, *2 lf
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Clinical Notes and Cases.
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Sensibility to pain and temperature were, if anything, slightly
increased on the right side. As regards the special senses, smell was
acute and discriminating, so also was taste ; colour appreciation was
good, but visual acuity reduced Sn. T e T in both eyes alike. The left
pupil reacted sluggishly, and the right pupil was perfectly rigid to
light; the consensual and accommodation movements were perfect
and active in both. The sense of hearing was unaffected. As regards
the respiratory and circulatory systems, nothing abnormal was
detected beyond the slightest possible roughening of the first sound of
the heart at the apex—the heart's rhythm was undisturbed, its
impulse of fair strength, and no apparent alteration in its dimensions
perceptible. The urine was pale, limpid, of sp. gr. 1009 ; contained
no albumen or sugar. Patient died after a residence of eight months.
Autopsy thirty-nine hours after death .—Body excessively ema¬
ciated ; rigor mortis everywhere absent; slight hypostatic lividity
over back ; greenish discoloration of abdomen.
The skull-cap was symmetrical, bones thin and light; no adhesions
of dura-mater; the longitudinal sinus contained a firm fibrous clot
extending through both lateral sinuses down into the jugular vein of
each side; this clot was strongly adherent to the lining membrane of
the sinus t and was evidently of long-standing Jormation. The brain
was of small size and generally reduced in consistence ; the convolu¬
tions, which were of fair complexity, showed, however, a universal
and marked attenuation and a peculiar rugose aspect of their surface,
such corrugation being much more marked in the anterior half of the
brain, both frontal lobes being very considerably implicated. The
membranes were thin and translucent; the minute superficial venules
at the vertex evidenced a long-continued stasis of cerebral circulation
here which had resulted in the formation of Jim decolorised blood-
clots marking out these vessels as whitish streaks to their minutest
visible ramifications. A superficial softened patch involved the
cortex of the posterior part of the left supra-marginal, anterior limb of
angular and second annectant gyri of this hemisphere; similar foci
of softening, characterised by their peculiar milky opacity, involved
both ascending parietals along their middle third; a few very insignifi¬
cant softened patches appeared on the fourth right annectant and
anterior end of the frontal gyri. The cortex generally was wasted
and thin. Upon cutting carefully through the ganglionic region at
the base, both outer and inner capsules were found perfectly free from
lesion; and, beyond a very minute haemorrhage of quite recent date,
involving the posterior part of the left lenticular nucleus, the ganglia
of both hemispheres showed no appreciable change. In the right
hemisphere, however, a blood-clot, half an inch in diameter, firm,
fibrous, not in the least decolorised, with a calcareous vessel occupy¬
ing its centre, involved the prefrontal sections of medulla just in
front of the spot where the head of the caudate dips down to the base.
In other respects the brain showed no material change.
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Clinical Notes and Cases.
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1884.]
The whole brain weighed 1,173 grammes; the right hemisphere
500 grammes ; the left hemisphere 510 grammes.
The heart was found free from any valvular lesion; the kidneys
were wasted, but not contracted and cirrhotic.
Remarks .—We have here an illustrative case of the asso¬
ciation of chorea with insanity, such as not unfrequently
occurs in asylum practice, and an analysis of the symptoms
presented by the patient as leading up to a recognition of the
nature and topographical distribution of the lesion or lesions
to be predicated therefrom cannot fail to prove instructive.
That the woman suffered from chorea was clear, but which
of the multiform species of this widely embracing generic
term her malady is to be classed amongst was not at first
sight very evident. We find in her case the usual diathetic
association of chorea—she had suffered from an attack of
rheumatic fever. Sudden mental shock or fright are ac¬
cepted as frequent exciting causes of choreic states, and this
patient's domestic relationships—penury, starvation, ill-
usage—introduced an element of intense mental disquiet
and anxiety which would amount to mental shock “ drawn
out thin," to use Dr. Hughlings-Jackson's expression. Pass¬
ing, however, from these less cogent points to the study of
the symptoms, we observe first that the convulsive phenomena
were limited to one side—the right; and we instinctively
demand a hemispheric distribution of lesions as accounting
for these unilateral choreic spasms.
We note that the onset and progress of the malady dates
from an attack of partial right hemiplegia with aphasia in
which face and arm participated to the entire exclusion of
the leg; a slow recovery ensues, and upon the restitution of
a fair amount of power in the right arm, this member,
together with the right leg, the facial and articulatory
muscles become the seat of choreic spasms. Such a history
reads like a case of ordinary post-hemiplegic chorea in
which a coarse lesion is usually located in the posterior
division of the internal capsule, impinging upon the thala¬
mus ; but observe, there was no association of tonic rigidity
with the choreic spasm. We may, therefore, safely ex¬
clude our case from the category of choreiform movements
consecutive to lesions of the converging medullated fan near
the capsule.
Nor, on the other hand, is it to be included amongst those
rare cases described by Gowers as “ hemi-ataxia;" our
patient exhibited no defect of muscular sense, was fully con-
xxx. 18
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260
Clinical Note* and Cases.
[July,
scions of the position of her limbs, and conld guide her
movements with fair certainty even with her eyes blind¬
folded when lying on her back.
A curious feature in the case is the extreme sluggishness of
the deep crural reflexes—the knee-jerk being almost abolished
in both legs; whilst, on the other hand, the triceps reflex,
not present on the left side, was very unusually brisk in the
right arm; the biceps muscle also on this side gave the re¬
action of degeneration. Whatever view be taken of these
signs of spinal implication, it must be remembered that the
right leg was not enfeebled beyond what might be explained
by the muscular atrophy due to prolonged disuse. Dr.
Dickinson's views of the pathology of chorea, and the sug¬
gestive cases of chorea in dogs where the choreic movements
persisted after high section of the cord, such as are quoted by
Gowers, Carville, Bert, and others, demand that we pay due
attention to the “ spinal symptoms ” associated with chorea.
We cannot, however, despite these symptoms and the reflex
iridoplegia in our case, long hesitate in deciding upon a
cerebral rather than a spinal origin for the choreic spasms;
paralysis of the face and arm of the right side with aphasia,
slightly diminished cutaneous sensibility upon the side of
paralysis, hemi-chorea associated with mental aberration, all
indicate a cerebral origin for the convulsive state. As to the
nature of the lesion P The outset of the “ stroke” was un¬
attended by lapse of consciousness, and this taken into
account with the age of the patient, the absence of albumen
in the urine, the presence of the rheumatic diathesis, would
indicate softening as the result of embolic plugging or of
thrombosis. The post-mortem examination revealed quite
symmetrically-disposed patches of softening in the motor
area of both hemispheres—over the middle third of each
ascending parietal gyrus, which are traced to a venous
thrombosis resulting from partial plugging of the lateral
sinus and extension of an old organised clot backwards into
the minute venules at the vertex; the left supra-marginal
and part of the angular gyrus are likewise implicated. Apart
from the significant distribution of these tracts of softening,
I would wish more especially to call attention to the con¬
ditions here so supremely favourable to the capillary plug¬
gings which such a venous stasis would predispose to—in
other words, to the conditions demanded for the establish¬
ment of chorea by the views of Hughlings-Jackson and
Broadbent. It is much to be regretted that from some
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202 Clinical Notes and Cases. [July,
wherever they were in contact ; also over the sacrnm. He remained
for several weeks in a more or less semi-unconscious state.
April 22nd.—Had another series of fits, which caused general con¬
vulsions of both sides. He lay on his right side, with his arms drawn
up over the front of his chest. There was considerable rigidity of the
left arm. His legs were also flexed, and could not be straightened.
He never regained consciousness, and died April 26th without any
further change.
Post-mortem. —Calvarium thin. On left side of brain, pachymenin¬
gitis with haemorrhage. Membrane distinctly formed. Lakelets in
both hemispheres, especially over the ascending frontal and parietal
regions. The appearance of the membrane gave the idea that there
had been a fine membrane formed, and more recently a fresh haemorr¬
hage, which had not got beyond the stage of coagulation. At the
base the fine membrane was easily separated from dura-mater.
The temporal bones on both sides were porous and brittle.
Cord .—Grey matter wasted. Brain 44ozs.
Lungs. —Right, much congested, small portions sinking in water.
Right 34ozs.; left, 12ozs.
Heart .—Pericardium adherent, adhesions recent. Atheroma of as¬
cending aorta. Heart weighed 12ozs.
Kidney8 .—Capsules adherent in both. Right, 5ozs.; left, 4£ozs.
Liver pale, 46ozs. Spleen, 3ozs.
Congenital Mental Defect with Delusions of Suspicion in
Twins. By T. W. McDowall, M.D., Morpeth. ( With
Portraits.)
As the mental defects of twins have of late attracted some
attention, the following brief record of twin lads, at present
under my care, and whose portraits are given in the accom¬
panying lithograph, may not be without interest, especially
as the lads afford a remarkable example of similarity, not
only in their bodily appearance, but in their mental
characteristics.
They are the illegitimate children of a woman who was seduced
whilst in service, was delivered in a workhouse, and has since resided
there almost continuously. Being unable to obtain the desired in¬
formation by correspondence, I went to the workhouse, saw and con¬
versed with the woman, and learned from her and the master as much
of her history as could be obtained.
She was only about twenty years of age when the twins were bora,
and since then she has had two illegitimate children. For the last
twenty years the workhouse has been her home ; occasionally she has
gone away for short periods when she could no longer endure the
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Clinical Notes and Cases .
263
1884.]
discipline of the house, but always to return when she had gratified
her lower appetites. Although iadustrious and not intemperate, she
has given much trouble by her lying, violence, and indecency. So well
is her character known by the officials and Guardians, that any com¬
plaint made by her is viewed with the greatest suspicion. Her stories
are* marked by absolute* unlikelihood, and appear to be invented with¬
out discoverable object, unless it be her desire for mischief and to have
lewd subjects under discussion. Her conduct and mental condition
have been a great puzzle to the poor-law officials. Her life has been
a curious combination of roguery, lewdness, and mischief-making. Her
mental state is difficult of definition and description. She is not de¬
luded, maniacal, or obviously deficient; but there is a moral perver¬
sion that clearly indicates congenital defect, or is the result of some
mental affection in early life. When judiciously managed she has
proved herself useful and obedient ; but wh^n annoyed she has given
much trouble by her outbursts of excitement, almost maniacal in
character, during which she has appeared to be quite beyond herself.
Her lewdness is abominable, and apparently incurable. Without
being careful of time or place, or even whether her desires can be
gratified or not, she will expose herself or solicit some old pauper,
then lodge a complaint with the master that so-and-so had been
attempting to ravish her. Such is the mother of my patients—a
strange combination of perversion and vice, yet not so peculiar but
that everyone who has seen much of criminals and lunatics can re¬
call similar cases. It may be safely taken for granted that it is from
her that her sons have inherited their mental weakness. All that can
be learned about the father is that he was a farm labourer and died a
few years ago.
The first lad to come under my care was George (Fig. 1 in the
lithograph). He was admitted 28th July, 1880, and was then
seventeen years of age. He was brought here in rags, having ab¬
sconded from the workhouse, and wandered over a large portion of
the north of England during several months, begging and living as
best he could, occasionally getting into gaol. He said that he greatly
preferred that form of life to living in a workhouse, where he was un¬
justly and unmercifully punished. It cannot be doubted that the
master had failed to recognise the boy’s true mental condition, and
had viewed his violence and waywardness as evidence only of wicked¬
ness, and had punished him accordingly. •
His condition on admission was as follows :—He was quiet, atten¬
tive, and answered questions civilly, coherently, rationally, and with
considerable humour. He seemed to be fairly intelligent, and had
evidently had some elementary education, as he could spell well, and
make fairly difficult arithmetical calculations promptly and correctly.
He stated that a number of men were coming after him with mur¬
derous intent; that they were armed with knives 3ft. long; that these
men, besides being murderers, were thieves and robbers ; that they
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264
Clinical Notes and Cases.
[July,
were in close and constant pursuit of him, and meant to destroy him;
and if he had a knife he would stab them. On ordinary subjects he
was rational enough. He knew his whereabouts, the day of the
week, &c. He gave an account of himself and of his relatives, and
laughed outright at some of his adventures whilst on the tramp.
He was at once induced to employ himself, and in a few weeks he
was sent to the tailor’s shop as an apprentice. There he has con¬
ducted himself, as a rule, very well ever since. He has not shown
any great aptitude for the work, but he can sew fairly well and put a
jacket together under supervision. He was found to be a masturbator;
sometimes he indulged in the habit to a great extent, but during
the last few months it is believed that he has nearly, if not alto¬
gether, abandoned it. At irregular intervals he has had attacks of
excitement and violence. Without any visible cause or previous
warning he has attacked the man nearest to him with bands and feet,
swearing and using abominable language. Such attacks have rarely
lasted more than a few hours, never a whole day, and were evidently
due to his delusions of persecution. Those attacks have diminished
in frequency and severity, but there are still peculiarities in his con¬
duct, and he is still deluded. In the airing-court he may frequently
be seen skipping sideways along the path, shaking his head violently
and uttering a curious sound. When asked why he does so, he laughs,
but gives no explanation. He very rarely now stops work altogether,
but when his delusions trouble him, he becomes a little unsettled,
perhaps weeps, and makes curious remarks to his neighbours ; indeed,
persons not knowing his delusions would be unable to make out what
he would be after. He now never fights, except with his brother.
As to his true mental condition, it may be described as imbecility
with delusions of suspicion. That there is a congenital mental de¬
fect cannot be doubted ; and it is exceedingly probable that his de¬
lusions developed at an early age. But as to this I can obtain no reli¬
able information. The master of the workhouse, who saw him grow
up, is now dead; the mother believes that her son is a very clever boy,
quite right in his mind, but cruelly ill-used. This is certain, how¬
ever, that although he is described as having been smart enough at
his lessons, he has been from early childhood a most unmanageable
youth, subject to fits of frantic passion, and dangerous to his neigh¬
bours.
Concerning the brother John (Fig. 2), extracts from the Case Book
will afford sufficient evidence of his history and mental condition.
He was admitted on the 10th August, 1881. The medical officer
certified that the lad was suspicious, surly, irritable, and violent; that
he had attacked several people in the workhouse without provocation,
and that on many occasions he has been dangerously violent.
History .—He has been all his life an inmate of a workhouse. He
has always been of a violent and malicious disposition, and has com¬
mitted numerous assaults. (The other facts have already been given.)
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Clinical Notes and Cases .
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1884.]
Present mental state .—He knows his surroundings, and says that he
has been sent here because he is wicked. He states that he has been
very ill-used at the workhouse, and gives that as a cause for his
violence. His memory is good. His expression is sullen and rather
stupid.
Physical condition .—It is only necessary to note that in the left
choroid there were patches of atrophy. This makes it probable that
he is the twin who had fits in early childhood.
It is really unnecessary to reproduce the entries as to his conduct,
&c. For a long time they only amounted to this, that he did a little
work in the upholsterer’s shop, that he behaved well, but was unsoci¬
able, sullen, suspicions, and deluded. He complained that the atten¬
dants and patients ill-used him and stole his food. Without having
ever committed an assault, except on his brother, whom he hates,
he has often threatened to be revenged on his persecutors. In
November last it was thought he might safely be sent to the shoe¬
maker’s shop. Here he has done remarkably well. He has worked
steadily and intelligently, and apparently with some benefit to his
mind, for he does not appear to be quite so sullen and unsociable.
He is still deluded, and states that both at work and here he is con¬
stantly tormented by people calling him nasty names. He is a
masturbator, and requires watching to prevent him indulging in in¬
decent practices with the idiot lads in the same ward.
The accompanying lithograph gives a fairly good idea of the appear¬
ance and facial expression of the lads. George’s portrait (the top
one), rather flatters him; the forehead is a shade high, and the nose
is too good. The expression is too intelligent; it should be lower and
more criminal. In life, the boys are so alike that a stranger could
not tell the one from the other. The structure of the head is de¬
cidedly low, almost criminal, and the expression is stolid and unin¬
telligent. They differ somewhat in stature and weight. George is
5ft. 5^in. in height, and 1501bs. in weight; John is 5ft. 3£in., and
1251bs. Their build and gait are identical, and their neck is thickened
by a slight enlargement of the thyroid.
So far as my experience goes, the case of these lads is
unique, and I have not discovered a similar one in medical
literature. It is not so very unusual to find twins bearing a
striking resemblance to each other, and plays have been con¬
structed to show the confusion which may thus arise. But
here we have two lads so alike that they are with difficulty
identified, and at the same time presenting symptoms of
mental derangement essentially similar.
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OCCASIONAL NOTES OF THE QUARTER.
Case of Gilbert Scott.
The past quarter has been rich in medico-legal interest.
There have been at least three trials of importance in which
insanity has played the chief part. The case of Weldon v.
Winslow must for the present wait till the judges have con¬
sidered the necessity of granting a new trial.
In the case of Torriano it was found that the testatrix was
of unsound mind, and the case merits a short and separate
notice, which we shall supply later.
In the case of Gilbert Scott several most serious points re¬
quire special consideration.
In the first place the trial was an extension of the power
of the Court of Chancery in a new direction. Hitherto the
Masters have been the sole judges in inquiries of this nature,
and they have done their work satisfactorily; but we believe
that they would at once own that it is better to have a judge
more used, from daily experience, to modes of procedure,
and to the receiving of evidence in the most difficult and the
strenuously opposed cases.
The case of Scott was the very first in which the question
of sanity was tried before a judge and a special jury, and we
are quite inclined to think that the result was eminently
satisfactory.
The majority of professional and lay papers united in
thinking that the history of the case justified the finding of
the jury, though it must be added that by a strange chance,
two leading journals had extraordinarily weak articles
throwing doubts on the unanimous verdict of the jury. The
weakness of these articles gave evidence of such ignorance of
the subject as allows us to ignore them.
That Mr. Scott should have retained his special abilities is
not astonishing to those who are intimate with insanity.
Many a dangerous lunatic is brilliant in general conversa¬
tion, and is trustworthy as a witness, common or expert.
Fortunately the judge fully understood this, and pointed out
that to manage one’s self and one’s affairs meant more than
being able to do one’s professional work; he pointed out the
necessity to society of a man’s being able to appreciate his
duties to his family and to his relations.
Digitized by L^OOQle
1884 .] Occasional Notes of the Quarter . 267
In the conduct of this trial, as usual, there was some con¬
flict of medical evidence.
In some cases there is necessarily honest difference of
opinion as to the necessity of shutting a man up in an asylum,
and, as the law stands, a physician often feels himself awk¬
wardly placed; for, though he may believe a certain man to
be insane, he may think him able to manage his affairs,
yet in giving his opinion he has, like the jury, to give a
double finding, “ of unsound mind, and unfit to manage him¬
self and his affairs.”
If the physician-witness has such difficulties, we think he
should let them be known, and should not give an opinion
which he believes to be untrue, even for the good of the
patient.
We do not suppose the time is near when the experts on
both sides will meet and arrange what they are to say; this
might be best for the so-called honour of the profession ; but
English common-sense and hard-headedness would oppose
this summary way of disposing of difficulty.
The history of the case was simple, and, when read con¬
nectedly, leaves no doubt on the unbiassed mind. A man of
great culture and refinement, a man who was looked upon
as a model of good breeding and tender feeling, one who was
very fond of home and domestic life, and who esteemed him¬
self fortunate in his home relationships, in a short time
became exactly the reverse.
There was no special shock, and the family history is not
sufficiently known to allow one to make reference to it.
Among the earlier causes of the disorder, or, as some will have
it, among the earlier symptoms, was alcoholic intemperance.
Those who knew him best say the drinking began after
the earlier symptoms, such as restlessness and irritability,
showed themselves.
For some time early in the summer of 1883 Mr. Scott gave
way to habits of intemperance.
He took considerable quantities of light wines, and at
times indulged in spirits; later he took anything which
came in his way, and became more restless than ever.
He developed ideas of persecution (partly due, it may be, to
alcoholism), he believed there were conspiracies against him,
and after appealing to the police and to the Home Secretary,
he was prepared to take the law into his own hands; he
roamed about at night, and was searching for conspirators,
and was possessed by the idea that he was drugged.
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Occasional Rotes of the Quarter. [July,
His menacing attitude, and his unrestrained conduct
generally, induced his friends to take further advice, and
he was sent into Bet hie m Hospital as a temporary measure,
so that time might be gained and opportunity given to decide
on the nature of his case and the probable future.
The general feeling of those who then saw him was that
the restless excitement, the sleeplessness, the desire for
drink and sexual excess, all pointed to general paralysis of
the insane. While in Bethlem he was extravagant in his
actions and in his talk, his dress was fantastic, and he
generally wore bunches of flowers or leaves in his button¬
hole. He did not understand his position, and said his com¬
panions in the ward were all sane. He was remarkably
affable, and talked in a very free way about sexual matters,
so as to disgust some of his companions.
At this time he was not only able to do the ordinary
mechanical part of his professional work, but he showed
power of originality in design quite equal to that of his
ordinary work.
He escaped ingeniously from Bethlem, and after returning
to his low haunts and evil companions for a time, he escaped
to France, where he was possessed by the idea that he was
pursued by detectives and was drugged. He returned to
England, and threatened to injure two people, including one
of his old friends, a barrister. He was examined by Dr.
Maudsley and Dr. Savage, and on their certificates he was
sent to a private asylum. The certificates testified to the
state of mind of Mr. Scott being one of restlessness with
suspicion. Both physicians believed that he was concealing
as much as possible his ideas, from' the excess of suspicion
which ruled his actions.
Once more Mr. Scott escaped to France, and after many
adventures returned to England, and for a time superintended
the building of one of his large churches. He behaved in
very strange ways, and consorted with strange companions.
He was ejected from places of public resort in consequence
of his behaviour, and he was considered by some to be
dangerous. He was said also to have retained his ideas
about the police conspiracy, and also about the drugging.
He met a Frenchwoman whom he had known in a brothel,
and went about with her. He introduced her to his wife,
and to other persons of social distinction, and saw nothing
wrong in so doing. - Even at this time he made at least one
Digitized by Google
1884.] Occasional Notes of the Quarter. 26J)
suspicious night journey, and returned with the excuse that
he had not had money to go where he wanted.
The above were the facts as stated by those pressing for
the inquisition; and the only difference that arose was
whether they could be explained away naturally, or whether
they had existed as symptoms of insanity, which had been
recovered from, or whether they were only the symptoms of
alcoholism.
Special private inquiries were held, at which represents
tives for each side were present, as well as a physician repre¬
senting the Court of Chancery, who acted as moderator of
the Court or guardian of the patient. These inquiries
seemed to have confirmed the opinion of the physicians on
both sides in their own faiths, and formed the ground for
severe cross-examination. It is noteworthy that, though
both parties were acting bond-fide , they differed strangely as
to the facts or statements in one or two particulars, and in
any future inquiry it would be well to have a shorthand
reporter to take notes of the investigation.
At the inquiry the witnesses were excluded, so that it was
not followed by those medically interested in person. The
medical witnesses on both sides were examined, and the
majority who had sufficient opportunities of seeing the
patient, and who had special knowledge of insanity, were
convinced that Mr. Scott was of unsound mind, and unfit to
manage his affairs.
On the other side, medical evidence was given from the
point of view that the mental excitement was merely the
temporary result of alcoholism.
Other evidence, such as that of men connected with Mr.
Scott only in business, was shown to be worthless. The
judge summed up excellently, concisely, and strongly,
pointing out that a man may be able to do professional work
and yet not able to be treated as sane.
It was shown how the patient had passed from a condition
of self-control to one of loss of control, and that disease was
the cause.
It is necessary once more to insist on, the importance of
recognising that drink may produce insanity, and that it is
not of much importance what the cause of insanity is, if it
can be shown that the patient is not responsible for his
actions in consequence of mental disorder.
All having experience of insanity and of alcoholism will
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270
Occasional Notes of the Quarter . [July,
be ready to admit that many of the symptoms of the insanity
were such as might fairly be attributed to alcohol. Sus¬
picion, ideas of conspiracies, and fear of poison and drug¬
ging are common in insanity due to drink, to morphia, and
to other active agents which affect directly the nervous
tissues.
Similar ideas may arise from other causes however. But
the point is this, that Mr. Scott was undoubtedly insane when
taken to Bethlem Hospital, although he had been drinking.
He was then suspicious and dangerous, and the witnesses
on his side failed to convince the jury that he had recovered
from his insanity at the time of the inquisition.
The attack of insanity was related to alcoholic excess, but
in what way P
We do not think it is possible in many cases to say, from
the symptoms, whether a person took to drink because he
was insane, or whether he became insane from drink.
Alcoholism will produce similar symptoms in both cases.
The history of the attack and the change in the habits of
the individual must decide which was the first symptom of
disorder.
This cause ctlebre ended by the jury finding an unanimous
verdict of insanity and inability, but, in the meantime, Mr.
Scott had crossed to the Continent, where he is now living.
Heis still superintending his works in England, and has
written to the leading daily journal a characteristic letter
defending his sanity. He says that in France he is sane,
as is certified by French doctors; in England he is insane,
at what point does the change take place P
We expect to hear that an appeal is to be made for a new
trial on the ground of some legal informality; we trust that
this will not succeed, as the terrible and ruinous cost of such
a proceeding seriously affects the patient’s future.
Dramatic Copyright .
A case of considerable importance with regard to the law
of dramatic copyright, has recently been decided by the
Court of Appeal. Everyone who is concerned in the
management of asylums has taken part in, or has
authorised performances which, whether dramatic or
musical, probably could not have taken place as a public
entertainment without infringing copyright; and in the
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belief that the subject is of peculiar interest to our readers,
we append extracts from the Daily News and Standard , the
one giving a short exposition of the law, and the other
showing what absurdities a contrary decision would have
involved.
“ Daily News,” May 18.
Yesterday the Court of Appeal, not without some hesitation, and
even division of opinion, decided that private theatricals are, if some
rather indefinite limits be observed, no infringement of dramatic
copyright in the piece performed. The case, which is one of great
public interest, arose in this way. A representation of Our Boys was
arranged to be given at Guy’s Hospital for the amusement of the
doctors and nurses in that institution. The play was acted three
times by an amateur dramatic club, of which the defendant in this
action was a member. Admission was free, and the Governors of the
hospital paid all the necessary expenses. Besides the special invita¬
tions, the actors received tickets to distribute among their friends,
and altogether more than a hundred and fifty spectators were present.
On one occasion there was also a reporter. Now, the copyright of
Our Boy8 belongs to Mr Duck, and he forthwith sued to recover
penalties under the Copyright Act of 1833, which was passed at the
instance of one of the most successful playwrights of modern times,
the late Lord Lytton. The statute says that (i Every author of a
play, opera, farce, or other piece, shall have, as his own property, the
sole liberty of representing, or causing to be represented, at any place
orplaces of dramatic entertainment any such production,” and it goes
on to provide for damages, or in the alternative for penalties of forty
shillings each. No question better suited for ingenious argument
could well be devised. What is a place of dramatic entertainment ?
Is it any place where, as a matter of fact, a dramatic piece has been
performed? If not, the words might just as well have been omitted
from the Act, and it is difficult to suggest a reason why Parliament
should have put them in. Is it, on the other hand, a theatre ? Must
it be a public place, or would it include such private theatres as were
erected by Charles Dickens long ago, and by Sir Percy Shelley quite
recently ? What does entertainment mean ? Lord Justice Bowen,
having recourse, as is natural enough in a case of philological diffi¬
culty, to the Authorised Version of the Bible, observed that it could
not mean mere amusement, because Abraham “ entertained 99 the
angels unawares, when all lie did was to give them food. It is
notorious that nothing bothers lawyers, especially judges, so much as
a definition. They will always avoid defining anything if they can.
When fairly driven into a corner they have been known to follow the
famous precedent of Bishop Blomfield when asked what an arch¬
deacon was. But to hold that a place of dramatic entertainment is a
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place wher e people are dramatically entertained is to make the Legis¬
lature in this instance talk nonsense. Lord Justice Bowen indicated
one way out of the difficulty by suggesting “ a place appropriated for
the time to dramatic performances! to which all, or a limited portion of
the public, are admitted.”
“Standard,” May 13.
A theatrical representation in a private drawing-room, before an
invited audience, is plainly not such a “ dramatic entertainment ” or
such a “ representation” as can do any injury to a copyright pro¬
prietor ; and the inference is natural that the Act does not include
such a case at all. The performance at Guy's Hospital differed only
in degree, and not in kind, from “private theatricals” of this descrip¬
tion. The audience were, it is true, invited by tickets, some of which
were issued in blank to those connected with the Institution. But the
recipients were, of course, bound to distribute these tickets among
their friends ; and this fact in itself no more constituted the affair a
public one than a ball can be said to be “ public” because some of the
invited guests have a general commission to bring “ dancing men ”
with them. The test whether money is or is not paid by the spec¬
tators is not, of course, the true one. If so, it would follow that a
London theatre might be opened gratuitously, for the express purpose
of ruining a neighbouring manager or a rival author. We gather
from the judgment of the majority of the Court of Appeal that the
true question is whether there has been a public performance of a
copyright piece. The question of publicity must be always one of
fact, and probably the performance at Guy’s Hospital went as near the
line without transgressing it as was possible. Nevertheless, we think
that the opinion of the public will entirely endorse the decision. An
amateur company which openly competes with professionals, and
invites the public to leave the performances of the latter for theirs,
stands on very different footing from that occupied by the defendant
in “ Duck v. Bates.” No reasonable man could think that the value
of the copyright in Our Boys, which had enjoyed so extraordinary a
run at the Vaudeville Theatre, could possibly be injured by its gratui¬
tous performance before an invited audience at Guy's Hospital. Had
the decision of the Court of Appeal been the other way, it is not too
much to say that organisers of the most ordinary drawing-room
theatricals would have had reason to be cautious how their pro¬
grammes were selected; while no real additional protection whatever
would have been afforded to dramatic authors or managers. No one
has any sympathy with piracy ; but amateur actors like those at Guy’s
Hospital were no more real pirates than the Pirates of Penzance.
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PART II.—REVIEWS.
Clinical Lectures on Mental Diseases. By T. S. Clotjstok,
M.D., F.K.C.P.E. London : J. and A. Churchill.
As in our short notice of the book last quarter we con¬
gratulated the author on his success, we feel it our duty to
point out more in detail the chief merits of the work, and
also some matters about which there may be ground for
difference of opinion.
Clinical lectures on insanity have long been wanted, and
even those by Dr. Clouston are not so complete as are
clinical lectures on other branches of medicine. The
physician to an asylum has, as a rule, too few students
and too many patients, so that he never has the exact know¬
ledge which the general physician has of the minute details
of his cases, and if he had, he would not have time to collect
and make the most of them.
We trust that at some of the hospitals for the insane,
races of students are arising who will be eyes and hands for
medical heads.
Dr. Clouston has encouraged his students and juniors to
assist him in his work, and much of the careful clinical ob¬
servation recorded in this book has been done by juniors.
The whole book is a clear reflex of the author’s mode of
thought and action, and recalls his personality in the wards
and by the bedside with great distinctness. He does not
propound any new philosophy, but, as might be fairly ex¬
pected, he is a great believer in localisation of function in the
brain. He is prepared to divide the brain into sensory, motor,
and other areas, including centres of organic life. He does
not agree with Ferrier in some of his localities, and looks
fondly to some of the inferior and parietal regions.
We cannot accept all his interpretations unquestioned or
unexplained. Thus he says that in excited melancholia the
motor centres are more excited than in other varieties. If
this be a paraphrase for saying there are active movements
in this variety, we accept it, but if it means that probably
the motor areas are primarily affected in this variety, we
want more evidence. We believe one French writer went so
far as to attribute repeated attempts at suicide to unre¬
strained motor excitement. This, like many other extensions
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of localisation of function, must be much more fully in¬
vestigated before it can be accepted. The present position
of the theory of localisation of function is a great advance
on the old one of phrenology, but will probably cease to make
any great advance for some time, till, in fact, careful and de¬
tailed examination of facts provides a new wave which will
carry progress further still. Every advance following the
discovery of some new law gets hampered, and for a time
arrested, by the too zealous use of it made by its friends, and
so it will be with localisation of function.
We must learn more about the simpler relations of sensa¬
tions and motions and their combinations before we can
attempt to localise complex functions.
Not only is Dr. Clouston ever ready to seize on the last
advance which science has made to assist in the understand¬
ing of symptoms, but he is ready to accept the most common-
sense modes of treatment, and nothing is so eminently satis¬
factory in these clinical lectures as the directions of man¬
aging and treating both friends and patients.
We shall refer to certain hobbies of our author later. He
is not only a believer in the localisation of function, but he
is on the watch for evidences of the evolution of types and
for the retrograde steps as seen in reversions. We are pre¬
pared to admit that among idiots there are examples of re¬
version, but among the actively insane we have failed to find
such examples, save in some cases of dementia.
Emotional disturbance can hardly be considered as a
reversion, and display of ferocity and so-called brutality in
the insane are quite unlike the ferocity of the animal in de¬
fence of life and freedom, in search for food, or following its
sexual desire. Dr. Clouston sees this. Thus, on page 99,
he says: “ Fear, the instinct of self-preservation, unreason,
suspicion, and the instinct of freedom, are all mixed up in
the case” of resistive melancholia.
We shall not be able to give a summary of the whole
book, for it is one of those so free from padding that it is in
reality a summary itself.
The book opens with a useful chapter on the clinical study
of mental diseases, and here, by the way, we would suggest
that the common use of the term u mental diseases ” is in¬
correct, though use has perhaps established it. We doubt the
correctness of speaking of disease of a function. Disorder of
function, but disease of an organ. We object to the state¬
ment at the foot of page 2 that “ It was soon apparent that
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the brain was the sole organ of mind,” more especially as
Dr. Clouston’s teaching is clear enough in pointing out the
mental relations of all parts of the body. There is a ten¬
dency to use new terms and to adopt older ones which is all
very well in delivered lectures, because they arrest the at¬
tention of an audience, but we doubt the advantage of their
use in a written lecture. “ Mentalisation ” and “ expiscate”
are not nice words, and Greek compounds are not to our taste.
The great tendency of the present day is to avoid purely
technical terms, even in pure science, and to add to our
nomenclature Psychalgia, Psychlampsia, Mono-psychosis,
Psychocoma, &c., is a burden not to our mind worth bear¬
ing. These terms may have served a useful purpose in the
author’s study of cases and arranging of facts, but we are
inclined to look upon them as scaffolding, neither orna¬
mental nor useful when the edifice is completed. Some minor
points are open to criticism. Thus, when considering appe¬
tite, Dr. Clouston firmly maintains “ The absolute dependence
of the appetite for food on brain and ganglionic integrity and
sound working” and “that there is no need for physiological
proof that appetite is a brain-function,” and further he speaks
of the ravenousness in diabetes as a brain-function. We
must demur to this, as appetite surely is one of the very
earliest essentials of life, existing primitively in chemical
affinity and developed by necessity of life before any nervous
elements exist.
As might be expected, all is clear and accurate in our
author’8 consideration of the relationships of insanity to
health and to other conditions of nervous disorder. Time is
not wasted in referring to the methods of classifications and
to nomenclature generally.
Dr. Clouston says that, at present, classification must be
unscientific and incomplete, but the present methods of
division are sufficiently practical.
A symptomatological division is used by Dr. Clouston,
though he refers also to Dr. Skae’s clinical classification, and
gives fourteen subdivisions, chiefly depending on general
or local causes for their names.
There is a very novel feature introduced at the end of
Chapter I., in two parallel columns, in one of which we see
the normal physiological brain-relations, and in the second
the bearing of these on insanity. Although we cannot accept
all the statements, they will prove helpful to the student,
even when put in too unqualified a form.
xxx. 19
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Directions for examining patients are given, and are use¬
ful in lectures, but of little use in print. None can learn to
examine patients from books ; the tactus eruditus comes only
from experience.
With characteristic cautions, advice is given as to getting
a letter of indemnification where there is danger of legal
trouble arising. Then one hundred pages follow on states
of mental depression, melancholia (psychalgia), and the
subject is well divided and fully considered. There is to our
mind no necessity for a definition of the disease we are con¬
sidering, but there is a tendency for the medical mind to
conform to the lawyer’s desire to have a definition. We
have no right to define what nature has left indefinite. Dr.
Clouston gives a definition of melancholia, and points out
the distinction between melancholy and melancholia. This is
necessary, but we do not want the definition.
His divisions of melancholia are: a, Simple; b , Hypochon¬
driacal ; c. Delusional; d, Excited (motor); e, Kesistive
(obstinate) ; f. Epileptiform ; g> Organic (coarse brain
disease) ; A, Suicidal and Homicidal.
The descriptions and the cases are as good and as graphi¬
cally told as it is possible.
We do not agree with all the divisions, and think that
many of the delusional melancholiacs ought to be placed
among the hypochondriacs; and it seems to us that many
more cases deserve to be placed under this last head than is
usually done. There are certainly insane persons whose
mental disorder is connected with exaggerated or perverted
sensations derived from their viscera. Such persons may have
general sensations, as that they are dying; or local, such as
that their brains, their intestines, or their reproductive organs
are wrong, and as such should be classed with hypochondriacs.
It is rather startling to come across such an expression of
opinion as the following about massage. “ For the cure of
some of the cases (of neurasthenia) a plan of treatment has
been adopted, the most irrational that was ever conceived by
the medical mind.” We trust Dr. Clouston will fairly try
massage on the first thorough-going cases of neurasthenia,
and though fresh air and exercise are excellent when they
can be enjoyed, there are some cases that we believe have
gone so far, that massage alone can save them and restore
them to fresh air.
The cases of visceral melancholia are interesting, but we
do not attribute any value to pigmentation or even ap-
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1884.]
parent deficiency of nerve-cells in the solar plexus; these
conditions may occur quite normally.
Special consideration of Section “ F ” leaves us in doubt
about the genuineness of this as a distinct group. Cases of
melancholia with epileptiform fits have been occasionally
met with, and have hitherto been looked upon as cases of
general paralysis with melancholic symptoms, or as cases of
senile brain-wasting with convulsive seizures.
Notwithstanding the cases described, we still believe there
is no distinct group of melancholic cases with fits. Dr.
Clouston himself says: “ If my views in regard to the
special pathological entity of general paralysis had not been
so definite, I should have been tempted, in looking at the
brain-lesions in some of these convulsive cases, to have
regarded the disease as an exceptional, localised, non¬
progressive, general paralysis.” And we believe he will
have to reconsider this position. The pathology of brain-
softening depending on vessel-spasm, or on primary degene¬
ration of neuroglia, apart from vessel-disease, is not satis¬
factory.
After the consideration of the groups of cases of melan¬
cholia, special symptoms are discussed: thus, suicidal and
homicidal tendencies and refusal of food. Full directions
are given as to feeding, and the nature of the food is
described.
All points are discussed with most praiseworthy care and
minuteness, and for melancholia in general our author has
one golden rule. In his own words : “ To them I preach the
gospel of fatness, the gospel of fresh air, of healthy secular
literature and active occupation, of iron and quinine and a
little bromide of potassium when needed.”
Mania is defined and divided into simple, acute, delusional,
chronic, ephemeral, and suicidal.
Simple mania is considered fully as a distinct though
slight perversion frequently affecting the moral side, and
many cases of 66 moral insanity ” are considered under this
head. Dr. Clouston does not seem to accept a form of mania
which has been called acute delirious mania, or typhomania.
He speaks of the third stage of mania as that of delirious
mania, and he says it does not often occur if the first two
stages are properly treated. Mania from delusions is very
shortly treated, and it seems hardly to have deserved special
recognition. Chronic mania is considered next, and we are
glad to see it placed here rather than among states of
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mental weakness. There are, doubtless, some cases of
talkative, destructive mania that are chronic, but instead
of looking upon them as cases of simple acute mania which
have become chronic, we believe they belong to a special
class, and are chronic from the first.
The conditions of homicidal mania are discussed, and a
graphic chart shows the ages at which mania, melancholia,
and general paralysis are most common. Most valuable are
the remarks on prophylaxis in mania, though we hardly
agree with our author in thinking beef-tea or meat a
poison for nervous children.
States of alternation, periodicity, and relapse are described
in Chapter V., the periodicity of all vital functions being fully
recognised. The pathology of these conditions is proved to be
that of chronic insanity generally. Delusions and delusional
insanity are next considered, the delusions of ignorance and
faulty education being referred to, as well as the delusions of
mental disorder. Monomania of grandeur is here examined
into and exemplified, but it must suffice to say that the con¬
sideration of this subject, as well as those of mental en-
feeblement and states of stupor, is clear and practical.
Chapter IX. on states of defective inhibition is one of
great value. Under this head the insane diathesis is de¬
scribed, as well as impulsive insanity and affective insanity.
Inhibition, like evolution and localisation, strongly appeals
to our author, and he is careful to explain his ideas of its
power. Dipsomania is here fully considered, and its many
relationships to neuroses shown in twelve groups. We do
not think the term “ neurine-stimulant craving ” either ele¬
gant or necessary. Good examples are given.
The section on kleptomania is short and to the point,
though we think reference might have been made to the two
varieties of this symptom—the one the mere collecting, as
seen in the general paralytic; the other the result of moral
insanity. Dr. Clouston accepts the facts of moral insanity
as simply indisputable. “It is not a question” he says u of
theory, but of fact,” (p. 348). We will not now discuss the
question as to whether the sense of right and wrong is, to a
large extent, an innate brain-quality.
No author on insanity fails to recognise the importance of
general paralysis of the insane, and most devote a large
amount of space for its discussion. We think that Dr.
Clouston has hardly done himself justice in giving only
twenty-five pages to this all-important subject. What he
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says is to the point, though we do not like his definition.
Varieties as seen among these cases are not fully considered,
though certain cases are described in which a special sense
has failed first and the general paralysis has followed. These
examples are rare, and in our opinion the mental, bodily,
and special sense-changes go on simultaneously, although
one may outstrip the other. Too low an estimate (3 or 4
per cent.) is given for melancholic general paralytics, and we
do not agree in thinking the hypochondriacal symptoms can
be explained frequently by visceral disease.
Many points, such as the relationship of nervous inheri¬
tance to general paralysis, are not discussed.
To Dr. Clouston there is one essential pathology for this
disease. He thinks general paralysis is premature death of
“ the most important factor in mentalisation—in fact, the
mind-tissue.” He will not allow that anything akin to in¬
flammation can be at the base of the disease.
The rest of the book takes into consideration the insani¬
ties associated with various physical states and bodily dis¬
orders, with poisoning by alcohol and the like, and also the
mental disorders associated with the various periods of life.
The chapters on alcholic insanity and phthisical insanity
are specially good.
The book is concluded by a chapter on the duties of
medical men in relation to mental diseases. In this sound,
useful, practical advice is given.
In closing this review, we feel that, long as this notice is,
we have only skimmed over the surface of much that is
deeply interesting and important.
The book is handily got up, and the plates are excellent.
The student must not be surprised if he makes or sees a
great many post-mortems of the insane before he meets
with so well marked a pathological specimen as that which
is represented in the first plate.
This is the best book, from a clinical point of view, at
present published in Great Britain,
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Body and Will. By Henry Maudsley, M.D. Kegan Paul,
Trench, and Co. 1883.
Prolegomena and Ethics. By the late J. H. Green.
Clarendon Press. 1883.
Anyone who wishes to realize in its clearest form the wide
divergence of the materialist and idealist currents of English
thought about mental problems cannot do better than read
together the two remarkable books which we have bracketed
for review. Their writers are typical of the schools they
represent, and have arrived, each for himself, at perhaps the
clearest and most logical theory to be deduced from their re¬
spective lines of argument. Yet their conclusions are, as
nearly as may be, diametrically opposed; or, at least, they
are on the face of them contradictory, and no clue as yet
appears by which the contradiction may be solved or ex¬
plained away.
Dr. Maudsley lands us, by a process which to him, and,
doubtless, to most of his readers, seems obvious and in¬
evitable, at the conclusion that mind and all its pro¬
ducts are a function of matter, an outcome of interacting
and combined atomic forces not essentially different in kind
from the effervescence that follows a chemical combination
or the explosion of a fulminate. It is a new form of force,
more complex and wonderful than others; but yet the mathe¬
matical result of them, inevitably fated from the begin¬
ning—if there ever was a beginning—and fated to exist in
this way and in no other; for the universe is bound in an iron
net, and the picturesque phantasy of chance or choice is only
the delusion of the fool.
Professor Green, summing up, before his unexpected and
untimely death, the philosophical results of many years
of hard and conscientious wrestling with the problems of
German „ and English thought, announces to us, on the
contraiy, that nature and matter have no reality but as
a function of that spiritual principle, which alone truly is,
and which is manifest to our consciousness in the double
aspects of thought and will. He does not in truth call
it God, though perhaps the ordinary reader would follow
his argument better if he did so. In any case, it is
that which is neither matter nor the result of matter—
which was not caused, but is free—which is in its essence
un-subject to time or space, for it transcends and creates
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them. In the universe, as we in our partial experience can
come to know it, it is revealed to us as law—as reason
manifest in order and harmonious interdependence of re¬
lations ; for things are to the thinker only meeting-points of
relation. In our own lives it is made manifest, not ade¬
quately nor all at once, but by a gradual development in
which the rational, spiritual possibilities of our nature are
at first latent or vague, though necessarily implied in all our
conscious human life, and become by degrees, in the very
work of knowing and experiencing, more fully realized ana
conscious of themselves. In the moral aspect of nature
this spiritual principle is seen in the form of an imperative
law, and therefore implies a freedom that is not possible to
phenomena in the order of physical or natural causation. The
existence of the absolute imperative of duty thus guarantees
to us of itself that we are not atonic resultants, and that,
whatever may befall us, we can never say that circumstances
and not ourselves have made us what we are. If we are, in
some as yet unexplained way, so limited in our spiritual
growth and movement by the phenomena of organic and
natural forces that they seem to govern our life, we are none
the less endued with the power to make them the servants
of our real selves, and by them to work out a destiny that is
in the best sense free. Nor is there any divorce between
this moral side of our being and that aspect of it which is
commonly described as thought, or reason, or mind. For will
is no extra quality or entity in human life, but is only reason
going out in act, as thought or knowledge is reason taking
in the data of nature, by which alone it is allowed to accom¬
plish its own growth. What Mind, Reason, Spirit, Will
might be if we could transcend the framework of space and
time and think of it without the complications of brain and
nerves, youth and age, sleep and disease, life and death—
what God, in a word, may be—Professor Green does not
profess to tell us. Indeed, his speculation is strangely
modest, and he is almost too anxious to answer outside diffi¬
culties from the scientific and materialist standpoint, when
it would have made his meaning easier if he had gone his
own way boldly. But he tells us enough to allow any pains¬
taking student fully to appreciate that point of view which,
uncommon as it seems superficially to have become, is yet
held powerfully, even in England. Dr. Maudsley is con¬
temptuous about “ metaphysics,” and the barren heights
of speculation. In a busy age like ours, with scientific work
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of practical utility pressing on every hand for investigation
and experiment, and with any number of interesting results,
capable of being verified by weight and measure and exhibited
by the electric light to admiring audiences, it is perhaps not
wonderful that mere hard thinking, which is dry and difficult,
and will never be understanded of the vulgar, should be at
a discount. But for those who study Mental Science with
an honest desire to solve problems the most momentous in
the range of human effort, and especially for those whose
practical work is along the borderland where mental and
physical facts are inextricably tangled together, it may not
be useless to remember, once in a way, that there are two
views on the subject of the relation of Body and Mind, and
that the idealists (to give them a misleading name) are not
necessarily either ignorant or mad.
The special reason for bracketing Prof. Green with Dr.
Maudsley is that be, at least, does mot ignore the difficulties
raised for the metaphysician by evolutionary biology. It
may be worth while, perhaps, for clearness sake, to state at
once his view of the relation between the spiritual and the
material side of human life. After explaining at length
his fundamental view that human experience, or knowledge,
or self-consciousness, cannot be a part of the process of
nature, since it is itself conscious of that process, and that
the simplest chain of perceptions is not a series of phenomena,
but implies necessarily “ the existence of an eternal con¬
sciousness in man” as the basis of any and every mental
act, he goes on to inquire how the presence of this eternal
principle can be reconciled with the fact that our conscious¬
ness varies and grows in the lives of each of us, in apparent
obedience to physical conditions of organism ? “ It seems/’
he says at p. 72, “ to have a history in Time. It seems to
vary from moment to moment. It apprehends processes of
becoming in a manner which implies that past stages of the
becoming are present to it as known facts; yet is it not
itself coming to be what it has not been ? It will be found,
we believe, that this apparent state of the case can only be
explained by supposing that in the growth of our experience,
in the process of our education to know the world, an
animal organism, which has its history in time, gradually
becomes the vehicle of an eternally complete conscious¬
ness. What we call our mental history is not a history
of this consciousness, which in itself can have no history,
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but a history of the process by which the animal organism
becomes its vehicle. * Our consciousness ’ may mean
either of two things : either a function of the animal
organism, which is being made, gradually and with inter¬
ruptions, a vehicle of the eternal consciousness, or that
eternal consciousness itself, as making the animal organism
its vehicle and subject to certain limitations in so doing, but
retaining its essential characteristic as independent of Time,
as the determinant of becoming which has not and does not
itself become.”
Dr. Maudsley will complain of this as being “ words—mere
words,” and he may also complain that the words are not
very easily understood; but if he and his school will give them
their attention, they will, at least, not be able to say that
that they do not state a tangible theory. Dr. Maudsley’s
own suggestion is in another direction. “The gulf between
the conception of the movements of cerebral molecules and
the self-consciousness of will-energy may well be due,” he
thinks at p. 101, “ to the different ways of acquiring them.
Molecular Action and Will may be one and the same event
seen under different aspects, and to be known as such one
day from a higher plane of knowledge. For if the object and
the brain are alike pervaded by such a hyper-subtile ether;
and if the impression which the particular object makes
upon mind be then a sort of pattern of the mentiferous un¬
dulations as conditioned within it by its particular form and
properties; and if the mind in turn be the mentiferous un¬
dulations as conditioned by the convoluted form and the
exceedingly complicated and delicate structure of the brain,
then it is plain we have eluded the impassable difficulty of
conceiving the action of mind upon matter—the material
upon the immaterial—which results from the notion of
their entirely different natures.” Is this theory any clearer
than the other ?
In fact, this theory does not really touch the point which
the disciples of Prof. Green would put to Dr. Maudsley at
all. If you could get outside your own mind and conscious¬
ness and percipient thought—if you could once effect the
salto mortale from my notion of things, phenomena, facts—
call them what you will—to objects or facts outside and inde¬
pendent of all consciousness or perception, then the mate¬
rialist might get under way, and with ingenious theories of
this kind might explain much. But how is he to leap off
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[July,
his own shadow ? What is a fact ? How can he ever dis¬
sociate an object, however apparently independent of his
personal control, from the one necessary condition that it
mnst, as far as he knows or ever can know it, have been cast
in the mounds of human thought and knowledge ? Every¬
thing he ever heard or saw, or knew by reading, or imagined
by recombining the elements of his remembered perceptions,
is a “ fiction of his mind,” in some sense, if not in Home’s.
He may picture to himself a glacial landscape with its
appropriate fauna, and no man visible. Yet neither ice, nor
animals, nor earth, nor air, nor time, nor space, are or could
be anything if consciousness or mind could be supposed
annihilated out of the universe of being. The very talk of
a universe, of being—of nothing , if you will—implies and
involves a conscious mind to which these notions are related.
It is not necessarily my mind or yours —it may not be neces¬
sarily any individual or limited intelligence such as we
know among ourselves—but Mind, as such, somewhere
and somehow, is a condition precedent of the existence of
anything. Let a man try to think the universe back to the
nakedest of beginnings—to a diffused nebula of atoms
equal and indifferent in everything except their distances
from one another, and already he will find, if he thinks it
out, that a hundred categories are involved in its picture
which are mind, and are as unthinkable, apart from mind, as
a poem or a syllogism.
To return, however, from this rather fundamental criticism.
It is, of course, to be recognised by all that for all the practical
problems of Mental Science as it is applied in pathology, in
education, in civilization, in a thousand forms, it is bound to
take strict account at every step of the physical concomi¬
tants of consciousness ; and is, indeed, more concerned with
these than with the idealist side of things, however true that
in itself may be. In this aspect, nothing could be better than
the third part of Dr. Maudsley’s book on “ Will in its Patho¬
logical .Relations,” although, even there, he is terribly pole¬
mical. But we must reserve what we have to say of it, and
of the singular Hymn of Pessimism with which it closes,
for another number.
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Review 8.
285
Behandlung der Psychosen mit Elektricitat. Von Dr. Tigges,
in Sachsenberg (Zeitschrift fiir Psychiatrie, xxxiv.,
Band, 6 Heft).
(Concluded from Oct., 1883.^
In a recent number (Oct., 1883) we reviewed part of Dr.
Tigges’s article, and we now proceed to notice briefly the re¬
maining portion.
Dr. Tigges describes one patient afflicted with chronic
mania with delusions who had sounds in the ears. The elec¬
trode applied in front of the auditory meatus caused the sounds
to become less audible, sometimes to cease entirely. When
the anode was applied to the forehead, and the kathode to
the neck beneath the occiput, the sounds were lessened; by
filling the ear with water, and placing the opposite poles
alternately in the ear, they were made to disappear. Another
patient had melancholia with delusions. She had a variety
of sounds in the ear, with voices telling her, amongst other
things, that she could not die. The application of galvanism
caused a complete cessation of these abnormal sounds, but
the voices came back sometimes in from half-an-hour to
seven hours after the application. After the voices re¬
turned, the knocking was again heard in the ear, whilst the
murmurs, ringing, and other sounds were later in recurring.
In a case of insanity there were subjective noises which had
endured for three years. Under the constant current they
almost disappeared, whilst the murmurs in the ear were
still heard.
Dr. Tigges found that in the greater number of cases
treated the sounds in the ear either totally disappeared or
became much fainter. Less frequently the only change
observed was an alteration in the quality of the sounds,
or they passed to the other ear. Sometimes they promptly
returned after the sitting, sometimes they came back the
following day; but, by continuing the treatment, the mur¬
murs in the ears either disappeared or became much less.
Occasionally the hallucinations of hearing disappeared along
with the sounds in the ear; but the one might come back
without the other, or the sounds would disappear, leaving
the voices. In one case, with vocal hallucinations there
were no subjective sounds, and the voices disappeared at the
first application. In many cases, which he does not detail,
Tigges tells us that he found the effect of electricity upon
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the sounds in the ear to be little marked, and the hallucina¬
tions of hearing not to be affected at all. When there were
organic lesions of the ear accompanied by voices little im¬
provement was effected. In these cases he was able to make
out “ Brenner’s sound-reaction,” which he had failed to do
with patients who had noises in the ears without any
organic lesion. Brenner found, as explained in a former
Retrospect, that a sensation of hearing was excited when
the chain was closed if the kathode was placed in the ear,
or near the ear; but when the anode was applied the sensa¬
tion of hearing was only produced by the opening of the
chain.
Dr. Tigges treated some cases of melancholia with apathy,
passing into melancholia with stupor, by passing the con¬
stant current through the brain; more rarely the inter¬
rupted current was used. He was not able to make out
clearly on what spots it was best to apply the electrodes.
Sometimes one method of placing them was found to do
well, and then its efficacy seemed to pass away for another
location. Currents were passed through the head, or the
sympathetica of the neck were acted upon, or the electrodes
were placed on the neck and over the dorsal vertebrae. He
found that by such treatment the motor rigidity was re¬
laxed, and the sensibility to pain appeared to be increased;
the patient became more lively and less averse to talk.
Sometimes this favourable influence soon passed away,
sometimes it was more enduring. In one case the in¬
creased liveliness lasted for two months. With another
patient marked improvement began after twelve days’
treatment, and in eighty days all the uneasy sensations
disappeared. This was a lad of eighteen, suffering from
headache, sounds in the ears, nightly hallucinations, melan¬
choly, and loss of memory. He had been in the asylum for
six months without any improvement until the electric treat¬
ment was begun. This is the only cure recorded. In another
case there was great improvement. In six more there was
amelioration of the symptoms without any decided effect on
the general character of the disease. Two patients died
while under treatment. Dr. Tigges does not describe or
tabulate all his cases, but selects such instances as he deems
will illustrate his remarks. He is inclined to believe that
some of the results observed to follow the treatment, such as
the cessation of pains in various parts of the body, are of a
reflex character; but where this improvement has followed
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287
application of the electrode to the parts around the ear, he
thinks that it must be due to the current passing through
the sensory or motor centres of the hemispheres.
Lectures on the Localisation of Cerebral and Spinal Diseases .
By Professor Charcot. Translated and Edited by
Walter B. Hadden, M.D.Lond. The New Sydenham
Society. 1883.
This work is marked by .the usual characteristics of M.
Charcot’s observations—original research, remarkable in¬
sight, and those powers of generalisation and of expression
which are essential to a successful teacher. As he truly
says of himself, he is no believer in the efficacy of generalities
deprived of their material substratum. On no subject is the
Professor more at home than on the localisation of cerebral
diseases, and every clinical student of pathology must be
glad to have such a guide in the fascinating study of the
regional diagnosis of affections of the brain. M. Charcot’s
nomenclature is always precise and well defined—an essential
requisite in this field of research, but one not sufficiently re¬
cognised, or at least acted upon, by many physicians. We
could have wished that the same desire to be lucid had in¬
duced him to adopt the practice of labeling the regions them¬
selves, in the plates, instead of following the customary but
troublesome course of reference letters. This really involves
the reader’s translation of a language of signs instead of
seeing the names of the various regions at a glance.
The early lectures give a rapid but clear sketch of the
topography and microscopical appearances of the healthy
brain. Then follows a description of lesions in the encephalon
and cord. Lectures V.—IX. are devoted to the arterial circu¬
lation of the cerebrum, and the central grey nuclei and their
lesions. Cerebral hemi-ansesthesia, crossed amblyopia, and
lateral hemiopia form the subjects of the tenth lecture, and
secondary degenerations of the eleventh. This completes
Part First of the book. The Second Part is devoted to
Spinal Localisations, and contains a vast amount of in¬
formation in a small compass. We do not attempt to give a
detailed notice of M. Charcot’s views and descriptions. Our
object in this short notice will be secured if we induce our
readers to possess themselves of the work itself. It is well
translated by Dr. Hadden, whose notes and introductory re-
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Reviews.
[Jtdy,
marks are decidedly useful. We congratulate the Sydenham
Society on having added so valuable a book to their series,
and on having secured so competent and sympathetic a trans¬
lator-one so thoroughly en rapport with the author, and an
courant with the matter of which the book treats. M. Char¬
cot’s treatises have long been favourites with English physi¬
cians, and the one under review will not, we venture to say,
be the least appreciated.
The Pedigree of Disease . By Jonathan Hutchinson, F.R.S.
London: J. and A. Churchill. 1884. (First notice.)
We have here, we are told in the prefatory note, a reprint
of the author’s lectures delivered in 1881 at the Royal College
of Surgeons. The purpose of the book must be read in the
hope expressed by the author, “ that these lectures may be
found to point in the right direction.” More than this is
not possible within the compass of some hundred and odd
pages, when the subjects dealt with have, as here, such wide
bearings. What are these subjects, and what is the direction
indicated to us ? To many we fear the path may seem a
backward one, which again brings us in view of those ques¬
tions vexed—some of us had hoped, buried—which so long
busied the minds of our predecessors. The words tempera¬
ment, diathesis, idiosyncrasy, bring back a medicine of the
past, recall ages dark with humours and vapours which
clogged the senses, and which the light of modem science
should have dispersed, but which, perhaps, she did but cast
into the shade; for it may be that a clearer vision will enable
us to penetrate these shades, and there discern the outlines
of disconsolates, yet claiming at our hands either decent
burial or restoration to the light of day.
Let us look, then, in the direction indicated, and, leaving
metaphor, approach our task in plain, nineteenth century
fashion. And first, this temperament— what is it?
The author’s definition is: “ The sum of the physical
peculiarities of an individual, exclusive of all definite
tendencies to disease.” Stress is laid on the excluding
clause as an essential in this definition, it being insisted
that temperament thus defined has nothing whatever to do
with disease—it is physiological, not pathological . It would
be impossible, perhaps, to improve on Dr. Lay cock’s defiui-
tion of temperament; Mr. Hutchinson thus quotes it: The
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1884.]
temperaments are “ fundamental modes of vital activity
peculiar to individuals/ 5 Note, however, that, whilst con¬
sistent with health, the temperament impresses its own
features on disease. If we might be allowed the simile, we
would enforce this by comparing temperament to the allo-
tropic state of the chemist. Thus, e. g., phosphorus in its
uncombined state is known to us .both as clear phosphorus
and as red phosphorus. In either state it is phosphorus, no
more, no less. But how different the fundamental modes of
activity of these two forms; and, granting that they should
be placed under conditions which, arbitrarily, we defined as
abnormal, how different the reaction in the two cases; in
other words, how different the manifestation of the disease.
Concerning these two forms of phosphorus, be it said, in
passing, that red phosphorus .would take rank among the
temperaments as lymphatic phosphorus.
With the word diathesis we at once enter the domain of
pathology. The organism now shows, however it has ac¬
quired it, a proclivity to disease; each diathesis corresponding
to a special type of disease. The author points out that this
proclivity persists through long periods, usually throughout
the life of the individual; further, that it may be inherited,
or it may be acquired. The order of statement and the mode
might, we think, in respect of the last, be with advantage
altered to : it may be acquired, it will be inherited; for what
is the relation of the offspring to the parents but bone of
their bone, flesh of their flesh, type of their type ?
Temperament and diathesis thus defined, Mr. Hutchinson
proceeds to discuss the criteria of temperament. This is one
of the most important parts of the book, though the results
obtained are not very encouraging, being of a negative rather
than of a positive character. We are told that “so long as
health exists 55 the data as to temperament are exceedingly
untrustworthy; and yet it is in health that temperament must
be studied, else an already very complex problem is yet
further complicated by the admission of new factors. Did
the older observers escape this danger P The author thinks
not; and he points to the very names of the temperaments as
they have been transmitted to us as indicating the presence
of the morbid element. Thus, selecting from Dr. Laycock 5 s
classification of the temperaments “ the last and certainly by
far the best attempt at classification, 55 we are presented with
the bilious and melancholic temperaments, both of which Mr.
Hutchinson thinks are but different degrees of the same
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thing, and very apt to pass the one into the other, as life
advances; and, yet more to the point, that the distinguish¬
ing feature in either “ is one which concerns disease rather
than temperament,” and “ that it might be more conveniently
known as the hepatic diathesis/ 9
Returning to the question of the untrustworthiness of the
data as to the temperament, and avoiding all confusion with
diathesis, the author states it as his belief that we have “ but
little to guide us in a classification excepting the conditions
which go to make up what we mean by complexion.” By
complexion, it is true, we mean something more than mere
degree of pigmentation; thus “ the state of the skin as regards
thickness, thinness, or transparency, and the various degrees
of freedom of distribution of blood in the capillaries of the
face,” all these are included in the word complexion; and
yet, for all this, it is probably true that pigmentation is that
on which we rely almost solely in our classification. Mr.
Hutchinson brings this home to us by putting the question—
Could you make the distinction of the temperaments among
a highly pigmented race, as, for example, among the negroes ?
Very possibly this question might have to be answered in the
negative; but we would caution against hasty opinion here,
for every day we are strengthened in the conviction that we
see what we look for. This cannot be better illustrated than
by family likeness. This is always far better appreciated by
the outside world than by the family circle. And why ? The
outside world seeks to group together, to classify, and it finds
likeness; but in the family circle the question is how to dis¬
sociate or individualize, and accordingly unlikeness is found.
With this warning, let us well consider the question put to
us by Mr. Hutchinson, and also admit the cogency of the
argument which dwells at some length on the subject of
climate and pigmentation, and on what may be termed the
accidental nature of this latter.
As the argument stands, then, in relation to classification
by temperament, certain of the older terms employed would
involve the fallacy of pointing to diathesis rather than to
temperament, whilst certain others would appear to rest on
a basis accidental rather than essential. How, then, are we
to discover the several “ fundamental modes of vital ac¬
tivity? ” for Mr. Hutchinson nothing doubts their existence,
though he thus disparages existing criteria. Will race serve
us? Will a British ethnology—on the need for which we
are told Dr. Laycock insisted—will such yield a means of
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1884.]
classifying? The author is cautious on this subject, and,
though of opinion that race would prove a more reliable
guide than any yet available, still is not sanguine of the
practical results to be thus gained. This must become at
once apparent when we consider the accomplished fact of the
intermixture of the races. But we would suggest on this
question of race and of family, both of which signify for us
heredity , whether we are not losing sight of the real object
we have in view, which is to discover the outward and visible
signs of an inward and hidden activity. It surely is but
jumping the difficulty, or admitting incompetence, to tell us
that certain modes of vital activity have a father and mother
(family) or a long train of ancestors with a vanishing point
in obscurity (race). Both of these facts we shall learn, if we
do but push our enquiries sufficiently diligently, and in this
our search we need never even pause to gaze at the indivi¬
dual before us. But if we be reminded that likeness runs in
family and in race, we would answer—Yes, but do we make
use of it? Suppose, for instance, two patients present them¬
selves, the one with decided Jewish cast of countenance, the
other moulded on no such type, and that enquiry elicits a
Jewish lineage for this latter, but none such for the former.
What then ? According to which of the data before you,
will you classify ? As we read Mr. Hutchinson we should
here rely on the history, and most probably we should be
right in so doing, but let us recognize clearly that in so
doing we proclaim the worthlessness of external conforma¬
tion as revealing temperament. It is in view of this,
and of the inextricable complexity of the subject, that Mr.
Hutchinson, in conclusion, suggests the actual abolition of
the word temperament. Is this advisable? Let us in the
first place remember that the word has obtained a deep hold
amongst us, and that it stands to us for something —let us
admit that this something is vague in the extreme, and that
the paths by which we would approach to a clearer recogni¬
tion are truly labyrinthine. But if we are to discard the
vague, what will remain to us in medicine? and if for fear of
deviating we are to halt, how many will be the quests that
we shall undertake ? Much of harm results from the view not
unprevalent amongst us, that the vague and the false are
synonymous, whereas they bear no relation one to the
other. The vague signifies the indefinite, and the indefinite
results, not from error on the side of the thing defined, but
from defect on the part of the definer. As it would seem to
xxx. 20
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us, our duty would be to let stand the “ temperament,” but
to discard the “ temperaments ” as they have been handed
down to us—to carefully avoid confusing diathesis with tem¬
perament and to beware of basing any distinctions on mere
accidental features—such as, perhaps, degree of pigmentation
may prove to be. Finally, to make use of “ race ” if possible,
fully recognizing the while that this is but the crutch we
look forward to throwing away in the future of a more de¬
finite biology.
With regard to diathesis, we tread surer ground, and, to
quote the author, “We can study the result of causes in
detail and with much precision,” and “ we can express our
knowledge in clear terms.” ... u It is in this direction that
the work of the future will be done,” thinks Mr. Hutchin¬
son. No doubt, more immediately; this accomplished, we
shall hope for the further step in the direction of tempera¬
ment.
We have not thought fit to apologise for the introduction
into a Journal of Mental Science of the above considera¬
tions ; lest, however, any should be inclined to question the
propriety of this, we would, in defence, only point to the de¬
finition of temperament here accepted, viz., “ a fundamental
mode of vital activity.” That the activity of our nervous
system, as a whole, is here included, none can doubt ; can
anyone doubt that, included equally, is the working of certain
more highly differentiated parts of this system ?
H. S.
Science du Cceur Humain on la Psychologic des Passions
d'apres les CEuvres de Moliere . Par Dr. Prosper
Despine. Paris: F. Savy. 1884.
The idea of a psychological study of a great writer is, as
far as we know, novel, and is certainly not without scientific
interest. In the book before us Dr. Despine has carefully
gone through the works of Moliere with the view of bring¬
ing out what he calls the Philosophy of the Passions con¬
tained in his dramatic works. Of the two forms of mental
science—that which concerns itself with the intellect and
that which treats more specially of those instinctive mani¬
festations which are found in the history of human senti¬
ment or passion—there are plausible reasons for maintaining,
as Dr. Despine does, that the second is not the less impor-
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tant. From that point of view mental science has, perhaps,
been remiss in devoting so little attention to the scientific
and inductive study of the emotional side of human life,
and it certainly has much to gain from a careful and compe¬
tent study of the great dramatists of the world. Both
tragedy and comedy, though in different senses, contain in
them what may not inaptly be styled a kind of mental
pathology. Both are concerned with aberrations from the
normal development of human life. In Comedy, the foibles
and follies of humanity are held up for the amusement of
the audience, and the interest of the play depends on the
fact that the actions represented, without being in truth
improbable, are yet so far out of the normal course as to be
incongruous and absurd. In Tragedy, on the other hand,
the interest of the action depends upon an intense excite¬
ment arising out of the play of passions developed to a
morbid intensity. The laughter on the one hand, and the
awe on the other, are equally indications that we are being
presented with a development of life which is passing
beyond the beaten tracks of common-sense and sanity, and
adventuring into the region that may be called the debat¬
able land between madness and mental equilibrium.
For these reasons it is not out of place in this Journal to
welcome the work of Dr. Despine as a contribution to the
pathology of mind. Moliere’s characters are not madmen,
but they are not precisely sane. The author has bestowed
admirable care and judgment upon his work, and the book is
one which will be read with great interest both by the literary
lovers of Moli^re himself and by those who seek sugges¬
tions of a scientific kind. If there ia anything.we would be
inclined to regret, it is that the author insists too much
upon the moralizing remarks which abound in Moli^re as in
every writer of his time, and attaches sometimes too much
importance to what was probably little more than an orna¬
mental flourish of rhetorical sentiment. We cannot help
wishing, however, that some student at once of literature
and of psychology would do for Shakespeare the same
service that Dr. Despine has done for the greatest of the
French dramatists. Without depreciating Moli&re, it may
be fairly maintained that there is much more true humanity
in both the comic and the tragic portions of the Shakes-
perian plays. A serious study of the philosophy of human
action and passion, as it is shown in the characters of Lear,
Hamlet, Othello, Antony, Lady Macbeth, Prospero, Falstaff,
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[July,
(supplementing Dr. Bucknill’s work), could not fail to be of
use. Probably no one could deal with the task so well as one
whose practice and study had been concerned with mental
pathology. If such a writer wished to do a real service to
science and literature alike, he could not do better than
imitate the diligence with which Dr. Despine has collated
every scene and line in which the characters and idiosyn¬
crasies of the leading actors are brought out. The labour
will not be wasted, for it is the secret of a world-writer that
it may be said of him, as Dr. Despine says of Moli^re, that
“ since he depicts the passions general to humanity, his
writings will be for all time.”
Hcmdbuch der Gerichtlichen Medicin , &c. Yon Dr. Hermann
Kornfeld. Stuttgart: Ferdinand Enke. 1884.
This book unfortunately does not adapt itself for review
in a journal of psychology; with the best intentions it is
not possible to find material for criticism. It is the usual
handbook of forensic medicine, in which the several modes of
death and their respective signs find consideration.
Pregnancy and its allied subjects receive their due, and in
a short chapter the subject of life-assurance is dealt with.
In the hope that something available might be forthcoming,
we turned to the chapter on simulated diseases, but in a
page or a page and a half epilepsy, catalepsy, somnambulism,
and contractures are despatched. Again, in the chapter on
toxicology, which is a long one, we had hoped to find the
nervous sypmtoms which attend the administration of certain
drugs somewhat more fully considered. Of course these are
matters of great interest to the psychologist, but they are
not dwelt upon sufficiently to admit of separate considera¬
tion here. The chapter on unsoundness of mind extends
over only forty pages, whilst the book records its six hun¬
dredth page. It will be seen from this that Dr. Kornfeld has
by no means developed this section specially. This chapter
is very largely made up of legal considerations, which are
simply recorded as matters of fact, not being discussed in
their bearings or fundamental principles. This, no doubt,
will serve the purpose of the student who is asked for a fact
and not for a reason, and it must not be supposed that we
are finding fault with the book for not discussing these pro¬
blems ; we are but explaining our inability to criticize. The
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1884.]
book would seem to be well adapted to meet the require¬
ments of the student; it is illustrated by some fifty wood
cuts, which for the most part appear well executed. We
must, however, make an exception in respect of the cut re¬
presenting the teeth of inherited syphilis as described by
Mr. Hutchinson. In conclusion, we must express our regret
that the nature of the subject-matter has precluded more
detailed examination of a work written by a Corresponding
Member of our Association, sent to us for review.
H. S.
PART III-PSYCHOLOGICAL RETROSPECT.
1. English Retrospect .
Asylum Reports.
(Continued from p. 129 J
Ipswich .—Out of 67 admissions, no fewer than four were found by
Dr. Chevallier to be not insane. One of these was a re-admission,
and was discharged the next day ; but in the others their condition
“ was such as to justify the belief, on the part of those instrumental
in depriving them of their liberty, that they were of unsound mind.”
When the Commissioners paid their official visit there were 118
males and 152 females resident; 98 of the former and 100 of the
latter were confined to the airing-courts. Only 52 men go weekly
beyond the grounds, and 35 women take exercise in them. The Com¬
missioners appear to be justified in considering this amount of exercise,
especially for the women, quite inadequate.
Kent , Barming Heath .—It is very creditable to the management
that in every case of death an examination of the body was made.
How Dr. Davies succeeds so well must be a mystery to many asylum-
superintendents, who, charm they never so wisely, receive the necessary
permission in from 50 to 75 per cent, of the deaths only.
The admissions were very numerous, and included many incurable
cases from workhouses. In connection with this subject, Dr. Davies
says :—“ I am convinced that, apart from overcrowding, these patients
exercise an injurious influence upon those whose disorders are of an
acute and consequently more curable nature. I think, therefore, that,
in the long run, it would be cheaper for the Guardians to provide
suitable accommodation for them in the workhouses, and forego the
present advantage of the grant in aid, when in an asylum. It is, how¬
ever, almost impossible to get this view adopted in the right quarters,
so that the only hope left is that the Government will, at no distant
date, reconsider this grant, and dispose of it in a less objectionable
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296 Psychological Retrospect . [July,
way. If a change of some sort is not made soon, the question of pro-
viding increased asylum-accommodation will once more force itself
upon your notice, as, despite every care upon my part, we are unduly
full.”
Two male attendants were seriously assaulted by patients who had
been considered harmless up to the dates of the attacks.
Kent, Chartham Downs .—The information contained in this report
is not burdensome. It has no report presented by the Visitors to
the Court of Quarter Sessions, no report by the Commissioners, and
but one by the Medical Superintendent, which is very brief indeed
when it is remembered that there were 771 patients resident during
the year.
Killamey .—It is satisfactory to find that the statistical tables re¬
commended by our Association have been largely adopted by the Irish
Commissioners and Superintendents.
The following remarks by Dr. Woods are interesting :—“ While
referring to the causation of insanity, I cannot help noting the return,
as shown in Table XII., of the social condition of the admissions, dis¬
charges, and deaths ; for while 58 per cent, of the admissions are
single, only 36 per cent, of the recoveries are single ; and while only
86 per cent, of the admissions are married, 55 per cent, of those dis¬
charged are married ; or, in other words, at this rate 77 out of every
100 married patients would be discharged recovered, while there would
be only 36 out of every 100 single. This result I have noticed for
some years, but I will not at present draw any definite conclusions.
Borne will think that there are far more single people in the popula¬
tion than married; the reverse, however, is the case, the last census
returns showing that Kerry had a greater population of married people
than any county in Ireland, 43 per cent, of the people between 15 and
45 being married, while only 24 per cent, never married. I believe
that early marriages have of late years been much more frequent, and
it is quite possible that regular living and other causes may combine
to make the social condition have a greater effect on insanity than
some are at present inclined to think.”
Lancashire, Lancaster. —Dr. Cassidy again expresses his determi¬
nation to try the open-door system. He says :—“ The principal
addition has, of course, been the Annexe Asylum, which is now being
rapidly got ready for occupation ; and I may take the opportunity of
stating that it is fully adapted and equipped for the most recent
modes of treatment, those, namely, so ably and forcibly described by
the Lunacy Commissioners for Scotland in one of the most interest¬
ing of their always valuable reports—the 23rd. No one, I think,
can read this account of the open-door and industrial system, and of
its results in Scotland, without feeling that there would be a failure
at least in courage and energy, if notin duty, not to give it a fair trial
in England. The scale on which we shall try it is a greater than
has yet been applied to it, and the difficulties to contemplate and.
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1884.] Psychological Retrospect . 297
perhaps, encounter, are, I fear, greater in this country than in Scot¬
land. It will be time enough, however, to enlarge on this aspect of
the question when the occasion comes. In the meantime there are no
airing-courts, all the doors have ordinary handles, work is abundant
and close at hand; and these, with careful supervision and willing
assistants, seem to be the essential requisites for carrying out this
system.”
We acknowledge to a feeling of impatience to learn the result of
this experiment, honestly judged in all its bearings; and in the
meantime willingly admit Dr. Cassidy’s courage and enterprise in
taking it in hand.
Lancashire , Prestwick .—The official report on the condition of this
asylum is again exceedingly favourable; the Commissioners remark¬
ing that it is, in the way of ward-decoration and embellishment, in
advance of most, if not all, other English asylums. It is suggested
that the amount of exercise beyond the airing-courts should be
increased.
Lancashire , Rainhill .—The larger portion of Dr. Rogers’ report is
devoted to the consideration of the improvements effected in asylum-
management during the 25 years he has had the direction of Rain-
hill. These remarks will interest lay readers especially and physi¬
cians not engaged in our speciality.
Lancashire , Whittingham .—The following paragraph from the
Commissioners’ report is very instructive :— u Among recent admis¬
sions is a man named John Ward, received here on the 13th instant
from Preston Prison by order of the Secretary of State, and
suffering from mania with general paralysis, and having well-
marked delusions. He complained to us of having been flogged
in Lancaster Castle, after his conviction at Lancaster on January
2nd ultimo, and the marks on his back, now becoming faint,
show that his story is true. We can only suppose that the
prison surgeon failed to recognise the man’s insanity, some of the
characteristics of which are now, and no doubt were then, dirty
and destructive habits.” Such an occurrence shows how necessary
it is that prisoners, especially those whose mental condition
should be the subject of accurate observation, should be under the
supervision of medical officers thoroughly familiar with mental
disease. It cannot be doubted that insane prisoners are sometimes
most unjustly punished for breaches of discipline; but what is worse,
others, awaiting trial, are not subjected to that thorough examination
which would lay bare the mental disease which ended in crime, and
thus wretches are condemned for offences for which they are not
responsible. The suggestions made by Dr. Orange in his Presidential
Address derive additional force from such occurrences.
The admissions during the year were 631. One half of these were
transfers from other asylums or from large workhouses, and they
probably constituted, Dr. Wallis remarks, the worst collection of
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298
Psychological Retrospect. [July,
cases, as regards their curability, ever admitted into a public asylum
in a similar period. Among them were 135 epileptics, 76 general
paralytics, 31 idiots, and many cases of senile dementia and other
forms of incurable brain-disease. These figures are sufficient to show
the extremely arduous charge Dr. Wallis has, and it is greatly to his
credit that he has his asylum in such excellent order as appears from
the Commissioners’ report.
Leicester and Rutland .—The charity connected with this asylum
appears to do really useful work. One patient was boarded at Is. per
week, four at 2s. 6d., one at 3s., one at 4s., 12 at 5s., 15 at 10s., and
four at 158.
Of 469 patients, 287 males and 232 females, only three were
general paralytics. This number must be regarded as very small.
For the present all intention to build a new asylum appears to be
abandoned.
In pointing out the dreariness of the airing-court in which the
more turbulent women exercise, the Commissioners recommend the
experiment of taking even the worst inmates into the front grounds.
Of the 46 inmates of the ward, some 80 at least never go beyond the
airing-court. This is a most important point in asylum-management,
yet too often not thoroughly attended to. For female patients espe¬
cially airing-courts are most injurious.
Leicester , Borough .—This asylum is being enlarged by the addi¬
tion of accommodation for 60 male patients.
Four of the female wards are now heated by steam.
Beer to a great extent has been discontinued as an article of diet,
and tea and coffee substituted. The change has worked well. Ap¬
plication was made by the nurses to have a money-allowance in lieu
of beer. The Committee decided to allow any attendant, nurse, or
servant to have either the ordinary allowance of ale or an equivalent
in money, and 31 members of the staff immediately availed them¬
selves of the money- allowance.
Here also the Commissioners advise exercise beyond the airing-
courts for all patients who are not too feeble in bodily health. They
find that 80 male and 64 female patients never go beyond the airing-
courts.
Limerick .—Various improvements continue to be effected in this
asylum.
As an illustration of either national or religious prejudice, it may
be noted that out of 82 deaths Dr. Courtenay succeeded in only two
cases in obtaining permission to make a post-mortem examination.
Lincolnshire .—The recent additions to the accommodation are
fully occupied, and the Visitors find themselves called upon to con¬
sider further enlargements.
We may reproduce Dr. Palmer’s remarks on the effects of the
Capitation Grant—that vexed subject about which we hear so many
and so contradictory statements.
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1884 .] Psychological Retrospect. 299
“ As having a direct bearing on the increase of admission, inde¬
pendently of cases sent directly from workhouses, it should also be
stated that the number of patients whose maintenance is defrayed
wholly or in part by friends has become much larger since the Capi¬
tation Grant in 1874, and that many patients who would formerly
have been taken care of at home are now maintained in the asylum
without any charge on the poor-rate, or, as may possibly occur in
some cases, with an absolute gain of the four shillings a-week allowed
by Government. The county rate, however, has to bear an increased
burden out of all proportion to the relief thus afforded to the poor-
rate, in consequence of the increased demand for asylum accommodation
which necessarily follows. Moreover, as the weekly rate charged to
the unions includes only the maintenance-expenses, the cost of
lodging (constituting the fabric expenses) becomes a needless gratuity
to the friends in all cases where they can afford to pay both. Such
patients form an intermediate class between the pauper and private,
and at present the charges in lunatic hospitals are not sufficiently
low to divert them from the county asylums. At the same time, as
the population of the county grows very slowly, and as the returns
from other unions show that the total number of its pauper lunatics
has increased but little for some years past, it may be inferred that if
a liberal and suitable dietary, with a good sound system of nursing,
prevailed in the imbecile wards of the workhouses, and if a judicious
amount of properly-selected and properly-applied outdoor relief were
allowed amongst the poorer class for the home-care of persons of
weak and unstable minds, the admissions would be so far diminished
that there would be no urgency for extensive additions to the asylum.”
These practical remarks are well worthy of attention.
Dr. Palmer reproduces some of the suggestions made by our Asso¬
ciation, in prospect of the introduction of a County Government Bill.
London , City of .—The percentage of deaths on the average
number resident is again remarkably low, namely, 4*2.
In his report Dr. Jepson mentions a case illustrating a fact some¬
times lost sight of, that chronic patients are not always to be trusted,
and that we may be deceived by the apparently most trustworthy and
harmless. “ A patient—one of the first admitted in April, 1866—
who had for some years previous resided in one of the Metropolitan
private asylums, being chargeable to the Corporation of London, and
who was the most trusted inmate in this institution, attempted to
commit suicide by cutting his throat, while in bed, with a portion of
an old jagged knife he had in some way obtained possession of.
The act was observed by another patient, who raised an alarm. The
incision severed the anterior wall of the windpipe, but no important
vessels were injured. The wound soon healed, and the patient made
a good recovery. The reason he gave for making the attempt upon
his life was that, ‘ after thinking about it for some time, he had
come to the conclusion, if he could not have a better head than the
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300 Psychological Retrospect . [July*
one lie possessed, he had better cnt it off, since it was good for so
little.’ He had some little time before lost the use of an eye through
a violent attack of iritis, and this illness was followed by a very
short attack of excitement, the first manifested during the 16 years
he had been in the asylum/’
The Commissioners direct attention to the frequent changes in the
staff, and suggest that the wages are insufficient. They say :—“ In¬
cluding laundrymaids and the head-attendants on each side, they
number 32 in all; more than half have not yet been in service here
for 12 months, whilst only 10 have been here for more than two
years. There are 11 day-nurses, two night-nurses, and three laundry-
maids, and yet since our colleagues inspected this asylum ladt year no
less than 22 nurses have left.” Such a state of affairs must be a
constant anxiety to the medical superintendent.
Middlesex , Banstead .—This great asylum has been further enlarged
by the opening of two blocks for 78 patients each. The total accom¬
modation is for 1,882—710 men and 1,172 women.
Dr. Shaw gives an example, if such were needed, of the great
benefit resulting from employment. The patient was a very power¬
fully-built man, sent from a workhouse, where he had been extremely
violent and unmanageable. “ When admitted he said he should be
quiet if he had plenty of work to do ; so we set him to work at the
gas-factory, and he has been since his admission as hard-working
and well-behaved a patient as any in the place. Epileptics (of whom
we have large numbers) would be much benefited by regular and
laborious work ; but it is not so easy to find it for them, as they
cannot always be trusted with spades and forks, and thus farm-work
is to a great extent put out of their reach ; for them we find pulling
a heavy roller, or hauling carts, the best exercise. It is a pity that
the female patients cannot be employed in the same way, for their
attacks of insanity are of longer duration than those of the men, and
we have not the same means of withdrawing them from their morbid
ideas.”
Middlesex, Hanwell .—We agree with the Commissioners that the
lot of foreigners in our county asylums is a hard one, and that the
representatives of foreign Governments show unwillingness to exert
themselves to get their countrymen sent home. This, in great part,
arises from the fact that there is great difficulty in recovering the
costs. We have even known a case where a Consul had to pay the
whole expenses because of his omission of some technicality. Now
that the subject has been taken up by the Association, 'we hope that
something will be done.
Mid-Lothian and Peebles .—As this is an asylum where the open-
door system has been in use for some time, we are tempted to give the
following remarks by Dr. Cameron on asylum-management:—
u The open-door system has been in full operation for several years
in this asylum j but as it is yet on its trial, and by no means generally
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301
1884,] Psychological Retrospect .
accepted by asylum-superintendents as practicable, except under
certain favourable circumstances, it may be well that I should say
a few words regarding my experience of it. Naturally, the first
question that is suggested is : Have escapes been more numerous
than under the old system of locked doors ? and I have to answer in
the negative. Again, as regards accidents, while there have happily
been comparatively few, I regret to have to record the death of two
patients by suicide within the last few years. Reference is made to
these accidents in the reports of the Visiting Commissioners. They
were in no way due to the open doors, but were such as probably no
precautions in the way of locks or walls would be likely to pre¬
vent. . . .
“ There need not necessarily be more than the usual proportion of
attendants to patients. But there can be no doubt that the responsi¬
bilities thrown on the staff are increased, and that the attendants are
forced to be constant in their attention, and to do by irksome personal
supervision what could be done in a much more simple and perfunctory
manner by turning a key. The unremitting attention which they re¬
ceive, taken in conjunction with a liberal dietary, and opportunities
such as the farm affords for outdoor labour, produces a degree of
contentment among the patients which is quite apparent, and the
result of which is the rendering possible of an experiment in the re¬
duction of restraint that might at first sight appear impracticable.”
Montrose .—The important alterations and improvement, begun
some six years ago, are approaching completion.
This asylum has now been in existence 100 years. It originated in
the benevolence and wisdom of the inhabitants of Montrose and neigh¬
bourhood, and was the first public hospital in Scotland devoted to the
treatment of the insane.
Apropos of the changes which have occurred in the treatment of
insanity during the last 100 years, Dr. Howden remarks :—
6i No one, I imagine, will dispute the improvement which has taken
place in the modes of treatment of the insane during the last 100
years; but in criticising methods we must avoid glorifying ourselves at
the cost of our ancestors. We have every reason to know that the
motives which dictated the use of the cell, the strait-jacket, and
such like appliances, were pure and humane, and that these were as
honestly thought to be the best means of treatment, just as we now
think that ample occupation, exercise, fresh air, healthy surroundings,
good diet, and the abolition, as far as possible, of all mechanical or
even personal restraint are most conducive to the happiness and re¬
covery of the mentally afflicted. In comparing the past with the
present, we must likewise consider the totally altered character of the
population of modern asylums. When there were only one or two
asylums in the whole of Scotland it could only have been the most
violent and unmanageable that found admission, and it is very probable
that there were as many cases of this kind in the old asylum with its
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302
Psychological Retrospect . [July,
30 beds as there are now at Sunnyside with its 500. The fact that
we find often in the old minutes applications made, not for admission
of a patient, but for ‘ a cell when there is one vacant/ speaks for itself.
In the present day our share of maniacal excitement is, as it were,
diluted by scores of quiet, industrious, and harmless persons, labouring
under the milder forms of mental alienation, who, if they would ever
have been admitted into an asylum 70 or 80 years ago, would cer¬
tainly not have been placed in cells or strait-jackets. Thus it seems
to me we are comparing two things totally different; and though no
one holds more strongly than I do the advantages of onr modern and
more enlightened system of treatment, I cannot help thinking that it
has to some extent been brought about and rendered more practicable
by the milder nature of the forms of insanity of our average popula¬
tion ; and I am not by any means sure that the Sunnyside Asylum
could be conducted as it is now if it contained 500 patients of the
same character as that of the small number who were in the house on
the Links 80 or 90 years ago.”
This is just one of those speculations which it is impossible to either
prove or disprove.
Monmouth , Brecon , and Radnor .—The extensive additions to this
asylum make satisfactory progress. Blocks for male and female epi¬
leptics have been completed, and are in use.
The Commissioners point out that the staff in several of the wards
is insufficient. Seventy males and 40 females do not go beyond the
airing-courts for exercise.
Dr. McCullough reports that after a year’s experience the disuse of
beer as a diet has certainly had no bad effect on the patients, whilst
he has no hesitation in saying that the effect on the attendants and
servants has been good. Amongst the lesser advantages, it has re¬
lieved the officers from the perpetual requests for beer on all sorts of
pleas. The new dietary, which was settled after many trials and long
and careful consideration, has given great satisfaction, and has proved
to be ample.
Murray Royal Asylum , 1882.—The administration of this asylum
continues to be marked by energy and ability. Numerous impor¬
tant changes have been introduced—among them the open-door
system. Concerning it, Dr. Urquhart reports :—“ By a combination
of watchfulness and trustfulness I think the best results are to be
obtained. Thus we had a case constantly requiring supervision, the
watchfulness of the night-nurse being tested by a tell-tale clock. Yet
we have found a most satisfactory outcome from the extended freedom
granted to a large proportion of the inmates. Two galleries are now
open as an ordinary house, and I hope to extend this system to the
whole of the north block in the course of this year. It is surprising
how little trouble this revolutionary policy gives, and most gratifying
to hear the encomiums bestowed on it by the patients themselves.
The liberty has not been abused since it was granted, some twelve
Digitized by <^.ooQLe
1884.] Psychological Retrospect. 303
months ago. The single escape which occurred during the year was
not in consequence of increased liberty. Of the 81 patients to-day in
the asylum, nine gentlemen and eight ladies go about unattended
beyond the grounds ; while 12 and 16 respectively are on parole
within the walls. Nine gentlemen and eight ladies have liberty
to go to church in Perth with and without attendants ; while one gen¬
tleman has a seat in one of the churches in town, and is a communi¬
cant there.”
Several of the gentlemen are now actively and usefully employed in
outdoor work. This is a method of treatment which might be
adopted in many asylums where gentlemen are received. In this
respect paupers are better off than their social betters.
1888.—It will be sufficient to notice that Dr. Urquhart again
reports most favourably of the open-door system.
A house has been leased at the sea-side, and small parties are sent
thither for change of air and surroundings.
(Zb be continued.)
2. American Retrospect .
By Dr. Hack Tukb, F.R.C.P.
Report of the Pennsylvania Hospital for the Insane , 1883, with Memo¬
rial of Dr. Kirkbride.* Philadelphia. 1884.
Although our Obituary of last Quarter contained a short sketch of
Dr. Kirkbride’s life, we avail ourselves of the above Memorial, which
has been subsequently issued, to present a more extended notice of
one who was regarded by his fellow alienists, and most justly, with
the greatest esteem.
Dr. Kirkbride held strongly the importance of the medical super¬
intendent having the supreme command in an asylum. His relations
to the managers were, however, of the most friendly character, and he
valued the help they accorded him, and the responsibility they shared
with him. Writing in 1859, he says :
“ I cannot well refrain from repeating what has been said on another
occasion, that with all these changes of men (on the Board) there has
been no change of principle, no abatement of interest in the good cause,
and that I have steadily received a degree of support and confidence
for which I shall always feel the deepest gratitude, and without which
much that has been accomplished would probably never have been
undertaken. Such support and confidence may often make a pleasure
of what would otherwise be heavy toil, and help to secure what no
pecuniary consideration could purchase.”
* The great freedom taken in condensing this Memorial must not be attri¬
buted to dissent from the passages omitted, but simply to lack of room.
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804 Psychological Retrospect . [July,
It is observed in tbe " Memorial ** that " To Dr. Kirkbride from the
first were given the power and the privilege of awakening in the minds
of the managers the spirit which prompted the Egyptian King to say
to the young Hebrew, * Forasmuch as God hath showed thee all
this, there is none so discreet and wise as thou art; thou shalt be over
my house, and according to thy word shall all my people be ruled.*
But lest it should be thought, especially by the young, that such ca¬
pacity and such favour are easily attained, it must be added that Dr.
Kirkbride’s attitude to the successive Boards was always that of one
entrusted by others with a great service, and responsible to them for
the strictest stewardship. Untiring diligence, unceasing labour, and
the greatest conscientiousness were the cheerful price he paid. * No
man ever had more pleasure in his work than I; it was always a plea¬
sure when I was well,* was the remark he made during his last ill¬
ness in looking back upon his life. Rest was grudged, and sparingly,
if ever, taken; labour was lavished, and this not with a vigorous,
physical frame, but with a constitution far from strong. When of
late years his family urged the propriety and necessity of longer va¬
cations, the answer invariably was, ‘ I am responsible to others ; the
Managers expect me to be at my post.' In an admirable sketch of his
character published in a medical journal, his overpowering sense of
duty is spoken of as his greatest excellence. In 1853, after passing
through a period of ill-health, but not of cessation from active duty,
he felt that his term ‘ of service in the cause had been nearly as much
protracted as can be required of one individual,’ but he worked on
with the same energy thirty years longer. Some men labour with
diligence and spirit, but speak as if in working they were always in
the shadow, and looking ever with longing to sunny fields of rest before
life is ended. Those who knew Dr. Kirkbride most intimately never
heard him speak of craving rest; to him the sunshine lay always in
and about the Hospital.**
A sketch of the regular duties of each day , in the Hospital, is a sub¬
division following “ Organization ** in the Report for 1841; these
have been carried on with few changes ever since. The two pages
containing the list are easily read, but it may be safely said they cover
an amount of self-denying labour, and of voluntary isolation on the
part of the physician, from much of the gratification which many hard-
workers in other positions feel they must allow themselves, of whioh
those ignorant of hospitals have scarcely an idea. This is true of all
faithful service in a hospital for the insane.
The importance of employment was early recognized by Dr. Kirk¬
bride, as will be seen from the following citations from early Reports:—
1841 : “ The importance of furnishing the insane with suitable means
of employment and amusement, is now so well understood, that we
shall merely indicate those to which our patients have resorted during
the past year.
“ At the head of the list we place outdoor labour, on account of
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1884.] Psychological Retrospect . 305
its importance in many of the curable cases, and its value in even those
that are the most chronic and incurable.”
“ The Workshop, of which we have had the use only during the last
two months of the year, is a valuable acquisition to our means of em¬
ployment.
“ Many of our cases, generally among the convalescent, have already
been pleasantly and profitably employed in this building, and the in¬
terest they have felt in their work, the entire change in their thoughts,
and the active use of their muscles, have rarely failed to contribute
to the rapidity and certainty of their cure. We have not as yet
attempted any kind of work by which to ascertain the amount of
income that might be derived from the workshop; it would unques¬
tionably be small, but, like other kinds of labour performed by the
insane, its value cannot be reckoned in dollars and cents, but as a
means of restoration or comfort to the inmates of the Hospital. Our
great object thus far has been to induce our patients to labour; for
the kind of work we have cared but little, and whatever object appeared
most likely to excite a new train of thought has received our appro¬
bation.”
“ The female patients employ themselves when indoors, in a variety
of fancy work—in sewing, knitting, making or arranging olothes, read¬
ing, games, etc.”
“ In fine weather, at all seasons, a large proportion of the patients
take daily exercise in the open-air, by long walks, either singly or in
companies—commonly within, but frequently outside of the enclosure.
“ A carriage and horses are kept expressly for the use of patients,
and are particularly enjoyed by the females.”
In 1842 he writes : i( Outdoor employments and amusements are
generally to be preferred; but a full variety should also be collected
within the building, for those who from any cause go out but little,
for stormy weather, and for the long evenings of winter, which are
often passed pleasantly and profitably.
“ Writing, drawing, painting, the study of the mathematics, and
other branches of learning, have tended to beguile many tedious
hours. Several gentlemen have been usefully engaged in imparting
instruction to others in the same ward, and two have been improved
by giving regular lessons, for a short time, in one of the modern lan¬
guages.
“ A great variety of games also tends to fill up the time spent in the
parlours and halls, and several musical instruments offer recreation to
those who are thus inclined.”
In 1843 : “ The value of mechanical as well as other kinds of em¬
ployment in the treatment of insanity is now so universally conceded
that no arguments are required in its favour. Two cases, after a
failure of all the ordinary means, appeared to be perfectly restored by
this kind of employment, under peculiarly discouraging circum¬
stances.”
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306
Psychological Retrospect .
[July,
“ The labour-problem in regard to the insane is probably best settled
by the conclusion that it is hardly possible to exaggerate the impor¬
tance of occupation of some kind for every class, but also that harm,
quite as easily as good, may follow employment in unwise forms, and
that a practical knowledge of the whole subject in regard to kind,
amount, and the physical and mental conditions of those on whom its
effects are to be tried, is indispensable to secure the best results from
its use.”
We especially direct attention to the above discriminating remarks.
Evening Amusements .—The need of amusements for the evening is
early referred to. In 1844 a very fine magic lantern was in use. In
1845 lectures were established. “ The regular course is being delivered
by my assistant, Dr. John Curwen, who, in addition to the faithful
performance of his ordinary duties, has spent much time and labour in
his efforts to make this experiment useful and successful.”
Dr. Kirkbride was never satisfied with his provision for the even¬
ings, until every evening during the nine months’ course of each year
was filled. In 1868, at the Department for Females, light gymnastics
were introduced, six out of seven evenings being from that time ap¬
propriated to some special form of amusement or occupation. The
officers’ weekly tea-party, introduced in 1866, and since then continued
throughout the year, filled up the only unoccupied evening of the
amusement season. This he considered as in some respects the most
useful of all the entertainments. Forty persons, three-fourths of whom
are patients able to take part, are invited successively from all the
wards to meet at table in the officers’ dining-room on these occasions.
Dr. Kirkbride himself always presided at this meal unless prevented
by some very unusual cause, seated where he could see almost every
one present. It was often evident that, while apparently engrossed in
making those about him happy, his thoughts were also busied with the
interests of many, reached only by his eye and not his voice.
It is a frequent remark in the Reports that only by enthusiasm on
the part of the officers can the amusements so necessary in a hospital
for the insane be properly carried on; this enthusiasm he never failed
to show in the highest degree. He made it a rule through his long
course as superintendent to attend all the evening entertainments,
thus insuring in wonderful measure the interest of both patients and
attendants, and the presence of the former. The mere fact of the
remarkable ardour with which he threw himself into this part of his
duty inspired the same in many an inert mind. An eminent English
physician, who had himself been a hospital-superintendent, making
him a visit of ten days, asked with surprise and incredulity, as evening
after evening his host excused himself for a considerable time, “ Is it
possible Dr. Kirkbride goes every evening to the amusements ? ”
Absence from the Hospital in the evening, indeed, until late years, was
unheard of; and even then only indulged in after an unusually labo¬
rious day, and was so sure a sign of fatigue, that his family scarcely
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1884.] Psychological Retrospect. 807
knew whether to be more glad or more sorry to see him enjoy, what
no man ever appreciated more, an unbroken evening in his own much¬
loved home.
The spirit always shown in regard to all the evening amusements is
summed up thus :—
“ No lowering of their character or diminution of their number can
ever be permitted while a proper appreciation of the high mission of a
hospital for the insane is felt by those entrusted with its manage¬
ment.”
Sunday .—In his Report of 1841, Dr. Kirkbride wrote that it was
a source of gratification to find that Sunday in the Institution was
almost invariably the day of greatest comfort and quiet among the
patients.
“ The objects of religious observance in hospitals for the insane are
various, not alone because their propriety is unquestionable, but also
because many patients derive real comfort from participating in them.
Some have satisfaction from thus mingling with the officers and other
patients, and occasionally an important moral effect in self-restraint is
produced, which may be the first step to future convalescence. This
effort at self-restraint has often appeared to me to be strongly brought
into exercise by the simple manner in which our assemblies have been
conducted.”
In referring again to the subject in 1857, he remarks: “ No visi¬
tors are admitted on this day, and all unnecessary labour is avoided.
It has long been a subject of remark that the quiet and repose about
the whole establishment which are then almost always to be observed
are very striking. This seems to be attributable to a deep-seated re¬
spect for the day, the effect often, no doubt, of early education, and
which is not entirely lost even when disease has taken from the mind
some of its highest attributes. On Sunday no leave of absence is
granted but to attend Divine worship, and throughout the grounds,
in the shady groves and pleasant summer-houses, as well as in the
wards, our inmates seem to appreciate the quiet and repose that right¬
fully belong to the day.”
Dr. Kirkbride was not always successful in preventing encroach¬
ments upon his time by persons willing to curtail, on the day of rest,
even his partial relief from engrossing duties, yet the peculiar rest¬
fulness and peace of Sunday in his own house have been remarked by
those who were his guests. Dr. Kirkbride had only too much oppor¬
tunity to see and realize how many good men, through a neglect of
natural laws, and through overwork, lower their capacity for benefiting
their fellow-creatures. Every day of life was passed by him in bless¬
ing others. On Sunday opportunity was granted to attune the
heart to the highest, sweetest tones, only that the harmony might
sound through each moment of the week, to be renewed again by the
next day of worship and of spiritual rest.
On that day he made it a rule never to leave the place in the
xxx. 21
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308 Psychological Retrospect. [July*
afternoon, that being the time given to his assistants ; and part of it,
through all these years, was almost invariably spent in walking about
the grounds with his family. The memory of these walks to all his
children is one of their most precious associations with the day of
days. For a number of years after the removal of Dr. Isaac Ray,
the eminent author of the u Medical Jurisprudence of Insanity,”
from Providence to Philadelphia, he received a visit every other Sun¬
day afternoon from this most valued friend, and together they took
both grave and sweet counsel upon many subjects, but above all upon
that which engrossed the mind and heart of each.
Until his illness in 1879 Dr. Kirkbride conducted the simple Hos¬
pital service, reading aloud several chapters from the Bible. Singing
of hymns by patients and attendants followed the moments of silent
worship at the close of the Bible reading. His voice was not loud,
but remarkably distinct; his clear and soothing tones were heard per¬
fectly by those seated farthest from him. The “ Doctor’s reading ”
was a tonic to many an aching heart.
“ Avoidance of Deception in Treating the Insane .—Deception is so
often resorted to by those who have charge of insane friends, and in¬
jury unintentionally done by it, that some remarks on the subject in
this place cannot be considered inappropriate. Those who have had
much intercourse with this class will generally agree that candour is
proper under all circumstances, and particularly where it is most apt
to be neglected, in bringing patients to a public hospital.” (1842.)
About a year ago there was much discussion in the religious news¬
papers as to whether deviation from the truth under any circum¬
stances can be considered right. One of Dr. Kirkbride’s family was
asked by a clergyman his views and his habit on this point in dealing
with his patients. The question was repeated to him, and he ear¬
nestly exclaimed : “ I hope you gave a most decided answer, and
made it thoroughly understood I never think it right to speak any¬
thing but the truth.” Only those who know much of the frequent
developments of insanity can understand the mental strain which un¬
failingly firm, tender, and sympathising candour with the insane
through a period of more than forty-two years involved. He had
also that rare combination of perfect sincerity and delicate tact which,
valuable in any position, is invaluable among the insane. In his last
report he speaks of these traits as important for workers in his field
of labour. “ No amount of compensation, however, no period of re¬
laxation from duty, will secure the highest form of usefulness, with¬
out a real enthusiasm in regard to the work in hand—a generous
sympathy with all who suffer, and the possession of a manner which
takes away all doubt of its being genuine. Such persons must be
possessors of that quality only to be described as tact, and so valu¬
able in all positions of life; and they must show, too, in all their
actions that they fully understand that the provision of all these
structures and their many and costly arrangements are for the
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special comfort and benefit of the patients, and not, beyond what
is necessary to show a hearty recognition of faithful services, for
those who are employed to have charge of them. If it were pos¬
sible to teach this matter of tact to persons about to enter upon
the care of the insane, it would be an invaluable preliminary study.
It is so common to be absent, however, where so many other valuable
traits are found, that, insensibly, we learn'to regard it as essential in
one serving as a care-taker upon those labouring under mental un¬
soundness, and that it must come naturally if it comes at all. It
cannot be too often repeated that to be specially valuable about a
hospital for the insane, no matter what the position of an individual
may be, the interest in the institution, its patients, and the conscien¬
tious performance of duty, must ever be far beyond any thought of
personal aggrandizement.”
Restraint .—In regard to restraint, the views of the five earliest
Reports are strikingly in accord with Dr. Kirkbride’s later opinions.
An extract is given from each to show fully the position taken by
him forty years ago : “ Our invariable rule is to remove all restraint
from the person of every patient upon his entering the Hospital, and
it is with extreme reluctance that it is ever re-applied.
“ Although the means heretofore detailed, and the aid of a vigilant
and efficient corps of assistants, have enabled a large number of the
patients to enjoy the privileges which I have mentioned almost from
their first entrance, it is not to be concealed that we always have in
our family some with that unfortunate temperament that blackens the
fairest scenes, distorts the purest motives, and misconstrues the
kindest actions ; and that many require some more decided restraint
until the violence of their attack has subsided.
“ No hospital for the insane can ever be without restraint; the very
character of the building, the laws for its government, and the super¬
vision and discipline that is required, impose a wholesome restraint
upon all who enter its walls. Fortunately the discipline and restraint
which the necessity of the case demands can hardly prove injurious.
The same cannot be said of the means formerly believed necessary,
the evils of which were of so terrible and lasting a character that too
much pains cannot be taken to diffuse more correct and enlightened
views on every occasion.
“ Seclusion to guarded chambers for a limited period is of vast im¬
portance in the treatment of insanity ; but, to prevent abuse, its dura¬
tion must be under the immediate direction of a superior officer of
the house. To no other persons can it be safely entrusted.
“ Every year brings us cases to prove the danger of seclusion being
improperly continued. Seclusion for very short periods I have found
sufficient restraint for nearly every case under care during the past
year, and with an average population of one hundred and fourteen
there have rarely been more than four or five confined to their cham¬
bers. On more than one occasion, for two or three weeks together,
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310
Psychological Retrospect . [July,
not a single male was thus restrained. At the time of writing this
Report, and during several previous weeks, there has been but one of
each sex in this situation. If proper provision is made for seclusion,
classification, and attendance, all the common kinds of restraining
apparatus may be dispensed with in the treatment of insanity, but of
the propriety of doing so under all circumstances I still entertain
doubts.
“ Had I felt anxious to make such a declaration, it would have
been in my power to have stated that during the past year no re¬
straining apparatus of any kind had been upon the person of a single
patient of this Hospital; but believing as I do that its occasional
employment may be conferring a favour on the patient, it has always
been resorted to where there existed a proper indication for its use.
The only indication for its use that is recognised in this Hospital is
the positive benefit or safety of the patient—never the trouble of
those to whose care he is entrusted—and the direct order of the
physician or his assistant, the only authority under which it can be
applied.”
In the second edition of his work on Hospitals, published in
1880, and already referred to, he writes : “ Physicians may differ
widely in regard to the particular forms of mechanical restraint that
may be most desirable, but it is safe to say that they are few in
number, simple in form, and little repulsive in appearance. In my
own experience, strong wrist-bands, soft leather mittens, connected
linen sleeves, and the apparatus for confining a patient in bed, are all
that are required ; the last-named, in certain conditions of a patient,
being of the utmost value, and often unquestionably a means of
saving life. My experience would indicate that on an average not
more than one or two per cent, of all the patients require any me¬
chanical means of restraint, that often a period of several months
may pass without their being needed, and that any Superintendent
may conduct an institution without applying them, in case he is
anxious to avoid the criticism of pseudo-experts, and willing to let his
patients lose the advantages that may result from their occasional use.
Attendants .—The views of Dr. Kirkbride in his earliest years as
Superintendent, in regard to the qualifications desirable in attendants,
have no uncertain sound. A part only of his remarks on this subject
in the first five Reports are quoted, but with some repetition, to show
how from year to year he emphasized the subject:—
“ To these situations we endeavour to appoint none but those who
are strictly temperate, moral, and of good intelligence. To perform
I perfectly the duties of attendant requires such a variety of qualifica¬
tions—such peculiar mental and physical endowments as are not
often combined in the same individual, that, in all our engagements,
it is understood that no one is expected to remain in the station who
is found deficient in the qualities we deem essential to its proper per¬
formance.
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1884.]
“ Few persons are to be found who possess all the qualifications,
mental and physical, and the peculiar temperament necessary to make
a perfect attendant. Without a trial, it is impossible even to say
who will perform the duties of the station sufficiently well to make it
to their own interest, or that of the institution, that they should re¬
main in it.
“ A high moral character, a good education, strict temperance, kind
and respectful manners, a cheerful and forbearing temper, with calm¬
ness under every irritation, industry, zeal, and watchfulness in the
discharge of duty, and, above all, that sympathy with those under
care which springs from the heart, are among the qualities which are
desirable, and as many as possible of which we endeavour to combine
in those who are placed in this station.
“ When all these are found in one individual, and he has been in¬
structed in the proper mode of performing his duties, his services to
any institution and to the sick are truly invaluable. Such an attendant
is really a benefactor to his species.”
“ A more numerous body of attendants, with higher qualifications,
is also necessary. They should be individuals who enter with zeal
and cheerfulness upon the performance of every duty ; who manifest
a true feeling of interest in the welfare and comfort of every patient,
and in carrying out every measure that may be proposed by the proper
authority. They must be able, under all provocations, to control
their temper; never to forget that they are dealing with fellow-beings
who are insane, and never tire in their endeavours to acquire that
tact which will enable them, by an invariably mild and kind, but firm
and dignified deportment, to control those who come under their care.
It need hardly be said that the services of those who do this cannot
be too highly appreciated, and that they are deserving of the warmest
commendation. Those who do not possess, or cannot acquire, these
qualifications, or who perform their duties solely to keep their
places, can never be desirable in a well-conducted hospital for the in¬
sane.”
“ A proper system of attendance upon the insane is so intimately
connected with the abolition of restraint that it seems natural to
speak of the two subjects in connection. In many instances the com¬
fort and happiness of patients depend very materially upon those who
fill this highly responsible, arduous, and useful station. When these
duties are faithfully performed—where the prominent motive for
action is the true Christian feeling which warms the heart towards
the afflicted, and makes us treat them in all things as we would
wish ourselves treated—every one who has ever required such
services will join me in declaring that their value can hardly be esti¬
mated.
“ There are many means by which a judgment may be formed of
the real qualifications of attendants, the most important of which are
the constant and varied supervision which enters into our system of
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812 Psychological Retrospect. [July*
organization, and the valuable communications often made by patients
themselves.
In the same year the Supervisors are mentioned : ft One for each
sex, whose duty it is to pass their time among the patients in the
different wards and pleasure-grounds, to endeavour to interest,
employ, and amuse them in every way in their power, and to see
that all rules for the attendants in their intercourse with the patients
are rigorously observed. Before retiring at night, the supervisors
furnish the physician with a written report of whatever has come
under their observation during the day.”
In 1844 Dr. Kirkbride suggests the employment of “ a limited
number of attendants of a higher order, who shall be released from
all the ordinary ward duties. They should be men with true
Christian feelings, courteous manners, intelligent and cultivated, and
possessed of a peculiar tact, in order to do justice to such a station.”
In 1846 he mentions : u In the female division of the house we
have this year commenced the employment of a lady, who, released
from the care and supervision of the wards, will be able to devote the
whole of her time as a companion to the patients . . . when re¬
quired, devoting hours of a day, or even whole days, to a single
patient.”
In 1848, in referring again to teachers and companions. Dr. Kirk¬
bride writes : “ If properly qualified, no persons can add more essen¬
tially to the comfort and happiness of the insane—can aid more
materially in carrying out, in the proper spirit, many of the directions
of the chief medical officer—prevent so effectually the occurrence of
difficulties among the patients, or between them and their attendants,
and secure so thoroughly to all interested the conviction that nothing
wrong can be committed by any one, and no duty be neglected, with¬
out certain and speedy detection.
a We continue to find a single individual of this class, of each sex,
of great value in our scheme of treatment, and the extension of the
number, so as to bring their influence still more effectually on indi¬
vidual patients, I regard as one of the most important improvements
to be made in the organization of hospitals for the insane. In carry¬
ing out any enlarged or liberal system of mental treatment their aid is
indispensable.”
In 1861: “ Many patients, especially when first entering a hospital,
should have particular care from such persons as have been referred
to, perhaps for days together. These companions, released entirely
from ordinary ward duties, by their tact and persevering attentions
may do much to give to patients pleasant impressions of their new
home, and pave the way for a ready acquiescence in what may be
necessary in the progress of the case.”
Manual for Attendants .—During 1841, in addition to all the
labours of that year of organization, he prepared a book of printed
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1884.] Psychological Retrospect. 813
rules for the attendants, of which there have been subsequently
two editions. This little manual, which has had value and influence
beyond the immediate field for which it was designed, is of itself
lasting proof of the views and the standard of this institution from
its beginning in regard to attendants. In the first Report we read :
“ Printed rules are furnished to the attendants when entering upon the
performance of their duties, and to which they are expected to con¬
form in every particular. In these rules, and on frequent occasions,
we endeavour to impress the attendants with a true view of the im¬
portance and responsibility of their stations—to give them some idea
of the principles which should govern them in their intercourse with
the patients, and the reasons for our different regulations. We insist
on a mild and conciliatory manner under all circumstances, and rough¬
ness or violence we never tolerate. We are not satisfied with the
simple performance of special duties, but wish to see an active interest
felt in all the patients—a desire to add to their comfort, and to
advance their cure—judicious efforts to interest or amuse them—a
watchful care over their conduct and conversation, and a constant,
sympathising intercourse, calculated to win their attachment and
command their respect and confidence.”
It is interesting to reflect that these are the views of attendance
and supervision laid down in this institution forty-three years ago.
The “ unvarying kindness and sympathy ” which were “ insisted on/*
and the patience of which Dr. Kirkbride was himself the example
through this long period, have ever been the rule ; absolute perfection,
indeed, has not been found, but it has never yet been found in those
who tend the insane out of hospitals, nor, indeed, among the dearest
friends and relations of the insane themselves. There has ever been
much unselfish labour each year, however, that enabled Dr. Kirkbride
to feel as he did when he wrote at a later time : “ I have also the
satisfaction to be able to report the valuable services rendered in their
respective departments by the supervisors, teachers, attendants, and
others connected with the immediate care of the patients. Upon the
care, vigilance, kindness, and sympathy of all these much of the com¬
fort of the insane must ever depend. To give all these in their full
efficiency requires an intelligent mind, a genuine good heart, a temper
under full control, and truly Christian principles. Wilfully to with¬
hold them ought to be considered ample proof of a weak mind
and vicious principles, with a complete forgetfulness of that Christian
motto which should be printed in letters of gold in every institution
for the insane, ‘ All things whatsoever ye would that men should do
to you, do ye even so to them.* ”
This was, indeed, his own rule of conduct, and those employed
about the patients, as they watched his submission of self in all points
to this law of heavenly love, his tenderness, and gentleness, and
patience, saw also the beneficent effects of his actions upon the
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814 Psychological Retrospect . [July*
sufferers under their charge, and consciously and unconsciously, both
in and out of his presence, many of them to a remarkable degree, fol¬
lowed his methods and imitated his example.
Finances. —This memorial would be incomplete were not Dr.
Kirkbride’s connection with the financial history of the institution
alluded to. In this important part of its administration, and in the
wise use of its moneys, the crucial tests of many men in other respects
of great ability and noblest impulses, he was not found wanting. The
same perseverance and hopefulness, the same calm foresight and
prudence, which he exercised as a physician, he showed also here.
His principles are stated in 1845 : “ In the expenditures of this
hospital it has always been a rule that everything should be done with
the strictest regard to economy—to that true economy which, in in¬
stitutions of this kind, consists in never spending a dollar without a
reasonable expectation of its being useful, and in avoiding waste
of every kind ; but at the same time making a liberal use of every
means that is likely to promote the recovery of the patients, or, when
that is not possible, to give them the highest degree of health, happi¬
ness, and enjoyment of which their situation is susceptible.** Much
of the past financial prosperity of the hospital is due to the large ad¬
ministrative ability of Dr. Kirkbride.
When the wards of the hospital were full, and the idea of the
erection of a new building suggested itself to him, the enthusiasm in
the project which he felt himself he succeeded in imparting to others.
Many, including the whole Board of Managers, threw themselves most
heartily into the work of raising by voluntary subscriptions the
355,000 dollars needed to build and furnish the Department for
Males. All will allow that, as Dr. Kirkbride originated the plan of
the separation of the sexes, so it was also bis energy and devotion
which eminently contributed to the raising of this large sum, and to
the accomplishment of what he considered the great work of his life—
the provision of a second hospital for this institution, with every
modern improvement, and the advantages of a separate building and
complete classification for each sex.
Free Patients .—In 1842 Dr. Kirkbride writes: “I cannot con¬
clude this report without calling the attention of the Board
to the great good effected by the free list and the amount of
suffering annually relieved by it; ” and in 1845, in reviewing the
work of five years, under the head of Benevolent Character of this
Hospital , he writes at greater length : “ It is not only a matter of
interest to those who are now contributors to the Pennsylvania Hospital
and to the community, but it is due to the memory of the men of a
past generation, who freely gave their time and money in fostering it
and promoting its prosperity, that the doings of this branch of the
corporation towards carrying out its charitable character should be
occasionally adverted to.*'
The Hospital has continued through all these years on its long
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1884.] Psychological Retrospect. 315
course of blessing. “ Purely unsectarian, it receives into its wards, as
long as there is room, the mentally afflicted of every class, profession,
or creed, without regard to residence, and, as far as it is able, dis¬
penses its benefits to those from our own State not blessed with this
world’s goods as freely as to those who seem to have nothing to ask
for but health.”
u No one connected with the institution has any pecuniary interest
in its income or in the receipts from the board of its patients.”
Those who would estimate the value of hospitals for the insane,
must remember that to Dr. Kirkbride the insane meant not only the
rich or persons in comfortable circumstances, but also the indigent,
who, with small homes and narrow means, can often make no ade¬
quate provision for ordinary illness. The poor he had, indeed, always
with him. None loved him better, or appreciated him more thoroughly,
or found in him a better friend, than his poorest and least intellectual
patients; his time, and skill, and sympathy were given to them with¬
out reserve. His whole personality, however, his courtesy of manner,
the sensitiveness of his nature, his ready tact and sense of humour,
all his powers of mind, never seemed so fully called into play, or so
admirable in exercise, as in those cases where acute intelligence, re¬
finement and cultivation combined often to" make the most difficult
and the most exacting of the many difficult and exacting cases with
which he had to deal. In treating the former he was like the skilled
musician playing with depth of feeling a melody in itself so sweet
and varied that nothing more skilful or more beautiful can be fancied
until with greater art he renders the elaborate composition through
which runs the same lovely air.
Association of Hospital Superintendents .—In 1845 Dr. Kirkbride
mentions the formation of the Association of Medical Superinten¬
dents of American Institutions for the Insane, which held its first
session in Philadelphia in the autumn of 1844, adding : “ The best
interests of the insane can hardly fail to be promoted by the cordiality
and good feeling which exist among its members, the zeal with which
its objects are advocated, and the friendly rivalry which animates each
one to be foremost in advancing the permanent welfare of all who are
afflicted with mental disease.” He was one of the founders of this
Association, and its President from 1862 to 1870. Of the thirteen
superintendents present at the first meeting, but two are now living,
and only one still remains in charge of an institution.”
Reports and Personal Recollections. —In his fourth Report Dr.
Kirkbride speaks of the practice of publishing reports of the opera¬
tions of hospitals for the insane having then become nearly universal,
and adds : “ The results of enlightened treatment, and the conclusions
of those who make insanity a study, are as likely to promote the ad¬
vancement of the cause as anything that can be written.” The
Reports of every hospital for the insane in this country, and of many
abroad, were sent to him. He read them all, generally making it a
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316 Psychological Retrospect. [July,
rule to do so immediately on their receipt, so that the remembrance
is distinct of seeing him seat himself after the coming of the after¬
noon mail in a chair near one of the western windows, report in hand.
His own long series remain not only a history of this institution
and a memorial of his work, bat as a whole these Reports form a
most practical treatise on insanity, deserving the attention of the
general reader as well as of the medical stndent. They give also,
indirectly, a picture of public opinion in regard to insanity and its
treatment daring the period of their publication. In the different
phases of the subject taken up from year to year it is seen where Dr.
Kirkbride, as an experimental teacher, felt his knowledge likely to be
of most avail. They are, with the book on Hospitals for the Insane,
his principal literary works.
He was naturally fond not only of the manual task of writing,
which he performed most rapidly, but also of giving utterance to his
thoughts on paper. He wrote good English, and had, as part of his
mental endowment the power of clear and correct, and often beautiful,
expression. But this was a native gift unlike that for building or for
mechanics, for management of general affairs or for personal influence,
which his high idea of duty bade him partly to restrain rather than
to develop to the utmost. “ I cannot feel it right to shut myself up
to write/* he would say, and sometimes, u I wish I could think that
duty allowed me to deny myself to those who ask to see me, but I
have never felt I could do so, even when I have writing on hand; ”
and therefore it became second nature to write, not as an author, but
as the physician and superintendent ready to answer every call.
It must, then, be remembered that these Reports were penned, not
in the seclusion of the student’s closet, nor as the fruit of that retire¬
ment which often produces fair but untried theories, false to philan¬
thropy, because untrue to experience, but by one fresh from the hourly
duties which pressed upon him, testifying of what he saw and speak¬
ing of what he knew. His exhortations to kindness and consideration,
and practical wisdom, in the care and treatment of the insane, both
acute and chronic, his descriptions of the high character needed in
persons occupying any position in an institution specially provided
for these sufferers, were written in moments snatched from his un¬
ceasing labours, and perhaps just after having his patience and his
tenderness sorely tried in soothing the irritable, or comforting the
sad, or calming the excited, or possibly—and this was still more
trying—after being made grievously aware that much of the best aid
he could secure in his great task was, at times, sadly below his
ideal. Indeed it was a frequent remark that he never had any
trouble in managing the insane, but that his only difficulties lay
in the management of the sane. After his return to his own
home from his duties at the hospital, the interruptions to his
literary work and to his correspondence, which often involved much
serious thought, and of which from first to last he took unaided
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1884]
charge, answering with his own hand every letter of every kind
requiring a reply, were almost endless.
Friends of patients came for inquiry, or to seek merely the comfort
his words afforded ; applicants for the position of attendant sought
him ; brother-physicians called to talk over some obscure case ;
husbands or wives, brothers or sisters, parents or children, brought
their afflicted dear ones to ask his counsel in their need—such visits
often requiring a long and separate interview with each party;
mechanics came to seek their orders about the building or the
improvements continually on hand; patients, nurses, employes, or
officers from the hospital asked his quick decision upon some knotty
point, the decision not always shutting off subsequent discussion.
It is a curious fact in this life of much correspondence and other
work with the pen, that neither at the hospital nor in his own
home had he a spot exclusively his own, where either in study
or consultation could he be sure of not being, at least, looked in
upon by those with whom he shared his right to each apartment.
His library at his own house was also the dining-room and
the favourite room of the home. There stood his desk and chair ;
there he wrote, and planned, and thought; there his older children
centred all the sweetness and most sacred memories of their early
lives; there in later years his younger children and his grand¬
children, never dreaming of causing annoyance, for annoyance was
never shown or expressed, came to play unchecked, and to seek
the unfailing sunshine of his presence. “ You never disturb me,
you never disturb me,” was the answer to any apology for seemingly
ill-timed interruption on the part of the older members of the family.
His sympathy was so ready in every enjoyment, in every vexation, his
judgment so ripe in every household decision, that even the burden of
the little things of family life—from which some men of large respon¬
sibility shrink rightfully as an irritating addition to their weightier
cares—was brought to him. How could one help carrying even
trifling troubles to such patient ears ; how could one resist craving the
sympathy of those tender eyes ; how could one wait for his rarely un¬
occupied moments to ask his wise and soothing counsel ?
Yet notwithstanding his wonderful gift in the management of the
housekeeping of the wards, so that report said : “ Dr. Kirkbride
never fails to see when a counterpane is laid crooked on a bed,” and
his eye was most quick to detect the least want of cleanliness at the
hospital, in his own home, criticism, unfavourable criticism, was un¬
known. At table, complaints of food which chanced to be im¬
properly prepared were more distasteful to him than the unsavoury
dish. “ Why speak of anything which does not suit you ; it requires
little discernment to perceive that an article is poorly cooked ? ”—and
so his taste was learned, not through fault-finding, but by the food left
untouched upon his plate. His hours for meals were never materially
changed. “ People know when they can find me at home,” was the
Digitized by LiOOQle
818
Psychological Retrospect. [July,
imperative reason for keeping the early dinner hour chosen in 1841.
For twenty-five years he breakfasted in summer and winter at half¬
past six, and coming down at that time his family almost always
found him at his desk. As may be inferred from his early rising, he
was in the habit of retiring early also. He writes : “ Abundant ex¬
perience justifies the opinion that regular and early hours for sleep
will do more than all other causes combined to enable any one with
no special constitutional advantages to undergo for long periods
much physical and especially great mental labour, with all the
depressing influences that every life is exposed to, without serious
injury.” Knowing the labour he was called to undergo each day, he
made it a matter of principle almost invariably to stop all mental
work, no matter how engrossing, at or a little after ten o’clock. His
usual hour of return from the hospital was nine o’clock, frequently
half-past, so that he took but a small part of the evening for his
own.
When others complained of weariness, he has been heard to
say : “I am always tired at night—I have scarcely ever known
what it was not to be so; ” but of the irritability of which many are
conscious as the result of great fatigue, he acknowledged himself
utterly ignorant. His strong will and his command of his powers of
mind were shown in the manner of seeking repose. “ I have long
made it a habit,’ 1 he said, in counselling those who complained of
inability to sleep, “to stop thinking the moment my head touches the
pillow ; had I not done so, I should never have been able to perform
the work, or to endure the trials or the fatigue I have undergone.”
Some of these are homely details, but when the strong light
of home, falling on a life of public service, discloses only beauty,
it is right to draw the curtain and reveal its rare perfection. And so
it was that the old house in which he lived, bright and cheerful as it
is with its many windows, whoever might be within it seemed
to grow dull and empty when he left it, and to be brighter and more
full of joy when he returned; thus his home-coming several times a
day from the hospital was ever, to young and old, a fresh and con¬
scious happiness.
But the peculiar feeling of restfulness and help in the mere know¬
ledge of his being near was probably never so fully realized by any
as by his female patients. The mere report in the morning that Dr.
Kirkbride was absent for the day caused a strange sense of loss;
his short yearly vacations, only twice during his long service pro¬
longed to four weeks, and generally lasting but three or less than
three, were weeks when personal troubles were hardest to bear, and
delusions of the mind most consciously painful; while his return,
even to those with whom insanity meant blackest despair, brought an
emotion more nearly akin to glad relief than any other the sufferers
knew. It may chance that some who read these words in the sunlight
of reason and the happiness of home will recall the feelings just
Digitized by <^.ooQLe
1884.] Psychological Retrospect. 819
described, and will remember how often they and their fellow-patients
gave them expression. A lady, living in England, who spent but a
day or two in his home some years ago, wrote lately : “ I suppose no
one ever came across Dr. Kirkbride, even for as short a time as
I did, without feeling a presence of goodness and kind wisdom, it did
one good to be near. One did not need to be sick in mind to acknow¬
ledge his healing, strengthening power.” This is, indeed, true ; but
to the insane this healing, strengthening power was priceless in its
influence. One, not long since his patient, writes : “ I have never
known any one whose presence commanded such reverence and love.”
Great as was the interest he took in directing the building and im¬
provements of the place, and great as was his ability in these respects,
it was within the wards that he found his chief delight, and there also
that the strength and the graces of his nature showed themselves most
clearly. In 1849 he wrote : “ The buildings of the hospital being now
completed, the undersigned looks forward with great satisfaction to the
increased amount of time which he hopes to be able to give to the interior
of the establishment, and to perfecting the means of restoring mental
and physical health, and smoothing somewhat the rough places on
the road of life of those who must look to this spot as their earthly
home.” To know him thoroughly, one needed to see him in the
wards surrounded by those to whom his life was devoted. Perhaps,
also, none knew him so well, or so thoroughly appreciated his power
over the insane, as those restored to reason under his care ; for they
had felt and realized in themselves the effects which others had only
seen. None prized so truly the value of his words, and even of his
looks, as those who in the sore distress of mental suffering and
despair, or amid the vagaries of a disordered intellect, had felt the
soothing, calming influence of a spirit which, whatever its inward
struggles might have been, gave to others the impression in all out¬
ward show of speech, and look, and tone, that it had reached a centre
of repose.
How conscientiously from the first Dr. Kirkbride exercised his
personal ministry, more potent, perhaps, in itself than the many re¬
medial agencies gathered within this institution, suoh sentences as
the following, taken from the earliest Reports, give a clear idea : “ At
the visit of the physician and his assistant, which commences at half¬
past 8 o’clock in the winter, and at 8 o’clock during the summer,
every patient is seen and spoken to—unless there is some special
reason for an exception.” " No favourable opportunity is neglected
for personal intercourse with the patients, and for free and friendly
conversation on any subject in which they are interested ; not except¬
ing, in many instances, their own cases and their own peculiarities or
those of their neighbours.”
This seems the place to speak of Dr. Kirkbride’s outward appear¬
ance, which was in keeping with his inner nature. Of medium height,
rather below than above it; slight in form in earlier life, in later
Digitized by <^.ooQLe
820
[July,
Psychological Retrospect.
years he was somewhat stouter. His hands and feet were small, his
step wonderfully quick and elastic. His face not handsome, but with
marked features ; his nose characteristic and unusual, but excellent;
his mouth in expression of will-power most decided, but also most pure
and gentle; his eyes, perhaps the most distinctive feature of a face
in which on examination every feature was noticeable, so deeply set
beneath an overhanging brow, that many thought them dark or even
black, were in reality blue, and by no means of the darkest shade.
They were very bright and clear, and in them tenderness was con¬
st-ant ; in moments of emotion they grew brighter with love or pity ; in
merriment they often sparkled. His brow was unusually broad and
full, and in youth was partly covered by thick black hair, which for
many years had been much thinner and tinged with grey. Some
persons, seeing him without acquaintance, failed to perceive anything
specially marked or striking in this man of middle stature, but to
others his face immediately disclosed the traits of an unusual
character, elevated above ordinary humanity, and those who knew him
best and loved him most, found his face as beautiful as the perpetual
revealer of the beauty of his soul.
Dr. Kirkbride had in him a large capacity for friendship, and for
inspiring it in others. Calm as he was in outward manner, and
usually most reserved in the utterance of his inward feelings, the still
waters of his heart ran through a deep, broad channel. Those who
knew him most intimately were sometimes almost startled by the proof
of the intensity of his affections. It has been said of him with truth,
“ few had so many friends.” Men of the most differing traits
spoke of him as " a most lovable man.” The nurse who tended him
through the last months of illness said : “ I never knew a man so
lovely.”
His power of winning friendship was great, and so also was his
faith in his friends. He was never known willingly to speak evil of
any man, but to refer to the wrong-doing of a friend was real and
acute pain, almost a torture, never voluntarily endured.
u A proper system of management in a hospital for the insane em¬
braces a liberal provision for securing the physical health and the
happiness of the incurable as well as for treating those who are likely
to be restored. It is a relief, in many cases not easily estimated, for
friends and relatives to know that those who are doomed to lasting
insanity may at least have a home where, as far as possible, all their
wants will be provided for and their safety insured, and where, if the
enjoyments of reason cannot be restored to them, life will often be
made cheerful and many of its pleasures be freely enjoyed. The
incurable cases have, in this institution, always received a large share
of attention.”
In 1848 he writes : “ In no branch of treatment for the insane is
there greater room for progress, nor one in which important results
are more likely hereafter to be attained, than in that which is directly
Digitized by <^.ooQLe
1884.] Psychological Retrospect. 321
mental in its character. It is not in the early period of the disease
that it is so essential, but after the acute stage has passed, where the
malady appears disposed to assume a chronic form, or even where in¬
dividuals seem to have reached that point at which they are too apt to
be styled hopeless, and where neglect and ill-treatment are sure soon
to make them so. It is, indeed, to the mentally lowest class of
patients in our hospitals that attention should be most steadily
directed ; it is among these that will yet be found the widest sphere
for benevolent labour, and from which results will occasionally flow
that will reward anyone who engages in the work in the true spirit of
perseverance and without faltering, because the field is less promising
than some others.
“ It must be in a low state of civilization when, in any institution
for the insane, the young and amiable, those who are highly talented
or accomplished—who are able to impart as much pleasure as they
receive in their intercourse with others—who give little trouble, and
whose delusions injure no one but themselves, are not treated with
kindness and attention, and do not receive the sympathy and affec¬
tionate care of those whom accident or official duties bring in contact
with them. But it is for those whose minds seem gone, and those
who offer nothing attractive in their characters, but whose diseases
have made humanity appear almost repulsive—careless in their
habits—violent or perverse in their behaviour, with an apparent in¬
capacity to appreciate many kinds of attention, that truly Christian
feelings and an imperative sense of duty seem required to actuate any¬
one to the kind of devotion to their welfare that is both desirable and
important.
u The lower and more troublesome the class of patients, the more
likely are they to be neglected, ill-treated, or injudiciously managed
by those who are not actuated by the highest and purest motives of
action. It is for the care of this class that good judgment, kind feel¬
ings, and cautious discrimination are especially desirable, and too
often least found. No one can tell how much harm may be done at a
certain stage of mental disease—and who shall say where this stage
begins or ends—by a single harsh word, by a rude manner, or a rough
tone of voice, nor how much aid to a recovery may be given by a
steady and unvarying course of conduct of an exactly opposite
character.”
Closing Years .—In October, 1879, Dr. Kirkbride was attacked
by an obscure and serious illness ; after various changes of condition,
some of which were to the last degree alarming, about the beginning
of the year he was so exceedingly ill that, in common with most of
his medical advisers, he himself despaired of recovery. To the sur¬
prise of all, he rallied and gradually regained his health. The
energy of his character and his enthusiasm in work proved not in the
least abated.
It hod for many years been his desire to re-write and to publish a
Digitized by v^ooQle
322 Psychological Retrospect. [July,
second edition of his book on Hospitals for the Insane—long since
out of print—feeling it a duty before his days of labour should
be over to make a complete record of his views on construction and
organization, but the ever-pressing and continual demands upon his
time rendered it impossible for him to carry out this earnest wish.
During a brief holiday just before his illness he had at last fairly
started, but only started, upon the task. The period of convalescence
was hailed as auspicious for its fulfilment. The hours of returning
strength, which most persons feel are justly devoted to light reading,
or to the other limited amusements permitted an invalid still confined
to his room, were spent in the difficult duty, far more difficult than
that of writing a new book, of remodelling and adding to his book,
published originally in 1853. In the early morning his voice was
heard playfully summoning to work : “ Come, remember we have a
book on hand ; no time is to be lost ; if there were pen and ink ready
I am sure I could dictate a good sentence.” Remonstrance was use¬
less, and to guard against an interdict by his physician, a promise of
entire secrecy was secured from his family, and it was well kept. His
attending physician made his visits to his patient, the doctors from the
hospital came bringing their daily reports, and friends called to con¬
gratulate the invalid on his improvement, quite unconscious that near
him the manuscript on which he had just before been busily engaged
had been hastily concealed.
Thus the spring months ran on, work once more the key-note of his
days, and after spending four weeks from home, more than three of
which were passed under the hospitable roof and the devoted care of his
friends, Dr. Charles H. Nichols and his wife—at the Bloomingdale
Asylum, New York City, of which Dr. Nichols is superintendent—he
returned home to resume, as far as possible, the old routine of hos¬
pital duty. His devotion to and enthusiasm in his charge were
unchanged ; between hospital-cares and the oversight of the printing
of his book, his time and strength were fully used, and at the New
Year, 1881, he had the pleasure of sending a copy of the secretly-com¬
pleted volume to his physician, causing the most entire surprise. The
old burdens had again came upon him, and except that he was willing
to take more rest than ever before, and that fatigue came more easily,
there was no greatly marked change in outward life, and certainly
none in the activity of liis earnest spirit. The many friends who loved
him blindly hoped that having passed 6afely through so severe a test,
and having shown the greatest tenacity of life and wonderful consti¬
tutional vigour in a frame by no means robust, he was to be spared
to them, and to his duties among the afflicted, far longer than the
ordinary term of human existence.
His last years were full of pleasant memories ; as a rule, never were
his spirits brighter. The weekly gatherings during this time, when all
his children and his grandchildren met around his table, will never be
forgotten, nor the zest with which he returned, after the enforced
Digitized by v^ooQle
Psychological Retrospect .
323
1884 .]
absence, to the 'evening entertainments of the hospital. As in his
youth he had won in an unusual degree the confidence and love of his
elders—as has’ been seen by the trust placed in him by older physi¬
cians and surgeons, and by the Boards of the Frankford Asylum and
of the Pennsylvania Hospital—so in age, he was the friend and chosen
companion of the young. His feelings remained unchanged ; within
him there was no growing old; age touched him lightly, and even
then its power was all without.
It may be mentioned here—and it was too striking a fact in
Dr. Kirkbride’s life to be omitted—that notwithstanding the vast
amount of labour he performed, he was still able, when he felt duty
permitted it, to command, as it were, a certain amount of leisure. He
had leisure for long, patient interviews with those who called upon
him in consultation; leisure to soothe and sympathise; leisure at
times to give his friends. “ Without haste, but without rest/*
described the conduct of his life.
At the close of 1882 and the beginning of 1883 many matters of
much importance and engrossing thought weighed upon him. His
hours of duty at the hospital became evidently more exhausting, but
he could not be deterred from his regular, and even more than regular,
visits.
In February he wrote the last of the numerous papers contributed
by him to medical journals—a review of “ Chapters in the History of
the Insane of the British Isles,” which appeared in the April number
of the “ American Journal of the Medical Sciences.”
His illness speedily developed into typhoid pneumonia; after a few
days his condition became very alarming. The prostration was so
entire that the services of a trained nurse were soon found necessary.
This was somewhat of a shock at first, as his family, unaided, had been
able to care for him through his previous illness, but with character¬
istic courtesy and self-forgetfulness, the assistant was received with
the greeting, “ I fear I shall not be able to give you much pleasure
as a companion.” When attacks of fever came on, and his mind for
the time was dulled, his affections kept all their brightness; then, not
several times during the day, but whenever the members of his
family approached his bedside, words of the sweetest tenderness were
spoken, so that when they left him for their rest at night, distracted
as they were with anxious fears, the accents of love they had heard
6till made melody about them.
After this period Dr. Kirkbride was from time to time on the point
of death, but rallied in a most unexpected manner, and even got out
of doors again. His mind was clear throughout his illness, and his
resignation was complete. “ I have not a thought,” he said, “ but
of entire thankfulness.” On Saturday, the 15th December, 1883,
although very weak, apparent gain was made. On Sunday morning,
the 16th, his condition was less favourable ; he became unconscious
about three o’clock in the afternoon ; about nine o’clock his pulse
xxx. 22
Digitized by <^.ooQLe
824 Psychological Retrospect. [July,
grew rapidly weaker, until gently and peacefully, at a quarter before
midnight, with only a momentary struggle, he expired.
During the days between Dr. Kirkbride’s death and his funeral,
great sorrow, but great peace also, was in his home. On Thursday,
the 20th December, after the family had met at an early breakfast,
the room before referred to—as at once dining-room and library—was
prepared for the last time to receive him. His desk was closed, his
chair was empty, the books collected through a long lifetime were
around him, never more to be opened by his fingers. The grey light
of the cloudy winter morning fell sharply on the brow which even in
death was full of the expression of intellectual power. All his family
gathered once more about him, who in that room had ever been the
centre of each social festivity, the fountain of each family joy. For
the first time they met with no response to filial love in those beloved
features; though of them he had said, four years before, when
he thought himself dying, lt I love them as much as it is possible for
a man to love his children.”
“ There were great underlying forces in him which I knew and
admired,” writes one who knew him well. “ All that was beautiful
in his character gathered around and sprung out of and adorned those
strong features, as the vines and wild flowers spring out of and
beautify the rock on which they grow. Gentleness and humility, and
patience and love,* were all charming parts of his native and Christian
character. But his intense earnestness, his resolute will, his stubborn
adherence to every principle that he adopted, the bravery of all his
convictions, the loftiness of his conscientiousness were the qualities
that lay like the rock beneath the beautiful surface that graced
his character.”
Conclusion .—Memoranda for a Report, found since his death, illus¬
trate some of his views :—
“ Contributions to Science .—The highest achievement of medical
science is the restoration of the sick to health. Whatever helps to
do this is a contribution of the highest form. In this list are
embraced all remedies of every kind, not medicine proper alone, but
everything that can have any claim to be styled a remedy—all moral
means, all surroundings of every kind, all the experience of the past,
as given in books, all the knowledge obtained by personal observation.
“ It is only when science fails in its efforts that the revelations of
pathological investigations—the field of the scalpel and the microscope
—become possible.
il While all the work where science fails in her first great object
is to be encouraged, in the hope that something may come in the
future, it is to be feared that much more is anticipated in many
quarters from this source than is likely to be ever realized, and that
too close a devotion to these investigations may lead to a neglect of
many means of caring for the insane, which we know from a long
observation never fail to be useful when properly and persistently
employed.
1884.]
325
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Psychological Retrospect.
“ The Work of the Future .—The work of the future will be found
to consist much more in perfecting in practice what is already theo¬
retically understood than in the introduction of great novelties. The
general principles that should be recognised in providing hospitals, in
managing them when provided, and the essential features of the
proper treatment of the patients, ought at this day to be tolerably
familiar to all careful inquirers in reference to the best interests of
the insane. Novelties are not to be rejected because they are novel¬
ties any more than the results of enlightened experience should be
ignored because they are not appreciated by those whose estimate of
their value is lessened simply because of their having been long used.
While extended observations and protracted experience may naturally
be expected to demand an intelligent trial of all proposals for radical
changes before their final adoption, they will not refuse this test to
any proposition for which reasonable grounds for trial can be given.
“ While many theoretical views are likely to continue to be
advanced and contested, it is fortunate that there are so many
practical points on which there need be no difference of opinion, and
that the most enthusiastic can always find enough to do, about the
propriety or expediency of which there can hardly be a question.
“ While referring to this work for the future, it may not be amiss
to suggest a few matters that may safely be kept before the attention
of governing bodies, and which are applicable to most—perhaps, it is
safe to say, to a greater or less extent, to all our institutions.
“ First among these may be mentioned—Rendering all buildings
occupied by the insane as nearly fire-proof as possible.
“ Improvements in the general attractiveness and home-like com¬
fort of the wards.
“ An increase in the libraries and of general reading matter,
directly accessible to the patients.
“ Greater facilities for carriage-riding, inside and outside of the
grounds, so that all patients unable to walk sufficiently may have
every advantage to be derived from this soutce. Among both sexes,
but particularly among the women, the benefit derived from this
form of passive exercise in the open air is very great, and the want
of extensive enough facilities for its enjoyment is everywhere lamented.
“ New modes of occupation and amusement, and of carefully
regulated labour.
“ Greater facilities for letting all the patients of every class have
the benefits that result from musical performances. The music that
can be given as often as desired by a few cultivated employes is an
institution to be regarded as a remedy of no small value.
“ A higher order and a greater number of companions to the
patients, and of attendants actuated by a genuine interest in the
work, so that cultivated patients—all patients, indeed—can constantly
have near them a reasonable amount of congenial society, capable of
fairly realizing the condition of those under their charge, and of
contributing to their comfort and happiness.
Digitized by <^.ooQLe
826 Psychological Retrospect . [July,
“The more thorough instruction and examination of attendants,
and the rejection of those who, after a reasonable trial, prove to bo
incompetent or unqualified for the work they have undertaken.
“ The manifestation on the part of those in authority everywhere
of a proper appreciation of the value of the services of those who
exhibit a special proficiency and fidelity in the performance of their
duties, whatever they may be, and, as now and then happens, evince
a self-sacrificing spirit which no money can purchase.
“Inducements should be offered, by adequate compensation and •
permanence of position, to secure the best talent in the medical pro¬
fession for the superintendence of these institutions, without which it
can hardly be expected that those likely to best fill these posts will
give up the more tempting and profitable as well as less onerous
results of other branches of professional labour.
“ The employment of an adequate force of attendants, thus reducing
the use of mechanical means of restraint to a minimum.
“ A sufficient number of medical officials to permit the most
thorough and careful study of every case, for keeping all records of
treatment, and increased facilities for pathological investigations.
“ The clinical study of insanity when permissible, so conducted as
to be of no injury to the patients, and to give to the general prac¬
titioner a greatly extended familiarity with the disease.
“ It is scarcely necessary to say that all great improvements in
institutions for the insane beyond their present capabilities necessarily
involve a considerable increase in the amount of their expenditures.
But if by the liberal use of these means the great objects for which
hospitals were established are promoted, it may fairly be claimed that
this is only to be regarded as a part of a wise system of economy.”
As all Dr. Kirkbride’s outward energies, for a period far exceeding
the usual term of active work, were given to the insane, so were his
thoughts also. As years went on, it seemed to those who knew him
most intimately, that while his soul expanded, and his sympathies
with all good aims deepened, his thoughts became more engrossed, if
it were possible, with the great object of his life.
It has been said of Dr. Kirkbride that—“ Labouring with a single
aim for the relief and welfare of those to whose care he had devoted
more than forty years of his life, he has left behind him, in what he
has written and in what he has done, a monument which will stand so
long as the care of the insane will require the aid of those institutions
with which his name and his fame have been so imperishably con¬
nected.”
The Board passed the following resolutions after his death :—
Resolved —That by the death of Dr. Kirkbride this institution has
lost a most faithful and efficient officer, whose untiring and well-
directed labours for some forty years have not only met with the
cordial approval and co-operation of this Board, but have wrought a
Digitized by <^.ooQLe
1884.] Psychological Retrospect . 827
high and enduring reputation for him, and for our hospital for the
insane, over which he so long and ably presided.
Resolved —That Dr. Kirkbride’s works for the relief of the insane,
both in the administration of his office in our institution, and by his
contributions to medical literature upon the subject of insanity and
its proper treatment, entitle him to rank very high among the bene¬
factors of his race.
Resolved —That by the death of Dr. Kirkbride we lose a friend
bound to us by uncommon ties of affection and esteem. No one
could come within the range of his influence without being made to
feel that his rare endowments of head and heart were such as to
attract the love and confidence of all his fellow-men, and throughout
his life he well deserved that love and confidence.
PART IV.—NOTES AND NEWS.
THE MEDICO-PSYCHOLOGICAL ASSOCIATION.
The usual Quarterly Meeting of the Medico-Psychologioal Association was
held at Bethlem Hospital on Tuesday, 6th May, 1884, Dr. Orange, President, in
the chair. There were also present—Drs. J. Adam, A. J. Alliott, R. Baker, D.
Bower, Bonville B. Fox, H. G. Hill, Henry Lewis, H. C. McBryan, Chas. Mercier,
W. J. Mickle, H. C. Major, A. Newington, H. H. Newington, J. H. Paul, W. H.
Platt, T. T. Pyle, H. Rayner, G. H. Savage, H. Sutherland, James Stewart, D. G.
Thomson, C. M. Tuke, D. Hack Tuke, T. Outterson Wood, &c.
The following gentlemen were elected Members of the Association, viz.:—
J. Walter Scott, M.R.C.S., &c., Assistant Medical Officer County Asylum, Fare-
ham, Hants; Robert L. Stewart, M.B., C.M. Glasgow, Assistant Medical Officer
County Asylum, Glamorgan.
The President said that he much regretted to have to inform the Members
of the Association that they were not to have Dr. Manley as their President for
the ensuing year, and they would be the more sorry to hear this when they
learned that the cause of his withdrawal was ill-health.
The General Secretary then read a letter from Dr. Manley, regretting his
inability, through ill-health, to fulfil the office of President, to whichhe had been
elected at the last Annual Meeting.
Dr. Savage said he was sure that the news contained in Dr. Manley’s letter
would be received with concern, and the least they could do would be to unite
in a vote of condolence, and to convey to Dr. Manley their regret that his health
necessitated his not holding office during the ensuing year, and their hope that
he might be able to fulfil the duties of President in some other year.
Dr. Adam seconded the motion, which was carried unanimously.
The President said that the rules of the Association provided that in the
event of any vacancies occurring in any of the offices of the Association, the
Council should have the power of filling them up until the next Annual Meet¬
ing. In consequence, therefore, of that unexpected vacancy, it had become the
duty of the Council to fill it up. It was not always an easy matter for a Council
to do what the rules of an Association empowered them to do. It was all very
well for the rules to say that the Council may or shall do such and suoh a thing,
and it was sometimes difficult to carry out what rules said might or should be
done; but he was sure the meeting would be gratified to learn that the Council
Digitized by <^.ooQLe
828
Notes and News,
[July,
had, on the present occasion, been able to discharge that duty, and they would
be doubly glad to hear that Dr. Rayner, who had for some years past been per¬
forming the duties of General Secretary, had, at the request of the Conncil,
consented, at this short notice, to undertake the duties of President for the
ensuing year. He was sure all present would be delighted to hear this, and he
saw that he might take it for granted that the thanks of the meeting might be
conveyed to Dr. Rayner for so kindly filling up the gap.
Dr. Rayner said that he had already thanked the Council for the honour they
had done him in selecting him to fill the vacancy in the office of President, and
he now begged cordially to thank the meeting for the kind way in which they
had endorsed the action of the Counoil.
Dr. Hayes Newington read a paper on “ Unverified Prognosis.” (See
Original Articles).
Dr. Stewabt said that the paper just read was one of such wide interest,
and opened up so many different points for consideration, that he scarcely knew
where to begin. He oould, however, warmly thank Dr. Newington for having
placed before them so many suggestive thoughts, and he would mention one or
two points which had occurred to him. It had been his own good fortune, early
in his dealings with insanity, to have had the opportunity in his father's asylum
of seeing the effects of religious excitement in the large district from which
the patients were derived, at the time of what was then called a religious
revival, and when allusion was made to an instance of religious rhapsody occur¬
ring in a case, incidentally, as it were, and not as the cause of the disease,
it occurred to him that religious exhibitions led oftener to incorrect prognosis
than perhaps anything else. He remembered that at the time he referred to,
the friends of the patients were very anxious to know whether the insanity,
which was in many cases very serious, was likely to be permanent. The diffi¬
culty in a great many cases was to recognise and discover, even with the assis¬
tance of the patients' friends, whether the religious rhapsody was due to the
last impressions of the* patient during the excitement of the revival, or whether
the excitement of the revival had brought out the insanity which originally had
nothing whatever to do with religion. There was, of course, in these cases a
natural tendency on the part of the patients’ friends to look upon the disease
which they observed to follow so closely upon the religious excitement as being
likely to result in permanent recovery j but, on the contrary, the disease in
which, to the untutored mind, the prognosis would have been favourable, turned
out to be anything but so. Those cases of insanity in which the disease was
brought out by the religious excitement of that revival, became more frequently
chronio than the majority of other cases. That suggested an element of diffi¬
culty in regard to prognosis which was interesting, taken in connection with
another difficulty. They often found that the daughter of an accomplished
gentleman, of good society, and who had been brought up in the lap of luxury
and refinement, would, upon the development of insanity, give utterance to the
most filthy and indecent expressions. In this case had the insanity warped the
power of self-control and prevented the elegantly-nurtured young lady from
controlling the impulses which were natural to herself, or was it owing to the
fact that, when insane, she would evolve apparently out of her own mind what
was incoherent in it P In this question a great deal was involved bearing upon
prognosis. In the case of religious rhapsody it was very often found that that
which had last caused the greatest impression on the mind was brought out
most prominently in the earlier development of the disease, but in the case of
the bad language there appeared brought out what most probably had not been
a late impression, but could only be accounted for upon the assumption that in
early years, when the mind was very impressionable, the patient might have
heard those things from servants and otherwise. Now, the question might
arise as to which of the states of the brain thus indicated was the more likely
to recover normal health, and he hoped that other speakers would help them
to unravel the mystery.
Digitized by v^ooQle
1884.]
Notes and News.
829
Dr. Savage remarked that in matters such as that now before them, it was
a pity they could not all sit together round a large table and talk it out. The
subject was one upon which everyone knew something, and if the question
passed round were, “ What were the greatest mistakes you ever made ? ” the
results would be very edifying. During the reading of the paper he himself
had put down a few of the cases in which he had made gross mistakes. Alco¬
holism was one of these. Did they all get well ? It seemed to him there were
certain cases which never did recover. Syphilis was looked upon as most
curable, but they had most of them had experience of oases suffering from
syphilis—syphilitio history and syphilitic symptoms without any doubt—yet
they could do no good with them ; and he was afraid they were likely still to
have such oases. It only made one hesitate about giving any prognosis. He
remembered years ago meeting a physician in consultation, to whom he gave
his opinion, and said, “ I think the patient will get well probably in three or
four months ” The physician turned round and said, “ You are paid for an
opinion, and not for a prophecy. I have given up prophecying for thirty years.”
The question arose, by the way, whether, where they did not believe there was
any chance of recovery, they had a right to hold out hope. There were cer¬
tainly classes of patients who seemed incurable. Such were cases of delusional
insanity, with hallucinations of all the senses, persons believing they had gal¬
vanic batteries inside them; persons who believed that smells and faeces were
always being poured into their rooms, and so forth. Still, in cases where he had
given very bad prognoses the patients did get well. One in particular he could
think of, who was recovering, although he had thought there was no prospect
of it, but there perhaps the questions suggested by Dr. Newington ought to have
influenced his mind, for the patient had been a taker of morphia. There was
haematoma of ear, too j and he remembered that up to recent times a person
with a string round his finger was looked upon as not likely to recover. It was
a question whether there was one condition which might be put down as hope¬
less. As to prognosis in youth, people came to him on visiting-days, saying,
“ I hope you think my son will get well j he has youth on his side.” This was
fallacious. With regard to the question often asked, “ Do you think this
person will have a recurrence ? ” he might say that in the more acute cases,
and the cases in which what had been called “ brain fever ”—the acute deliri¬
ous mania—had occurred, his opinion was that they were less likely to recur
than others. Then, were oases more likely to recover because the cure was
rapid ? One read in text-books that the prognosis was worse when the patient
got well rapidly. He feared that was a fallacy, or, at all events, a question for
further consideration. He had briefly referred to some of the many stumbling-
blocks he had met with in regard to prognosis, and hoped that the other
speakers would add information upon the subject.
Dr. Mercieb, after referring to the many points opened up by the paper,
eaid that he could heartily endorse Dr. Newington’s first conclusion, that when
friends of patients asked questions the best way was to take them into their
confidence. The time had gone by when the medical man could pose as an
oracle, and much more good was to be gained by gaining the confidence of the
patients’ friends. There were many oases in which no certain prognosis could
be given, and if they did not take the patients’ friends into their confidence they
must shuffle, and that was neither dignified nor right. Dr. Newington had
mentioned an exceedingly interesting case of a patient who appeared to be the
subject of general paralysis with a perfeot assemblage of symptoms, but who
afterwards, as it appeared from history, might have had all the symptoms
accounted for by previous circumstances of his life. Dr. Newington said that
the history might mislead, but it struck him (Dr. Meroier) that the history
might account for the disease. It was impossible to take any one factor; they
never got the same assemblage of factors and symptoms, and each case must
be taken upon its own merits. There was a certain class of hallucinations in
which he thought they were almost justified in giving a competent prognosis,
Digitized by {jOoq le
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Notes and News.
[July,
and he might gay that in hit own experience, where they had hallucinations of
hearing, associated with alcoholism, with the prolonged use of alcohol the
prognosis was decidedly unfavourable. He had never known such a case to
reoover. As to rapid recovery, he had been told by an experienced alienist
always to expect a relapse in such cases, and in the instances which had come
under his notioe this had been verified.
Dr. Hack Tukk was glad that Dr. Newington had referred to the conditions
of the patient in the future as well in the past, and laid great stress upon that.
It was a most important point, and, of coarse, introduced an element of very
great difficulty. Dr. Newington had referred rather to the unfavourable con¬
ditions which would arise; but they ought also to take into account the favour¬
able ones, among which might be quoted the effects of change. A prognosis
most unfavourable might be given and remain true up to the time of a change
of residence. In assuming the importance of heredity in giving prognosis, Dr.
Newington, no doubt, referred rather to the question of relapse than of re¬
covery from the first attack. If not, probably more stress might have been
laid upon the probability of recovery from the first attack, even with strong
insane inheritance. He (Dr. Tuke) did not doubt that the fact of inheritance
would make relapse more probable. A much more important consideration,
and one to which Dr. Newington just referred, was the constitution of the
patient. Though he might have no insane ancestors, one so often found, on
examining a case, that the patient had been somewhat peculiar throughout life,
and taking that into consideration, the prognosis would have to be very un¬
favourable ; whereas, if there were a distinct change from the natural character
from some cause, the prognosis would be comparatively favourable. With
respect to what Dr. Stewart had remarked, it had often struck him that one
reason why ladies carefully brought up gave expression, when they became
insane, to such bad language, was that the very fact of the restraint which
had been used by them while they were well to avoid expressions of that kind,
and in every way to get rid of them—the strenuous effort made to keep the mind
clean—resulted, when insanity took place, in a reactionary outburst of the foul
language which had been repressed when the patient was sane. He had been
very much interested in the paper, and it struck him as very remarkable that
they had never had one read so specially upon prognosis, except, indeed, that by
Dr. Sutherland. Probably the reason of this was the extreme difficulty of
speaking in any way dogmatically upon the point, and laying down definite rules.
The President said that aB he must then leave, he would take that oppor¬
tunity of expressing his thanks to Dr. Newington for his paper. He agreed
with Dr. Savage that it was a paper opening up many important questions,
and one upon which all present might have something to say ; and in saying
these,few words he could not attempt to exhaust the subject, but only wished
to thank the author of the paper and to express his regret at having to leave
before the end of the meeting. No doubt what Dr. Hack Tuke had said as to
the paucity of papers on prognosis was true. It might be owing to the fact
that the particular class of patients who came under Dr. Sutherland and Dr.
Newington’s treatment had relatives who were muoh more desirous of obtain¬
ing information about their afflicted friends than some others were. He
himself was at the extreme opposite pole in regard to that. There was in his
own case, certainly, no excessive haste and eagerness among friends to gain
information as to the patients ; and they could imagine the difficulties which
physicians laboured under in such circumstances.
Dr. Eayner then took the chair.
Dr. Hayes Newington, in reply, said that he knew that he would hear some
remarks as to the wideness of the subject. He was alarmed when he found
that he had written so much, and, as a matter of fact, he had knocked off
about a third; which would account for Dr. Hack Tuke not hearing about
many cases where favourable results had occurred. With regard to Dr.
Savage’s remark on the ethical question, whether one was justified in giving a
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1884.]
Notes and Nens.
331
prognosis when they saw such a case as that of the general paralytic to whom
he had referred living twenty years in comparative comfort, he thought one
might say that no case was incurable; and so the ethical question suggested
need not arise. As to youth, he had very much the same views as Dr. Savage.
It must, of course, be borne in mind that youth was a kind of sieve, being the
first critical time at which hereditary predisposition showed itselfj and in
these oases heredity was an important consideration. As to Dr. Mercier’s
remark on the paralytic case, he was entirely at one with him. He really
wished to accept the history, but the opinions of two physicians of the first
order had forced him to abandon that view.
Dr. Mercier asked whether the physicians were in possession of the history ?
Dr. Newington said he thought so. He then referred to Dr. Hack Tuke’s
remark as to the change of a patient from one asylum to another, and said
that he should probably have introduced that into his paper if he had had
time. He had seen good results from it, and had been going to suggest that
some energetic superintendent of a county asylum should make a suggestion
to his Committee as to an exchange with another asylum of cases whioh were
hanging fire. He had seen this done at Morningside. With respect to Dr.
Orange's remark as to the friends requiring information, the truth was that
they had to pay a great deal of attention in private asylums to the friends'
wishes. In county asylums medical superintendents really did not have meet¬
ings with the friends to anything like the same extent.
Dr. Bonville Fox read a paper on “ Exaltation in Chronic Alcoholism.”
(See Original Articles).
Dr. Bayner said he felt sure they must all thank Dr. Fox for his paper. He
only regretted that the lateness of the hour would not permit their entering
upon any full discussion of it that afternoon. If they attempted to com¬
mence a discussion of it, he feared that justice could not be done to it in so
brief a time as remained at their disposal. He would, therefore, leave it to
the meeting to say whether the discussion of the paper should be postponed
to the next meeting j or would Dr. Fox be disposed to allow it to pass undis¬
cussed F There still remained to come on resolutions standing in the name of
Dr. Mercier of considerable importance, and he thought the meeting would
like to be able to deal with them before separating.
Dr. Bonville Fox said that he would defer to the wish of the meeting.
Dr. Stewart said that Dr. Fox's paper related to a matter of such general
interest now, that it would be a great pity if an Association such as theirB should
lose the opportunity of discussing it. If no one else would step into the gap,
he should be very happy to introduce the subject in some short way at their
next meeting, which, however, would be the annual one.
Dr. Bayner said it was quite in the power of the meeting now simply to
adjourn the discussion.
Dr. Stewart said he would move that the discussion of the paper be post¬
poned to a future meeting ; that would leave the question open.
Dr. Savage seconded the motion, whioh was carried j Dr. Hack Tuke re¬
marking that if the space in the Journal permitted the paper should appear
in the July number, in which case the members would be able to have it before
them and discuss it at the next meeting.
Dr. Mercier then read the following:— I desire to draw your attention
to a class of persons, probably the most unfortunate and the most unhappy in
Her Majesty’s dominions ; and not only to them, but to another and probably
more numerous class—our fellow-countrymen, who are immured in the
asylums of foreign nations, and are separated by impassable barriers from
their country, their home, and their friends. The facts are doubtless suffi¬
ciently familiar to all present, but this is one of those cases in which familiarity
has, I will not say bred contempt, nor even indifference, but has allowed all
vivid recognition of the facts to lapse out of consciousness. In the same way
those who are always resident in a mill become at length unconscious of its
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Notes and News.
uproar. It may not, therefore, be gnperflaoas to dwell on the subject with a
little insistence. The lot of a lunatic sequestered in an asylum is at the very
best a forlorn and pitiable one. It is pitiable even when it is alleviated by
every amelioration that affection can prompt, that ingenuity can devise, or
wealth can purchase. Even the lunatic who is blest with abundance of this
world’s goods, and with the more effectual solace to be found in “ troops of
friends,” is in pitiable case, for he is deprived of the most precious of all
human possessions—his personal liberty. The fate of the pauper lunatic is
far harder; but few of us, I venture to think, familiar as we are with the
facts, realize the full severity of what they have to bear. They live a life in
common; solitude and privacy are to them unknown. Day and night, month
by month, and year after year they are compelled to associate with companions
whom they have no voice in choosing, and whose manners and habits are many
of them distasteful and repulsive in the extreme. Of the chronic lunatic it
may truly be said that he labours without reward, he lives without hope, and
he dies unregretted. Dark as this picture is, it by no means represents the
worst. There is one class of lunatics the special hardship of whose lot forms
a conspicuous feature in every report of the Commissioners in Lunacy, and
whose troubles form a perennial text for their homilies. These are the out-
county patients; and we are all familiar with the forcible expressions with
which the Commissioners refer to the justice of their complaints that all
access of friends is denied to them. Confined in an asylum outside the limits
of the county to which they belong, they are so far separated from their
homes, either by distance or by time, or, what is equivalent to both, by
expense, that they are precluded from even an occasional visit of those who are
near and dear to them. Still, however, they are among their fellow-countrymen.
They are among those whose manners and customs and ways of living are akin
to their own, who speak the same language, and to whom they can without
difficulty make known their wants. It is far otherwise with the unfortu¬
nate people on whose behalf I now appeal to you. Separated from their
native country, from home, from family and friends, there are not a few
of these unhappy beings who are unable to speak a word of the language spoken
around them, and who are as completely cut off from all human converse as if
they were condemned to perpetual solitary confinement. In the midst of a
crowd, they live a life of nnutterable loneliness. The people by whom they are
surrounded, but from whom they are separated by a barrier impassable,
although impalpable, are foreign to them in language, in habits, in mode of life,
and in religion. Deprived of country, of home, of liberty, of reason, and of all
companionship, their lot is one which, for the elements of unhappiness that it
contains, can scarcely be paralleled among the human race. When we re¬
member that this description applies not only to those citizens of foreign
nationality who are immured in the comfortable asylums of our own land, but,
in a still more aggravated sense, to those of our own oountrymen who are
sequestered in the bare and comfortless asylums of some continental countries ;
when we remember that the system of management and treatment of lunatics
is not in all countries as humane and merciful as it is with us; when we bear
in mind that the roving disposition of our race must ensure the existence of a
greater number of Englishmen in foreign asylums than of foreigners in the
asylums of this country; the appeal to your sympathies and tt> your sense of
justice will become, I hope, irresistible. The resolution that I have the honour
to propose formulates a principle. It does not attempt to enter into details of
practical working, for that is, as I imagine, not within the scope of our func¬
tions. The difficulties in the way of making a working arrangement may be
great, may, if you please, be insuperable; but what does man come into this
world for, but to make difficult things easy, and impossible things possible ? If
we do not move in this matter, no one else will. But our function is to supply
not the machinery, but the force to move the machinery. The evil will not be
remedied until the facts are known, and unless we publish the facts, they will
Digitized by <^.ooQLe
1884.]
Notes and News.
883
not be made known. We may not succeed, but we can at least do our best, and
attain the relief of knowing that the responsiblity for the evil does not rest
upon those who have done their best to remedy it. I beg to move—
(1) That, whereas the confinement of persons in lunatic asylums of nationality foreign to
their own places such persons in a position of peculiar and exceptional hardship, it is, in
the opinion of this Association, extremely desirable that arrangements should be made
between this and other nations for the transference of such persons to the country to which
they belong. (2) That a copy of the foregoing resolution be forwarded to the Secretary of
State for Foreign Affairs (with an explanatory note).
Dr. Hack Tuke seconded the motion, saying that in travelling in
France and Germany he had seen some of the disadvantages under which
English patients in foreign asylums laboured, and he < could endorse what
Dr. Mercier had said. Undoubtedly, however, the evil was much greater in
regard to foreign patients in English asylums.
Dr. Rayner said that he could endorse what Dr. Mercier had said respecting
foreign lunatics in English asylums, and there could be no doubt that their
condition militated against their recovery. He had mentioned this fact in one
of his annual reports. The proportion of foreign lunatios at Hanwell was
double what it ought to be, which might be partly due to the want of re¬
coveries, partly to the natural attraction which a large town like London had
for insane persons of a roving disposition, and partly also to the indifference
to the shipment of lunatics to this country. In New Zealand, Australia, and
elsewhere very stringent rules were made to prevent shipment of lunatics.
In England there were no rales, and as a consequence we get more for our
share. Having regard to this, he doubted whether they would find that the
proportion of Englishmen in foreign asylums did bear such a proportion to the
number of Englishmen scattered over the face of the earth, because foreign
countries took care to get rid of English lunatics. The subject was of great
importance, and he thought that Dr. Mercier’s proposals should be adopted,
both from a scientific and a politico-eoonomical point of view.
The motion was carried unanimously.
The proceedings then terminated, and the members afterwards dined
together at the Holborn Restaurant.
Correspondence.
To the Editors of “ The Journal of Mental Science.”
Gentlemen, —If Dr. Huggard’s criticisms of my Definition of Insanity are
left unanswered, it may perhaps give rise to the impression that I regard them
as unanswerable, but at the same time they exhibit so complete, fundamental,
and far-reaching a misapprehension of my position that I despair of being able
to deal with them within the limits of a letter, and must leave the matter over
until I can deal with it at such length and with such completeness as will not,
I trust, leave room for further mistake.
I would point out, however, that while in his first criticism Dr. Haggard
attributes to me words that I never used, he gives, in his second criticism, to
the words I did use, a meaning widely different from that in which they were
employed by me. When I speak of the environment as a “ term,” it is, as is
clearly laid down in the page from which Dr. Huggard quotes, as the term of
a relation—as “ one of the terms between whioh the relation subsists.” Dr.
Huggard deals with it as if I used it in the sense of a logical term—a distor¬
tion of meaning which partakes of the nature of a pun.
Tours truly,
Chas. Mercier.
April 10.
Digitized by <^.ooQLe
834
Notes and News.
[July*
AFTER-CARE.
The Annual Meeting of this Society will be held on Thursday, the 3rd of July,
at 3 p.m. Lord and Lady Brabazon have kindly allowed the meeting to take
place at 83, Lancaster Gate.
H. HAWKINS,
Hon. Sec.
Chaplain’s House, Colney Hatch,
June 15,1884.
BRITISH MEDICAL ASSOCIATION.
Annual Meeting, Belfast, July 29th, 30th, 31st, and August 1st, 1884.
Section—Psychology.
President ... George Henry Savage, M.D., London.
Vice-Presidents ... D. Hack Tuke, M.D., London.
Isaac Ashe, M.D., Dundrum, Dublin.
Dear Sir, —We beg to remind you that the next Annual Meeting of the
British Medical Association will be held at Belfast on Tuesday, 29th July, and
the three following days. In the Section of Psychology, in addition to the
usual papers, the following special subjects have been selected for discussion:—
1 . Envployrnent of the Insane .
2. Varieties of General Paralysis .
3. Use of Alcohol in Asylums,
4 . Moral Insanity and Imbecility.
5 . Legal Persecutions by Discharged Patients.
We trust that you will be able to be present at the meeting, and to take part
in the discussions. Although it has been thought desirable to introduce special
subjects for consideration, it is by no means intended to exclude other topics,
and we shall be happy to receive any communication which you may desire to
bring before the Section. The titles of all such papers, and notices of inten¬
tion to join in the debates on the first three of the special subjects above-
named, should be sent to us not later than the 28th of June. It is necessary
that abstracts of all papers to be read in the Section should be sent to us before
the 12th of July.
We are, dear Sir, yours faithfully,
ALEX. STEWART MERRICK, M.D.,
District Asylum, Belfast.
S. REES PHILIPPS, M.D.,
. St. Ann’s Heath, Chertsey.
N.B.—No paper must occupy more than 15 minutes in reading, and subse¬
quent speeches are limited to 10 minutes.
REVUE BIBLIOGRAPHIQUE UNIVERSELLE DES SCIENCES
MfiDICALES.
We have been requested to insert the following:—
Revue bibliographique universelle des Sciences medicales avec Index alpha-
b&tique annuel indiquant les matieres contenues dans les journaux spdoiaux et
les ouvrages publics en toutes langues et dans tous les pays, classes d’apr&s
l’ordre m4thodique des sujets trait4s, suivi d’une Table alphab&tique des auteurs,
publication mensuelle dirig4e par le Doctenr Cte. Meyners d’Estrey.
Digitized by <^.ooQLe
Notes and News.
335
1884.]
I/objet de cette Revue est de mettre le praticien et Fauteur k mdme de
retrouver immfediatement les souroes k consulter pour un sujet quelconque.
La Revue Bibliographique formera tons les ans un fort volume grand in-8°
d’au moins 600 pages. Prix de Pabonnement: 30 fr. par an. Pour s’abonner,
il soffit d’6crire k M. Ch. Gr&miaux, secretaire general, place Saint-Miohel, 6,
Paris.
MEDICO-PS Y C HOLO GIC AL ASSOCIATION.
THE ANNUAL GENERAL MEETING
Will be held at the
Royal College of Physicians, Pall Mall, London,
On Wednesday, the 23bd of July, 1884,
Under the Presidency of H. Rayneb, M.D.
I. MEETING OF COUNCIL AT 10.30 a.m.
II. GENERAL MEETING AT 11 a.m.
Agenda:
1. Dr. ObANGE will resign the Chair.
2. Reading the Minutes of the last Annual Meeting.
3. Statement of Accounts.
4. Election of Officers and Council.
6. Fixing the Place of next Annual Meeting.
6. Election of New Members.
7. Election of Honorary Members.
8. Reports of Committees.
Aftebnoon Meeting at 2 p.m.
1. The Pbesident’s Address.
2. Paper by Dr. Newth, on the value of Electricity in the Treatment of
Insanity.
The ASSOCIATION Dinneb will take place at u The Ship,” Greenwich, at 7
p.m. Members wishing to attend are requested to communicate their intention
to the Treasurer, Dr. Paul, The Terrace, Camberwell, S.
LUNACY AND PAUPERISM.
At a recent Poor Law Conference in Glasgow, Dr. Yellowlees read a highly
interesting paper on the above theme. He urged that every county or district
should have two type% of asylums for its pauper insane; one a hospital, fully
equipped with the best means of treatment, and receiving all new cases, the siae
not exceeding 300. Another building, erected at half the cost, should be devoted
to chronic cases only, and should receive no patients except from the cure*
asylum.
Digitized by <^.ooQLe
336
Notes and News,
ALCOHOLIC BE YE RAGES IN ASYLUMS.
The following circular has been forwarded to the Superintendent of every
Asylum in Britain, except Private Asylums. Should any Superintendent not
have received one, he is requested to communicate with the undersigned:—
1. Average number of Patients resident during last year (1883).
2. Persons having their Meals in Asylum in addition to Patients.
3. Do you give Beer or any Alcoholic other than medicinally P And if so
what is the allowance P
4. If not, do you give any substitute ?
5. What was the average weekly cost, per Patient, in 1883, for supplying
Alcoholics (including Brewery expenses, when Beer is brewed in Asylum) P
6. What was the expenditure during the above year in—(1) Beer, (2) Porter,
and (3) Wine or Spirits, respectively ?
7. Are your Attendants and Servants allowed Beer ?
8. If not, what, if any, substitute or equivalent do you give P
9. If Beer and other Alcoholics have been disused as a beverage in your
Asylum, will you briefly state your views as to the result upon the health of
the Patients and the discipline of the Wards p
Please address reply at ewrVy convenience to
Dr. D. Hack Tuke,
Hanwell, W.
Appointments.
Grant, Henrt L., Assistant Medical Officer at Garlands Asylum, appointed
Assistant Medical Officer to the Buckingham County Asylum, Stone, near
Aylesbury.
Huggard, W. R., M.A., M.D., appointed Assistant Physician to the West
End Hospital for Diseases of the Nervous System, Paralysis and Epilepsy.
King, Thos. Radford, M.D.Ed., appointed Resident Medical Superinten¬
dent, Hokitika Hospital, New Zealand.
Phillips, Sutherland Rees, M.D., M.Ch.Q.U.I., appointed Medical Super¬
intendent of the Asylum, St. Ann’s Heath, Chertsey.
Scott, J. W., late Surgeon R.N., appointed Junior Assistant Medical Officer
to the Hants County Asylum, Knowle, Fareham.
Sheldon, Thos. Steele, M.B.Lond., M.R.C.S., Appointed Medical Superin¬
tendent of the Chester County Asylum.
Smith, Wm. Beattie, F.R.C.S., L.R.C.P.Ed., appointed Acting Medical Super¬
intendent of Sunbury Lunatic Asylum, Victoria.
Tatham, C. J. Willmer, M.R.C.S., L.S.A.Lond., appointed Assistant Medical
Officer, Wameford Asylum, Oxford. 1
ERRATUM.
In the April number—page 40, line 2, for w certain” read “ uncertain.”
We regret being obliged to postpone to a future number a review of
the Collected Articles of the late Professor Las^gue, of Paris. His “ Etudes
Medicates,” edited by M. Albert Brun, are in two large tomes, and are a mine
of scientific Wealth*
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THE JOURNAL OF MENTAL SCIENCE.
[Published by Authority of the Medico-Psychological Association]
No. 181. new n! e £! es ’ OCTOBER, 1884. Vol. XXX.
PART 1.—ORIGINAL ARTICLES.
Presidential Address , delivered at the Annual Meeting of the
Medico-Psychological Association , held at the Royal College
of Physicians , London , July 23rd, 1884. By H. Rayneb,
M.D.
Gentlemen, — I cannot commence my address without re¬
minding the Association of the regrettable circumstance
which has resulted in my having had conferred upon me the
honour of occupying this position to-day.
Dr. Manley, who had been elected President at the last
annual meeting, would have officiated in that capacity on the
present occasion had not an attack of illness unfortunately
compelled his resignation. I am assured that the Association
will sympathise with me in my regret at not being a listener
to-day to the rich stores of information which Dr. Manley’s
ripe experience would have furnished, and will unite with
me in the anticipation that, with restored health, at a future
date Dr. Manley may yet fill the Presidential chair.
For myself, called upon somewhat late in the year to oc¬
cupy this post, I could have wished for a few more years of
experience before undertaking this duty, and a few more
months in which to have collated facts in relation to the sub¬
jects I am about to bring under your consideration. For
the purpose of an illustration, a man’s mind may be con¬
sidered as a solvent for experiences, and it may be held to be
desirable, in psychic as in chemic processes, that the solvent
should have approached saturation before crystallization
is commenced. I feel that I should have desired a denser
solution from which to deposit thought-crystals, to be sub¬
mitted to the critical examination of this Association,
although I am assured of personal consideration for my
shortcomings.
xxx. 23
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338
Presidential Address ,
[Oct.,
Mental disorders constitute a subject so extensive and
many-sided that it would seem impossible that there should
be any difficulty in selecting an aspect or relation from which
to view them with some prospect of novelty. My illustrious
predecessors in office, each delving at a special side of the
subject, have however, scarcely left an opening which I can
assay without tempting a, to me, invidious comparison.
Thus, in recent years, the History of Insanity has been
graphically described by Dr. Hack Tuke, Mental Pathology
by Dr. Maudsley, Therapeutics by Dr. Crichton Browne,
Legal Relations by Dr. Orange ; and I might extend the list
still further to show that the past and present have been so
fully covered that only the future of insanity would appear to
be left for consideration.
The future of insanity, indeed, offers a large and important
subject for speculation, whether considered in relation to
legislation, probable increase, or progress in curative and pre¬
ventive measures; and to these points I shall specially
endeavour to direct attention.
The Association is aware of the fact that “ The Consolida¬
tion-and Amendment of the Lunacy Laws” is the title of a
Bill that has been announced as one of the Government
measures in the next Session of Parliament.
Legislation in this direction has been pending for several
years past, and from the uncertainty pertaining to Parlia¬
mentary performance may still be deferred; but so definite
and authoritative a promise as that which has been recently
given, renders it at least probable that this is the last oppor¬
tunity that may occur at an annual meeting of our Associa¬
tion of expressing opinions on some of the most important
matters involved in this legislation, many of which seriously
affect the welfare of the insane and the professional interests
of alienist physicians.
The private asylum question is foremost among these,
forming the basis on which rests the agitation that has in
great measure brought about the desire for legislation.
The agitators who inaugurated this movement have not re¬
frained from casting the most virulent aspersions on the
moral and professional character of the private asylum pro¬
prietors, who constitute an important part of our Asso¬
ciation. These gentlemen are debarred by the circumstances
of the case from answering the vilifications thus shrieked at
them; and I strongly feel that I should be neglecting a duty,
as your President, and as a disinterested member of this Asso-
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1884.]
by H. Bayner, M.D.
339
ciation, if I did not emphatically express my opinion as to the
gross character of these aspersions, and my belief that they
are without any foundation whatever in existent facts.
The result of the recent Parliamentary Commission would
have entirely exonerated the proprietors of private asylums
in the eyes of all but persons whose minds were prejudiced by
imaginary wrongs, or by the remembrance of a past state of
things, or by the desire to reap advantage from coming
changes.
The total abolition of private asylums is one of the stock
cries of these agitators, and has been re-echoed even by some
of our medical authorities. The advisability of this pro¬
cedure is a fair subject for debate, but, when considered with
a view to practical results, it must be remembered that at
present the State has made no provision to replace the private
asylums, and that to accomplish this would require time and
a very considerable outlay of capital. Due consideration also
should be given to the fact that the private asylum proprietors
have hitherto provided for a great public need, and have
invested both professional reputation and capital to this end.
A gross injustice would be committed were any great
change made without recognising these circumstances.
If fair recompense were made by the State, most private
alienists, I believe, would welcome the abolition of their
establishments.
That such a change is right and politic is by no means
certain.
If the State assumes the care of every insane person, such
a measure might be practicable; but so long as the guardian¬
ship of the insane devolves upon the relatives the right of
contract must also remain. The State has no more right to
insist that a father should send his insane son to a State
asylum than to insist on his sending his sane son to a Board
School, provided the father possess means to make a better
provision, or one more in accordance with his own views.
On the professional side, justice would seem to demand
that the physician who has obtained special reputation, or
experience in mental diseases, should not be debarred from
reaping the advantages thereof to himself, or from being of
service to his fellow-men.
Legislation of the character proposed would involve an un¬
precedented deprivation of liberty of action to the friends of
the insane and to members of our profession.
I believe that the absolute compulsory closure of the private
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340
Presidential Address ,
[Oct.,
asylums would, at no distant date, direct popular prejudice
against the public asylums. The allegation would soon be
made that the superintendent of a public institution, whose
increase of salary depended on the monetary success of bis
establishment, bad considerable temptation to prolong the
detention of well-paying patients.
The physicians appointed to such public asylums might not
always be selected on the strict basis of fitness. Nepotism is
not yet absolutely dead, and, in the future, political lobbying,
as in the United States, might make one road to such ap¬
pointments.
The abolition of private asylums ought logically to involve
the abolition of single patients; yet this last is a mode of
treatment strongly advocated by some of the medical oppo¬
nents of the private asylums, and is apparently regarded by
the Lord Chancellor’s visitors as the summvm bonum of
insane care.
The duty of the State would seem to be primarily demanded
for the provision of such institutions as are a public necessity,
and there already exists a great and urgent public want of
institutions where insane and imbecile persons can be treated
at a cost of from ten to fifteen or twenty shillings a-week.
At present, a large number of persons are most unjustly in
pauper asylums, on the footing of paupers, whose mainten¬
ance is entirely paid for by their friends; and a large num¬
ber of imbecile children are retained at home without treat¬
ment because their friends object to sending them to pauper
imbecile asylums, and have no other alternative. The lunatics
who are paid for are sometimes much annoyed at their
position, and at other times are irritated by not being treated
in a different manner from the absolute paupers. This en¬
forced pauperisation induces relatives to avoid their responsi¬
bilities, either wholly or in part; while they would probably
be stimulated to greater exertion if their insane relatives
could be differently classed.
Some public institutions have a few patients already at
the rates indicated, while others, that at one time devoted
many of their beds to this class, have been tempted from
their purpose by more lucrative inmates.
The need for public institutions of the character I have
described is both great and urgent, and I would suggest that
the opinion of the Association should be forcibly and prac¬
tically expressed on this point.
Apart from the provision of such asylums, the onus lies on
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by H. Rayner, M.D.
341
1884.]
the State to prevent unfair contracts or the abuse of the
laws with regard to the care of lunatics; and any safeguards
or supervision that may be deemed necessary to accomplish
these objects will be hailed with satisfaction both by the
specialty and the profession at large.
The order of admission to private asylums is presumably
one of the leading subjects to which legislative attention will
be directed. In discussing this, recognition should be made
of the fact that relatives, in sending insane persons to an
asylum, are only providing for their proper treatment, and
that to delay or hinder this by legislative enactment is as in¬
humane to insane persons as it would be to persons suffering
from inflammation of the lungs or broken legs.
The hindrance to treatment caused by the present system
of certification, from being habitual and customary, has
come to be almost regarded as a necessary and unavoidable
evil.
The delay arises from a variety of causes; foremost is the
prejudice against certification, a not unnatural one when
consideration is given to the popular views of insanity and
the lifelong stigma cast upon the individuals and their rela¬
tions by being practically branded as insane. Can it be
wondered at that medical men delay such a proceeding by
every possible means ? Even when the medical attendant has
brought himself to express his opinion of the necessity of
such a procedure, the friends will often not yield their con¬
sent for a considerable time.
Beyond this again, comes the delay in fulfilling the neces¬
sary formalities. , >
In some cases,.owing to fear of possible litigation, a medical
man refuses altogether to sign certificates, and another has
to be sought, who may require time for examining a patient
whom he has not seen before, and whom another practitioner
has refused to certify.
Where the medical attendant is willing to undertake the
responsibility, and knows, or is of opinion, that the person
is insane, certification may still be delayed from hesitation
as to being able to describe in writing the symptoms per¬
ceived in a way that shall prove the existence of insanity and
form a valid certificate.
In reference to the prejudicial results of these delays, I
have the opinion of two medical coroners, of large Metro¬
politan districts, that suicides have directly and indirectly
resulted from them, and, I believe, that if the attention of
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842
Presidential Address ,
[Oct.,
coroners throughout the country could be directed to these
matters, ample testimony of a similar character would soon
be accumulated. Instances of homicide and other criminal
acts, resulting from the same causes, might, I believe, be
also adduced; of injury to bodily health and impairment of
prospect of recovery, many members of this Association could
largely testify.
The remark has been made that when a law is bad or un¬
necessary, it is usually broken or avoided by public consent
in the most wholesale manner, and this appears to be the
case with regard to certification.
Hundreds of insane persons are yearly taken from their
homes and are detained for days in workhouses without being
certified. The necessity and practical advantage of this pro¬
cedure is recognised and admitted.
Many of these workhouses are in no respect adapted to
the treatment of the insane, and yet if these persons were
similarly taken to asylums, where all available means are
provided, what an outcry would result.
Private patients also have been not unfrequently deprived
of all liberty of action for weeks or months before their
removal to an asylum; so that as a mere safeguard of personal
freedom, certification would appear in practice to be useless.
The opponents of the present lunacy-laws have often
spoken of the power of giving certificates as if it were a
valued privilege of the profession, while the fact is that it is
a disagreeable duty, which commonly entails loss of practice.
An old practitioner once told me that he had never signed a
certificate of insanity without losing his attendance on the
family in which this had occurred. Moreover, it is a duty
that I consider ought never to have been thrust on the
profession, to be discharged at haphazard by any member,
however unqualified or unwilling to undertake it.
If the State requires certificates of this kind, trained and
specially qualified medical officials should be appointed to
furnish them.
Lord Shaftesbury recently pointed out that “ since 1859
there had been 185,000 certifications, every one of which had
been found just and good.” This alone should show how little
real danger there is of attempts being made to incarcerate
sane persons in asylums. I would suggest that this danger
would be better met by stringent personal examination by
governmental officials after admission, of all patients received
into private asylums, or private care, rather than by causing
Digitized by Google
1884.] by H. Kayneb, M.D. 843
the delays of treatment with the attendant evils which are
now incurred.
Better by far that in the 185,000 certifications there should
have been a few cases of wrong admission than that a single
death by suicide or a single loss of recovery should have re¬
sulted from these precautions.
I should regard any addition to the present bars to the
treatment of the insane as savouring of a cruel and inhumane
disregard of their real well-being, based upon the survival in
the public mind of that old prejudice against insanity,
founded on the erroneous belief of demoniacal possession.
This it is that leads even the most intelligent and well-
meaning layman to give attention to the clamorous exaggera¬
tions of demi-lunatics. Against this prejudice our specialty
must never cease to fight, until our asylums become hospitals,
and our patients are regarded and treated as human beings
suffering from bodily infirmity.
This, however, is the age of the tyranny of minorities, and
it is probable that further obstacles to treatment may be
developed by coming legislation.
The suggestion that meets with most favour from intend¬
ing legislators, provides that the order of admission to
private asylums should be signed by a magistrate on the
petition of relatives or friends.
We must hope that the magistrates’ duty will be limited
to ascertaining that the medical persons signing the certifi¬
cates are qualified to discharge that function, and are not in
any way contravening the provisions of the statute. For¬
tunate indeed will be the insane if they escape thus lightly,
and are not required to demonstrate their insanity to the
magistrate at least, if not to an intelligent jury.
The State, having duly satisfied itself in regard to the
legality of an admission to an asylum, ought to ascertain, at
the earliest possible date, that there was a medical necessity
for such procedure. This should be accomplished in such a
way that neither the patient, his friends, nor a court of law
could at any time doubt for a moment that the person ad¬
mitted was insane. The onus of this duty should not be thrown
on the private asylum proprietor, who is not in any sense a
servant of the State. At the earliest possible date after
admission the patient should be visited, and his insanity
tested and certified by one of the present Lunacy Commis¬
sioners, or by medical Sub-Commissioners, or by district
medical inspectors of the insane. Four or five additional
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844 Presidential Address , [Oct.,
officers ought easily to perform this duty, even if the
registered hospitals were included, the admissions in 1882
having been only 1,096 to the licensed houses, 106 to single
care, and 896 to the lunatic hospitals.
If this duty were efficiently performed by responsible
officials, under the direction and supervision of the Lunacy
Commissioners, much would have been effected to remove
the clamour against private asylums and the Lunacy
Laws.
The supervision of the detention of the insane might be
carried on by the same officials in their visits to certify
the admissions. The total number of private patients being
only about four thousand, this task would not be too heavy,
and should in some measure be made to relieve the work
of the present Commission.
The necessity for some aid to the Lunacy Commission
must be obvious, when it is considered that since its appoint¬
ment the number of lunatics and of asylums has more than
doubled, while the complexity of the functions discharged
has been almost indefinitely extended.
So great an increase in the extent and importance of the
duties of the Lunacy Board demands that there should be a
considerable increase in their rate of pay. This formerly
presented a respectable contrast with that of asylum-superin¬
tendents, but at the present time the general difference is
not very large, and there are several asylum posts at least
which are quite as lucrative as a commissionership.
It is to be feared that in the future the best men will not
be attracted to the Commission unless some such change be
made, and that the influence of the Commission will thereby
undergo considerable diminution.
The increased power of supervision which would be gained
by the appointment of sub- or deputy-commissioners, should
tend also to obviate the danger which at present exists of
the friends of patients, both in private asylums and public
lunatic hospitals, taking charge of them against the advice
of the medical officers. This action on the part of friends
not rarely leads to suicide, and constantly to relapses and
damage to the patients. The knowledge of individual cases
which the sub-commissioners would acquire should enable
them to support medical officers in preventing such ill-
judged action on the part of friends.
The appointment of additional medical help to the Lunacy
Commission should tend also to remove the present anomaly
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by H. Rayner, M.D.
345
1884.]
of barristers being called on to express opinions on condi¬
tions of disease which demand at least a medical training,
if not a special experience in the study of insanity.
The County Boards Bill is a legislative bogy that has been
shaken before our eyes for many years past. This at present
seems very remote, but when the evil does arrive, it may be
found that the interests of the insane may not be affected in
the unfavourable manner that has been anticipated. Before
this arrives it must be devoutly wished that a Minister of
Public Health may be appointed, and that insanity may fall
under his control.
In any case, the Association should not fail in repeatedly
bringing to the notice of the Government the resolutions
adopted by this Association in regard to the application of
the Government grant to the maintenance of asylums, and
in reference to the pensions of asylum medical officers being
assimilated to those of the higher class of civil servants.
I would suggest also that representations be made in
regard to increase of pay. This, at present, is fixed ac¬
cording to no definite scale, so that some medical officers,
after many years of service, find their incomes of less value
than at the commencement.
I would suggest that while there should be special increase
for special good service, there should be a regular rate of in¬
crement, so that this should not depend, as at present, on
any one of a score of accidental circumstances.
The future of insanity, in regard to the probability of
increase, or even of decrease, is perhaps the most interesting
of the forecasts of this subject, and is also of great practical
import in connection with the provision of additional asylums
or other accommodation. The accumulation of certified
lunatics in recent years, constituting an advance from 36,000
in 1859 to 76,000 in 1883, has been due chiefly to Several
causes the relative values of which are unascertainable, and
so do not afford data for estimates which might themselves
be invalidated by the introduction hereafter of new disturbing
causes. This only is certain, that the past apparent increase
has not been due to a corresponding development of insanity
in the community. This increase, apart from growth of
population, has been chiefly due to the extension of the
registration of lunatics, to the action of the Irremovable Poor
Act of 1861, and to the Government Grant to Lunatics, 1874;
to these may be added the increased longevity of lunatics in
asylums. The two first causes have probably ceased to be
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346 Presidential Address , [Oct.,
operative 5 the two latter have not yet exhausted their pos¬
sibilities.
On the other hand, there are some favourable elements in
the outlook.
The confinement of so many insane persons in asylums
ought sooner or later to tell on the production of insanity
by heredity.
Education, although as at present conducted productive
of some amount of insanity, will ultimately prove one of the
most potent agents in prevention, both by its direct and
indirect influence. The increase of the wages and leisure
of the working classes in recent years at first led only to
additional intemperance, the sole recreation permitted them
by the state of ignorance in which they had been kept. In
the future education may lead them to more varied and
intelligent recreation, with beneficial results to their mental
health and temperance.
Temperance, from this and other influences, is making
some progress in the working classes ; and there is every
reason to believe it will continue to advance, and in its turn
favourably affect the statistics of insanity.
General paralysis of the insane appears to me to have been
the one form of mental disorder in which there has been an
undoubted and very considerable increase. Yet, even here,
I believe that some favourable points may be found.
In my earlier experience, railway employes seemed to
furnish an unduly large contingent of this disease, which has
latterly diminished. This change being associated, I believe,
with the relief from excessive hours of work which this class
of men has obtained, I wish that the same relief could be
gained for the police force, for London coachmen, and other
classes who have unduly long hours of work, and who con¬
tribute an excessive proportion of this form of disease.
It would be impossible, in the time at my disposal, to give
due consideration to the action of all the various causes
brought into play by rapidly advancing civilization ; and I
must be content in pointing out the fact that during the last
four years at least, the rate of increase of insanity appears to
have been checked.
This satisfactory information is stated in the Reports of
the Lunacy Commission, which show that the ratio of ad¬
missions per 10,000 of the population in the last four years
has been 5*16, which compares favourably with 5*26, the
average of the four preceding years.
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1884.] by H. Rayneb, M.t>. 847
From this and other considerations hope may he felt that
the additional asylum accommodation to be provided for in
the near future will not be so extensive as that which has
been required in the past; and it would seem desirable that
such future additions as may be necessary should be regarded
as the completion of the structural apparatus for the treat¬
ment of the insane. On this view, opportunities hereafter
arising should be used for correcting errors that have
occurred in the past hurried provision for the sudden
expansions of lunacy.
Of the various modes of providing increased accommoda¬
tion, additions to old asylums appear to me to be the most
costly, since they sooner or later entail complete structural
re-organization of the whole administrative fabric, and the
results of such changes are often otherwise unsatisfactory.
Some of the old asylums, indeed, are structurally unfit for
the treatment of recent cases on any large scale, and might
with advantage be relegated to the reception of chronic
patients.
Large imbecile asylums may possibly have the advantage
of economy, yet I am unable to comprehend that the associa¬
tion in one large day-room of 140 imbeciles can be conducive
to their comfort, especially at such a distance from their
homes that they are practically divorced from their friends.
The aged imbeciles, if quiet and orderly enough to live in
the same room with so many others, might surely be better
provided for in their own parishes, where they might still
receive some pleasure from the visits of their friends, on
whom they would exercise the humanizing influence de¬
veloped by bestowing care and attention on the sick and
helpless. The present system, on the contrary, tends to
produce in the poor the habit of shirking their responsi¬
bilities to their aged and helpless relatives.
The Poor Law system is not readily moved in the direction
of more liberal measures, but I am assured that the more
this question of the care of the aged poor is enquired into
the greater reason will be found for a more philanthropic
treatment in workhouses; and one result of this, if adopted,
would be a considerable diminution of the numbers requiring
imbecile asylum-accommodation.
In place of increasing imbecile, or enlarging old asylums,
I trust all future opportunities will be seized to build
hospitals or asylums of moderate size for recent cases, in
which ample space, generous dietaries, and a large medical
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848 Presidential Address , [Oct.,
staff shall be provided, in recognition of the fact, which
cannot be too often repeated, that liberal (even lavish)
treatment of insanity in its early stages is the truest
economy, resulting in an increase in recovery-rate, and
consequent diminution of the chronic insane.
The future of treatment is, I think, the most hopeful out¬
look of our present position, and I would that the prospect of
prevention were as favourable.
In the memorable address of 1881, Dr. Hack Tuke pointed
out the difficulty of proving by statistics that there had been
any considerable advance in the proportion of recoveries, and
I must confess my inability to prove, by direct reference to
figures, that such progress has been made.
Indirect evidence, however, is not wanting. The increased
number of general paralytics and of aged persons in the
admissions of late years ought very considerably to have
reduced the recovery-rate; this has not been the case, and
the conclusion, therefore, may fairly be drawn that there has
been an increase of recoveries among the smaller proportion
of curable admissions.
Our progress in treatment , however, would appear to have
been more conspicuous on the negative than the positive
side, and to have consisted in great measure in clearing off
established errors.
Long after Conolly had dealt the death-blow to mechanical
restraint, chemical coercion survived in the form of tartrate
of antimony, cathartics and narcotics. The abuse of these
has been gradually dying out; and, as I am firm in the belief
that the most troublesome chronic lunatics of the old rSgime
were due to these abuses, I cannot but regard this as an im¬
mense gain.
The craving for specifics, which may be regarded as the
search for a medical philosopher’s stone, that should trans¬
mute disease into health, and in a few days undo the morbid
nutrition of a lifetime, or even of two or three generations,
has also died out.
Some alienist physicians are inclined to believe that our
knowledge of the action of drugs on special parts of the
nervous system may be used with advantage in forwarding
the restoration of healthy nutrition of the brain; others, and
I am one of these, believe that the difficulty of adjusting the
dose, of regulating the intensity and duration of drug-action,
has not been yet surmounted, and fear that collateral disad¬
vantages, produced by these drugs in the disorder of assimila-
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1884.] by H. Rayner, M.D. 349
tion and nutrition, would always more than counterbalance
any good that might be produced by their direct action on
the nervous centres.
I must confess that I have rarely satisfied myself of having
produced beneficial effects from the administration of such
remedies; but, on the contrary, have often had no doubt
whatever in regard to the evil done both by my own pre¬
scriptions and those of others. During the chloral epidemic
a few years since, I saw several cases of mere brain-fag, or
simple melancholy, which had been converted into protracted,
restless, suicidal forms of melancholia by the use of chloral;
and I have seen such ill-effects follow the use of other drugs,
when used with the view of curing states of chronic mal¬
nutrition, that I feel it a duty thus openly to express my
opinion. I do not, of course, debar myself from the use of
them in cases of transient functional disorders.
Much has yet to be learnt in our attempts to influence
directly the nutrition of the brain by the application of heat
or cold, by electricity, by counter-irritation, or by local
abstraction of blood. Dr. Tuke also will probably advocate
the use of hypnotism and the influence of the imagination ;
but these are scarcely as yet within the range of practical
therapeutics.
Whatever are the views held on the preceding points, all
agree that reparative nutrition of the brain is not probable
without an antecedent or corresponding improvement of the
general bodily health, and that it is necessary to be a good
general physician to become a successful alienist.
I have great pleasure in noting that the winner of the
Association Prize Essay for this year, Dr. Rutherford Mac-
phail, has, in Clinical Observations on the Blood of the Insane,
directed his observation to the action of tonics on the blood,
an earnest, I trust, of future exertions in this and similar
directions.
The open-door system is a point of treatment which has
drawn considerable attention of late. This has been ably
discussed by Dr. Campbell in the last number of the Asso¬
ciation Journal. I can add nothing to his acute examination;
but would say that I agree with him, that evidence is re¬
quired of the advantages of this plan, and in refutation of
the disadvantages that have been imputed to it.
Asylum dietetics still offer a considerable field for progress
and improvement.
The nutritive value of these, as far as I can gather from
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850
Presidential Address ,
[Oct.,
past asylum-reports, has, in many instances, diminished
during the past twenty years. This diminution, where it
has occurred, may be said to be counterbalanced by a more
liberal distribution of extras ; but with the greatest care and
attention, in this respect, a lowered diet scale is a source of
danger to recent cases treated in large asylums, in which
acute and chronic cases are mingled.
In variety of dietary much advance has been made—a
fortnightly diet table having, in some cases, superseded the
weekly monotony. I shall hail with congratulation the in¬
troduction of the first monthly list.
Beyond this, I think that more definite recognition should
be given to the necessity for adapting the dietary to the
winter and summer. Some such adjustment occurs in the
natural course of events; but these modifications, resulting
from season, might, with advantage, be increased, and be
more definitely stated in asylum-dietaries.
While on this topic I would suggest that the Association
should draw up and adapt an uniform system of diet scales,
so that it may be possible to arrive at the absolute nutri¬
tional value of a given dietary, and to compare it with others.
Some time since I endeavoured to make such an analysis
and comparison of existing dietaries; but I must confess
that I did not complete my task, the necessary computations
being so numerous and perplexing. For example, in many
diet tables, meat, uncooked meat, uncooked meat free from
bone, were or were not distinguished, and this meat might,
in quality, be beef, pork, or mutton, and, in state, be boiled
or roast, salted or tinned. The proportions of ingredients in
compound preparations were not infrequently described by
that definiteness of quantity which is recognised in the
expression, “the size of a lump of chalk.” I will only add
that my own diet-table may be taken in illustration of my
remarks.
Apart from these questions, more systematic attention
might be given to cooking. Good cooking depends on know¬
ledge and labour: the latter is a drug in asylums, and the
former might be increased by greater facilities for inter¬
change of information, which might be furnished by a corner
of the Journal being set apart for cooking queries and sug¬
gestions.
I cannot pass from the subject of dietary without alluding
to the introduction of enforced total abstinence in asylums.
The chief arguments advanced in favour of this measure
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351
1884.] by H. Rayner, M.D.
are economy, benefit to asylum discipline, and advantage in
treatment.
The economic argument may be dismissed, for there is not
much doubt that the value of the beer will have to be sup¬
plied in another and possibly more expensive form; but this
argument should not by itself be of value even if true.
If the distribution of beer leads to irregularities, this must
surely be a matter of discipline to be overcome or avoided ;
and matters might be rendered worse by a regulation which
would enlist the sympathy of friends, patients, and employed
on the side of smuggling. This can scarcely be admitted as
a valid reason.
It would seem unjust that because A drinks, B should be
deprived of his beer; nor does it seem right to deprive a man
of an habitual article of diet simply because he has become
insane, since experience has taught that the deprivation of
a habit may seriously interfere with nutritional repair.
Regarded as a therapeutic measure, it does not accord with
the general plan of asylum treatment which aims at inter¬
fering with personal comfort as little as possible.
Even as special treatment for the inebriate, its advisability
is open to debate. I believe that in these cases the most
assured success is obtained where the will of the patient is
enlisted, and habits of self-control are cultivated and
developed; by this forcible proceeding, on the contrary, the
will and desire of the patient may be arrayed against what
may be considered an injustice. Formerly I recommended
total abstinence to inebriates, but I found this so unsatisfac¬
tory in its results, that of late years I have insisted only that
stimulants should never be taken except at meals, and then
in a dilute form. This plan has been much more successful.
I have so frequently noted in the history of patients
admitted within the last few years that the mental disorder
had developed after a more or less protracted period of total
abstinence, not always in intemperate persons, that I have
been led to consider that there may be danger in recommend¬
ing this, by itself, as a panacea for inebriety. In every case
it should be accompanied by other changes in the mode of
life; by suitable treatment, in fact. The necessity for this
is widened by the knowledge that persons in moderately good
health often suffer considerably in their attempts at total
abstinence. The disregard of precautions in adopting tee-
totalism often leads to an intensified outbreak of intemper¬
ance, or to a break-down in the nervous system.
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352 Presidential Address , [Oct.,
I shall require convincing proof of the advantages of this
means of treatment before adopting it.
Much advance is still to be made in the amount of medical
attendance to be given to the insane in this country. English
asylums are built on the most liberal scale, but the medical
staff, until quite recently and with a few exceptions, was
provided with a strongly contrasted niggardliness.
In most countries it would be easier to obtain £5,000 for
structure than £500 for treatment, this perhaps being due in
some measure to the source whence the funds are derived.
Although some progress has been recently made, the pro¬
portion of medical officers to patients is still much smaller
in this country than in America and many continental
asylums.
Combined efforts are needed that this anomalous contrast
between lavish expenditure in building and niggardliness in
treatment may be rectified.
The training and instruction of asylum-attendants affords
ample scope for progress; much has been done, but much
remains to do. Dr. Campbell Clarke has published in the
Journal this year some results of his efforts at instructing
his attendants, who, I am assured, will be rendered more
efficient by having an interest in their work. No more im¬
portant curative influence could be brought to bear than by
developing intelligent and zealous activity in this direction
among lay asylum-officials.
I have been so strongly impressed by improvement occur¬
ring in the most unhopeful cases, as a result of the bestowal
of special care, that I have almost come to regard the one as
having a direct relation to the other.
Large as are the possibilities of advance in curative
measures, the great field for future progress lies in the pre¬
vention of insanity.
Efforts in this direction should be recognised as a funda¬
mental duty by every alienist physician, and the members of
this Association would render important service to the com¬
munity, by seizing every opportunity of diffusing information
in regard to facts relating to the causation of insanity.
To render our efforts more successful, it is desirable that
our knowledge on these points should be extended, and this
would be very considerably aided by the adoption of a system
of collective investigation.
The Statistical Tables of the Association may be con¬
sidered as a collective investigation, but outside the broad
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1884.]
353
by H. Rayner, M.D.
lines which they pursue are innumerable points which require
examination. I would wish that two or three of these should
receive special attention in each year.
Keeping in view the importance of our duties in regard to
the prevention of insanity, I would suggest that the first
subjects to which attention should be directed should be
those relating to the genesis of insanity.
I am of opinion with reference to mental disorder that the
paraphrase might be used, nemo repente fait insana , with
the liberal translation, that it takes more than one genera*
tion to produce a lunatic.
In the finer degrees of heredity alone exists a boundless
field of enquiry. What valuable additions to our preventa¬
tive knowledge would be gained, by arriving at some definite
conclusion why, in a neurotic family, one member may be
healthy, another neurotic only, another insane, or another
phthisical. These are questions which, however difficult,
I believe would yield to an extensive combined enquiry.
I will not weary you with suggestions of possible subjects
for research—their number is legion, and many of a character
to overtask individual powers or opportunities of observa¬
tion.
I shall endeavour to make my suggestion on this point bear
fruit by submitting to the Association a* f resolution for the
appointment of a Committee for Collective Investigation,
which, I trust, will obtain the earnest support of individual
members.
Vague and ill-defined as our present knowledge of the
genesis of mental disorders is, we may assert that these are
dependent on conditions that are removable or avoidable, and
are not the necessary concomitants of civilization, or the
inevitable attendants on humanity; and that insanity may
therefore be regarded as being largely preventable.
I have intimated my conviction of possible increase in
curative results, and I cherish the hope that in no distant
future, in spite of, even by reason of, farther advance in
civilization, the present rate of development of insanity,
through the combined action of preventative and curative
influences, may undergo not only arrest, but diminution.
Utopian although this expectation may be, the possibility
of its fulfilment should unite to more vigorous exertion in
the warfare waged against the prejudices, ignorances, and
errors which constitute the chief forces of our arch enemy.
Disease.
xxx. 24
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354
[Oct.,
The Value of Electricity in the Treatment of Insanity. By
A. fl. Newth, M.D., Haywards Heath.
Read at the Annual Meeting of the Medico-Psychological Association, July 23,
1884.
In the “ Journal of Mental Science ” for April, Dr. Alex¬
ander Robertson has referred to some observations of mine
on the effects of galvanism in the treatment of insanity.
These observations were made more than ten years ago. The
cases chosen were not quite suitable or satisfactory; they
were few in number, and the treatment was not thoroughly,
carried out. Still the results were far from being unsatis¬
factory ; in fact they alone were quite sufficient to satisfy me
that electricity, if properly and perseveringly applied in suit¬
able cases, is a powerful means of cure. I am confirmed in
this opinion not only by the results of these crude experi¬
ments, and others more recently and more carefully per¬
formed, but also from the value of electricity in other
neuroses to which insanity is analogous. There are few
who can deny, at least reasonably deny, that such neuroses
as paralysis, chorea, neuralgia, anaesthesia, &c., are benefited
in a most decided manner by electricity. There are forms of
insanity, as all authorities on the subject affirm, which seem,
if they really are not, identical with these neuroses, and it is
not at all preposterous to assert that if it does good in one
form of nervous disease it must do good in the other.
The therapeutical value of electricity in mental disease is
not by any means hypothetical only; it has been repeatedly
proved to be of real value by numerous observers in this
country, in America, and especially on the Continent. So
long ago as 1804 Galvani’s nephew, Aldini, is reported as
having cured two cases of melancholia by galvanism to the
satisfaction of several disinterested physicians who watched
the cases. Even prior to this we read that Dr. Bischoff, of
Jena, and Dr. Augustin, of Berlin, cured several cases of in¬
sanity with paralysis by galvanism. Some very interesting
researches on the subject, extending over fourteen years,
have been published by M. Teilleux,* M. Awzouy, formerly
physician to the Asylum of Mareville, Caesar Lombroso, of
Leipzig, Remak, Benedict, and other well-known Continental
* “ De 1’Application de l’Electricity an Traitement d’Alienation Mentale.”—
“ Annales Medico-Psychologique,” 1869.
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855
1884.] Electricity in the Treatment of Insanity.
physicians, have all recorded their belief in this remedy. In
England we have Dr. Radcliffe, Dr. Clifford Allbutt, Dr.
Duckworth Williams, and last, but not least, Dr. Althaus,*
writing also in favour of it.
We are, however, I believe, indebted to Dr. Arndt, of
Greifswald,t for the most complete record of the use of elec¬
tricity in insanity, and his remarks deserve attentiye study,
for his experience met with such marked success that he looks
upon this remedy as simply invaluable in insanity. He be¬
lieves that the reason why alienists have not been so success¬
ful hitherto with this agent is because their selection of cases
has not been sufficiently critical, and the applications have
been so unsystematic. This is no doubt very true; and
when we read in the report of a case that " galvanism has
been tried but was of no benefit/’ it is probable that this
means very little more than that it was not properly applied.
I believe that if these cases of apparent failure were inquired
thoroughly into, some cause would in nearly every case be
found for the want of success, and that under systematic
skilled galvanic treatment the same cases in which it seemed
to have failed would have been relieved, if not cured by it.
It may seem that, in saying this, I am making a very strong
assertion ; but when we consider how few there are who have
much more than a very vague idea of the effects of electricity,
the nature of the current, the proper mode of application,
and the cases for which it is suitable, we cannot be surprised
at there being so many failures. Dr. Althaus very truly re¬
marks, “ even by a careless employment of galvanism a few
accidental successes have been obtained; but in ninety-nine
cases out of a hundred, empirical galvanists, being unac¬
quainted with the physiological effects of electricity, have
been disappointed, and have brought the remedy into unde¬
served contempt.”
These remarks refer to the use of electricity in disease
generally and not to its use in brain disease specially.
It is not, however, necessary, though it might be ad¬
vantageous, that medical men who intend applying electricity
in the treatment of disease should be thoroughly versed in the
science of galvanism and its physiological effects. There are
a few simple rules which may be followed, even by those who
do not profess any acquaintance with the subject, with some
* See review of mine in “ Journal of Mental Science,” Vol. xx., p. 99.
t “ Die Electricitat in der Psychiatric.”—“ Archiv fur Psychiatrie und
Nervenkrankheiten,” Vol. ii., p. 271.
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356
Electricity in the Treatment of Insanity , [Oct.,
amount of success. It will not be unimportant if we con¬
sider some of the causes that tend to failure, and a few im¬
portant points to be noticed in order to obtain any benefit
from electricity.
The first consideration is the choice of a battery, and this is
one requiring great care and judgment. There are so many ap¬
paratus in the market which differ in their value considerably.
Some are perfectly useless, others do more harm than good ;
some work all right for a time, and then fail to act; others
apparently increase in power after a brief use; whilst others
again are intermittent in their action. Now it stands to
reason that an instrument with any one of these defects
would be perfectly useless, and therefore we must seek one
that shall be uniform in its action. But it is also necessary
that the battery shall be portable, easily set in action, and
not easily put out of order, powerful and reliable in its action
and economical. In this age of electric bells and electric
light it ought not to be difficult to get an apparatus fulfilling
all these requirements; but I very much doubt if there is one
that really does so satisfactorily. I have used Stohrer’s
battery, which is cheap, easily put in action, and works very
well for a time ; but the connections soon corrode, the zincs
get fouled, the carbons blocked up, and the entire apparatus
requires to be constantly attended to in order that it should
work properly. Perhaps the Leclanch6 battery that Dr.
Robertson used may be more reliable; there is also one called
Spamer’s, which appears to be a promising and useful affair,
and another suggested by Dr. Max Taube, which seems very
complete and convenient.
The best plan, of course, would be to obtain the advice of
a thoroughly experienced electrician as to the choice of a
proper apparatus. And as the batteries are so liable to get
out of order and require constant attention, it would, I think,
be well to make arrangements with an experienced person to
see to the apparatus frequently and keep it in proper order.
No doubt the post-office authorities would allow the men who
attend to their batteries to do this at a mere nominal rate.
It might be a very great advantage, if it is possible, and it
is certainly feasible, to obtain a vessel of some sort con¬
taining a large supply of electricity, which could be given
off slowly as required, and which could be sent to be re¬
charged when it is exhausted.
I have found an electro-magnetic apparatus answer ad¬
mirably in many cases; it is very portable, is always ready
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1884.]
357
by A. H. Newth, M.D.
for use, and will keep in order for years. It is, however, by
no means suitable for every case.
This leads me to remark that, before deciding on a battery,
it is necessary to determine what form of electricity is to be
used. Of course no one now-a-days would think of using
frictional electricity, so we are limited in our choice to the
various forms of galvanism or the continuous current, to
electro-magnetism or Faradism, and to magneto-electricity.
The physiological and therapeutical effects of these differ
inter alia considerably; but these effects are not thoroughly
understood as yet. We know, however, that a continuous
current passing from the nerve-centre towards the periphery
is a powerful sedative; that an intermittent current, an in¬
duced current, or an electro-magnetic current, is powerfully
stimulating. But the continuous current has also, what has
been called, a catalytic effect—that is, it has the power, in some
unknown way, of removing a morbid condition of the tissues
caused by defective circulation or by effusions, probably by
stimulating the tissues to an endosmotic action. It is also
electrolytic , but it is very doubtful if this effect could be
utilized in diseases of the brain, however desirable it might
be to do so, if it were possible.
The continuous current in its effects is also anti-spasmodic ,
anti-paralytic , restorative , stimulative and tonic , according to
the mode of application. It is therefore most essential for suc¬
cess that the necessary effect that is suitable for each parti¬
cular case should be carefully considered. It has been pretty
well determined experimentally, and by the researches of
Pfluger, Cyon and others, that a state called anelectrotonus ,
or depressed nerve-action, is produced at that part of the
nervous system which is connected with the negative pole of
the battery (the anode), and an increased excitability in the
neighbourhood of the positive pole (or cathode). The former
state has been called anelectrotonus , and the latter catelectro-
tonus. In excited states of the nervous system it is evident
we must obtain the former effect, and in depressed states
the latter.
There is, therefore, another very important point to be
considered, namely, the direction of the current. Properly
speaking, there are two currents, one passing from the anode
(negative) to the cathode (positive), the other from the
cathode to the anode; but the latter, being a feeble and un¬
important current, is generally disregarded, and the former
is the one that is spoken of as “ the galvanic current.”
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358
Electricity in the Treatment of Insanity , [Oct.,
A battery that has been some time in use, without proper
attention, becomes over-polarised, and other currents are
formed, or the chief current may pass in the reverse direction.
This may also happen from some faulty construction, or
arrangement of the elements, conductors or connections.
These errors may account for many failures in the use of
the electric battery. They also suggest the extreme im¬
portance of having a good galvanometer attached to the
apparatus, in order to show the force and direction of the
current.
As to the mode of application, I think, as a rule, it will be
found best to apply one electrode to the back of the neck,
about the second or third cervical vertebra, and the other
electrode to some distant part of the body, as the hand, the
foot, the lower part of the spine, the region of the liver,
kidneys, &c. I do not think it advisable to apply both elec¬
trodes to the head at the same time, for unless we wish to
obtain a powerful stimulant effect, or electrolysis, or some
such effect, it is questionable what good it can do in this
way. It may, however, be useful in order to cause absorption
of some tumour (or effusion) on the brain by catalysis; but
it is probable that the same result would be obtained by one
pole only.
In certain cases it is better to apply electricity mediately—
that is, for the operator to hold one of the electrodes and the
patient the other ; then the operator places his hand on the
part he wishes to be affected. In this way the current first
passes through the operator, who can judge the power of the
electricity by the effects on himself.
There is an advantage, which frequently may be of extreme
value, in placing one electrode at or near the nervous centre,
and the other at some distant part, and that is, that by this
means we obtain a more diffused effect, and can also act
upon some important diseased organ. Insanity is often due
to, or is complicated by, disease of the liver, spleen, kidneys,
&c., and by directing the electric current to these organs they
may be benefited. It is a well-known circumstance that the
skins of lunatics are often impaired in their functions; elec¬
tricity, and especially magneto-faradism, has a powerful effect
in restoring the function of the skin, accelerating the pulse,
and rousing the activity of the whole nervous system. The
nerve-power of the brain may in this way be acted on through
the skin, and restored to health. The late M. Awzouy,
already mentioned, has very strongly advocated this method
Digitized by <^.ooQLe
1884.] by A. H. Newth, M.D. 359
of treating insanity, which he proved to be successful in many
cases.
Probably the safest way to use the electric battery is to
apply the negative pole (anode) to the head or back of the
neck, and the other to some distant part. In this way we
get a sedative tonic effect produced on the brain, if we em¬
ploy a steady, continuous current; if we use the electro¬
magnetic current we get a stimulant tonic effect.
In conclusion, I would most strongly urge those who have
the care of the insane to give the electric battery a fair trial
for a lengthened period, with careful attention as to the
choice of cases and the galvanic effects. I feel confident that
if a proper battery is correctly applied to suitable cases great
benefit will be experienced from it. But it cannot be too
strongly urged on the notice of all who wish to employ this
remedy that galvanism is not a remedy to be used indis¬
criminately, or in a haphazard way. It is not a toy, but a
very potent means of doing good or harm, and must be used
very cautiously and scientifically. Though we fear there are
few who can claim to be really scientific galvanists, or who
follow scientific principles, still there are many who can use
electricity with tolerable success if reasonable precautions
are taken, and some amount of common sense is observed,
in the choice of cases and mode of application.
On Pathological Research in Asylums for the Insane . By
James Adam, M.D., Mailing Place, Kent.
According to the latest returns, published by the Com¬
missioners in Lunacy in their Blue Book for 1883, sixty-
seven thousand four hundred and eighteen patients were
registered as under treatment in the various asylums of
England and Wales, and as being under private care during
the previous year.
Of that number, four thousand seven hundred and eighty-
five died, a proportion of deaths (per cent.) to the total
number under treatment of 7'61—or, calculated upon the
daily average number resident, of 9*11.
On consideration of these figures, the question naturally
arises, is practical pathological and generally scientific use
made, to the fullest available extent, of this vast field for
study and research ?
As might be expected from the fact that fifty-five thousand
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360 Pathological Pesearck in Asylums for the Insane , [Oct.,
one hundred and three patients out of the total number
above given were under treatment in county and borough
asylums, by far the larger proportion of deaths occurred in
these institutions, namely, four thousand one hundred and
thirty-two ; and it is to them, therefore, that we must
principally turn attention for replies to these questions.
The deaths in registered hospitals for the insane during
the same period numbered one hundred and seven; in metro¬
politan licensed houses, two hundred and forty-seven; in
provincial licensed houses, one hundred and ninety-six; in
naval and military hospitals, sixteen; in criminal asylums,
eighteen; in idiot-establishments, forty-eight; whilst the
considerable number of twenty-one patients are reported
as having died while under private care as single patients.
In many, probably most, of these institutions, opportunity
also occurs for examining the bodies of patients after death,
and to them we must also look for answers to the questions
in a proportionate degree.
There are at present no data readily available for ascer¬
taining in what proportion of the deaths occurring during
the year 1882 post-mortem examinations were made. Some
four or five years ago official returns showed that out of the
total number of deaths taking place in asylums, no less a
proportion than 65 per cent, of the bodies were examined by
the asylum medical officers.
In 1882, however, the following report is made by the
Lunacy Commissioners, showing a great falling off in this
respect:—
The mortality of the year, calculated on the average daily number
resident, was 12*16 per cent, for the males and 7*57 for the females,
or 9*64 for both sexes.
These ratios differ but slightly from those of last year, and upon
the whole must be considered favourable. The ratios of recoveries
and deaths are given in appendix (B) for each particular asylum,
where are shown also the total deaths and the number of post-mortem
examinations made in the several establishments.
We found it necessary in our last report to remark that a great
falling off was to be noticed in the practice of making these very
necessary examinations, and the attention of medical superintendents
was specially drawn to the fact.
We are now glad to be able to report a great improvement in this
respect as regards the returns for 1881. Of the total four thousand
seven hundred and fifteen deaths which occurred last year, two
thousand seven hundred and eighty-nine were the subjects of post¬
mortem examination.
Digitized by v^ooQle
361
1884.] by James Adam, M.D.
The proportion of these autopsies to the total deaths in county and
borough and State asylums for the year 1880 was 37 per cent., but in
1881 it had risen to 59 per cent.
In many asylums we are glad to observe that this ratio is greatly
exceeded, though elsewhere comparatively few examinations are still
made. Their value, from a pathological point of view, and as a means
of detecting injuries which may have escaped notice during life, is
now generally admitted ; and we hope to find the example, so well
set in some asylums, followed universally.
As a rule, permission to make post-mortem examinations
on the bodies of patients dying in asylums does not ap¬
pear to be difficult to obtain, but to have power to do
so within a reasonable period after death (which is often
all important when brain-appearances are concerned) is
rendered more certain by the observance of a practice
which now prevails in many asylums, that of giving a
printed notice to the friends on the admission of a patient,
that in the event of death occurring the body will be ex¬
amined unless a written objection is made by them at the
time. The same result is, it is believed, also obtained in
some other asylums by a permanent Coroner’s order to the
effect that an examination should be made in every case
before the cause of death is certified to him.
But as there are no rules without exceptions, so difficulties
and opposition have been, and may be again, encountered in
some instances by asylum-superintendents, it may be from
unexpected sources, whilst endeavouring to obtain sanction ;
and it is understood that even at the present time medical
superintendents of some of the Colonial asylums are forbid¬
den by their governing bodies to make autopsies.
It would be well also if the existing state of the law were
more clearly defined and made known than it seems to be at
present with regard to cases where post-mortem examination
is made without sanction of friends, and where no Coroner’s
order has been issued.
A case which may give rise to a decision on this point has
occurred recently, in which a surgeon of one of the Dublin
Hospitals has been threatened with an action for thus acting,
regarding which the “Medical Press and Circular” has the
following remarks:—
As a question of law, it is more than doubtful whether any action
lies for the making of a post-mortem examination, because we believe
no one has a right of property in a cadaver, and no money claim can
be made for injured feelings.
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362 Pathological Research in Asylums for the Insane , [Oct.,
A few years ago it was resolved by some having an especial
interest in mental pathology to take steps to ascertain the
opinions and feelings generally entertained with regard to the
pursuance of its study practically by medical superintendents.
As the opinions thus elicited were almost unanimous, very
important, and very exhaustive, it may be useful to recapitu¬
late some of them here. With no uncertain voice it was
stated that not only was it desirable, but that it was abso¬
lutely necessary, that post-mortem examinations should be
prosecuted with vigour, and to the fullest possible extent, in
asylums. Some superintendents stated that their asylum-
rules made the practice compulsory on the part of the
medical officers, and those rules had received the sanction
of the Home Secretary; others drew very forcible com¬
parisons between the special importance of making post¬
mortem examination on the bodies of patients dying in
asylums and those dying in any other kind of hospital or
institution.
The various opinions and reasons given may be shortly
summarized and enumerated thus :—
1st.—Bodily disorders, injuries or diseases, even of an ex¬
tensive character, may be so obscured and masked in the
insane by the mental symptoms that they cannot be detected
during life.
2nd.—The practice of making post-mortem examinations
in asylums deters attendants and others from ill-using
patients, as injuries inflicted by them are certain to be
detected, and it thus proves a safeguard and protection to
patients.
3rd.—It protects good attendants of asylums against
groundless charges, not unfrequently made, of ill-using
patients.
4th.—The true cause of death is frequently difficult to
arrive at without a post-mortem examination, a difficulty
increased according to the numbers under treatment for the
reasons firstly mentioned, and thus are rendered necessary
reports to coroners, and consequent inquests.
5th.—Mortality-tables, showing causes of death, are not
accurate or reliable as scientific records without it.
6th.—For the following general reasons: To increase
knowledge of the special disease treated by the physician
himself, and for the good of others; a very eminent
authority remarks that, were it not for such work, scientific
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363
1884J by James Adam, M.D.
medicine would become extinct; to verify diagnosis of
disease ; to settle without doubt the cause of death; to
clear up obscure symptoms; to prevent on the part of the
medical staff a slip-shod method of physical examination of
the living body; to yield increased interest in cases under care,
to complete the history of the case in the case-book; to pre¬
vent the scientific spirit being killed by routine asylum-work.
7th.—For the education of the medical staff of an insti¬
tution, especially its junior members. The latter enter on
this branch of the profession with a view of perfecting their
knowledge of diseases of the nervous centres, and to fit
them for the higher positions in the treatment of mental
disease; and the best men of the various universities and
colleges would certainly be deterred from joining the
medical staff of an institution which debarred them from
the usual privileges in this respect.
Having recapitulated the very many excellent reasons
given by practical men for the performance of post-mortem
work in asylums, the question remains to be considered : Is
advantage taken, to the fullest possible extent, of the ex¬
tensive field for pathological research formerly alluded to,
not only as affording practice, information, and the means
of reference to individual members of the medical staff of
any particular asylum or hospital, but for the information
of the whole specialty and the general body of the profession
as well ?
The facts quoted from official returns, showing the extent
to which practical pathology is already prosecuted in many
asylums, taken in connection with the valuable results to be
found recorded in the various case or post-mortem books of
asylums, are perhaps sufficient answer to one portion of the
question ; but with regard to the second portion, probably it
would not be possible to give quite so satisfactory a reply,
for the record once made in case or post-mortem book,
except in comparatively rare instances, does not further see
the light.
Looking to the important additions which might be made
to our more intimate knowledge of mental pathology, and
the deductions which might be drawn from the comparison
of morbid appearances in a large number of cases presenting
essentially the same mental and physical characteristics
during life, it seems worthy of consideration whether some
means might not be adopted for facilitating such compari-
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364 Pathological Research in Asylums for the Insane , [Oct.,
sons, as, for instance, by giving in a tabular or other con¬
venient form the collective results obtained in each asylum.
To some extent, an attempt has been made in this direc¬
tion already, for a few asylum-superintendents publish in
their annual report a brief outline of each case examined.
This would not, however, appear to be, even if carried out
more extensively than it is at present, a convenient form for
reference to collective results.
On the whole, the tabular seems to offer the best, easiest,
and most convenient form for reference; but the formidable
difficulty presents itself of reducing to this form the immense
number of morbid appearances which come to be recorded in
the complicated and numerous component parts of the
nervous centres.
Notwithstanding this difficulty, an attempt, although
necessarily in the first instance a very imperfect one, is here
made to give an outline of the form such tables might be
made to assume. (See pp 366 and 367). Imperfect as it is in
its present state, it may serve as a basis to begin upon, and
experience and practical working may probably lead to much
simplification of the more important details in course of
time.
Should some such tabular form meet with general accept¬
ance, the asylum-report would seem to offer the natural and
most ready means for giving the necessary publicity for the
information of the profession at large, and more directly to
those specially interested, the value of the asylum-report
would be materially enhanced thereby, and it would
probably add to the interest in, and prove not the least
important of, the many excellent tables already appearing.
Of course, where such a delicate matter as brain appear¬
ance is concerned, the opinion of different observers may
differ widely, and much would depend upon the operator’s
skill, powers of observation, and previous instruction; but
the general result could hardly prove otherwise than valuable,
and comparison of views obtained in this manner would, in
course of time, tend more than anything else to correct
previous errors, and to induce accurate methods of observa¬
tion and recording.
Since the foregoing was written, questions have more than
once been asked in the House of Commons on the subject of
the disposal of the dead in asylums.
On March 25th Mr. Healy asked the Chief Secretary for
Ireland whether it was a fact that subjects for dissection
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365
1884.] by James Adam, M.D.
were supplied to the Queen's College, Cork, from the Cork
District Lunatic Asylum, and, if so, whether it had been
done with the sanction of the Board of Governors; and, if
such were the case, what was the total number supplied
during the college sessions 1881-2 and 1882-3, and the
average expense of each.
Mr. Trevelyan replied—The hon. member is no doubt
aware that the difficult subject of the supply of anatomical
subjects for the purpose of schools of anatomy is strictly
regulated by statute, and that inspectors of anatomy are
appointed to insure that the law is complied with. The
rules for the management of district lunatic asylums re¬
quire that, on the death of a patient, immediate notice
should be given to the relatives of the deceased, in order
that the body may be removed for interment. In the case
of unclaimed bodies only the Governors have authority to
authorize anatomical examinations if they see fit. In all
cases, remains are subsequently removed for interment in
consecrated ground, as required by the statute, and certifi¬
cates to that effect forwarded by the inspector of anatomy.
I have satisfied myself that the law is fully complied with
at Cork; but the subject is one with regard to which the
law, while requiring for the protection of the public that
particulars shall be regularly laid before Government, does
not require the publication of details, and I do not think
details should be given in Parliament. I trust the hon.
member will not press his inquiries.
Mr. Healy asked whether he was right in understanding
that the right hon. gentleman declined to say whether the
bodies of these unfortunate deceased Irish lunatics were
given over for dissection. He presumed that the right hon.
gentleman considered such a practice scandalous.
Mr. A. O’Connor wished to know whether the Cork Dis¬
trict Lunatic Asylum received any money consideration for
the bodies.
No answer was given to the question.
On the 1st of April, Mr. Healy having returned to the
question of the Cork District Lunatic Asylum,
Mr. Trevelyan replied—The inspector of anatomy for
Munster is allowed to reside in Dublin. He is required
to keep an office in Cork, and the arrangement is open to
review should inconvenience arise. The other three pro¬
vinces of Ireland are under one inspector, who also resides
in Dublin. Before the arrangement as to the Munster in-
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Table No. I.—Post Mortem Examination. Naked Eye Appearances.
* Case recorded thus.
Table No. II.—Post Mortem Examination. Microscopical Appearances.
368 Pathological Research in Asylums for the Insane, [Oct.,
spector was sanctioned, it was ascertained that there is
but one inspector for all Scotland, and there are two for
England, both of whom reside in London. It is therefore
clear that in no part of the country is continuous residence
on the spot considered necessary for the discharge of the
duties of these officers. I stated, in reply to a former ques¬
tion, all that I feel called upon to say with regard to the
powers and duties of the governors of lunatic asylums in
this matter. I pointed out that the law does not require the
publication of details as to dissections, and in the interests of
humanity and of medical science any attempt to force pub¬
licity is greatly to be deprecated. With regard to the last
paragraph of the question, I think it must be perfectly clear
to anyone that no school of anatomy could be carried on
without incidental expenses, and I am sure that there is no
such school in the country which students can attend with¬
out paying fees. If any of the students at Cork think tliat
any improper charge is made in their case they should
address the college authorities. I am informed that nearly
150 students of Queen’s College, Cork, presented an address
to the Professor of Anatomy on Friday last stating that
they had heard with regret that action had been taken to
make the class regulations in anatomy and physiology the
subject of questions in Parliament, and so tend to create
an erroneous impression in the public mind regarding the
relations subsisting between the professor and students in
these departments. These relations, they say, have always
been of the most cordial character, and any representation
of them as otherwise must incur their unqualified repudia¬
tion. I am informed by high medical authority in Dublin
that if these questions are continued a feeling may be
aroused among ignorant people which would render it im¬
possible to carry on anatomical studies at Cork, and perhaps
in any other part of Ireland.
“ The Thirty-eighth Eeport of the Commissioners in
Lunacy,” just issued, contains the following remarks
The percentage of post-mortem examinations to the deaths (nearly
69 per cent.) is higher than we have hitherto been able to report, and
reflects, we consider, great credit on the Medical Superintendents of
asylums as a body ; though, indeed, the average would have been
considerably improved had more examinations been made in certain
asylums. Thus at Littlemore (Oxford, &c.) Asylum, there were but
13 examinations to 42 deaths, a per centage of 30*95 only. At Staf¬
ford the per centage was 33*06 (40 examinations in 121 deaths). At
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369
1884.] by James Adam, M.D.
the Hull Borough Asylum the proportion was the smallest, but we
have little doubt that at the new asylum it will be possible to hold
more examinations.
On the other hand, it is worthy of remark, that at the Kent
Asylum at Barming Heath, there was a post-mortem examination
after each of the 129 deaths, and this was also the case at the
Leicester Borough Asylum, though of course the deaths were much
fewer, being only 37.
A reference to the column in Appendix (B 1 ) will show that in
several asylums there were nearly as many examinations as deaths.
The Data of Alienism . By Charles Mercier, M.B.
(Continued from page 16.)
Following the estimation of the state of the blood comes
naturally that of the state of the circulation; and for the
purpose of the alienist the efficiency with which the peri¬
pheral circulation is carried on is the main thing to be
determined. From his point of view it is of far less impor¬
tance to discover an insufficiency of the mitral valve than to
find a cold blue flabby hand or nose; for a damaged valve is
consistent with an efficient supply of blood to the highest
nervous centres; but if one part of the peripheral circula¬
tion is seen to be badly carried on, the inference is un¬
avoidable that the circulation in other peripheral regions is
similarly defective. The direct evidence of the condition of
the cerebral circulation obtainable by the ophthalmoscope
should not be neglected. Although the “ heat of the head ”
is a matter of prime importance among the laity, and is
commonly considered by physicians as of some value, yet,
having regard to the fact that the whole of the face and
scalp are supplied by branches of the external carotid artery,
while the encephalon receives its blood mainly from the in¬
ternal carotid, I was for some time doubtful whether much
stress should be laid on this external temperature. I have,
however, seen a case in which not only did the head sweat
freely, but steam rose visibly for many consecutive hours
from the scalp of a woman lying in a well-warmed ward,
and without any fluid or medicament being applied to the
head. In that case there was found after death the most
excessive congestion of the whole cerebral substance,
xxx. 25
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870
The Data of Alienism ,
[Oct.,
The Respiratory Function .—Perhaps the most important
and useful piece of advice that could be given to a person
entering on the care of the insane would be : “Always
suspect that your patient has pneumonia. 99 Probably more
than one-half of the mortality of dements is due to this
disease, which very often is extremely insidious in its onset,
attended by few and slight symptoms, and by ill-marked
physical signs. An old woman is noticed to be more feeble
than usual; she totters as she walks ; she declines her food.
But she makes no complaint, suffers no pain, coughs so
little that it has not been noticed; her pulse is quiet, her
tongue clean, her temperature little or not at all raised. On
close observation you notice that she breathes a little more
rapidly than usual, and her respiration is shallow, but there
is nothing very marked—nothing to make you suspect grave
disease. Yet when you examine the chest you find the base
of one lung completely consolidated. Such is the history of
scores of cases. Again, of whole classes of idiots, almost
every individual dies of tuberculosis. The connection, too,
of phthisis with some forms of non-con genital insanity is
established. Occasionally the lung-disease and the insanity
appear together. More rarely the activity of the one dis¬
order alternates with that of the other. The tendency
towards phthisis is always a factor of especial gravity in a
case of insanity. Hence the alienist should be constantly
on the watch, in the young for phthisis, and in the old for
pneumonia.
The estimation of the renal function is important to the
alienist not only because the accumulation of waste-pro¬
ducts in the blood, which failure of this function permits,
may directly produce alienation; and not only because of
the close connection between renal disease and gout, which
is another direct cause of such disorder—but because the
condition of the renal function in middle life is an index, if
not to the amount of, at least to the tendency towards,
fibroid degeneration, not only in the kidneys, but in all the
tissues throughout the body. If, in a person who has
recently and gradually become insane, we find urine of low
specific gravity, albumenuria, uraemic retinitis, and the
hypertrophied heart and square-headed pulse, earthy com¬
plexion, and dry skin that accompany granular kidney, we
have obtained not only a fairly complete statement of the
bodily health, but also a most important insiglit into the
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by Charles Mercier, M.B.
871
1884]
probable nature of the change in the highest nervous
centres which underlies the insanity. Knowing the pro¬
gressive nature of this change, we are able to found upon
the datum thus gained a definite and confident prognosis,
which will be at least as unfavourable as to the insanity as
it is to the bodily health. The copious flow of urine that
accompanies or follows some forms of mental perturbation,
although it takes place through the kidneys, is more an in¬
dication of altered vascular pressure than of altered renal
function, and no definite alteration of the renal secretion
has yet been observed to be associated with more prolonged
disturbances of the superior nervous processes.
Digestion and Us Accessories .—The connection of the diges¬
tive function with the function of the highest nervous
centres is most intimate and most obscure. That the
normal working of the highest nervous arrangements de¬
pends on an adequate supply of nourishment, and that this
again depends on the integrity of the digestive function, is
the most fundamental aspect of this connection, but it is not
the one with which we are most concerned. The amount of
nutriment added to the blood may be miserably deficient in
quantity, and inferior in quality, without any very marked
deterioration of the action of the nervous centres beyond a
simple diminution of activity; but the manner in which the
digestive function is carried on—the condition not merely of
the process of assimilation which is its outcome, but of all
the contributory processes—is bound up with the mode of
action of the superior nervous arrangements in an intimate
correlation of which the rationale is extremely obscure.
What are the most constant and most reliable symptoms of
tubercular meningitis? Not headache, not delirium, not
fever, not convulsion—not any symptom directly referable
to cerebral disturbance; but constipation and a sunken
belly. What is the one symptom that never fails in cerebral
tumour? Again, not convulsion, not optic neuritis, not
paralysis, nor aberration of mind; but vomiting—persistent,
“ purposeless” vomiting. Such vomiting as occurs in gross
intracranial disease is not present, it is true, in any form of
insanity as such, and the existence of constipation in a case
of insanity is in this country, and at the present day, in no
danger of being overlooked; but there are other aspects of
the association between disturbance of the digestive func¬
tions and disturbance of mind which require notice. The
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372
The Bata of Alienism ,
[Oct.,
unutterable misery which accompanies severe nausea, such
as that which occurs in sea-sickness, is well known, and the
profound prostration and agony which may follow a com¬
paratively trifling blow upon the abdomen is likewise a
matter of general notoriety. In these instances a grave
abdominal disturbance is accompanied by a mental disturb¬
ance of corresponding gravity, and the association between
them is manifest and conspicuous. Bearing in mind the
principle already adverted to, that all morbid processes are
but exaggerations of the processes of health, we might well
expect to find that abdominal disturbances less sudden and
less severe would be accompanied by mental disturbances
having the same character of depression, but showing differ¬
ences of degree, of mode of onset, and of duration, corres¬
ponding with the differences of the bodily lesion. And it
is so. The very names of the two chief forms of mental
depression—hypochondriasis and melancholia—indicate that
many centuries ago there was some dim recognition of this
association between the abdominal functions and mental
states, and at the present day its validity is maintained no
less by the special facts of alienism than by the common ex¬
perience of intelligent people. Let us look at some of the
facts.
When a child is whining and fretting, its mother says
that “ its stomach is out of order,” and gives it a purge ; and
her opinion and practice are commonly justified by the event.
A nightmare is held to be. sufficiently accounted for by an
indigestible supper taken over night. The chronic dys¬
pepsia from which Carlyle suffered is adduced in apology
for his morose disposition. Dysentery and diarrhoea are the
scourge of armies, but much more of defeated armies.
Many thoroughly well authenticated cases are on record of
jaundice following a shock of grief. When subscriptions
are to be collected for a charity, the donors are first warmed
into an expansive and generous mood by the administration
of a good dinner. It may be said that the resulting state of
mind is partly due to the direct action of the imbibed
alcohol upon the nervous centres, and no doubt this is so ;
but still, even since the practice of total abstinence and the
use of non-alcoholic drinks have become widely prevalent,
the subscriptions following a public dinner often amount to
thousands, while those elicited by the most successful
charity sermon, which is delivered to fasting stomachs, very
Digitized by Google
1884.]
by Charles Mercier, M.B.
373
rarely exceed two or three hundred pounds. The essential
conditions to happiness have been cynically stated to be a
good stomach and a bad heart, and, whatever our opinion
may be as to the latter, there can be no doubt whatever of
the indispensableness of the former.
Although it is, as a rule, very dangerous to make a
sweeping assertion founded upon merely what Whewell
termed the colligation of facts, yet it is probably quite safe
to say that chronic melancholia is invariably accompanied
by constipation, which is commonly very intractable. It is
a very conspicuous feature of the malady. All writers on
insanity insist upon the close association of chronic melan¬
cholia with failure of the digestive function; so much so,
that the treatment secundem artem is directed mainly to
restoration of this function, and experience shows that, as
this yields to treatment, the mental condition improves.
“Make a melancholy man fat,” says Rhazes (a.d. 850),
“ and thou hast completed the cure.” While, if the consti¬
pation and anorexia are insurmountable, the mental con¬
dition is hopelessly beyond cure. Leaving for a moment
this aspect of the subject, let us see what is the experience
of physicians with respect to chronic gastro-intestinal
torpor. Dr. Fenwick speaks of the gloom and irritability
that accompany chronic gastric catarrh. Niemeyer remarks
on the frequency with which hypochondriasis accompanies
the same malady, and says there is usually some mental
depression. “ I have seen,” he says, “ a general discourage¬
ment, an under-valuation of mental power, despair as to
business, &c., induced by chronic gastric catarrh, and have
seen these symptoms disappear on the cure of the disease.
Only a few years since I treated a very wealthy man for
chronic gastric and intestinal catarrh, who, during the
disease, thought he was near bankruptcy, and left unfinished
a building that he had begun because he thought that he
had not sufficient money to continue it. After spending
four weeks at Carlsbad, his old strength and feelings re¬
turned ; he finished his house with great splendour, and has
been well ever since.” Again, he says that in chronic intes¬
tinal catarrh there is almost always great mental disturb¬
ance. “ The patients either occupy themselves entirely with
their physical state, and have no brains or time for anything
else, or they are subject to a total indifference or despair.”
Dr. Allchin, speaking of the same disorder, says that “ there
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Google
374
The Data of Alienism,
[Oct.,
would seem to be a special inclination for the mental quali¬
ties to become affected, so that the intellect may become
dulled and sluggish, the temper irritable, and the patient
may fall into a condition of marked hypochondriasis.’ 5 Now
what is the manifest and unavoidable inference from this
remarkable consensus of observation from two such different
sets of sources ? Alienists find that chronic mental depres¬
sion is invariably associated with chronic gastro-intestinal
torpor. Physicians find that with chronic gastro-intestinal
torpor there is almost always mental depression. Is not the
inference inevitable and unimpeachable that chronic melan¬
cholia and chronic gastro-intestinal torpor are different aspects
of the same malady ? I do not say—and I protest strenuously
against the view—that either of them is the cause of the
other. The position taken is that they are the obverse and
reverse sides respectively of the same bodily condition.
When there is feebleness and want of momentum in the
currents of energy emitted from the grey matter of the
highest nerve centres, this defect has a subjective accom¬
paniment in mental depression, and issues objectively in
that general lethargic inactivity that characterises conduct
in melancholia; when the same deficiency of action occurs
in the nerve centres that set going the intestinal move¬
ments, it results in constipation and its attendant deficiencies
of function. Those cases in which the superior nerve centres
are most deficient, or most conspicuously deficient in the
amount and grade .of activity, come under the care of the
alienist, and are called melancholia; while those in which
the deficiency of the lower centres is the most prominent
feature come under the care of the physician, and are termed
chronic intestinal catarrh or chronic constipation; but the
fundamental nature of the malady is the same in both. The
same tissue—the grey matter—is at fault, and the fault is of
the same nature in both; but in one the main weight of the
defect lies on one region of the grey matter, and in the other
on another. A similar view enables us to connect together
the obstinate constipation of old age with the general sub¬
sidence of bodily activity, and with the mental decline that
occurs in advancing life, and to assimilate this whole group
of changes to that of melancholia.
The skin is developed from the same layer of the blasto¬
derm as the superior nerve centres, and the two structures
remind us of their community of origin by the simultaneous
Digitized by Google
1884.] by Charles Mercier, M.B. 375
variations that they frequently undergo. The skin, and its
modifications, the special sense organs, are, moreover, the
medium through which all influences from the environment
must pass in order to affect the organism, while in the
superior nerve centres all such impressions are ultimately
registered; and in this close biological relationship is indi¬
cated another explanation of their concomitant variations.
Whatever its rationale , this correlation between the varia¬
tions of outer and inner structures renders that member of
the couple, which alone is open to direct observation, of
especial interest and importance, since from its changes we
can often safely infer the quantity, if we cannot judge of the
nature or direction of the changes that are occurring in the
other—just as from the verdure of a landscape we can judge
of the amount of activity that is going on in the roots
underground, though we may not be able to estimate its
nature.
Instances of this relationship are abundantly numerous.
White horses have from time immemorial been considered
less vigorous and enduring than coloured ones. Albino
animals of every kind are much feebler and less active than
those possessing a normal amount of pigment in the skin.
Many drugs which have a special action on the nervous
system have a special action on the skin also. Bromide of
potassium produces a pustular eruption. Arsenic has a
powerful remedial effect on certain skin diseases. Silver
given internally for epilepsy produces staining of the skin.
Opium checks all secretions save that of the skin, which it
promotes. Belladonna gives rise at once to delirium and a
scarlet rash.
The temporary alterations in the skin that accompany
transient changes of feeling are among the tritest of facts.
The flushing of shame and of rage, the pallor and sweating
of fear, the bristling of the hair in horror, are our com¬
monest experiences of the connection under consideration;
but with these we are not now directly concerned. What
we are interested to know is whether changes of mind more
profound or more enduring are accompanied by changes in
the skin of corresponding magnitude and duration. If we
accept the existence of physiological laws—if we believe
that variations of bodily function necessarily result from
antecedents, and neither appear in the absence of these
antecedents, nor fail to follow their occurrence—we may be
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876 The Data of Alienism , [Oct.,
certain beforehand that such correspondences do occur, and
the evidence of their existence is neither dubious nor far to
seek. Dr. Hack Tuke speaks of the harsh, or moist and
clammy skin of melancholia, and states that in mania it
occasionally emits a marked and diagnostic odour. Further,
he says : “ I have known alternations in the colour of the
hair corresponding to alternations of sanity and insanity
Dr. Crichton Browne says that in some cases of insanity the
state of the hair is a sure and convenient criterion of the
mental condition. Dr. Bucknill states that in a great many
cases of chronic mania the hair becomes harsh and bristling,
and the skin of the scalp becomes loose. I am acquainted
with a patient who, after an attack of mania, shed the nails
of several fingers and toes. The frequency with which de¬
ments pick sores in their skin is worthy of remark here—
urged to do so, no doubt, by some sensation referred to the
part. But instances of slow and enduring alterations of
skin accompanying slow and enduring alteration of the
highest nervous centres—although a very wide consensus of
opinion testifies to the frequency and definiteness of their
occurrence—are by their very nature too inconspicuous to
compel conviction on the part of those indisposed to believe
or to attach importance to them. Fortunately there is
another class of instances in which a rapid and conspicuous
alteration of the skin has followed so closely upon a violent
disturbance of the superior nervous system that no doubt
can be entertained of the connection between them. Of
such instances the blanching of the hair that accompanies
or follows depressing emotions is one of the most striking.
The following account by Staff-Surgeon D. P. Parry is
probably the best authenticated case on record :—“ On Feb.
19th, 1858, a prisoner in the S. of Oude was brought before
the authorities for examination. Divested of his uniform,
and stripped completely naked, he was surrounded by
soldiers, and then first apparently became alive to the
dangers of his position. He trembled violently, intense
horror and despair were depicted on his countenance, and,
although he answered the questions addressed to him, he
seemed almost stupified with fear; while actually under
observation, within the space of half-an-hour, his hair
became grey on every portion of his head, it having been,
when first seen by us, the glossy jet black of the Bengalee
aged about 24. The attention of the bystanders was first
attracted by the sergeant, whose prisoner he was, exclaiming,
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377
1884.] by Charles Mercier, M.B.
‘ He is turning grey/ and I, with several persons, watched
the process. Gradually but decidedly the change went on,
and a uniform greyish colour was completed within the
period named/’ Analogous cases present instances of the
connection here illustrated in an equally unmistakable
manner. Le Cat quotes from the “Journal Encyclope-
dique” the case of a man who had, after being very
angry, an apoplectic attack, which ended in paralysis of
the right side, and at the same time this side of the body
became completely yellow, not excepting the right half of
the nose. During the first French Revolution a woman was
condemned to death by a Parisian mob, and the lantern (the
instrument of execution) was actually let down at her feet.
She was reprieved, however. Shortly after her colour began
to change, and in a few days she became as dark as a moder¬
ately dark negro. She died in 1819, aged 75, more than 30
years after, her skin remaining dark until death. Laycock
relates the case of a young lady, aged 16, who met a man
in the dark, who insulted and greatly terrified her. In the
morning her eyelids were yeUow. The colour gradually ex¬
tended over her face for eight days, until it was covered.
Then the yellow deepened into black. Eight days after the
arms began to turn yellow, and became slowly black. The
colour remained for four months, at the end of which time
she rapidly recovered. I have recently published in “ Brain ”
the case of a woman whose skin always presented a con¬
spicuous change of hue at the onset of her attacks of
epilepsy, and resumed its normal colour on the termination
of the attack.
Such occurrences as these show indisputably that between
changes in the skin and changes in the superior nerve
centres there is an intimate correlation; and these con¬
spicuous instances are, we may be certain, only exaggera¬
tions of similar but smaller changes that accompany feelings
of less intensity—changes whose recognition and measure¬
ment await the extension of our powers of observation.
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378
[Oct.,
Clinical Observations on the Blood of the Insane. By S.
Rutherford Macphail, M.D. Edin., Assist. Med. Supt.,
Garlands Asylum, Carlisle; being the Essay to which
the prize of £10 10s., together with the bronze medal of
the Association, was awarded in 1884.
The older writers on Insanity including Pinel, and Esquirol,
believed that functional disturbances of the higher nervous
centres were the chief factors in producing mental disease.
Whether this is the case or not, and whether functional
disease of the brain may exist without appreciable change
of structure, there can be no question that the quantity
and quality of the blood circulating through the higher
nervous centres affect their functions in an important
manner.
First as to quantity. According to Bucknill and Tuke* the
effect of blood on the brain, when in excess, is that of lethargy,
while a diminution of its quantity is productive of syncope
and unconsciousness. Both these conditions, described as
congestion and anaemia, may be due to temporary irregulari¬
ties in the supply of blood to the brain, and may pass away
without leaving any ill consequences behind, although their
frequent occurrence acting on a highly susceptible organism
may produce minute changes, manifesting themselves by
various morbid mental phenomena. Andral, quoted by
Bucknill and Tuke, lays down the axiom that " in every
organ the diminution of the normal quantity of blood which
it should contain produces functional disturbances, as well
as the presence of excessive quantity of blood.” It is
difficult to determine whether these alterations in the
quantity of blood circulating through the brain are local
or general in character, but it seems reasonable to premise
that both conditions are possible. It is not, however,
sufficient to refer mental symptoms to hypersemia in one
case and to anaemia in another, for they themselves are
frequently mere effects. In this connection the importance
of the vaso-motor system must not be overlooked. Maudsleyf
believes that all active emotions are accompanied by changes
in the circulation, through vaso-motor inhibition, and that
* “ Psychological Medicine,” page 586. f “ Pathology of Mind,” page 193.
Digitized by
Google
1884.] Clinical Observations on the Blood of the Insane . 379
vascular disturbances may be produced by them within the
brain very much as blushing of the face and neck is produced
by shame. Irregularity in the blood-supply of the brain
produces a condition of irritation of that organ, though this
need not necessarily go on to actual mental disease. The
sluggishness of the circulation in the extremities of many
asylum patients, especially dements, is very noticeable ; and
if this be any criterion of the state of their cerebral circula¬
tion, there is little difficulty in accounting for their mental
symptoms.
The quality of the blood may be impure from some error
in the processes of digestion, assimilation, or excretion. To
take the most common instance of this, the presence of bile
in the blood, even in healthy and strong-minded individuals,
gives rise to gloomy forebodings and melancholy conceptions.
Also uric acid in the blood of a gouty patient causes an
irritability of temper which is sometimes so severe that it
passes into an outbreak of maniacal excitement. Arguing
from such well-known facts as these, and knowing the effects
of certain drugs, as chloroform producing anaesthesia, nitrous
oxide gas producing laughter, and alcohol producing hilarity
and excitement, we must admit that the brain may be
affected through its nutrition, or, in other words, through the
quality of its blood-supply.
Of course the affections of the nervous system must not be
approached from the vascular side only, but this aspect of
the question is worthy of attention. In this connection it is
interesting to remark that nervine sedatives are more or less
vascular depressants, and that nervine tonics tend to raise
the blood pressure.*
The bodily symptoms of insanity have had a fair share of
attention devoted to them in late years. If we believe, as
many do, that mental disease can be regarded by the physi¬
cian only as abnormal manifestation of the psychical function
of the brain due to bodily conditions, it is desirable to in¬
vestigate thoroughly the physical condition of all patients
who are mentally affected.
Patients admitted into asylums may be broadly divided
into three classes—
(1) A small group consisting chiefly of cases of recent
insanity with no ostensible symptoms except those of mental
derangement.
* “ Handbook of Treatment,” Fothergil), page 509.
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380 Clinical Observations on the Blood of the Insane , [Oct.,
(2) A large group with well-marked symptoms of bodily
disease which can be directly connected with the psychical
symptoms.
(3) A group, intermediate in size, suffering from general
debility or want of tone of the system, and in whom no
organic or absolute physical disease can be detected.
Clouston* describes this third group as “ such a lowering
of the general condition of the body that it must be reckoned
truly abnormal. This condition of body undoubtedly precedes
certain forms of insanity and accompanies them. That there
is no specific disease in most of such cases is proved by the
recovery of many of them, and by the long life of many of
the others.” In 100 patients whose mental symptoms had
lasted under six months, Dr. Clouston found 13 cases of this
description. I have gone over the records of the last 500
patients admitted into this asylum, and I find that 47 men
and 62 women of that number were in weak bodily health on
admission, and in whom no specific disease was discovered
after repeated physical examination. This excludes all old
people over 65 years of age. Of these 109 cases 23 men and
29 women, or 47-7 per cent, of the total number, have been
discharged recovered.
Griesingerf goes further than Clouston, and says that
many inmates of asylums die from anaemia and marasmus
without any serious local affection except perhaps a slight
degree of atheroma of the vessels being discovered.
Chiefly with the object of ascertaining whether poverty of
blood plays the same weighty predisposing part in the pro¬
duction of insanity that it does in the production of other
diseases, I have made a series of observations, extending
over a period of sixteen months, on the blood of insane
patients. This is a field of clinical investigation which, so
far as asylum-physicians are concerned, has as yet had little
attention paid to it, although in the case of many diseases,
physicians have been helped to a right diagnosis, and have
derived many indications for treatment from a systematic
examination of the blood.
The morphological elements of the blood in the normal
state are the red and white corpuscles; by the aid of the
* “ The Bodily Symptoms of Insanity.” “ Practitioner,” 1871, Vol. ii.,
page 12.
f “ Mental Diseases.” New Sydenham Society’s Translation, page 437.
Digitized by Google
381
1884.] by S. Rutherford Macphail, M.D.
microscope small granules floating in the serum may also be
recognised, and when coagulation has taken place, a reti¬
culum of fibrin. The colouring matter of the red corpuscles,
or hsemacytes, which gives to the blood its red colour, is called
haemoglobin.
In examining the blood for clinical purposes there are
three points to be considered—(1) Its richness in corpuscles;
(2) The richness of the corpuscles in haemoglobin ; and (3)
The amount of water diluting the corpuscles. Instruments
of considerable precision, called respectively the Haemacyto-
meter and Haemoglobinometer, have been devised for ascer¬
taining the richness of the blood in corpuscles and in haemo¬
globin. Inasmuch as the number of corpuscles present in
any given bulk of blood is merely an expression of the pro¬
portion of corpuscles to the amount of plasma, variations in
the number of haemacytes counted might be caused by an
increase or decrease in the quantity of plasma occurring,
while the actual number of the corpuscles is stationary.
Unfortunately we have as yet no means for determining this
third factor during life, and this diminishes the value of
results obtained by the above-named instruments.
All the methods devised for ascertaining the corpuscular
richness of the blood consist in making a definite dilution of
a certain quantity of blood, and counting the corpuscles in a
certain volume of that dilution. Potain, Malassez, and Hayem
have each devised an instrument adapted for clinical purposes,
but their methods are cumbrous and inconvenient. The
instrument I have used is Dr. Gower’s haemacytometer,*
which is more simple for ordinary use, and is accurate
enough for all practical purposes.
To eliminate as far as possible any instrumental error in
the numerations, I invariably counted more than one drop
of the mixture, and in the case of any marked discrepancy
three or four drops have been examined and the mean of all
the observations taken. The same instrument has been used
throughout, and the blood to be examined was drawn from
the finger without pressure.
The amount of haemoglobin in the blood is ascertained by
means of the haemoglobinometer. The method consists in
diluting a known volume of blood and comparing it with a
* For full description see “Lancet,” 1st December, 1877, and “Practi¬
tioner,” 1878, page 1.
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382 Clinical Observations on the Blood of the Insane , [Oct.,
standard solution. The average amount of haemoglobin in
each corpuscle is represented by a fraction of which the
numerator is the percentage of haemoglobin, and the per¬
centage of red corpuscles the denominator. The observations
with the haemacytometer and the haemoglobinometer were
made simultaneously. Each observation took over half an
hour to complete, and in not a few of the cases considerable
difficulty was experienced in inducing patients to submit to
the necessary puncture. The total number of observations
represented by this paper is 420.
It is obvious that limitations of time and opportunity
must narrow the scope of any experimental observations in
such an extensive field of investigation; but the observations,
which up to this time I have made may serve as an intro¬
duction to the further study of this important and interesting
subject.
The special points I have endeavoured to determine are:—
(1) What is the amount of haemoglobin and of red and
white corpuscles in the normal condition of the blood ?
(2) What is the condition of the blood in the class of
patients who constitute the chronic inmates of asylums ?
(3) Is the blood deteriorated in well-marked types of
insanity, as General Paralysis and Epilepsy?
(4) Do variations occur in the blood of patients subject to
attacks of periodic excitement ?
(5) What is the state of the blood in patients when
admitted ?
(6) What is the state of the blood in patients who
recover ?
(7) What are the effects of various blood tonics on cases
of recent insanity?
(8) Can any definite conclusions be arrived at from these
observations which would be of practical value in the cura¬
tive treatment of the insane ?
I.
As a basis from which to work I first of all made a series
of observations upon 30 cases of persons in presumably
perfect health of body and mind. These, 15 males and
15 females, were selected chiefly from officials of the Asylum,
and their respective ages ranged from 22 to 38 years. I give
the results in a tabular form, showing the percentage amount
of haemoglobin and bsemacytes, and the proportion of white
to red corpuscles in each instance.
Digitized by <^.ooQLe
383
1884.] by S. Rutherford Macphail, M.D.
A Table giving Percentage amount of Haemoglobin and of
Hsemacytes, and proportion of White to Red Corpuscles
in the blood of 15 healthy persons of either sex.
Healthy Male Blood.
Healthy
Female Blood.
No.
Percentage
of
Haemoglobin
Percentage
of
Hsemacytes.
Proportion
of White to
R. B. C.
No.
Percentage
of
Haemoglobin
Percentage
of
Htemacytes.
Proportion
of White to
R.B. C.
1
100
99*9
1 to 440
1
85
94*7
1 to 360
2
96
103*2
1 to 350
2
78
91*5
1 to 310
3
90
101*4
1 to 450
3
90
96*7
1 to 420
4
96
98*8
1 to 360
4
90
94*
1 to 280
5
90
99*2
1 to 430
5
88
90*9
1 to 360
6
100
102*4
1 to 480
6
80
93*2
1 to 380
7
90
99*
1 to 380
7
85
94*1
1 to 220
8
105
99*8
1 to 420
8
78
92*3
1 to 280
9
85
95*2
1 to 380
9
95
95*9
1 to 360
10
100
102*6
1 to 480
10
82
96*1
1 to 480
11
100
103*4
1 to 420
11
84
92*
1 to 380
12
95
102*5
1 to 340
12
88
91*7
1 to 430
13
95
101*9
1 to 440
13
80
89*8
1 to 210
14
104
105*1
1 to 510
14
90
95*2
1 to 290
15
95
102*7
1 to 450
15
86
94*8
1 to 460
Averages.
96 |
101*14
1 to 442
85*2
93*52
1 to 348
The average percentage of haemoglobin is 96 in men and
85 in women. The variations are considerable, and there are
greater fluctuations between the highest and lowest per¬
centages in the observations in males than in those of
females. The average number of red blood corpuscles per
cubic millimetre is in men 5,075,000; and in women
4,676,000, or, expressing this in percentage form, male
healthy blood, 101* 14; female, 93*52. These results are
rather higher than those of Laache,* who, in an analysis
* u Die Anaemie ” von 8. Laache. Christiania, 1883. Reviewed “ Medical
Times,” 1884, page 28.
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384 Clinical Observations on the Blood of the Insane , [Oct.,
of 60 cases, found the mean to be 4,970,000 per cubic milli¬
metre for men, and 4,430,000 for women (99-4 and 88*6 per
cent.). Speaking generally, we may represent the amount of
red corpuscles in healthy male blood by 100, in females by a
slightly lower percentage. In my observations the average
proportion of white to red corpuscles is 1 to 442 for males ;
1 to 348 for females. There were variations in the individual
percentages and proportions, but these call for no special
comment.
In the observations with the haemacytometer a diluting
fluid of constant strength, that recommended by Gowers,
(sodae sulph. grs. 104, acid acet. 3 i, aquas destill, ad £iv) was
employed. This solution has some effect in changing the
shape of the corpuscles, but has no influence on their
diameter. The size of the red discs varies considerably, even
in healthy blood. Hayem, quoted by Dr. Norris,* says that
75 per cent, of the corpuscles are of average size, 12 per cent,
small, and 12. per cent, large. This is an important point,
for it is obvious that if the small forms are more numerous,
the average corpuscular diameter is lower than normal, and
if there be a number of large cells in the blood under obser¬
vation the corpuscular diameter of the cells is relatively
increased. In my observations I simply made a general note
of the relative size of the corpuscles in each instance, and
did not attempt to go into detail. In healthy male and
female blood the large majority of the haemacytes were of
an average uniform size, while large and small forms collec¬
tively did not exceed 10 per cent, of the total number. In
two instances in the case of men I noted that large-sized
corpuscles were more numerous than usual, and the blood of
one female contained about 50 per cent, of blood discs below
the normal size. In none of these cases, however, did the
percentage of haemacytes vary much from the normal
standard.
Small granule-cells were observed in fully two-thirds of
the cases. These small particles, called by some “haema-
toblasts,” are a normal constituent of the blood, and, unlike
the ordinary red blood corpuscles, are stained red by carmine.
It is stated that they become relatively more numerous in
blood which is undergoing recuperation. A few corpuscles
were crenated, but I am not prepared to say whether this
crenated condition of the cells was influenced by the diluting
solution employed.
* “ The Physiology and Pathology of the Blood,” page 165.
Digitized by Google
1884.] by S. Butherford Macphail, M.D.
385
II.
I adopted the following means for ascertaining the con¬
dition of the blood in the class who form the unrecovered
residuum of asylum-patients:—I took 40 dements or chronic
maniacs in average bodily health, and had them weighed
periodically. These patients had been resident in the asylum
for periods varying from four to 22 years, and none had been
under medical treatment for some years previously. I give
the series of observations in tabular form, dividing the cases
into four groups according to age. I submit also a few re¬
marks on each group.
B. Tables showing percentage of Haemoglobin and Haema-
cytes in the blood of a series of Dements at three different
periods, and Weights at four different periods.
Table I.— Ten Dements Between 20 and 30 Years.
Period
of
Resi¬
dence.
Weights in lbs. at four
different Periods.
Percentage of Haomoglo-
bin.
Percentage of Haema-
cytes.
Case.
Jan,
’82.
June,
’83.
Nov,
’83.
Mar,
’84.
June.
Nov.
Mar.
Aver¬
age.
June.
Nov.
Mar.
Aver¬
age.
1
6 yrs.
143
146
146
146
75
70
74
73
96*8
97*4
96*9
97
2
5 yrs.
134
130
128
129
64
66
65
65
95*7
90*8
92*2
92*9
3
8 yrs.
153
150
144
147
62
64
62
62*6
89*7
85-9
87*8
87*8
4
4 yrs.
160
164
162
162
65
68
65
66
88*6
90*1
89*5
89-4
5
4 yrs.
156
154
156
155
62
68
66
65*3
95*6
94*5
94*2
94*7
6
7 yrs.
158
156
155
155
70
68
62
66*6
94*7
93*3
94*1
94:
7
5 yrs.
149
151
152
149
68
64
64
65*3
86*2
85*1
86*8
86
8
11 yrs.
139
144
146
145
68
68
68
68
87*7
89-2
88*5
88*4
9
7 yrs.
133
125
126
126
55
55
"4
55
55
82*7
81*8
82*2
82-2
10
4 yrs.
164
159
158
158
70
72
72
71*3
91*4
92*1
91-8
91*7
Avgs.
6*1
148*9
147*9
147*3
148*03
65*9
66*3
65*3
I
65*8
90*91
1
90 02
1
90-40
90*44
The period of residence of the patients varies from four to
11 years. Their weights range from 126 to 164 lbs., and it
will be observed that the weights, taken at four different
periods in 26 months, show slight variation in individual
instances, the difference never exceeding 7 lbs., while the
average weight for the 10 patients at each period of the
xxx. 26
Digitized by Google
386 Clinical Observations on the Blood of the Insane , [Oct.,
year is very uniform. The percentage of haemoglobin is
considerably below normal, and varies from 55 to 75 per
cent., as compared with 96, the normal standard. While
the amount of haemoglobin varied in individual cases, the
percentage in each is very uniform at the three different
periods, thus showing that the season of the year has little
effect on the quantity of haemoglobin. Although the lowest
percentage of haemoglobin was observed in the lightest
patient, it is not clear that we are justified in assuming any
relation between the variations in weights and variations in
the percentage of haemoglobin, for in two of the cases a higher
percentage was registered during the period when the weight
was lowest. The percentage of haemacytes varies from 3*7
to 19*3 below normal, while the average is fully 10 per cent,
below the standard. As in the case of the haemoglobin,
there are variations in the absolute and relative averages at
different seasons of the year; but this does not occur in such
a precise form as to enable one to make any deductions.
. Table II.— Ten Dements Between 30 and 40 Years.
Case.
Period
of
Resi¬
dence.
Weights in lbs. at four
different periods.
Percentage of Haemoglo¬
bin.
Percentage of Hsema-
cytes.
Jan,
’82.
Nov,
'83.
Feb,
’84.
May,
’84.
Nov.
Feb.
May.
Aver¬
age.
Nov.
Feb.
May.
Aver¬
age.
B
18 yrs.
166
162
167
164
70
70
70
70
92-8
92-6
91-8
92*4
pc
14 yrs.
148
K
148
148
70
70
72
70
92-1
91‘7
»
91-9
1
11 yrs.
139
133
136
136
68
74
70
706
89-2
92*0
9
90-6
1
9 yrs.
138
138
139
138
66
70
64
66-6
86-7
87*8
88'4
5
14 yrs.
170
166
166
164
66
68
68
67-3
86-1
88-4
88-3
6
21 yrs.
151
147
148
74
68
72
71-3
93*9
92-5
92*8
93
7
9 yrs.
121
116
120
119
65
64
65
64-6
86*5
83-8
85
85-1
8
6 yrs.
135
129
130
128
60
58
62
60
87*4
89*7
87*9
88-3
9
4 yrs.
152
152
150
152
75
70
72
72-3
89*2
90
88-7
89*3
10
11 yrs.
138
135
130
124
58
60
60
59-3
85
87*2
85-6
85-9
Avgs.
11*5
145-8
1430
143*3
142*1
67*2
67*2
67*5
67*3
89*33
89-65
89-07
89-35
It is worthy of remark that we have diminution of the per¬
centage of corpuscles with an increase of haemoglobin. The
Digitized by Google
387
1884.] by S. Butherford Macphail, M.D.
converse likewise occurs, and we have a decrease in the per¬
centage of haemoglobin and an increase in the number of
corpuscles.
The average period of residence of the patients in this
group is 11£ years. There is a greater variation in the
weights at different periods than in the previous group, one
patient alone losing 14 lbs. in 29 months, while the average
loss of weight for the 10 patients during that period is
3 # 7 lbs. The percentage of haemoglobin is very uniform,
both in the individual cases and in the average of each
period. The average amount of haemoglobin is slightly
higher than in the first group. On the other hand, the
average number of haemacytes is 1*1 per cent, lower, while
the variations in the averages for each period of the year are
more uniform, and the individual averages are less uniform
than in Table I. There appears to be no relation between
variation in weight and increase or decrease in the percentage
of haemoglobin and haemacytes.
Table III.— Ten Dements Between 40 and 50 Years.
Period
of
Resi¬
dence.
Weights in lbs. at four
different periods.
Percentage of Haemoglo-
bin.
Percentage of Haema¬
cytes.
Case.
Jan,
'82.
Dec,
'83.
Mar,
'84*
May,
'84.
Dec.
Mar.
May.
Aver¬
age.
Dec.
Mar.
May.
Aver¬
age.
1
15 yrs.
160
158
156
154
75
70
70
71*6
96*1
91*7
92*5
93*4
2
7 yrs.
158
150
148
148
65
68
65
66
89*2
96*1
92*2
92*5
3
20 yrs.
140
133
132
132
62
64
64
63*3
90*8
89*5
90*8
90*3
4
5 yrs.
150
154
150
150
78
75
75
76
95*1
91*5
91*9
92*8
5
6 yrs.
152
151
154
154
65
65
68
66
91*7
94-1
92*7
92*8
6
17 yrs.
164
158
162
161
65
68
68
67
88*9
91*7
87*9
89*5
7
22 yrs.
140
144
139
138
64
65
65
64.6
88*9
90*2
89*1
89*4
8
18 yrs.
184
190
190
196
64
65
64
64*3
87*8
89*2
88*1
88*3
9
22 yrs.
154
154
152
150
58
55
58
57
79*3
79
80*9
79*7
10
15 yrs.
140
137
139
136
62
65
60
62*3
84*6
85*7
83*9
84*7
Avgs.
14*
154*2
152*9
152*2
151*9
65*8
66*0
65*7
65*8
89-24
89*87
89
89*37
The special points in this table are : An average period of
residence of 14£ years; an average loss of weight of 2-3 lbs.
Digitized by Google
388 Clinical Observations on the Blood of the Insane , [Oct.,
in 29 months; an average percentage of haemoglobin similar
in amount to that in Table I., hut less than in Table II.; a
lower percentage of red corpuscles than in either of the
previous groups.
Table IV.— Ten Dements Between 50 and 60 Years.
Case.
Period
of
Resi¬
dence.
Weights in lbs. at four
different periods.
Percentage of Haemoglo¬
bin.
Percentage of Hacma-
cytea.
Jan,
’83.
Dec,
’83.
Mar,
’84.
May,
'84.
Dec.
Mar.
May.
Aver¬
age.
Dec.
Mar.
May.
Aver¬
age.
]
14 yrs.
172
176
174
175
65
68
68
67
87
86*9
87*8
87*2
2
22 yrs.
118
108
108
110
74
68
70
70*6
87*4
87
88*9
87*7
3
12 yrs.
156
155
»_
-
66
-
66
87*7
-
-
87*7
4
22 yrs.
158
154
148
152
68
70
65
67*6
87*8
87*1
86*6
67*1
5
13 yrs.
172
168
172
173
55
60
60
58*3
88*4
87*3
87*8
87*8
6
7 yrs.
163
158
156
158
68
70
70
69*3
87*7
86*9
86*5
87
7
15 yrs.
174
176
172
172
70
70
70
70
86*3
85*9
86*7
86*3
8
22 yrs.
148
148
154
149
70
72
70
70*6
86*7
87*2
87*2
87
9
22 yrs.
175
171
170
166
60
58
60
59*3
87*4
86*9
85*4
86 5
10
22 yrs.
138
143
145
147
58
60
58
58*6
87*8
89*2
88*6
88*5
Avgs.
17*1
157*4
155’7
155*4f
^ 155*71
65*4
j 66*2t
65*6t
I ,
65*73
87*42
87*15t
87*27t
0D
-J
£
* Died of Pneumonia, March, 1884. t Average of Nine Observations.
This table is incomplete, inasmuch as one of the patients
died of an intercurrent attack of pneumonia, and his blood
was examined only on one occasion. The table, however,
brings out more forcibly the diminution in the average per¬
centage of red corpuscles noted in the third group.
The proportion of white to red corpuscles was also ascer¬
tained, but as they showed so little variation from the normal
standard, I have not given the results in the tables.
The relative size of the corpuscles was fairly uniform.
There was an almost complete absence of small forms,
though corpuscles of large size were observed in several of
the cases. Small granule-cells were seen in only six of the
40 cases under observation, and when they were detected
they were ill-defined, and did not occur in groups, as is the
case in normal blood.
Digitized by Google
389
1884.] by S. Rutherford Macphail, M.D.
Of these 40 patients, six in the first group, five in the
second group, three in the third group, and four in the
fourth gro\ip had a course of ferruginous or nervine tonics
during the earlier period of their residence in the asylum,
but in no instance had tonics been administered during the
three years preceding the observations.
Four patients in the first group, three in the second, and
one in the third group were known to be masturbators, and
it is worthy of remark that the average percentages of
haemoglobin and of haemacytes in these cases were rather
below the percentages in the tables in which the observations
on their blood is detailed. With the object of seeing whether
this was merely a coincidence, I examined the blood of four
other patients known to be addicted to masturbation; and,
without entering into detail, I am in a position to state that
the percentage of haemacytes in the patients examined was
considerably below the normal standard, while the amount
of haemoglobin was also diminished, though to a less extent.
Summarising the results of my observations on the class
of dements or chronic maniacs, an examination of the fore¬
going tables appears to warrant the following conclusions:—
(1) The percentage of haemoglobin is considerably below
the normal standard, and does not appear to be influenced
by the age of the patients.
(2) The percentage of haemacytes is likewise diminished,
and this diminution progresses with the age of the indi¬
vidual.
(3) The proportion of white to red corpuscles is normal.
(4) The blood is deficient in haematoblasts.
(5) In the patients over 30 years the weight decreases,
but this decrease does not appear to influence the relative
percentage of haemoglobin and of haemacytes.
(6) The period of residence and the season of the year do
not affect the absolute proportional averages of the con¬
stituents of the blood.
(To be continued.)
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[Oct.,
CLINICAL NOTES AND CASES.
Case of Sexual Perversion in a Man. By George H. Savage,
M.D., Bethlem Hospital.
A young man, single, aged 28; father violent and exci¬
table ; one brother odd, and another a drunken scapegrace.
The patient himself is of middle height, anaemic and
emotional. He began his description of his state of mind by
saying that he felt he must kill himself. He said he did not
feel any real mental depression, but he felt so ashamed of
his unnatural state that he wished he were dead, to pre¬
vent scandal to his family. He had been to hear many re¬
ligious teachers, and, in fact, was sent by one of these to see
me.
He had always been industrious and hard-working, and
made a good living as a traveller for a foreign house. He
had led a very solitary life, and had never indulged in worldly
amusements.
He was proud of repeating that he was a professing
Christian. He had but one pleasure, and that was in music,
and of late he had given this up, as it took him into society,
where he met other men. At eleven years of age he learnt
to masturbate, and had continued the habit ever since.
He has never indulged in sexual congress. He says he has
no desire or lust after women, and, though he will not be
sure, he thinks he never did have any lust for women.
He told hi6 employer of his feeling, and said that he felt
that he must embrace him. This the master resented, and
said if he “ came any more of that stuff” he should discharge
him.
He says in America he was fairly comfortable, because the
men were only of moderate size and height; but that in
England, where there are so many men over six feet, he is
perfectly miserable. He says the sight of a fine man causes
him to have an erection, and if he is forced to be in his society
he has an emission.
He has no loss of memory, no tremulousness ; his senses
appear to be normal in every respect, and his reasoning powers
in no way affected.
I recommended him to follow his occupation with energy,
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Clinical Notes and Cases .
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1884.]
to seek mixed society, to go to places of amusement in cities,
and to pursue his musical tastes.
I have no further news of him.
I have met with only one other man, who was in a general
hospital, who had similar symptoms, but he had malforma¬
tion of his genetalia, and his sex was at least doubtful.
In one female patient, in Bethlem, there was powerful lust
towards those of her own sex. She died, and an infantile
uterus was discovered. One wonders if this perversion is as
rare as it appears, when we meet with trials such as have
been held in Ireland.
Supposed Case of Acute Mania , Terminating in Death after a
Succession of Epileptiform Attacks . By W. E. Ramsden
Wood, M.A., M.D., Assistant Medical Officer, Bethlem
Royal Hospital.
History of Case .—W. P., aet. 38, was admitted into this hospital
May 19th of this year, suffering from acute mania. He was trans¬
ferred from Camberwell House, where he had been aboutra month.
From his friends we heard that he had had a slight attack three years
ago. He is said to have been very much worried in his domestic ar¬
rangements ; they acknowledged also that he had given way to drink
for a long time. The first symptoms were evinced by his becoming
generally excitable, and going out at any hour of the day or night
and preaching in the streets. This occurred about six weeks before
his admission here. Within a few days he had hallucinations of sound
and sight. He thought that his father (who has been dead some
years) came down from heaven to him ; also that a mouse, which was
really our Lord, had held a conversation with him. On Easter Sunday
he preached in his church for two hours and a half. During this time
he was very sleepless, and considered himself a prophet.
He was said to have had rheumatic fever three years ago. His
father died of chronic rheumatic arthritis. Otherwise there is no
history of neurosis in his family.
On admission it was noted that he was a thin man of medium
height, dark hair, beard, &c. He had a very haggard expression.
He was utterly incoherent, and noisy. He recoguised nobody, was
continually chattering, and constantly using the most obscene and
blasphemous language. He was somewhat exhausted, but had
tremendous outbreaks of violence. At first he took food only after a
great deal of persuasion. Pupils equal; no tremor of facial muscles.
June 11th.—Taking food well, and is gaining flesh. Very noisy
and incoherent all day and night. Has become very dirty in his
habits. Recognised his wife and brother.
June 18th.—In the same noisy, incoherent condition; refusing
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392 Clinical Notes and Cases . [Oct.,
food ; getting emaciated. Voice becoming very hoarse from continual
shouting.
June 28th.—Dulness at right base, extending upwards to angle of
scapula. Tubular breathing over area of dulness. Getting much
weaker and quieter.
July 11th.—Last night, about 8 p.m., suddenly taken with an
epileptiform seizure; the first lasting about twenty minutes. This
was soon followed by three others, the patient not regaining conscious¬
ness in the intervals. In two fits the right side was strongly con¬
vulsed, and in two the left side was similarly affected. He passed his
motions and water under him. After these he slept quietly for some
time.
July 12th.—Very drowsy for some hours after the attacks, but took
nourishment fairly well. Later in the day he became excited again
and very restless. The patient has lost 2 stone 1 lb. in weight since
May 9th.
July 13th.—At 5 a.m. had another series of epileptiform seizures.
The convulsions were confined chiefly to the left leg and the right
arm, with a good deal of contortion of the facial muscles. This con¬
dition lasted about four hours, when the attacks ceased. He never
again showed any signs of consciousness, but gradually became weaker,
and died at 3.45 the same day.
P.M. was made 42 hours after death. Calvarium dense. Much
flattening of frontal lobes, especially marked in the left second frontal.
Adhesions, most marked at the base of the first frontal of the right
side, extending along to the extreme front. On the left side there
were adhesions over the first and second frontal, but less numerous
than on the right side. There were adhesions also in both regions
along the longitudinal fissure. The brain-substance was very
soft, and there was some excess of subarachnoid fluid at the base.
Weight of brain, 49 ozs.
Heart firmly contracted, valves and muscular substance normal, a
a few small patches of atheroma on the aorta ; 9 ozs.
Lunge .—Excess of fluid in both pleural cavities, but most in the
left. Lower lobe of right lung solid and friable. Lower lobe of left
lung in a similar condition to that of the right, but less advanced.
Right lung, 26 ozs.; left, 22.
Liver uniformly dark in colour; 50 ozs.
Kidney 8 ,—Capsules separated easily. Right, 4 ozs. ; left, 4 ozs.
Spleen normal ; 3 ozs.
The chief interest of this case is its rapid termination.
During the progress of the case the symptoms were only those
of very acute mania, and I may say that general paralysis of
the insane was hardly thought of; but from the succession of
epileptiform seizures, and the post-mortem appearances, one
could hardly classify it under any other form of mental
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1884.]
Clinical Notes and Cases .
393
disease. In conclusion, I would only add that this is another
case which ought to prove how important it is that there
should always be a post-mortem examination in all cases that
die in asylums; for I presume that there are few who would
not acknowledge that the chances of hereditary predisposition
to this patient's offspring are considerably lessened by the
fact that the case proved to he one of general paralysis, and
not a case of acute mania rapidly terminating in death.
Case of Insanity after Head-Injury . By Dr. H. Rayner,
Han well.
The following case is interesting as showing traumatic
injury as an exciting cause:—
A. D., 26, admitted 12th December, 1883. Traveller, a well-deve
loped young man, without history of insanity in his family ; but one
brother died of phthisis, and two others died in infancy of convul¬
sions, and two of water on the brain.
He has always been healthy and strong until present illness, but
had taken a considerable amount of stimulants in the transaction of
business. Three weeks ago, when under the influence of liquor, he
fell from the step of his vehicle backwards, sustaining a wound one
inch to the right of the occipital protuberance. He was “ stunned ”
at the moment, and was more or less insensible for twenty-four hours
afterwards, during which time he had three “ fits,” bit his tongue
badly on the right side, and was much convulsed.
The next day he complained greatly of pain all over his head, be¬
lieved that he was giving away watches and chains, became restless
and unmanageable, and was finally brought here after three weeks.
On admission, slight inequality of pupils existed, the right being
the larger. There were also tremor and slight inco-ordination of the
facial muscles. His appearance suggested the idea of general
paralysis, but there was no mental enfeeblement, and the exaltation
had disappeared. He complained of sleeplessness and of pain in the
right frontal and anterior parietal regions. The sleeplessness rapidly
improved, but for some time he complained of inability to sleep for an
hour or two after retiring to rest. The pain in the head and sleep¬
lessness gradually passed away, but after they had ceased were easily
reproduced by exertion, or anything which increased the general or
local circulation (as dancing or reading). He was discharged re¬
covered on 7th Feb., 1884, and has since remained well.
The treatment consisted in rest at the outset, combined
with milk diet, and, later on, tonics, with absorbents.
The history of this case suggests that there had been
some contusion or commotion of the cortex of the cerebrum
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394
Clinical Notes and Cases .
[Oct.,
at the seat of contre-coup, which, from a careful considera¬
tion of the direction of the blow, was probably localised in
the upper surface of the left anterior lobe and the adjacent
parts of the motor area.
The toxic effect of the alcohol acting on this contused
area may be presumed to have caused the epileptic attacks;
the mental symptoms were probably due to hyperesmia of
the same areas, the local loss of vascular control being
further evidenced by the difficulty in going to sleep and by
the recurrence of headache on excitation of the circulation.
The recovery was chiefly due to the excessively good
nutritional and reparative powers of the individual. In a
less healthy person, or under unfavourable circumstances, it
would not be difficult to imagine a chronic degenerative
process developing from an injury attended with such symp¬
toms.
OCCASIONAL NOTES OF THE QUARTER.
The Lunacy Laws .
There is apparently no subject in the present day upon which
more seems able to be said and written, or about which the
public appears to have less exact knowledge, than that of the
Lunacy Laws.
It is so easy to talk glibly about danger to the liberty of the
subject, and so difficult to guard against the license into which
that too often degenerates.
So much feeling is imported into each discussion when the
periodical recrudescence in the public mind on this question
occurs, that a temperate and reasonable discussion of it becomes
almost impossible. While the supposed heinousness and danger
of the Lunacy Laws are set in the light by the interested or the
ignorant, there seems to arise a conviction that whatever is
must be wrong, and the dangers to society of delay in treat¬
ment, and the risks of reliance upon the apparent harmlessness
of mild forms of insanity, are temporarily relegated to an ob¬
scurity, out of which they too often have a rude resurrection.
While no well-informed person doubts that the Lunacy Laws
are capable of improvement, and that personal liberty needs to
be hedged about by every safeguard with which the law and
public opinion can environ it, so no one should fail to remem¬
ber that society has a right to be protected, not only from gross
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1884.]
895
Occasional Notes of the Quarter .
crime and its consequences, but also from minor evils which
insanity in certain phases has a special faculty of originating.
The whole subject is one of extreme delicacy and diffi¬
culty, and needs to be handled, not by emotional legislation
which can only make matters far worse than the worst which
is now possible, but by the deliberate judgment of competent
persons who possess both the knowledge and the capacity to
deal with the matter in the best interests of all who are or may
be concerned, in other words, of society in general, and not of
a section of it only. It is easy to apply derogatory adjectives
to the members of our specialty and of our profession gener¬
ally, and to accuse them of inferiority, dishonesty, or heartless
conspiracy. But it would be at least fair to withhold accusa¬
tion until more or less general dereliction has been proved, and
to assume that a class of persons is innocent until it has, in
some measure at least, been proved to be guilty.
Amid all the heat of discussion two facts should, we think,
be borne in mind—the first that a Select Committee of the
House of Commons, after an exhaustive enquiry as to the
operation of the Lunacy Laws, have reported that they were
unable to detect any instance of mala fides in their administra¬
tion, and the second that there is probably no medical man who
would not welcome such alterations therein as should deprive
him of a responsibility towards the public which brings with it
but little gain, no honour, and a liability to serious annoyance,
vexation, and loss.
Just before the last number of this Journal went to press, a
discussion occurred in the House of Lords with reference to
the Lunacy Laws, which it may be well to reproduce here as
showing not only the crude views which are entertained upon
this subject in some quarters, but the sober convictions of an ex¬
perience as varied and extended as that of Lord Shaftesbury,
whose whole career has borne witness to an honesty which is
beyond suspicion, and an earnest and practical hostility to
oppression and wrong in whatever form they might be con¬
templated, which must give his words unusual force.
The following report appeared in the daily papers of the 6th
May :—
HOUSE OF LORDS.
THE LUNACY LAWS.
The Earl of Milltown rose to call attention to the observations
made by Mr. Baron Huddleston in the case of “ Weldon v. Winslow,”
and to move “ that in the opinion of this House the existing state of
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396
Occasional Notes of the Quarter. [Oct.,
the Lunacy Laws is eminently unsatisfactory, and constitutes a serious
danger to the liberty of the subject.” The noble Earl proceeded to
quote from a summary of the facts of this case published in The
Times . He would abstain from commenting on the merits of a case
which was still sub judice , but he might be permitted to quote the
opinions of Judges on the present condition of our Lunacy Laws.
The noble Earl then read copious extracts from The Times reports of
the judgments of Mr. Baron Huddleston on the trial, and of Mr.
Justice Manisty on the application for a new trial. The Lunacy Laws
of this country consisted chiefly of the statutes 8 and 9 Viet., chap.
100, and 16 and 17 Viet., chap. 96. Lunatics were in the eye of the
law divided into two classes, paupers and non-paupers. The former
class did not merely include paupers in the strict sense of the term,
but a constable or relieving officer might arrest anyone found wander¬
ing abroad and bring him before a justice of the peace, and on the
certificate of one medical man and the warrant of justices, for whose
competence there was no guarantee, such a person might be incarce¬
rated for life. Thus any one of their Lordships might be confined for
life in that manner as a pauper lunatic. But if the lunatic was found
to possess means, he was transferred to a licensed house. In the case
of a non-pauper the certificate of two medical men was required.
There were in this country 68,000 pauper lunatics and 7,000 non¬
pauper lunatics. The state of the law was positively startling. Any
person who could obtain certificates from any two out of the 20,000
medical practitioners on the register could consign any other person
to incarceration in a madhouse, while no private person could obtain
the release of such incarcerated individual without the consent either
of the person who brought the incarceration about, or of the Lunacy
Commissioners. Moreover, no criminal prosecution could be instituted
for breach of the Lunacy Laws except by the Commissioners in
Lunacy. The necessary certificate could be signed by any medical
practitioner who had seen the patient for a single moment, and from
his decision there was practically no appeal. In case of even gross
cruelty being practised upon the patient, the police could not interfere
because the order of the Commissioners was a sufficient warrant for
everything that was done in the matter. In regard to the practice of
keeping lunatics in private asylums, kept simply for profit, the whole
system had been described by the noble Earl below him (the Earl of
Shaftesbury) as utterly abominable and indefensible, and it certainly
was one which ought not to exist in this age and country. He trusted
an end would be put to the present intolerable state of things, and
that a most damning blot would be removed from the Statute-Book
(hear, hear). He concluded by moving the resolution of which he had
given notice.
The Earl of Shaftesbury said their Lordships would at once perceive
that his reply must be somewhat prolonged, so many were the details
and charges made by the noble Earl who had just sat doyvn (the Earl
Digitized by Google
397
1884.] Occasional Notes of the Quarter .
of Milltown). Had he (the Earl of Shaftesbury) not been on the
Commission in Lunacy for more than 50 years, first as Acting Chair¬
man, and since 1845 as Permanent Chairman, he would not have
interposed ; but he thought it necessary, and almost a point of duty,
to explain the state of things and calm the public mind. The special
case of Mrs. Weldon could not then be discussed, “as the matter was
still sub judice. The lady had moved for, and had obtained, a new
trial; and nothing at present could be said on the question. He
wished, however, to state that the affair had never come before the
Commissioners—their jurisdiction did not begin until a patient had
been lodged within the walls of some licensed house. Neither did he
know anything of the case, except what he had gathered from the
newspapers ; but it certainly had struck him that, if the evidence had
been no stronger on the certificate, had one been sent to their office,
than that which appeared only in general rumour, he, at least, should
have been disposed to set the lady at liberty. But the obiter dictum
of Baron Huddleston might come under observation. It was as
follows, and taken from The Standard , 19th March, 1884:—
Now, I say distinctly, I wish I could treat this case apart from all technicality ;
but I must express my astonishment that such a state of things can exist, that
an order can be made by anybody on the statement of anybody, and that two
gentlemen, if they have only obtained a diploma, provided they examine a
patient separately, and are not related to keepers of a lunatic asylum, and that
on this form being gone through, any person can be committed to a lunatic
asylum. It is somewhat startling—it is positively shocking—that if a pauper,
or, as Mrs. Weldon put it, a crossing-sweeper, should sign an order, and another
crossing-sweeper should make a statement, and that then two medical men, who
had never had a day’s practice in their lives, should for a small sum of money
grant their certificates, a person may be lodged in a private lunatic asylum, and
that this order and the statement, and these certificates, are a perfect answer
to any action.
Now, he was certain that if the learned Baron had known the law, o t
had read the Keport of the Committee of the House of Commons
printed in 1878, he would never have made such an observation.
First, he spoke, after a very invidious fashion, of any two gentlemen
who had obtained a diploma. His Lordship should have remembered
that, by the amending Lunacy Act of 1862, the qualifications of
those who were empowered to grant certificates were very stringent.
It is said that the term physician, surgeon, or apothecary, whenever
used in the Lunacy Acts, should mean a person registered under the
Medical Act of 1858 ; a person, therefore, of adequate professional
fitness. He added, equally invidiously, that they might never have
had a day’s practice—possibly, though not probably—and, indeed,
were practice in lunacy required as a qualification, we should not find
one in 10,000 of the Medical Profession at present masters in the art.
He closed by an assertion that these certificates were a perfect answer
to any action. Where had the learned Baron found this law ? Had
he never heard of the case tried in the Courts of “ Hall v. Semple,”
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398
Occasional Notes of the Quarter .
[Oct.,
in which Mr. Hall, a liberated patient, prosecuted Dr. Semple for
negligence in framing the certificate, and obtained damages to the
amount of £150 ? There was a similar power against the person who
signed an order of admission. Three years ago, the case of “ Noel v.
Williams" had been tried in Court. Mr^ Noel, a discharged patient,
sued his brother-in-law, Mr. Williams, who had signed the order;
and though Mr. Williams obtained a verdict on every point, he had
to bear the expenses of his defence, a sum which amounted to not less
than £3,000. As to the order, he (the Earl of Shaftesbury) admit¬
ted that it was a weak point; theoretically,' it was, no doubt, imperfect,
though practically it had worked without any evil results. The history
might be stated from bis own evidence given in 1877—
With regard to the orders, I understood your Lordship to agree that it is in
some respects undesirable that a person, a perfect stranger to a patient, should
sign the order; do not you think that where there is a case, and no near
relative is to be found to sign the order, it would be desirable that the order
for admission should be signed by some public official ? I believe I explained
the reason of the state of the order to be this—In the year 1845, when we
were framing the Bill, we were exceedingly puzzled as to what to do, so many
cases had come before us of persons being suddenly seized in hotels, in lodging-
houses, in mere apartments where there was nobody who knew whence they
came or whither they were going; they were foreigners, Americans, medical
students and law students, and all sorts and sizes of people, travellers only
resting for a night, and we were obliged to leave it in that way that any per¬
son might sign the order for admission into any asylum. I have no doubt, but
I do not recollect it, that we saw it was very imperfect, and that we intended
to amend it, but we forgot it j and so little abuse arose upon it, and so very
few bad cases oame before us, that we totally forgot the matter.
Here, again, the learned Baron had put the case most invidiously. A
crossing-sweeper, he said, might be called to sign an order of admis¬
sion into a lunatic asylum. Well, but there were things so utterly im¬
probable as to amount almost to impossibilities. The Queen might
make a crossing-sweeper a Duke, and give him a seat in their Lord¬
ships’ House ; but did any of their Lordships fear such an issue ? It
was a weak point, no doubt, and required amendment; but in nearly
40 years there had been no complaint, and probably not one in 500
orders had been signed by any but some relative or friend. All this
was before the Committees of 1859 and 1877, and they had not taken
the formidable view of the learned Baron. They had accepted many
of the propositions of the Commissioners, and had added some of
their own, which were then wanting in enactment. And here he might
add, in reply to the assertion of the noble Earl opposite, that the order
could inflict perpetual confinement, that the Commissioners could,
if they saw fit, set aside the order. But let their Lordships then
consider the ominous announcement of the noble Earl, that the state
of the Lunacy Laws constituted a serious danger to the liberty of the
subject. The two Committees of 1859 and 1877 had come to no
Digitized by
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Occasional Notes of the Quarter .
399
1884.]
snch conclusion; on the contrary, they had rejoiced in the many and
vast improvements. How could they have feared for the liberty of
the subject in the face of such a statement as that he had made be¬
fore them ? From 1859 to 1877 there had passed through the office
of the Commissioners 185,000 certificates. Of these, some six or
seven had demanded the attention of the Select Committee of the
House of Commons; but all, upon investigation, were found to be
just and good. During the same interval there had been 90,000
liberations, of which 22,000 were from licensed houses. The Returns
up to the present day were equally satisfactory, a sufficient refutation
of the common assertion that persons thrust into private asylums
would never get out. There were, he believed, fewer cases of mistake
in placing patients under care and treatment than of miscarriages of
justice in Courts of Law. The noble Earl ought, in candour, to have
quoted that part of the Report in which the Select Committee had
spoken of the vast and beneficial progress made in the treatment of
lunacy. It was as follows :—
The Committee cannot avoid observing here that the jealousy with which
the treatment of lunatics is watched at the present day, and the comparatively
trifling nature of the abuses alleged, present a remarkable contrast to the
horrible cruelty with which asylums were too frequently conducted less than
half a century ago, to the apathy with which the exposure of such atrocities
by successive Committees of this House was received, both by Parliament and
the country, and to the difficulty with which remedial enactments were carried
through the Legislature, while society viewed with indifference the probability
of sane people being in many cases, confined as lunatics, acquiesced in the
treatment of lunatics as if they were outside the pale of humanity, and would
have scarcely considered a proposal to substitute for chains and ill-usage the
absence of restraint, the occupation and amusement, which may be said to be
the universal characteristics of the system in this country at the present day.
And, again, they said—
Assuming that the strongest cases against the present system were brought
before them, allegations of mala fides were not substantiated.
He could assure their Lordships, from long observation, dating back
more than 50 years, that it would require much time, and much power
of description, to set before them the state of degradation and suffer¬
ing in which lunatics were found by the inquiry that commenced in
1828. Manacles and leg-locks were in universal use—many were
chained to the wall, almost all in filth, disorder and semi-starvation.
He mentioned all this to show that great and good things had been
done under the existing Lunacy Laws; and that some gratitude was
due to God for having given the will and the power to raise them
from such misery. Now, he did not mean to say that perfection had
been reached—very far from it; but he urged their Lordships to pro¬
ceed with care and caution, following experience, and the discoveries
of science, and not preceding them by hasty legislation, which might
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400
Occasional Notes of the Quarter. [Oct.,
throw them back to the condition of half-a-century ago. But while
they were considering, and jealously guarding the liberty of the sub¬
ject, they must also consider the value and necessity of early treat¬
ment of insanity. On one point there was, it might be asserted, a
consensus of opinion among all medical men, and, indeed, laymen, who
had studied the question. Quotations of evidence to that effect might
be multiplied, almost without limit. Dr. Sutherland maintained that
if cases were taken at the very commencement of the disorder, full 85
per cent, might be cured. Dr. Conolly stated certainly not less than
50 per cent.; but the whole might be summed up in a most valuable
extract from the Report of Mr. Ley, the Medical Superintendent of
the great County Asylum at Prestwich, in Lancashire —
“The total number/’ said Mr. Ley, speaking of a particular year, “of
curable cases in the 446 admissions was 209 ; 113 of these have been sent out
recovered, and, in all probability, 70 more will be discharged during the
current year. Eighty-nine per cent, of the total recoveries occurred in those
who were admitted while the attack was yet recent; only 11 per cent, are
from those who were allowed to remain without proper treatment for a long
time after the malady had declared itself. The duration of residence in these
recoveries varied from four weeks to twelve years, the average duration being
much augmented by the recovery of some few who had resided in the asylum
above a year.”
This was his summing up, and this was the summing up of every
medical man he knew.
“ These results,” Mr. Ley continued, ‘‘ prove what has so often been urged
before, that insanity in its early stages is as curable a disease as any other in
the catalogue of human disorders/’
The evidence from America was abundant and equally decided.
Though he would not add anything to the law to give facilities for
the shutting up of persons under the charge of insanity, so fearful was
he of the possibility of error, he would do nothing to diminish them.
He spoke in the interest of the patient, for whom a cure thus became
comparatively easy, and in the interest of the world at large also, who
had a deep concern in the abatement of that terrible disorder. The
impediments were grave and numerous already—the reluctance of
parents and relatives to see, and then believe, the first symptoms of a
disturbed intellect; the serious step of consulting a medical man on
the point, even though he were the physician of the family ; the fear
lest anything should transpire, and the public be admitted in any way
to the sad secret: all these feelings postponed the final decision, until
by long continuance the affection had become almost hopelessly con¬
firmed. If, then, that repugnance existed under the present system,
what would it amount to were the magistrate called in or a jury sum¬
moned, who never allowed anyone to be mad unless he had committed
some overt act whereby the disorder was proved to be nearly inveter-
Digitized by v^ooQle
1884.] Occasional Notes of the Quarter . 401
ate ? Here the pauper had a great advantage over the class above
him. He was taken to the asylum in the first stage of his affliction,
and hence the public asylums claimed the superiority in the number
of cures. Certainly, the tables showed that it was so, though,
perhaps, by reason of the very early discharge, there were many cases
of relapse. Too long detention after cure had been urged against the
licensed houses. In former days it might have been so, but by no
means always with a bad motive. He did not believe that many such
cases could occur in the present day. He did not deny the difficulty
—he might say the perilous difficulty in attempting to undertake early
treatment—of discerning between a transient eccentricity of habit,
manner or temper and the slight symptoms of incipient mental dis¬
turbance. An error on either side was deeply injurious. The error
which led to the confinement of the patient might inflict, though the
patient was speedily removed, the taint of supposed insanity ; but the
error which denied the necessity of it might inflict a greater harm,
and fix on the patient the malady for ever. It demanded almost
superhuman sagacity, and showed how necessary it was to be cautious,
to avoid hasty legislation, and await the further developments of that
important branch of science. He feared that all the proposed enact¬
ments that tended to increase publicity, and render impossible that
amount of privacy that was naturally and justifiably demanded in
these delicate matters, would tend to a vastly extended system of
clandestine confinement. Single patients, as they were called, were
persons living alone under restraint, and committed to the charge of
a doctor, a clergyman, or an attendant. Where two or more, being
lunatics, resided under the same roof, the law required that a license
should be taken out ; where only one, a certificate. There was great
difficulty in the discovery of such cases ; many of them were put out
on the false plea that they were nervous, not lunatic, patients, and,
therefore, not subject to the law. Evidence of their existence reached
them in a variety of ways ; and on sjuch evidence, if sufficient, an ap¬
plication was made to the Lord Chancellor for a power to visit the
house. The Commissioners, in 1862, had visited 161 single patients;
but in 1884, they had visited 449, an increase in 20 years of 288.
How many more there might be he could not say, so secret were they,
and so scattered over the whole country. It had been asked in the
House of Commons whether it were not true that many were sent
abroad ? On that point the Commissioners could give no informa¬
tion. Now, the state of these single patients demanded the utmost
thought and attention. Care and inspection, it was true, had greatly
mitigated their lot ; but the peculiarity of the circumstances exposed
them, on the slightest relaxation of vigilance, to a return of all the
evils and oppressions of former days. The condition of these sufferers
had, in former days, been most deplorable; their treatment might
have varied according to the position and character of those who had
xxx. 27
Digitized by <^.ooQLe
402
[Oct.,
Occasional Notes of the Quarter,
charge of them ; but, in the great hulk of the cases, it was, beyond
doubt, fearfully oppressive. He had it on the personal testimony of
those who had endured the solitary incarceration. One lady asserted
that she was frequently strapped down on her bed for 24 hours, while
her nurse went out on a junket; a gentleman had assured him that
he had endured the same, and showed the scars on his legs made by
the cords wherewith he was confined. If visited, these poor people
had then but small relief; they had none to bear witness to their
testimony ; and every statement they made was attributed by the at¬
tendant to mental wandering. Now, then, these patients were
singularly unhappy ; for, in houses where many patients were re¬
ceived, any one patient had the supporting evidence of his fellows ;
for, though the testimony of a patient in respect of himself was often¬
times very questionable, the testimony of patients in respect of others
was very good, and had oftentimes been received in Courts of Justice.
He had said more than once, and he repeated it, that were anyone of
his own family visited by that sad affliction, he would infinitely prefer
to consign him or her to a licensed establishment than to the care
and treatment of a single custodian. Their Lordships would easily
perceive that the temptations, the payments being oftentimes very
high, and the facilities for long detention and delay of cure, must,
under such a system, be very great. The last point on which the
noble Earl opposite had commented was on the principle, character,
and condition of private asylums, or, as they were properly denomi¬
nated, licensed houses. The noble Earl had quoted some strong
passages given in evidence by him (the Earl of Shaftesbury) before
the Committee of the House of Commons in 1859. Now, he did not
vary, in principle, one hair’s breadth from what he stated at that
period ; and the noble Earl would have done well to have given his
explanatory evidence in 1877. It was as follows:—
Yonr Lordship said, in answer to the honourable Member for Mid-Surrey,
last Thursday, Question 11,449, that it was a notion prevailing in many minds
that the principle of profit in regard to the treatment and maintenance of
lunatics in private asylums should be eliminated.—Yes; it should be, if
possible, no doubt. If I recollect the Question put to me by the Right
Honourable Chairman, it was as to the establishment of hospitals, and I
answered that I thought it would be a good principle to make the hospital
system the basis of the system for the reception of patients of all kinds, but
that I should be very sorry to do anything that should go to the total pro¬
hibition of licensed houses; because, though I believe the operation of
the hospital system might probably tend very much to reduce the number of
licensed houses, I had strong conviction that those that survived would be of
the very highest character. It is absolutely necessary we should have some
licensed houses, because many have a particular taste that way, and because
there is a form of treatment there that you never could have in any public
asylum. You say you are ready to admit it is a notion that prevails in the
minds of a great many people, but the sooner that is eliminated the better ?—
Yes, no doubt. That idea has grown up from evidence given to the public
mind, and not often from personal knowledge P—Yes; and I judge of it from
1
Digitized by <^.ooQLe
1884.]
Occasional Notes of the Quarter,
403
conversation, and from what I read, and what I hear. I know that that feeling
does prevail in the pnblio mind, and naturally enough. I do not blame the
public for it j and, indeed, I very much praise the public jealously upon the
subject. Perhaps your Lordship remembers the evidence you gave in 1859, in
which you condemned the vicious principle of profit, as you called it, perhaps
more strongly than anybody else ?—Yes; I condemned it very strongly, and I
condemn it nearly as strongly now ; and, therefore, I want to put as great a
limit upon it as 1 possibly can. Your Lordship has modified your views upon
this subject ?—Yes; to this extent—the licensed houses are in a far better
condition than they were in every possible respeot; but I have said, and I
wish to repeat, that if we were to relax our vigilance the whole thing, in every
form of establishment, would go baok to its former level.
The Committee of 1878 had reported that the permitted continuance
or discontinuance of licensed houses must be left to public opinion;
and it was certainly remarkable that, though there were perpetual
expressions of dislike and fear of such receptacles, no steps were ever
taken, or even proposed, to provide substitutes. Since 1859, hospitals
had not increased in number; two had been added ; but that was
only apparently so, those two having come into separate existence by
disconnection from the asylums of Gloucester and Nottingham.
Nevertheless, the feeling of the country would continue, he doubted
not, to prevail in favour of the public principle, which, when
established, would require, he could assure their Lordships, no small
amount of care and supervision. In illustration of what he had said,
he might put before their Lordships the present state of private and
hospital accommodation. The licensed houses amounted, in all,
to 97 ; 35 in the Metropolis, and 62 in the Provinces. The hospitals
for lunatics proper were 13 ; for idiots, 2. The increase of licensed
houses in the Metropolis since 1859 was 1 ; the decrease of pro¬
vincial houses in same time, 15 ; but that might be accounted for by
their greater size. The inmates in hospitals were 3,146 ; in licensed
houses, 4,779 ; making a total of 7,925. Of that total, 1,398 were
paupers, leaving thus, of paying patients, 6,527. He could not
conclude'without recalling their Lordships’ attention to the vast, he
might say the blessed, improvements, made in the custody and cure
of the insane, an answer, in itself, to many reckless and ignorant
charges. Let them only consider the present treatment of the
pauper lunatic. They had often seen, no doubt, those palatial
buildings, the public asylums, erected solely for the poor. Every
mode of a physical or moral character was resorted to for the charge
and cure of these uufortunate beings. Their diet, their apparel, their
residential comforts, were of the best quality. Their amusements
were not forgotten; and occupation, adapted to their line of life, was
regarded as among the most remedial processes. The women were
engaged in employments of all kinds suited to their sex, and
agriculture was esteemed so beneficial to the men, that land to the
extent of 200 or 300 acres was assigned to many of the provincial
asylums. AH was minutely and carefully visited by constituted
Digitized by v^ooQle
404
Occasional Notes of the Quarter .
[Oct.,
authorities, as he would show by the statement which followed. It
exhibited not the maximum, but the minimum, of the visitations—
Public
Asylums,
County and
Borough.
Two or more of Committee of
Visitors.
Two Commissioners in Lunacy.
Onoe at least every two months.
Once a year at least.
Hospital.
Members of Committee of
Management.
Two Commissioners.
Various—according to Regula¬
tions approved by Secretary of
State—generally once a month.
Once a year at least. Twice of
late years, by special Resolu¬
tion of Board.
Private
Provincial
Licensed
House.
Two Visitors at least, one to ]
be Medical. J
One Visitor.
Two Commissioners.
!
Four times a year.
Twice a year (“ Single Visits ").
Twice a year.
Metropolitan
Licensed
House.
Two Professional Commis¬
sioners.
Any one Commissioner.
Four times a year.
Twice a year.
All this had been effected by degrees, by the results of observation,
by the applications of experience. The contrast between 1828 and
1884 was well nigh incredible. All they required was care and
caution, and that legislation should follow, and not precede, the guid¬
ance of practical science. But the appeal for such caution was met
by hasty and nervous agitation. They had reason on their side, but
it was encountered by nothing but expressions of fear. While of all
the maladies that afflicted mankind, none were so intricate and
appalling as those which disturbed his reasoning faculties, there were
none upon which the public at large were more prompt to give an
opinion, and enforce a remedy. He could only again and again
implore the deepest and most serious consideration on such a subject.
They were now in a far better state of hope for progress in scientific
knowledge. A large Association of intelligent and right-hearted men
had come into existence, formed of the superintendents of the great
asylums and others who gave their time and their minds to that im¬
portant study. They had their conferences, their meetings, their
periodicals, and interchange of thought and inquiry. The services of
these gentlemen were priceless—every day added something to the
stock of facts, and on facts alone could treatment advance. He
trusted that by investigation and patience they would be able, by
God’s blessing, to arrive at some alleviation, if not a full remedy, for
the most mysterious affliction that had been permitted to fall on the
human race.
Lord Coleridge pointed out that the resolution was of a somewhat
Digitized by <^.ooQLe
1884.]
405
Occasional Notes of the Quarter.
abstract character, and remarked that in that House, as elsewhere,
debates on such resolutions were likely to be in some sense debates in
the air. Nevertheless, because he had had a good deal of experience
of cases connected with the subject, and very much also in consequence
of the speech of the noble Earl who had just spoken, he would say a
very few words. The resolution had reference not to the profoundly
interesting question of lunacy itself, but simply to the practical
administration of the laws affecting the detention of persons supposed
to be lunatics. The system administered in this country owed its
origin to the noble Earl who had last sat down, and it was difficult for
anyone who had not arrived at his age to adequately comprehend the
enormous improvement made by the measures of 1845 and 1853 in
the system, if system it could be called, which was in existence before
that time. For that great improvement he believed we were mainly
indebted to the noble Earl opposite. But 1853 was more than 30 years
ago, and it was no discredit to the noble Earl to say that the experience
of 30 years might have taught us that in that system there was a good
deal to be amended. In many cases the system, though excellent on
paper, broke down in practice. In the great majority of cases it was
absolutely clear to the intelligence of any ordinary person who was
moderately acquainted with the matter that the individuals confined
were insane ; and in another large class of cases it was equally clear
that the persons whom it was proposed to confine were not insane.
It was on the dividing line that the real difficulty arose, and then the
system, though excellent on paper, broke down. If we could, as in
France, deal with a man’s property by means of a family council, there
would be very little to be said, but in this country no such system
existed. For the reason that here it was a question of personal liberty,
it was extremely important that care should be taken that the system
by which persons were incarcerated should be watched with the
severest jealousy. His noble friend had probably misunderstood the
judgment of the learned Baron, who must have known that though a
certificate was a defence to the keeper of the asylum, it was no protec¬
tion to those who had set the doctors in motion. He had himself
known of ten or a dozen cases at least where the system had broken
down. In some of these cases persons who were not insane had been
imprisoned, while in others insane persons had been so outrageously
treated that juries would have been with difficulty prevented from
giving verdicts against the persons who set the law in motion. He
recollected that in a case that came before himself it was shown that
a person had been committed to a private lunatic asylum on certificates
of medical men who were interested in the asylum, and that, although
the man had been afterwards formally discharged under their certifi¬
cates, he had been re-arrested within ten minutes afterwards on others.
He had no doubt that in that case, however, the person confined was
a fit subject for confinement. The jury who had tried the case were
naturally indignant with a state of the law which allowed such
Digitized by <^.ooQLe
406
Occasional Notes of the Quarter . [Oct*,
proceedings. His experience with regard to private lunatic asylums
had not been a happy one. It was unfortunately the case that medical
men possessing the highest minds did not devote themselves to this
particular class of disease, and, moreover, it was repugnant to such
men to mix themselves up with a system which combined commerce
and trade with their profession. In his opinion it should never be the
interest of the keepers of private lunatic asylums to retard a cure (hear,
hear). It was unfortunately the fact, as had been shown by the
statistics referred to by the noble Earl, that the percentage of cures
effected in the county lunatic asylums was far larger than that which
was effected in private lunatic asylums. In the former it was clear
that it was not the object of any one to retain a patient longer than
was absolutely necessary, because the maintenance of such a patient
was a matter of cost and not of profit, whereas in a private lunatic
asylum the interest was the other way. He could only say that his
experience led him to believe that it was unwise to hold out induce¬
ments to the keepers of private lunatic asylums to retain their patients
as long as they could (hear, hear.) It had been said in reference
to this class of disease that a medical man would have just as much
reason to effect a cure speedily as in the case of any other class
of disease ; but it must be remembered that the inducement was not
the same, because such cases were not likely to be talked about among
the friends of the patient.
The Lord Chancellor said that if he asked their Lordships not to
agree with the motion of the noble Lord it was not because he thought
that the Lunacy Laws were not capable of improvement or amendment,
for such was not the opinion of the noble Earl at the head of the
Lunacy Commission nor of those who had investigated the subject,
but because he thought it would be very unwise on a subject of so
much importance and difficulty to pass a resolution condemning too
severely the existing system of the Lunacy Law as being eminently un¬
satisfactory. He fully admitted that there were many things in our
Lunacy Law which were not as satisfactory as they might be, but he was
sure that their Lordships would be most anxious to preserve an equally
balanced mind in dealing with a subject of such difficulty and impor¬
tance and not run the risk of defeating a salutary object for the sake
of obviating conceivable and possible, but in his opinion highly theo¬
retical, dangers. It must be remembered in the first place that the
Lunacy Laws were meant for lunatics and not for sane people, and that
they must be such as were calculated to deal wisely and properly with
the lamentable fact that there were at all times a large number of per¬
sons requiring treatment for mental diseases. When the Commis¬
sioners made their report in 1878 there were over 66,000 lunatics,
and it was probable that at the present time that number had
increased. These unhappy persons must be dealt with, not only for
their own sakes, but for the sake of the community at large—for their
own sakes in order that they might be cured, and might not become
Digitized by v^ooQle
1884.] Occasional Notes of the Quarter . 407
the prey of designing persons, and for the sake of the community that
they might not, being at large, become dangerous to other persons as
well as to themselves. In these circumstances, wise and proper laws,
humanely administered, are necessary as safeguards by which the
safety of lunatics and of the community at large could alone be
secured. Looking to the result of every public investigation which
this matter had received, and especially to the last careful examina¬
tion in 1878, he thought it was too much to say that the proportion
of cases in which there was any reason to suppose that abuses
took place was infinitesimally small in comparison with the cases in
which the present law had been properly administered. It had been
said that there was too dangerous a facility for bringing persons into
confinement as lunatics who might not be so, and that under the exist¬
ing system, there was a temptation to persons who had an interest in
doing so to retain them. There might be persons who wished to shut
up their relatives without sufficient grounds for doing so, and such
persons might be able to find two medical practitioners to assist them
by giving certificates of lunacy. These were undoubtedly points
requiring careful attention, and as to which every safeguard which did
not go too far in the opposite direction ought to be adopted. It
should be remembered that some of the cases which were investigated
by the Lunacy Commissioners were absolute breaches of the law, and
no system of law, however good, would prevent persons from
committing a breach of it. It was worth while to consider whether
it was not possible to amend the present law, and so diminish the
probability of abuse in its administration, without throwing too great
an impediment in the way of a proper administration of the legislation
on the subject generally. The Commissioners, in their report of 1878,
showed the system in operation in Scotland of what were called
emergency certificates, and suggested an amendment in the law in
that direction, and without binding himself to those suggestions in
every detail, he thought that some amendment in that direction was
worthy of consideration. In the meantime it must not be forgotten
that there were checks and safeguards under the present system—
medical certificates and visitations, both by the Lunacy Commis¬
sioners, and by Visitors appointed by the Court of Chancery, none of
whom had personal or pecuniary interest in the cases which they had
to visit , and inquire into (hear, hear.) Careful reports were made,
and in any case to which special attention was called these reports were
inquired into. He thought everything that could possibly be done
was done by the visits of the Commissioners and the Visitors. He
had frequently seen letters from unfortunate patients, in which they
stated their own views of their own cases; and he always desired, where
the matter justified it, special reference to be made by the Visitors in
such cases, and he was bound to say that the letters themselves
contained, as a rule, internal evideuce of some unsoundness of mind,
and, in some cases, where they were not satisfied, further inquiry showed
Digitized by <^.ooQLe
408
Occasional Notes of the Quarter. [Oct.,
that, although the unfortunate persons were capable of acting and
writing like sane persons, yet, at other times, not only were they of
unsound mind, but positively dangerous. With regard to private
asylums, to which the noble Lord (Coleridge) referred in terms which
he should not controvert, but which he could not corroborate, because
he had little knowledge, still some of them, and not a few, were con¬
ducted by men of the highest character. He was sure the noble Lord
must feel that the subject was one of the most difficult character. The
decision at which the Committee of 1878 arrived was that the matter
had better be left to the spontaneous action of the public. Some
thought these private asylums should be immediately abolished, and
others thought that they met an acknowledged want, and so forth.
The matter was very much debated, and a Bill by Mr, Dillwyn was
passed in the other House, but it failed to pass through their Lord-
ships’ House. Another member of the House of Commons moved a
resolution that all lunatics should be brought under the care of
the State, and that was rejected by a large majority. There were
circumstances which could not be left out of consideration. Those
lunatics who had considerable property were entitled to have their
comfort provided for as far as possible. They must be put into the
care of some persons, whether they kept licensed houses or not, to whom
the expenditure must be entrusted. The inquiry which had been held
by the Committee showed that no serious abuses existed, and he must
say that their hearty thanks were due to the noble Earl (Shaftesbury),
his colleagues, and also the Visitors, for their great labours (hear,
hear). They provided the most effective safeguards that could be
devised. He would not dwell on the safeguards, but he should under¬
take, on the part of the Government, if they continued to possess the
confidence of Parliament, that in another session they would bring
forward a Bill, of which the object would be to consolidate the exist¬
ing law with such improvements as were recommended by the
Committee of 1878, and others which might occur to them as
advisable. He hoped, under the circumstances, the noble Earl would
not divide the House on his motion.
The Marquis of Salisbury thought that, after the announcement
just made, his noble friend would consider that the useful objects of
his motion had been attained, and would not press it to a division.
The debate to which the motion had given rise was of a very valuable
character, and he did not think the existing Lunacy Laws would
survive the blow they had received from the noble and learned Lord
opposite. The subject was one which was extremely difficult, but he
thought every one who had listened would agree that the securities
for the liberty of the subject under the Lunacy Laws were very much
less than were granted in every other part of the law of England. It
was said that they must make lunacy laws for lunatics. That was all
very well, but the very gist of the complaint was that occasionally
sane people were detained. There were two classes of very obvious
Digitized by <^.ooQLe
409
1884.] Occasional Notes of the Quartet.
motives. There were people who would want for their own motives
to get rid of relatives whom they might find inconvenient, and whose
property they might desire to secure. Motives of that kind were
familiar in fiction, but he feared that they were not altogether strange
in real life. On the other hand, there was a strong motive in the
keeper of a private asylum to keep wealthy patients, showing a
tendency to recover, on account of the rich harvest of profits. These
were very great and strong influences. What facilities did the law
give them ? As far as the initial stages of confining lunatics were
concerned, it seemed to him the law was no security (hear, hear).
Any person, no matter how deep an interest he might have in shut¬
ting you up, had a right to take any two doctors he could find, no
matter how obscure, and get an order to shut you up. Who could
say there was any security in the initial stages ? The whole defence
of the present system lay in the inspection conducted by the Lunacy
Commissioners, who had certainly acted with very great assiduity and
success. He entirely agreed with the noble Earl as to the great debt
of gratitude they all owed to the noble Earl the First Commissioner
and those who worked with him—it was impossible to exaggerate the
debt the country owed to him in his conduct of that difficult and
thorny part of the law (hear, hear)—but the older guardians of
English liberty would have been startled had they been told that a
man’s liberty was entirely dependent on the vigilance of a department.
The great defect in the administration of these laws was the absence
of publicity. If the doctor had to go before the magistrate, or the
inspection of the Commissioners was so public that any one concerned
could witness what was done, then there would be an adequate
security for that liberty which now entirely rested upon the high,
administrative and moral qualities shown by his noble friend and his
colleagues. Under these circumstances no one would say that the
state of the law was satisfactory when that was the sole defence for
its present state, and the motive for abusing the law was sometimes so
strong. It might be said that if this publicity were insisted upon
the necessary result would be that the feelings of families would in
many cases lead to clandestine imprisonments taking place. He con¬
sidered that the noble Earl had made out his case, and shown that the
state of the law was not satisfactory. On the other hand, after his noble
friend’s declaration that legislation would be proposed by the Govern¬
ment, he thought the motion might properly be withdrawn (hear, hear).
After a few words from Lord Stanley of Alderley,
The Earl of Milltown, in view of the proposal of the Government to
introduce legislation at a future date, agreed to withdraw his motion.
His object had been more than gained by the discussion that had
taken place and by the promise he had obtained from the Goyem-
ment. He was still of opinion that the arguments in favour of his
motion were unanswerable.
The motion was then withdrawn.
Digitized by <^.ooQLe
410
Occasional Notes of the Quarter .
[Oct.j
The above is a fair specimen of the discussions which from
time to time arise in Parliament and the country with reference
to this vexed question.
Public servants of whatever class ought not to object to
reasonable criticism upon their acts, and the members of
the medical profession practising our speciality are, we believe,
no more thin-skinned than the members of other professions,
or other members of our own. But we certainly think we
have a right to ask that we may be generally credited with
ordinary honesty and integrity such as would be presumed to
belong to persons to whom the most important interests are
entrusted in other departments of our profession, in relation to
the treatment of patients, the care of the public health, and
the discharge of medico-social and medico-political duties.
Upon many occasions on which the honour of our profes¬
sion, in its relation to the subject of insanity, has been called
in question, we have had an earnest and powerful advocate in
Lord Shaftesbury, as upon this occasion; and we desire to ex¬
press to him, on behalf of the Association which this Journal
represents, and of the members of our profession who are en¬
gaged in the practice of lunacy, our grateful acknowledgement
of his kind, and intelligent advocacy.
The public interest has been largely excited, and the
preceding observations have some of them received a remark¬
able illustration by recent proceedings in the Law Courts.
These proceedings and their results show conclusively how
widely even skilled opinions may differ on questions of lunacy-
law interpretation, and how a great need consequently exists
for at least such codification and explanation of the existing
statutes as shall enable those who are bound by, and have to
act under, them to beep themselves well within the lines of
legality and safety. They certainly also accentuate, in a very
unmistakable manner the dangers and liabilities under which
certifying medical men perform functions which are imposed
upon them by the public, practically without their having any
power of repudiation or means of protection.
It may be that the evidence produced at the recent trials
showed that there had been a less strict compliance with the
provisions of the law than there should have been, or there
may be other deductions to be drawn from it. But the result
certainly seems to have demonstrated the necessity of a
demand being made by the medical profession generally,
either that the duty of signing certificates of insanity shall be
taken from them and transferred to other hands, or that they
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shall, in some way, be secured against the vexation and
pecuniary loss to which anyone who has been certified as
insane has now the power to expose them.
The public exclaims against the monopoly of the medical
profession to confine lunatics; the medical profession should
surely now resist that which the public has forced upon them,
their monopoly to endure persecution and suffer loss for the
discharge of a public duty.
It may be in the interest of the public that future certifica¬
tion should be entrusted to specific public functionaries
properly qualified, and duly protected. It cannot fail to be of
vital importance to medical men that immediate steps be taken
to relieve them from duties which they have not solicited, with
their discharge of which the public are evidently not satisfied,
and which are at all times attended by unpleasantness, and the
evidently not remote possibility of serious pecuniary loss.
Weldon v. Semple.
One chief feature in this case is the opposite opinion formed
by two judges as to the law of lunacy, and we are inclined to
think that, with all its faults—we had almost said follies—the
trial of Weldon v. Winslow was more according to law than
was the one of Weldon v. Semple. Both judges seem to have
agreed in thinking there was something “ shocking ” in lunacy
proceedings, and that there was necessity for immediate change
in the laws regulating detention of persons of unsound mind.
Everything in the lunacy world indicates unrest and unstable
equilibrium, and we only hope that legislation will not follow
in a panic.
The present legislation is the result of much care and expe¬
rience, and, if not the best possible, is far better than what
would follow hasty radical measures. Of one thing we are
sure, and that is that troublous times are before those en¬
trusted with the care of the insane. Already we know of
several threatened proceedings by former patients. From
experience we know that there are certain very dangerous
patients, who have a craving for legal proceedings, and who
really believe themselves to be persecuted or injured by unjust
detention. Some of these are to the manner born, and come
of nervous, unstable parents ; others are discontented in conse¬
quence of imperfect recovery, repeated attacks of insanity, or
because the form of the insanity was marked by querulous
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412 Occasional Notes of the Quarter . [Oct.,
discontent; many alcoholics belong to this last class. Such
litigious lunatics have been long recognised, though not suffi¬
ciently described.
Besides the persons who are of markedly unsound mind,
there are others in whom eccentricity approaches insanity so
closely that even experts may be misled, and it is with these
cases that the more danger occurs. The public and judges
themselves look with very different eyes upon such cases when
they are related to themselves from what they do when they
have to decide in a question of liberty or freedom. Sanity or
insanity is not considered then, but only whether a certain un¬
fortunate person should practically be confined for life. There
are many persons who are sources of endless family trouble,
and even disgrace, who are recognised by their friends to be
odd or insane, but who are so acute that it were dangerous for
any physician to attempt to state in a certificate the grounds
for his belief in their insanity. These cases, we fear, must at
present be accepted as part of the cross which has to be borne
by their relations, and must not be sent to asylums or re¬
strained in their actions.
It is to be remembered that most of these cases can be
steered by judicious management, and also that their peculiari¬
ties are so much part of themselves that to send them to an
asylum is to condemn them to lifelong confinement—a most
serious step to take.
Without in any way assuming that Mrs. Weldon belongs to
this class, or to any class of mental unsoundness, the present
series of prosecutions naturally calls our attention to the
dangers involved in certifying to the mental state of any
patient.
In the case under consideration at present we feel it our
duty only to point out what is known of the proceedings, and
to leave the issues of facts untouched.
The case may be well considered from different points of
view. First, let us suppose that a gentleman of position has
a wife who develops strange ideas, and who, in consequence
of these ideas, ceases to perform her duties as a wife, and
causes anxiety not only to her husband, but to her own rela¬
tions. Later, if this person develops symptoms which,
though not necessarily evidence of insanity, are more com¬
monly present with mental unsoundness than with sanity, it
is not to be wondered at that the husband should consult some
specialist whose name is well known, and that he should
suggest that consultations should be arranged by this specialist
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Occasional Notes of the Quarter .
413
to determine tlie nature of the disorder and the best way of
treating it. A consultation takes place; and the specialist
advises that a certain course should be followed; the husband,
ignorant of the method to be followed, asks the consultant if
he will arrange the matter, and follow the treatment which is
most suitable to the cure of the patient. It is not astonishing
that the consultant should refer to medical men whom he knows,
and to whom he has referred other cases. All consultants must
know the difficulty there may be to get certificates signed even
for lunatics who are raving, and we fear this danger will be
increased by the present trials.
The medical men are informed of some of the particulars of
the case, and attempt to visit the patient; but difficulties
arise, and subterfuges have to be made use of to obtain an
interview. We personally object to any doctor disguising him¬
self or his profession in examining cases, but we all know that
stratagem is needed in some cases, and even Baron Huddles¬
ton contended that a doctor might disguise himself to obtain
an interview. All this being done, two doctors go together to
see the patient, provided they do of themselves, and apart,
obtain facts indicating insanity, and it seems quite a new read¬
ing of the lunacy law to insist on the doctors never having
seen the patient together.
The doctors having obtained facts satisfying themselves of
the insanity of the patient hitherto, have not been expected to
call together all possible evidence in support of their judg¬
ment, or else every certificate would involve days of ques¬
tioning. It seems to us most anomalous that on the one hand
the doctor is expected to form an independent judgment, and
yet he is to get all the collateral evidence as well.
The above may be said to be one side of the question. The
other is that a husband, being tired of a wife of strong will
and definite purpose who renders his life uneasy, determines to
get rid of the bother by putting her into an asylum. He
calls in a specialist who has an asylum and offers him liberal
terms to get her out of the way ; the latter takes the job,
calls in his friends to assist him, primes them with statements
which are perversions or exaggerations of fact, and they,
willing to serve him, go through a form of examination,
acting up merely to the letter, not the spirit of the law,
and thus place the patient under certificates.
We ourselves do not believe that the latter is at all a likely
thing to happen.
There is yet another way of looking at the matter, which is
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414
Occasional Notes of the Quarter.
that misrepresentation of facts by friends may lead a doctor to
believe that a peculiar person will be benefited by temporary
seclusion under his care; and other doctors, who know and
believe in his judgment, may too readily accept the facts
which are told them, and see and hear everything with a
strong bias. In this last case no bad faith or evil intention
exists on any side, and the most that can be said is that care¬
lessness was present. Each person who has followed the trial
must have been struck by the very strong opinion formed by
the judges. It is to be regretted that men of sound judg¬
ment should be ready to accept the charges against doctors,
and this makes one anxious to know why the evidence of
medical men should be so mistrusted.
The lessons to be learnt are that even greater dangers arise
to the proprietors of private asylums than was suspected, and
that a very strong feeling is abroad against the maintenance of
institutions for the detention of lunatics in which there is a
strong inducement to keep patients who might be at large.
We ourselves accept the evidence brought before the Parlia¬
mentary Committee showing that no cases of undue or
unjust detention in these asylums could be discovered. The
principle is one which seems to be dangerous, but the
difficulty is great when we want to provide a remedy, and we
believe there will be a reaction when some judge or poli¬
tician has been killed by a lunatic who was too cunning to be
certified.
Private asylums are not the only ones interested in paying
patients; a superintendent of a paying hospital feels the effect
of the loss of highly paying patients in his annual returns, and
the doctor with one patient cannot be always content at the
.prospect of losing the person who pays his rent.
As to the signing of certificates, we regret to find that
many men whose judgment is of the soundest refuse to run
the risk involved in signing a certificate. We do not believe
that any plan for signing on oath will be of any service, and
the attempt to have magisterial sanction or authority will
delay the treatment of many cases till the time for cure is
past.
It has always seemed an anomaly that in all other diseases
the treatment is decided upon after consultation by two or
more medical men, but in lunacy independent judgment is
considered best. Who has not met with dangerous lunatics
who might be interviewed for an hour without their delusions
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being detected, unless a hint were given by the family doctor ?
Then all is cleared up and the certificate signed.
Lunacy law will be amended, or probably re-made, and the
foundations will be laid at the cost of some martyrs.
PART II.—REVIEWS.
Outlines of Psychology , with Special Reference to the Theory of
Education . By James Sully, M.A. London: Longmans,
Green and Co. 1884.
A work by Mr. Sully bearing this title is sure to interest
medical men whose practice is concerned chiefly with the
psychical manifestations of disease. However skilful a
man may be as a physician, he can scarcely fail to increase his
success in dealing with the insane when to his knowledge of
medicine he adds knowledge of the laws that govern mental
phenomena. It might be added that such knowledge will not
merely improve his professional insight; it will quicken his
perception and aid his judgment as a man of the world;
leading to facility in tracing motives, in analysing character,
and in influencing the conduct of others.
The present volume is designed for the general reader as
well as for the student. Its main object is to present the
leading facts of the science of mind, and to point out the prac¬
tical application of them. In working out this object the
author entirely avoids questions in metaphysics. Mr. Sully’s
point of view is that of the Association School of Psychology
as modified, or rather expanded, by the doctrine of evolution.
As an exposition of the present state of psychology the book
may be said to carry out its intention satisfactorily. Without
presenting anything striking either in the way of fresh analysis
or in the manner of setting out the facts, it may be said to
exhibit succinctly the current views of the Association School
though it may be doubted whether a reader would carry away
with him as clear and definite a grasp of the subject as he
would from Bain’s “ Compendium of Mental Science.” This
comparative inferiority is probably due to the fact that Mr. Sully
is somewhat sparing in concrete examples to illustrate general
statements. For this reason, though the style is clear and the
meaning is never uncertain, the various laws of mind are hardly
realized in all their bearings and in full force.
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Reviews.
[Oct. f
The usual threefold division of mind into Feeling, Knowing,
and Willing, serves as the basis of description ; and a glance
at any peculiarities in Mr. Sully*s treatment will afford an
insight into the nature and method of the book.
The fundamental attributes of the intellectual operations
are resolved into Assimilation and Discrimination. Another
property of intellect, according to Prof. Bain, is Retentiveness.
All knowledge clearly implies the capability of retaining,
recalling, or reproducing past impressions. But retentiveness
occupies a different place in knowing from that of discrimina¬
tion, &c. It is rather a condition of knowing, of coming to
know, than a part of the active knowing process itself.
Besides, as we shall see later, it is the principle which underlies
the growth or development of intellect, and not only of this, but
of mind as a whole.’* Now, although growth in any depart¬
ment of mind requires memory, it is not the less true that
Emotion and Will embrace an intellectual element in so far as
they are marked by recoverability. In other words, retentive¬
ness stamps on any quality of mind an intellectual phase.
The highly retentive senses, Sight and Hearing, are more
intellectual than the less retentive, Taste and Smell. Action
is intellectual in proportion as it is guided by memory rather
than by present feeling. Hence it does not seem altogether
accurate to remove retentiveness from the sphere of intellect,
and to make it merely a general condition of mental develop¬
ment.
Mr. Sully*s view of memory does not make his treatment of
it any the less interesting. Under the head of Reproductive
Imagination (Memory), the conditions of reproduction and the
laws of association are stated. Facility in recollection, apart
from original endowment, depends upon depth of impression
and association of impression. Depth of impression is due to
attention springing from emotion or other source, and to
repetition. Association of impression includes the various
modes ordinarily recognized—Contiguity and Similarity with
their composites. The training of the memory affords occa¬
sion for some useful observations. A note of warning is also
raised against the undue exaltation of memory. “ It cannot
too clearly be borne in mind that to acquire any amount of
knowledge respecting the particular and concrete is not to be
educated. Perfect knowledge implies the taking up of the
particular or concrete into the general, the connecting of a
variety of particulars under a universal principle. It follows
that memory may be over-stimulated. A certain knowledge of
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417
the concrete, a certain store of images, is undoubtedly neces¬
sary to the exercise of the higher intellectual faculties; but if
the teacher aims simply at mass or volume of details, the
higher ppwers of the mind will be unexercised. Such a course
would involve growth , or bare increase in the bulk of mind,
but not development”
Belief is regarded as “ a perfectly simple mental state,
having a unique character of its own.” Though “ it
has a certain emotional complexion,” and though there is “ a
close relation between” it a and activity,” it is essentially
intellectual in nature. Thus, though “ closely related to other
mental states, it cannot be analysed into these.” This can
scarcely be considered a full account of the nature of belief.
Some justification is surely required to regard as simple a
mental state presenting so strongly the appearance of com¬
positeness, and which by different psychologists has been
relegated to each of the different departments of mind, Emo¬
tion, Intellect, and Will.
The emotions are classed in three groups or orders, “ con¬
stituting successive stages in the progress of emotional life.
First of all come what may be called the Individual or Per¬
sonal Emotions.” “ In the second place we have the
Smypathetic Feelings. By these are meant participations in
others’ pleasurable and painful experiences, and kindliness or
benevolence of disposition generally. These are purely repre¬
sentative feelings. In sympathy or fellow-feeling we have to
imagine or represent how another feels. And the sympathetic
feelings follow the personal feelings, because they pre-suppose
some amount of 6 first hand ’ emotional experience. They are
non-personal and common as distinguished from the individual
and personal feelings.” “ In the third place we have a group
of highly complex feelings know as Sentiments, such as
patriotism, the feeling for nature, for humanity. These are
commonly brought under three heads, the Intellectual Senti¬
ment, or the attachment to Truth, the Esthetic Sentiment, or
admiration of the Beautiful, and the Moral Sentiment, or
reverence for Duty (including the worship of moral excellence
and the feeling for humanity). These emotions in their
developed form attach themselves to certain qualities in things
or abstract ideas, truth, beauty, moral goodness. They involve
a higher form of representativeness than direct sympathy.
They depend to a considerable extent on sympathy, and may
be said always to involve it in an indirect form. Hence they
follow it in the order of development. They are essentially
' xxx. 28
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418 Reviews. [Oct.,
non-personal and common emotions.” In the further exposi¬
tion of the feelings there is little of note.
In his account of the Will, Mr. Sully follows the current
views of the Association Psychology. The old controversy of
the freedom of the will is disposed of in a few paragraphs. In
effect, the solution is the one that has found favour with men
of science since the days of Locke. We may properly speak
of the freedom of the man, but not of the freedom of the will.
To the medical man engaged in psychiatric practice the dis¬
cipline of the will is a problem of fundamental interest.
Touching the limits of punishment, Mr. Sully says :— €t All
punishment is suffering, and as such, an evil. More than this,
it seems to estrange educator and child rather than bring them
together. Finally, it is repressive, checking and arresting,
instead of evoking activity. Hence it can only be inflicted
when necessary either for the good of the offender himself or
by way of example and warning to others. Vindictive punish¬
ment, blows and harsh words administered in temper, and as
a relief to feelings of annoyance, check the will without dis¬
ciplining it. Punishment cannot be justified except in cases
where it is likely to be effective as a deterrent. Thus it ought
never to be inflicted where it is likely to be inoperative through
feebleness of will. Children have only a certain power of self-
restraint, and of anticipating consequences. Hence, to punish
them for actions lying beyond their control, as for example
crying, may be pure cruelty. Again, it is inhuman to punish
a child for actions which are in no sense wrong. Trifling
faults, such as obstreperousness in an active boy, are not meet
subjects for punishments. Great care should be taken before
punishing a child for an action to see that there has been an
evil intention. Thus it would be immoral to punish a boy
severely for breaking a vase the value of which he could not
be supposed to know. Also the motive must be taken into
account. Thus a child who plucks a flower in the garden in
order to give pleasure to a sick brother or sister ought not to
be punished.” On the other hand, “ If it does not supply a
sufficient force, it is useless. Weak, indulgent parents, adverse
to severe punishment are often unkind in the worst sense by
admmistenng slight punishments, which are wholly inadequate,
and so of no good to the child.” The insane are often said to
resemble children. The likeness holds good in many respects ;
but in an essential point it breaks down. The character of the
child is plastic; the character of the insane has to a large
extent hardened in its mould. On this ground it is that the
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419
punishment of the insane is objected to. To say that an insane
person should not be punished for a crime, because he “ could
not help it,” is simply to betray confusion of thought, or to
accept a doctrine that, rigidly applied, would render punish¬
ment in any case indefensible. The object of punishment is
to modify character, to add a new force to the abiding springs
of conduct. The possibility of carrying out this object is the
one thing to determine in considering a question that cannot
yet be regarded as definitely settled—Whether in any case it
is right to punish the insane. No matter how numerous may
be those who say that an insane person should never be
punished, and no matter with what heat of passion they uphold
their view, the question cannot be regarded as settled so long
as clearly-thinking, humane men, with competent knowledge,
hold the opposite opinion. The subject is, however, a large
one, and would repay with interest a thorough-going discus¬
sion.
A feature of great value in Mr. Sully’s book is the copious¬
ness of bibliographical reference. At the end of each chapter
is a list of ‘writings on the subject dealt with.
The work is a good one for those who, having no previous
acquaintance with the subject, desire to be put in possession of
the main facts of psychology. Notes on the training of the
various qualities of mind render the book specially interesting
to persons concerned in education.
W. R. H.
The Pedigree of Disease . By Jonathan Hutchinson, F.R.S.
J. and A. Churchill, 1884.
(Continued from page 292.)
That the argument may not be a broken one, it is necessary
that we should very briefly re-state the results obtained in the
first part of our review of Mr. Hutchinson’s book. A very few
words will suffice. The subjects under consideration were
Temperament and Diathesis. These were, in the first place,
defined, in the next, contrasted; and here it will be remembered
that Temperament applied to the organism in Health, Diathesis
to the same in Disease. From this we passed to a discussion of
the criteria of Temperament, which ended in the conclusion
that, though the data available were most scanty, though these
scanty data were most unreliable, yet that temperament was
not a feu follet, but a searchable something, and accordingly to
be sought. This brought the first part to a close.
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Reviews.
[Oct.,
We now have to pass on to consider another of the vague
bequests of the past—Idiosyncrasy. Concerning this, Mr.
Hutchinson insists, and very truly, that the word is intended
to indicate our ignorance of causes, not our disbelief in them.
Idiosyncrasy signifies to us a behaviour of the organism for
which we cannot account—for which no knowledge we may
possess concerning the organism gives us warrant. What we
are pleased to term individuality is a fact of the same class,
but of a lower order, for idiosyncrasy is “ individuality run
mad; ” this definition can scarcely be improved on.
Looked at thus, the question which next arises is—under
which heading shall we place Idiosyncrasy—under Temperament
or Diathesis ? On this point, we think the reader would be
somewhat confused as to the answer the author intends to give,
for on page 24 we read —“ Idiosyncrasy is, indeed, to a large
extent, nothing but diathesis brought to a point; ” whilst
further on, bottom of p. 25, we read —“ We have defined idio¬
syncrasy to be a peculiarity of the individual, usually a rare
and exceptional one, which does not necessarily entail any de¬
gree of proclivity to disease .” By the first of these
statements we are led in the direction of Diathesis, by the
second in that of Temperament. If we halt midway, we may
take this comfort to ourselves that had we followed either indi¬
cation we should have attained only to a partial truth. Let us
examine the question a little more closely; and first in the di¬
rection of Diathesis. Imagine a family with a well-marked
pathological tendency—say in the direction of phthisis—hos¬
pital and general practice will tell us every day concerning
such that this tendency will be manifested by the different
members of the family in very varying degree; in some it will
be possible, by careful treatment, to keep in abeyance the
tendency; in others, treatment may fail to do so, but may
yet prove a powerful factor in modifying the course of the
disease; whilst in one, perhaps, we may find that, despite
the most careful preventive treatment, the disease arises,
and then, apparently without the smallest regard for
curative or palliative means, runs an uninterrupted and
rapid course. Clearly here we have “ diathesis brought
to a point,” in this one member the pathological tendency
culminates. Why—we do not know. Let us now look
at the question from another standpoint, and suppose, e.g.,
that a capacity for work marks a family, this we know to
be the case not uncommonly. Whilst then the family, as a
whole, is known by this quality, energy, we shall perhaps find
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that, in one particular member this same quality will manifest
itself in a most unusual degree, in the performance, viz., of an
almost incredible amount of work on very possibly a spare diet
and a seemingly inadequate allowance of sleep. Again, we have
individuality “ running mad,” if you like, but in the direction
of temperament this time, for surely none would dream of class¬
ing, as pathological, capacity for work. We are looking, in
fact, at “ a fundamental mode of activity of the organism.”
Again, we could hardly class as indicative of a pathological
tendency, the fact that one organism will react to a very minute
dose of atropine, whilst another will show an unusual insensi¬
bility to the same drug. There is no pathological tendency
here—nothing, indeed, “ but a fundamental mode of activity.”
Clearly, then, it would seem that individuality may signalize
itself both in health and disease, and therefore that idiosyn¬
crasy is not only Diathesis, but also Temperament brought to
a point.
We may here remark incidentally that the fact of our em¬
ployment of such a word as idiosyncrasy is significant of scien¬
tific degradation. If we search the exacter sciences—mathe¬
matics, physics, even chemistry, we search in vain for such a
term; yet we might, if we so willed, use the term even in these
—as, for instance, in the case of a number of balances, some of
which we discovered would turn to a milligramme, others not
to a centigramme. Here is idiosyncrasy, but the physicist is
content to say that one is more sensitive than the other, fully
satisfied that, if he investigate, the reason will be forthcoming
in a greater nicety of finish of the fulcrum, or in a higher or
lower pitching of the centre of gravity of the beam of the
balance. Nothing whatever would have been gained by the use
here of the word idiosyncrasy, just as we gain nothing by it.
It is, indeed, we think, a very useless term. Let us not be mis¬
understood, the word idiosyncrasy is not meaningless—on the
contrary, it means something very definitely, only it is useless,
because we already possess words capable of expressing that
meaning. It may be argued that the word avoids periphrasis;
but even admitting this, it may be questioned whether the dis¬
advantage of a periphrase is not more than counterbalanced
by the objections to the multiplication of terms.
Leaving this, we have next to consider a very important
subject. Accepting the term idiosyncrasy, as we must here, we
find the statement, p. 25, “ that they (the idiosyncrasies) de¬
pend upon structural peculiarities, we can not doubt, though
we may be quite unable to demonstrate their physical cause.”
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[Oct.,
Here, surely, is an article of faith on which Pathology must
stand or fall; to this we must all give in an absolute adhesion
—we shall see, later on what adhesion to this statement in¬
volves. Mr. Hutchinson next advances to the further point,
that not only must functional idiosyncrasy involve structural
idiosyncrasy, and mce-versd, but that structural idiosyncrasy may
be the only fact which may strike us, i.e., the functional pecu¬
liarity entailed may be quite subordinate or altogether escape
notice. As examples of such structural idiosyncrasy, we find
instanced—coloboma, retention of their sheaths by the retinal
nerve-fibres, clefts in the eyelids, absence of levator palpebrae,
hare-lip, etc. We think this part of the book particularly
valuable, enforcing, as it does, the doctrine that functional
peculiarity involves structural peculiarity; for, knowing that
the structural peculiarities above recorded must entail corres¬
ponding peculiarities of function, and yet that these latter are
not apparent, we shall, with this before us, find it the less diffi¬
cult to grasp the teaching that abnormal function will also in¬
volve abnormal structure, though the latter be not apparent.
The above instances of structural idiosyncrasy do not involve
any definite pathological tendencies. They remain stationary
as fundamental modes of structure—the counterpart of tem¬
perament ; but we may find structures showing peculiar and
definite departures from the normal—which departures we
must class as morbid—and then our structural idiosyncrasy
associates itself with diathesis. This diathetic form Mr.
Hutchinson illustrates by certain skin diseases, e.gr., by mollus-
cum fibrosum, xanthelasma, psoriasis, and others; and in con¬
cluding this part he points out that it is not very far from the
position thus reached to the consideration of the development
of morbid growths in general as indicative of local morbid pro¬
clivities of certain tissues. Should we be very much further
on our way if we granted this ? That is a question we are not
desirous of entertaining, but we think that we are the further
for this juxtaposition of structure and function which the em¬
ployment of the term structural idiosyncrasy effects. It is
hardly possible to ring the changes too often on these points,
for—to alter an old saying :—“ What the eye doth not perceive,
the mind doth not believe.” Let us see how this applies.
Take the doctrine of Heredity in insanity: is it not held by
many authorities in this domain that this is not proven, i.e.,
that the evidence is not such as to exclude simple coincidence
on the laws of probability ? Admitted, but none the less can
you doubt the doctrine of Heredity here ! To answer this we
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may observe that it is not hard to trace in the resultant of two
forces the likeness to its parents; but multiply the forces, not
fiftyfold, but a thousandfold, and then seek in the resultant
the resemblance to any one of its parent components. What
will be the result ? You may then not only not see a likeness,
but you may see apparent unlikeness; and yet would. any
physicist in the world deny that this same resultant bore the
traces of the component we were seeking ? Can we not even go
further, and ask the question, if theoretically one could deny
the possibility of a resolution of the resultant into its con¬
stituent components, and then behold the likeness sought!
As well, indeed, might you deny that the projection of a given
flake of foam was the offspring of and resembled its countless
parent forces, on the grounds that you could not prove it, could
not eliminate chance, as deny in things mental that cast of
thought in the parent will be projected into the psychosis of
the child, and be there for him who knows how to look for it.
Anything short of this belief shakes at the foundations of a
structural psychic pathology, and it is well that we should
recognize this. It is, it must be confessed, a praiseworthy
condition of mind which avoids giving facile credence to
doctrine, and demands demonstration, but it is doubtful
wisdom which, on the grounds of negative, not positive
evidence, discredits a principle.
Our task is nearly finished, for it would not be in place here to
follow Mr. Hutchinson in detail. The broad lines of the argu¬
ment of the book are throughout amply illustrated by examples;
thus, Idiosyncrasy is considered in reference to diet, to drugs,
to the, poison of specific fevers, to local irritants; and under
each of these headings we find most valuable material, much of
which is the result of, or is enforced by, the author’s own most
careful observation. Diathesis finds similar extensive exemplifi¬
cation, which, however, does not call for criticism here. If, in
taking leave, we may be allowed a Parthian shaft, we would
draw attention to a statement on page 71. We are there asked
to accept as a definition of diathesis “ that it is any condition
of 'prolonged peculiarity of health giving proclivity to definite
forms of disease ” Tins definition we think not very happy in
its wording, for surely the conditions under which health
should give proclivity to disease would cease to be health. It
would not have been needful to draw attention to this, which
may be but a slip on the part of the author, if it be not on the
part of our understanding, but that it seems to us most essential
to be very clear on these points of definition, and here to recog-
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nize concerning diathesis that entering on this we take leave of
health, and find ourselves in the domain of the morbid—Tem¬
perament taking account of all conditions on this side of
disease.
It is impossible to conclude without expressing to the
author of the “ Pedigree of Disease ” our gratitude for having
again brought into prominence problems so important. It is
needless to say that the subject is ably handled; this could
not be otherwise by so accurate an observer and so careful a
thinker. But Mr. Hutchinson has other qualifications more
especially his own, viz., a most exceptionally wide range of
observation and large store of accumulated facts; these
it is which fit him as very few others to treat of subjects of
the nature of those dealt with here. If the result of his
labours are not very definite, let us remember that the best
minds of the past have been engaged in the attempt to master
the difficulties besetting the consideration of Temperament,
Diathesis, Idiosyncrasy, and have not been more successful.
To Mr. Hutchinson has belonged the task of showing us what
we ought to know and do not know, and of pointing out to us
the direction in which we should search.
Need we again apologise for criticizing this book here—surely
not. Had we examined evidence in detail, this might have
been called for, but we have limited ourselves to the considera¬
tion of points of doctrine, and these concern every element of
the body, not omitting those serried ranks of cells of the cortex
cerebri, of which Physiologists count up five layers! It is
here more particularly that Idiosyncrasy finds a home, and here
more particularly that we are called upon to believe that under¬
lying the eccentric behaviour is corresponding eccentricity of
structure. Should doubts arise, let us quell them as unworthy,
and following the wise example of Sir Thomas Browne, in re¬
lation to other subjects it is true, never allow such doubts
stretch the Pia Mater of our brains.
H. S.
The Law of Sex: being an Exposition of the Natural Law by
which the Sex of Offspring is Controlled in Man and the
Lower Animals. By George B. Starkweather, F.R.G.S.
The subject of this volume is one of great interest. If it
can be shown that the determination of sex is amenable to
control, a potent spring of disappointment and of domestic
unhappiness would be dried at its source.
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The book is a large octavo of 276 pages, and has an
appendix with 40 illustrative portraits. We will give here a
concise view of the contents, and then add one or two critical
remarks.
The author claims “ to make known a new discovery of a
great law of Nature; nothing less than the law which governs
the sexes, and whereby the sex of offspring can be controlled.”
The first third of the book may be said to clear the ground.
The problem is stated, facts requiring explanation are set
forth ; and the insufficiency of previous theories is shown. The
second third states the law and the grounds on which it is
based. The remaining portion of the volume is devoted to
practical applications and specific directions.
Of the preparatory matter, the only portions calling for
notice are of previous theories of sex. Of these two may be
mentioned ; Dr Napheys’ modification of the Ovularian theory,
holds that the sex is determined in the ovum independently of
the male or fertilising element, that the ovum goes through two
distinct stages of imperfect and complete development; and
that females are the result of a union early in the period of
heat, males of a union towards the close of heat. The evidence
for this theory and the evidence against it, as presented by Mr
Starkweather, balance each other. Another doctrine, of more
respectable antiquity, has numbered many illustrious men
amongst its champions. It holds that the sex of the offspring
is determined by (1) the Comparative Vigour; (2) the Relative
Age; and (3) the Nutrition of the Parents: the offspring
following the sex of the parent that stands highest in these
qualities. A large amount of positive evidence supports this
view; but there are also facts unexplained by it, and facts that
contradict it. The author’s own theory is the only one that
explains all facts and that accords with universal experience.
We now come to Mr Starkweather’s exposition of his own
Law of Sex: that “ Sex is determined by what I shall
designate as the 6 superior parent ; ’ also that the ‘ superior ’
parent produces the opposite sex” “ ‘ Superiority,’ then—
which must be understood as a fuller and higher development
of organization—is what determines sex.” “ Cerebral develop¬
ment is the key to ‘ superiority .’ ” Three qualities of
cerebrum have to be taken into account: the quantity; the
quality; and the activity. “ Activity is the principal con¬
sideration in determining ' superiority; ’ ” and its phases,
whether physical or mental for example, and its relation to
inactivity must be carefully noted. “ The head is an epitome
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of the individual.” The nose is the chief indicator of activity.
A long nose and marked features indicate “ superiority.” “ A
drooping eyelid is an invariable sign of ‘ inferiority/ ”
“ Seniority in age is usually an element of € inferiority *—
and, other things being equal, the younger parent will
assuredly be the € superior,’ and will therefore produce the
opposite sex in the offspring.” " In no given case can they
(the sexes) be equivalents absolutely, or a hermaphrodite would
result.”
The forty illustrative portraits are used to typify comparative
superiority and inferiority, and to forecast the proportion of
boys and girls that would result from the union of such
persons—if they should have children. It is not stated
whether the portraits are fictitious, or are intended to repre¬
sent real persons. They are probably fictitious. So much for
the statement of the law. The verifications follow. Striking
exemplifications are related. Seeming contradictions are
brought forward and explained or reconciled. Mr Stark¬
weather says, “ I could not rest satisfied until able to tell
approximately, upon seeing any couple, the proportion of the
sexes of their children, and the probabilities when seeing but
one of the parents. And this power I have now enjoyed for
some years.”
The practical application of the law is the control of the sex.
“ How far can this theory be made to apply where the parents
are already married ? In other words, how far is it possible
for parents to decide the sex of their future offspring ? To
those questions I reply, briefly, but confidently, that in the
vast majority of cases it is quite possible.” Specific instruc¬
tions are given for the production of each sex ; the object
underlying the directions, being—if the husband and wife do
not already hold the requisite relative superiority and in¬
feriority for the desired sex—to convert the “ inferior ” into
the “ superior ” parent. To ensure a daughter the husband,
to ensure a son the wife, must go into training. Persons
interested in the subject, however, will do well to consult the
book for more precise information, lest they should find too
late, that they have trained on erroneous principles, or in the
wrong direction. According to the theory advocated, “ public
opinion would soon be formed, under the power of which it
would be a social disgrace to a man to have only sons, while a
stigma would attach to all families exclusively of one sex.”
Mr. Starkweather might complain that an outline so bald as
that given here only does injustice to his theory, through the
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inevitable suppression of many facts in corroboration. It
must of course be confessed that such a charge would have
some foundation. The same effect cannot be produced by the
mere heads of arguments as is produced by the detailed
reasonings. So much may be admitted. But a countervailing
advantage balances this defect, the weak points do not stand so
clearly exposed.
Whether the doctrine in question, the Law of Sex, as
expounded by Mr. Starkweather, is true wholly or in part, is
outside our province to discuss. That question must be decided
by the unbiassed investigation of a very wide range of facts.
The point here is a narrower issue. It is simply this, how far
does the evidence put before us warrant the conclusion drawn
from it ? In other words, how far are the “ proofs ” satis¬
factory ?
It is clearly impossible to examine the facts in detail. Space
requires the broad surface of criticism to be ground to an edge.
The first remark is that throughout the book there is no
evidence of a mind trained to scientific investigations, or to
consider beforehand the requirements of proof.
The second criticism is that the vagueness of “ superiority 99
and “ inferiority,” and the dependence of these qualities upon a
number of circumstances beyond the reach of calculation always
leave an open door of escape to the erring prognosticator of sex.
To bring to book and convict the professed phrenologist or the
skilled weather-prophet (skilled, that is, in vague language) is
well-nigh impossible. To prove the baby-prophet wrong, in
theory at least, would be not less difficult.
A third fault (if it be a fault) is akin to the weakness of
Jonah’s prophecy. The doctrine is suicidal; it works out its
own defeat. Mr. Starkweather claims for his theory that
it affords alike the power of prevision and the power of con¬
trolling sex at will . Prevision might formerly have been
possible to those acquainted with the “ Law.” But now that
Mr. Starkweather’s information has been published to the
world, a higher endowment of the race will be required to
discern the learnings of the added element of will.
In conclusion, it may be remarked, that at best the “ Law
of Sex ” is only an empirical generalization as yet not
resolvable into the laws on which it depends. Even as such,
if true, it Jias great value. Probably it does contain a sub¬
stratum of truth ; and, if so, the subject would repay the work
of a competent investigator.
W. E. H.
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Sur la Theorie de la Paralysie Generate: de la Folie Paralytique
et de la Demnce Paralytique Considerees comme deux
Maladies Distinctes. Par le Dr. A. Baillarger. Paris :
1883. 8vo., pp. 117.
The views defended in this pamphlet have long been enter¬
tained by M. Baillarger. In 1858 he sought to prove that in
the maniacal stage of general paralysis two morbid conditions
co-exist, one permanent and incurable, which he termed
“ paralytic dementia,” the other transitory and accessory,
which he described as “ congestive mania.” This opinion was
fully discussed at the time in Prance, but did not meet with
general acceptance. He now so far modifies it as to give the
name of “ folie paralytique 99 to what he previously called
“ congestive mania.” He shows that “ paralytic dementia 99
may run its full course without any maniacal symptoms what¬
ever ; and, further, that a maniacal condition, closely re¬
sembling that of general paralysis, may occur in various other
disorders, such as alcoholism, locomotor ataxia, &c. He
admits, indeed, that this “ folie paralytique ” is much more
frequently connected with general paralysis than with any
other affection, so that its presence should always make us
suspect that disease. Probably, with this qualification, these
two statements will be denied by no one; and the question
then becomes one of terminology and description rather than of
fact. M. Baillarger’s scheme has, no doubt, the advantage of
bringing into prominence the presence of a delirium, like that
of general paralysis in other diseases, and so, perhaps, of
enabling us to trace the connection between this particular
symptom and the state of the nervous system of which it is the
evidence. Its disadvantage, which much outweighs this, as
it seems to me, is that it breaks up what is obviously a single
anatomical and clinical process into two, and thus gives an
incorrect view of the facts to be accounted for.
J. R. G.
Called Bach. By Hugh Conway. Bristol: J. W. Arrow-
smith.
We understand that the sale of this book has been very
large, a fact which of itself is sufficient evidence of its
popularity. How far it is evidence of its merits is quite
another question, and one which must be discussed on other
grounds in these columns. It is foreign to our purpose to
enter on a minute criticism of its literary qualities, but
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1884.]
we may be permitted to say that the secret of the success of
the book lies in the fact that the author never permits the
interest to flag; he has set himself a task, and he keeps his
shoulder against the collar all the way, the result being that,
by a natural sympathy, the reader gets as much interested in
the story as the narrator. The present writer is not ashamed
to say that happening to take up the book as it lay on a
drawing-room table one Sunday evening, without having
heard of it before, he did not lay it down until he had
finished it. The fatigue felt afterwards was considerable,
but it was not the mere fatigue ensuing upon ordinary work;
there had been a considerable outlay of mental force in keep¬
ing the attention fixed on what, in spite of many absurdities,
is a very fascinating book. The tale is short enough to permit
the author to keep himself at high pressure without any
risk of a collapse, and we can, as we say, vouch for it that
he communicates the high pressure to the reader.
The story consists of a narration of a schoolboy who went
blind from lenticular cataract. When grown up, and still
blind, he lived in London; and he wandered from his house
one night, and losing his way, was directed to a wrong street
by a drunken man. In this street was a doorway similar to
his own, the family likeness apparently extending to the lock,
for his own latchkey turned it. He had some doubts whether
it was his own house, and he felt for a bust which he knew
ought to be there, to take his bearings from it, but not finding
it, he recognised the fact that he was in a strange house.
Much perturbed by this discovery, and not without mis¬
givings, that if the rightful owner caught him feeling for the
bust, he might leave him to explain the matter before a
magistrate, he groped his way about and heard voices in a
room, the door of which he had touched in feeling for the
bust. He came to the conclusion that it was better to knock
and explain who he was than to let them find him; but, as
he raised his fingers to tap, he heard another voice, a woman’s
voice, singing to an accompaniment on the piano. The song
was a difficult one from an opera not well known then in Eng¬
land, and the singer, of course, sang so like a mistress of the
art that our author began to think he had intruded on a com¬
pany of “ professionals,” and congratulated himself, because
he thought he should have less difficulty in explaining his
presence ; it being apparently the custom of “ professionals ”
to wander into strange houses in the middle of the night
and feel for busts. Suddenly he heard “ a spasmodic, fearful
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gasp that could convey but one meaning. “ I heard it suc¬
ceeded by a long, deep groan, which terminated in a gurgling
sound which froze my blood. I beard the music stop suddenly,
and the cry, the piercing cry, of a woman ring out like a
fearful change from melody to discord, and then I heard a
dull, heavy thud on the floor! ”
Our author “ threw open the door, rushed headlong into
the room.” . . . “ My foot caught in something, and I fell
prostrate on the body of a man. Even in the midst of the
horror that awaited me I shuddered as I felt my hand, lying
on the fallen man, grow wet with some warm fluid which
slowly trickled over it.” He was, of course, arrested by the
others in the room, and had some difficulty in explaining to
them that he was blind. They peered into his eyes with a
strong light (one of them turned out afterwards to be a
medical man), and they put him to a test, which we here
transcribe for the benefit of those who have to examine
malingerers. “ I stood motionless. * Walk this way—
straight on—four paces/ said the voice. I obeyed. The
third step brought me in collision with the wall. No doubt,”
adds our author, “ this was an extra test as to the truth of
my statement.”
The end of this portion of the story was that his captors,
afraid, perhaps, that if they walked him against anything
else he might put his hands out, and save himself, and so
spoil the success of their trick, gave him an opiate, and left
him " drunk and incapable ” at a police-station, whence h©
was conveyed home, and returned to consciousness on his
own bed, his housekeeper sharing the belief of the police
that the charge on which he was delivered to them was true.
The second part of the story may be said to be that which
is devoted to an account of the cure of his lenticular catar¬
act. After a very tedious recovery he goes abroad, to Turin,
where he visits San Giovanni, and the first use he makes
of his newly-recovered sight is to stare about him in church,
where he sees a very pretty girl. After a series of adventures
he contrives to become acquainted with this girl, when she
returns to England, and finds that her history is shrouded
in mystery. He, however, marries her with the consent of
her “ uncle,” a Dr. Ceneri. This Dr. Ceneri bargains that
“ the man who marries Pauline March must be content to
take her as she is. He must ask no questions, seek to know
nothing of her birth and family, nothing of her early days.
He must be content to know that she is a lady, that she is
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very beautiful, and that he loves her.” These conditions
are gulped down, after a little hesitation on the part of our
author, and he marries her. After the marriage, and while
on the honeymoon, he discovers that the reticence of the
“ uncle ” had extended so far as to omit to inform Mr.
Yaughan, our author, that Pauline March, taken as she was,
was taken insane. She had no knowledge of the past, and
though we may often wish for that faculty ourselves, it is not
one which we should desire to be associated with our brides.
Lest we should be accused of giving a perverted meaning,
by an abstract, we append the author's own description of
her “ case”:—
“ Slowly at first, then with swift steps, the truth came
home to me. Now I knew how to account for that puzzled,
strange look in those beautiful eyes—knew the reason for the
indifference, the apathy she displayed. The face of the
woman I had married was as fair as the moon, her figure as
perfect as that of a Grecian statue, her voice low and sweet;
but the one thing which animates every charm—the mind—
was missing!
“ How shall I describe her ? Madness means something
quite different from her state. Imbecility would still less
convey my meaning. There is no word I can find which is
fitting to use. There was simply something missing from
her intellect—as much missing as a limb may be from a
body. Memory, except for comparatively recent events, she
seemed to have none. The powers of reasoning, weighing
and drawing deductions, seemed beyond her grasp. She ap¬
peared unable to recognize the importance or bearing of
occurrences taking place around her. Sorrow and delight
were emotions she was incapable of feeling. Nothing ap¬
peared to move her. Unless her attention was called to them
she noticed neither persons nor places. She lived as by
instinct—rose, ate, drank, and lay down to rest as one not
knowing why she did so. Such questions or remarks as
came within the limited range of her capacity she replied to
—those outside it passed unheeded, or else the shy, troubled
eyes sought for a moment the questioner's face, and left him
as mystified as I had been when first I noticed that curious
enquiring look.
“ Yet she was not mad. A person might have met her out
in company, and after spending hours in her society might
have carried away no worse impression than that she was
shy and reticent. Whenever she did speak her words were
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those of a perfectly sane woman ; but as a rule her voice was
heard only when the ordinary necessaries of life demanded,
or in reply to some simple question. Perhaps I should not
be far wrong in comparing her mind to that of a child—but
alas! it was a child’s mind in a woman’s body—and that
woman was my wife ! ”
There is some more to the same purpose, but the
above will suffice for a description of the heroine. Mr.
Vaughan, however, was married to this interesting crea¬
ture, and found himself in something of the same plight
as the celebrated Admiral Dalrymple, who paid £20 for a
dunghill, and then offered £10 to anyone who would tell
him what to do with it. He therefore resolved to try if
the recovery of the mental state could be effected, and
with* the view of discovering the previous history of his wife,
he tracked down Dr. Ceneri, who, however, was not very
communicative. He did inform Mr. Vaughan that she had
“ received a. great shock—sustained a sudden loss. The
effect was to entirely blot out the past from her mind.”
Another character now appears, one Macari. He passes
himself off for Pauline’s brother. In consequence of a tale
which he relates of having once, in battle, transfixed the
heart of an Austrian soldier with a bayonet, and by gestures
illustrating his story, Pauline has a fainting fit, from which
she recovers only to undergo an accession of mental excite¬
ment. In the course of this she starts, followed by Vaughan,
on a midnight stroll, and, quite unconscious of her sur¬
roundings, she makes for the house into which he had
strayed three years ago, when he groped for the bust. She
reached it, and Vaughan having his old latch key with him
(the house was now uninhabited, and, as is customary in
such cases, the door was left on the latch), he opened, and
they entered. She made for the old scene of violence, sat
down to the piano again, sang the difficult song again until
she came to the place where she had before stopped sud¬
denly, when she again gave the cry of horror. Our author
then held his wife’s hand for a few seconds, and saw through
folding doors into the next room, where there was a blaze of
light, with four men grouped around a table. These were
Dr. Ceneri, Macari, a short man with a scar on his cheek,
and a young man falling out of his chair stabbed to the
breast. Dropping his wife’s hand, the vision vanished. He
afterwards charges Macari with the crime, who does not
deny it, but alleges that he killed the man because he had
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seduced Pauline and declined to marry her. This Vaughan
will not believe, maintaining that Pauline is perfectly pure,
and to make a long story short, he hunts up Ceneri, who
informs him that Pauline’s brother was the murdered man,
Macari was the murderer, and was a disappointed lover of
Pauline. The reason of the murder was Macari becoming
vindictively excited by the brother calling him a low-bred
beggarly Italian adventurer. Ceneri had previously to this
become mixed up with certain Russian conspiracies, and
was now on his way to the Siberian mines. There is a very
graphic account of the journey Vaughan took to have an
interview with him.
. Having established the fact of Pauline’s purity, he returns
to England and to her. She does not remember him at fjrst,
but afterwards acknowledges that she has seen him in her
dreams, travelling. They lived near each other for some
time, and ultimately she recognized him, and he was made
happy. She has, of course, quite recovered her mental
equilibrium.
The story thus is an attempt to portray a case of what
has been termed Melancholia Attonita in the heroine.
Every one with experience of the insane will see how faulty
is the portrait, and how inexpert the hand which has drawn
it. The author seems to have read about melancholia; to
have seen a few cases in asylum wards or elsewhere; to have
noted the symptoms which were most apparent, and, to his
eye, the most pitiful; and to have taken the most pleasing
of them, and ascribed them all to one case, however incon¬
gruous they might be. Anything which he did not know of
melancholia was supplied by his richly endowed imagination,
which is never at fault, and makes ample demands upon the
credulity of the reader. By his gift of assuming an appear¬
ance of earnestness, he carries the reader along with him,
but the calmer after-perusal of the story reveals all its
defects. He is rich in incidents of the Deus ex machina type,
such as where the whole story of the murder is revealed to
him when he takes hold of his wife’s hand; but the style
itself is bald enough. Thus he has nothing more novel to say
of Pauline’s appearance than that “ her face was as fair as the
moon; her figure as perfect as that of a Grecian statue,”
&c., &c., &c. This inflated style is not inconsistent with the
method of the story, but it is singularly ill-suited to the
description of a case of Melancholia Attonita . All the
objectionable details of such a case are ignored, not as
xxx. 29
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though they should not be spoken of, but as if they did not
exist; the result being an incongruous medley of symptoms.
It is this which always makes the difference between real
cases of insanity and those of the story-teller. He says in
one passage that Pauline was not mad. Now, without wish¬
ing to drive him to bay on the mere meaning of a word, if
she was not mad, in the general acceptation of the term,
what was she ? The fact is that he has no definite idea of
the case himself, and seeks refuge from giving a definition,
in a shower of words. “ There is no word, I can find,” he
says, “ which [it] is fitting to use,” and we certainly agree
with him. No writer could put the whole of the details of
such a case before ordinary readers ; and while for not doing
this we do not blame him, yet on the other hand he is to be
censured for describing beauties which could not have been
there, and suppressing many repulsive details which most
certainly would, thus casting a glamour on the picture, and
putting silly-romantic notions of insanity into the heads of
people, making many a girl, no doubt, sigh and wish she
could be a Pauline ! This abstinence from everything which
might disgust in the description of her mental state is all
the more remarkable when we reflect that the author does
not hesitate to touch on unpleasant matters when it suits
his purpose, as where he describes with unnecessary precision,
his hand in contact with the blood of the murdered man.
Such, then, is the wonderful creation which we have seen
compared to Ophelia , and to Undine / There is nothing in
common with either. Ophelia is sufficiently true to life to
warrant one in expecting to find her counterpart in any
large asylum, and indeed there are but few in which there is
not at least one Ophelia; while Undine was professedly an
imaginative sketch of what a being would be, not without a
mind, but without a soul.
Practical Essays. By Alexander Bain, LL.D.
All Prof. Bain’s writings may be termed whetstones of
intellect. Whether they secure agreement or excite dissent,
they seldom fail to stimulate the reasoning powers, and to stir
up suggestive trains of thought.
The present volume consists chiefly of articles reprinted from
magazines. All of them are interesting to those who have at
heart the progress of mankind; a few are of special value to
the student and to the psychologist.
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The first essay deals with common errors on the mind.
Adverting to the doctrine “ that mind is something indefinite,
elastic, inexhaustible—a sort of perpetual motion, or magician’s
bottle, all expenditure and no supply,” the writer says, “ we
now find that every single throb of pleasure, every smart of
pain, every purpose, thought, argument, imagination, must
have its fixed quota of oxygen, carbon, and other materials,
combined and transformed in certain physical organs. And as
the possible extent of physical transformation in each person’s
framework is limited in amount, the forces resulting cannot be
directed to one purpose without being lost for other purposes.
If an extra share passes to the muscles, there is less for the
nerves ; if the cerebral functions are pushed to excess, other
functions have to be correspondingly abated. In several of
the prevailing opinions about to be criticized, failure to
recognise this cardinal truth is the prime source of mis¬
take.” After quoting the inculcation of cheerfulness by
various writers. Dr. Bain says :—“ I contend, nevertheless, that
to bid a man be habitually cheerful, he not being so already, is
like bidding him treble his fortune, or add a cubit to his
stature. The quality of a cheerful, buoyant temperament partly
belongs to the original cast of the constitution—like the bone,
the muscle, the power of memory, the aptitude for science or
for music; and is partly the outcome of the whole manner of
life.” How can the object, “ to rouse and rescue the English
population from their comparative dulness to a more lively and
cheerful flow of existence ” be carried out ? “ Not certainly by
an eloquent appeal to the nation to get up and be amused.
The process will turn out to be a more circuitous one.” “ The
only answer not at variance with the laws of the human con¬
stitution is—Increase the supports and diminish the burdens of
life.” A kindred error is “ the prescribing to persons indis¬
criminately certain tastes, pursuits, and subjects of interest, on
the ground that what is a spring of enjoyment to one or a few,
may be taken up, as a matter of course, by others as to the
same relish.” “ I have heard a man out of health, hypochon¬
driac, and idle, recommended to begin botany, geology, or
chemistry, as a diversion of his miseries. The idea is plausible
and superficial.” “ We may gaze with envy at the fervour of
a botanist over his dried plants, and may wish to take up so
fascinating a pursuit: we may just as easily wish to be
Archimedes when he leaped out of the bath ; a man cannot re¬
cast his brain nor re-live his life.” A taste is the offspring of
natural endowment or of prolonged ,education. These reflec-
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Reviews .
[Oct.,
tions, too often unthought of, might well be laid to heart when
we seek a clue to rouse a melancholic patient from his gloom.
The fallacies hanging round the old dogmas of Free Will and
Moral Ability and Inability are discussed briefly.
The second essay, on Errors of Suppressed Correlatives,
contains numerous examples of a fallacy that Dr. Bain always
delights to expose. One instance may be quoted. €i It is a
fallacy of the suppressed relative to describe virtue as deter¬
mined by the moral nature of God, as opposed to His arbitrary
will. The essence of Morality is obedience to a superior, to a
law; where there is no superior there is nothing either
moral or immoral. The supreme power is incapable of an im¬
moral act. Parliament may do what is injurious, it cannot do
what is illegal. So the Deity may be beneficent or maleficent.
He cannot be moral or immoral.”
One other article, the essay on u The Arts of Study,”
deserves also a word of notice. Persons who have not yet
definitely formed for themselves a plan of work will find some
helpful suggestions. The leading ideas are to select a text-
book-in-chief, and to make abstracts, improving where possible
the author’s form or method of exposition. Little sympathy
is shown towards mere “ book-gluttons, books in breeches,” as
Macaulay, Sir William Hamilton, De Quincy and Johnson are
called. “ Gibbon was a book devourer, but he had a plan; he
was organising a vast work of composition. Macaulay also
showed himself capable of realising a scheme of composition;
both his history and his speeches have the stamp of method,
even to the pitch of being valuable as models. Hamilton and
De Quincy, each in his way, could form high ideals of work, and
in part execute them ; but their productiveness suffered from
too much bookish intoxication.”
In regard to style, some slipshod phrases, coming from such
a master of expression as Dr. Bain, can only excite surprise.
On page 83 is an impropriety of phrase equal to any of those
pointed out on page 196 of his own grammar. Speaking of
the fundamental sciences—Mathematics, Natural Philosophy,
&c., he says that u Mathematics precedes them all.” This is
making Mathematics precede itself! On page 213 we see this
specimen of concord —“ Both positions has its peculiarities.”
Notwithstanding these oversights the volume will repay the
attention of a couple of hours : one can read the brains out of
it in that time. W. R. H.
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437
PART III-PSYCHOLOGICAL RETROSPECT.
1. German Retrospect .
By William W. Ireland.
The Supporting Tissue of the Central Nervous System .
Dr. Gierke, of Breslau, has, in two articles in the “ Neurologisches
Centralblatt ” (Numbers 16 and 17, 1883), given the results of
special researches on the neuroglia. He accuses Deiters, Boll,
Golgi, and Jastrowitz of making incorrect descriptions, and of mis¬
taking the results of their own reagents and dyes for natural struc¬
tures. Gierki promises to publish his researches at greater length
with illustrations, which are highly necessary in the description of
delicate tissues. In the meantime he gives a number of details
which could only be fairly reproduced by translating his papers. The
neuroglia is the supporting tissue or frame-work of the nervous
centres. It forms one-third of the substance of the grey matter, and
its cells throw out branching processes which, taking the shape of
flattened fibres, form sheaths for the nerve tubes. These never lie
against one another, as Boll imagined. The cells of the neuroglia in
the spinal cord of the sheep have a diameter of from 0*005 to 0*008
mm., and their processes are sometimes as long as from 0*4 to 0*2
mm. The neuroglia is everywhere, save at a part of the medulla
oblongata, where the nerve tubes of the stratum zonale Arnoldi
crowd upon one another, and lie directly under the pia mater. In
other places, as in the substantia gelatinosa Rolandi, the neuroglia
prevails, and there are few nerve elements. In contradiction to those
who hold that the perivascular spaces may be owing to retraction of
the dead tissues or contraction of vessels, Dr. Gierke maintains that
there is not the slightest doubt that the perivascular spaces exist in
the living brain. They are of varying calibre, and their strongly de¬
veloped cellular ramifications are analogous to the sinuses in the
lymphatic gland. In some places*as in the central canal of the
spinal cord, he has found the large vessels surrounded by perivascular
canals, which he has traced into real lymphatics.
On the Development of the Nerve Fibres in the Gyri of the Human
Brain.
Dr. Franz Tuczek has a well-written paper on the subject in the
“Neurologisches Centralblatt” (No. 20, 1888). Huschke observes
that a child comes to the world with one-third of the volume of his
brain; he acquires the second third in his first year, and the last
third is formed between this time and his twenty-first year. Merkel
has shown that the development of the skull takes place at two sepa-
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Psychological Retrospect .
[Oct v
rate periods from birth to the seventh year; then follows a pause till
the Commencement of puberty ; then a second period of increase,
which goes on till the completion of growth of the cranial bones.
According to Huschke and Bischoff, in the first year of life the brain,
grows about 450 grammes—that is, more than 1 cc. a day. Dr.
Tuczek finds that Exner is mistaken in thinking that there are no
nerve fibres in the brain of the new-born child, fle himself made an
examination of four bodies of children, the oldest of whom was 27
days. The fibres in the hemispheres are generally very fine, as they
go a short way, being supposed to keep up the communication be¬
tween the groups of nerve cells. Dr. Tuczek gives the following
conclusions :—
1. In the hemispheres of the brain nerve fibres having an axis-
cylinder appear first in the medullary and then in the cortical matter,
the development going from the centre to the periphery of the brain.
2. The nerve fibres with axis-cylinders first appear before the end
of the ninth month of intrar-uterine life in the medullary and cortical
substance of the paracentral lobes, and the anterior and posterior
median convolutions; then in the occipital lobes and in part of the
island of Beil. The other convolutions do not yet contain any such
fibres. According to Flechzig these nerve fibres appear first in the
pyramids of the medulla oblongata, and then extend upwards to meet
those in the brain.
3. The further development of the nerve fibres in the hemispheres
goes on in a symmetrical manner. Except those in the paracentral
lobule, the median convolutions, and the occipital lobe, there were no
nerve-fibres with axis-cylinders in the hemispheres of a child 27 days
old, and even in those situations the fibres could only be found in the
lower third of the cortex. Thus there were no fibres running from
the upper layers of grey matter across the gyri.
5. The appearance of the fibres comes latest in the frontal lobe,
both in its superior and basal parts. No traces of such fibres could
be found in the gyrus rectus, the orbital part of the frontal lobe, and
in the second frontal, either in the cortical or medullary matter.
On the Histo-Genesis of the Human Brain .
Dr. Signo-Fuchs has communicated to the Academy of Science at
Vienna his researches on the development of the tissues of the
brain (“ Centralblatt fur Nervenheilkunde,” No. 1, 1884). He used
33 brains from the sixth month of foetal development to the eighth
year of life.
The following is said to be a short resume of his conclusions :—
Deiter’s cells are found in their normal arrangement in the brain of
the child five months old.
T,he pyramidal cells are already recognizable in the new-born
infant. He found the typical fifth layer in the cortex of a child aged
seven months. Fibres with axis-cylinders were found in the white
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Psychological Retrospect.
matter of the brain towards the end of the first month after birth ;
in the second month they were found radiating upwards.
In the superior stratum of the cortex the first fibres with axis-
cylinders are found in the fifth month, in the second layer after the
completion of the first year, while the fibres connected with the fibres
arcuatas in the third layer appear in the seventh month.
In the child of eight, perhaps in that of seven years, the fibres of
the cortex and medullary substance have taken the same arrangement
as in the adult. Those fibres in the cortex which afterwards become
the thickest appear first. They increase in calibre as they grow older.
Dr. Fuchs has never observed a decided case of division of a fibre
with an axis-cylinder. He could not find the great ganglion cell
described by Exner in the upper layer of the cortex of the new-born
child.
The Cortical Centres for Touch , Sensibility , and the Muscular
Sense.
Dr. W. Bechterew, of St. Petersburg (in a communication to the
“ Neurologisches Centralblatt,” No. 18, 1883), states his reasons for
believing that such centres really exist on the surface of the hemi¬
spheres. Hitzig and Nothnagel thought that, after extirpation of the
motor area of the brain, there was a loss of muscular sense ; but
Bechterew states that he could not, in his experiments, satisfy himself
that, after extirpation of the motor area to the hemispheres, if the
lesion did not pass beyond the bounds of this area, such a loss of sen¬
sibility really existed. If the animal allowed its paw to rest in incon¬
venient and unaccustomed positions, this was from the awkwardness
of its adjustments owing to the injury of the motor power. Dr.
Bechterew makes no reference to the observations of Goltz, who stated
that, after a removal of any considerable portion of the cortex, there
was a loss of sensibility on the opposite side of the body.
Having come to the conclusion that the centre of sensation for the
skin and muscles must exist apart from the motor area, Dr. Bech¬
terew sets himself to look for these centres behind the median gyri.
Avoiding the lots already knocked down to Ferrier and Munk, he
finds a considerable area quite unoccupied. The function of this ex¬
tensive region, which in the human brain is represented by the
parietal lobe, has not been ascertained by any physiologists. Munk,
it is true, has made some claims on this area as centres for the sensi¬
bility of the eye and head ; but to this Bechterew objects that
such a large surface of brain cannot be put apart for the sensi¬
bility in so small a part of the organism. Dr. Bechterew arrives
at the conclusion, from his experiments on dogs, which occupied
several months, that after destruction of these parts there were
marked alterations of sensibility, and he finds that lesions of par¬
ticular parts induce derangements of feeling of touch alone, or of the
muscular sense of sensibility to pain.
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Psychological Retrospect .
[Oct,,
Dr. Bechterew promises to publish in a more extended form the
results of his researches ; in the meantime we may indicate the situa¬
tion of his three new centres. That for the perception of touch is
described to lie in the dog immediately behind and outward from the
motor area. The centres for the muscular sense and the sensibility
to pain mast, he thinks, lie close together, as sometimes a lesion
caused injury to the one function or to the other. The centres are
believed to be situated near the summit of the temporal lobe, above
the commencement of the Sylvian fissure.
Fatty Qranules and Cells .
Dr. Virchow has returned to an old subject in a paper read to the
Berlin Medical Society (“ Centralblatt fur Nervenheilkunde,” No. 2,
1883). Twenty years ago he observed fatty granules in cells lying
free in the white substance of the brains of dead-bom or new-born
children who had died soon after birth. He considered that these
were of inflammatory origin, the result of degeneration, and thinks
so still. This form of degeneration is, he holds, analogous to the
yellow softening of adults, only that in the first case the axis-cylin¬
ders are more involved. Virchow has examined 44 new cases, which
confirm his views. He has seen along with the fatty cells and
granules increased size of the neuroglia cells, but never found the
fatty cells accompany general malnutrition alone. Dr. Jastrowitz
stated that he had found these granular cells in the brains of almost
all children whom he had examined. He believed that they have
something to do with the development of the nerve fibres, and it was
a confirmation of this that they occurred always in rows. If they
were more common in the brains of weak and anaemic children, it was
because the children’s growth was retarded. He said that Strieker
had shown that every embryonal cell was at one time granular, and
in the brains of young and healthy animals he (Jastrowitz) had seen
these same granular cells. He was not satisfied that the chemical
tests were sufficient to prove that these cells were really fatty, and
Dr. Liebreich stated that in numerous examinations in the brains of
individuals of all ages he had failed to extract fat.
On Recurring Degenerations from Lesions to the Cortical Motor
Centres and the Motor Columns of the Cord .
Dr. Lowenthal (“ Pfliiger’s Archiv.,” Band xxxi., Heft 7 and 8,
quoted in the " Neurologisches Centralblatt,” No. 16,1883) has made a
microscopical examination of the animals operated upon by Professor
Schiff. In some of these the motor area of the brain had been re¬
moved ; in others the spinal cord had been cut at the level of the
fifth cervical vertebra.
He found that, after extensive but not deep extirpations of the
cortical motor area, there is a secondary degeneration of the lateral
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1884 .] Psychological Retrospect .
columns. This degeneration is much less marked than what follows
sections of the cord.
In an addition to Lowenthal’s paper Professor Schiff remarks that,
after this secondary degeneration of the cord following injuries to the
brain of the ape, there is wasting of the paralysed muscles which
here and there has a resemblance to progressive muscular atrophy.
Schiff, in the same number of u Pfliiger’s Archiv.,” admits that, in
his experiments in 1870, he had allowed himself to be deceived by
the diversion of electrical currents, and that he now believes the
posterior columns of the cord are the only parts excitable by elec¬
tricity.
Lesions in Rabies Canina.
S. Ivanow (reported by Dr. Bechterew in the “ Neurologisches
Centralblatt,” Nov. 14, 1884) has made a histological examination
of ten brains of dogs which died from hydrophobia, at the Veterinary
Clinique at St. Petersburg, and two brains in which the disease was
suspected, accompanied with examinations of ten healthy brains for
comparison. The following were the lesions found in all the cases of
hydrophobia:—There was a general hyperaemia of the tissues of the
encephalon, reaching at some places to acute inflammation, and in
spots here and there there were smaller extravasations. Around the
vessels there was a number of lymphoidal elements, with which the
venous and arterial walls were also infiltrated. In some places there
was thrombosis of the vessels. In some spots the lymphoidal elements
had passed into miliary abscesses. A few more cells were degenerat¬
ing or degenerated, but in general the nerve cells were spared. The
yellow hyaloid lying upon the vessels, described a few years ago as
characteristic of rabies, is now regarded as a normal appearance found
in all dogs who have attained a certain age. These alterations were
found most marked in the medulla oblongata, after this in the corpus
striatum and the optic thalami, while they were much less apparent
in the hemispheres of the brain. These lesions explain in a great
measure the symptoms of rabies, such as the difficulty of deglutition,
the loss of motor power in the tongue and of the lower jaw, the in¬
creased or diminished salivation, and the presence of sugar.
On Insanity Following Exposure to a High Temperature .
Dr. Rud Victor has an elaborate article in the “ Allgemeine Zeit-
schrift fur Psychiatrie ” (XLer Band, lstes and 2tes Heft) on this
subject. In the first half he makes a study of sunstroke and its
effects on the nervous centres. It would appear that exposure to a
powerful sun is sometimes followed by delirium and convulsions in¬
stead of stupor and coma. Such preliminary symptoms may be suc¬
ceeded by paralysis, loss of memory, and mental weakness. Some¬
times the patient falls into an incurable chronic state which bears a
considerable resemblance to general paralysis. Dr. Victor records the
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442 Psychological Retrospect . [Oct.,
instance of six hundred Belgian soldiers who were in 1853 exposed to
a march of four hours’ duration in a very hot sun. Of these four
hundred fell out, fourteen died, and twenty-two became insane. The
bodily heat rises under exposure to a fierce sunshine to from 43° to
45c.
It is doubtful whether exposure to the glare of the sun can cause
meningitis, save when assisted by unusual thinness of the cranial
hones ; hut the effects observed after death showed congestion of the
membranes, extravasation of the blood corpuscles, and abscess and
sclerosis of the brain.
Dr. Victor then proceeds to consider the effects of forced heat as
observed in the engine-rooms of steamboats, iron and other foundries,
where the workmen are exposed to an artificial temperature, some¬
times running up so high as 65c. Esquirol, Simon, Eulenburg, and
others made no doubt that this was sometimes a cause of mental de¬
rangement. Moreau and Voisin have described a form of insanity
which they called folie des cuisiniers , affecting cooks exposed to the
heat of great fires. Dr. Loeser found that the workmen at the gun
manufactory at Suhl suffered very much from the forced heat, and
were affected by subcutaneous inflammation. The workmen at the
furnace were often troubled by headache, giddiness, a feeling of
general weakness, and disorders of digestion. Sometimes they fall
down insensible, and have to be carried into the fresh air. Amongst
the work-people this illness goes by the name of Hiitten Katyc. In
one case the insensibility lasted for two days. In some parts of their
work the men are obliged to cover their heads with wet cloths.
For the last ten years a series of cases have passed from the gun-
foundry of Spandau into the asylum of Eberswalde. Eliminating
some cases where the insanity appeared to be owing to other causes.
Dr. Victor gives a description of fifteen patients admitted to this
asylum after habitual exposure to great heat in gun-foundries, the
high temperature exciting changes in the brain, and afterwards in¬
sanity.
Five of these casep had hereditary tendencies to insanity, and one
was a drunkard. In all cases the disease came on gradually, gener¬
ally commencing by disquietude and headache ; then followed a stage
of depression, sometimes passing into melancholia with suicidal ten¬
dencies. In ten of the cases the disease had a strong resemblance to
progressive general paralysis, there being paralytic disturbance of
speech and inequality of the pupil. The stage of melancholy was
succeeded by acute mania; the patients gave utterance to senseless
boastings, declined in bodily and mental health, and were unclean in
their habits. Then followed epileptic and apoplectic attacks, and,
after a prolonged decubitus, death in a state of marasmus. Of the
other five cases, two were melancholic and three demented. Of the
fifteen patients, nine died, four were discharged, of whom one was
cured, and two remained still in the asylum in a state of dementia.
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Psychological Retrospect .
The lesions found after death were discolouration and thickening of
the membranes, adhesion of the dura mater to the bones, oedema of
the pia mater; adhesion of this membrane to the convolutions were
only observed in one or two cases. There were also noticed granula¬
tions on the surface of the ventricles and atrophy of the brain sub¬
stance—in short, the appearances of diffused chronic inflammation.
Of the six cases published by Bertens, three recovered and two showed
symptoms of progressive paralysis.
Dr. Victor argues, from the absence of other apparent causes in
most of his patients, that we have here to do with a specific disease,
from exposure to a high temperature exciting changes in the brain
resulting in insanity.
On Insanity Arising from Auditory Hallucinations .
Dr. Fiirstner brought this question before the meeting of the Medical
Association at Carlsruhe in October, 1883 (“ Zeitschrift,” Band xl.,
Heft 1 and 2, and “ Neurologisches Oentralblatt,” No. 12, 1883). In
addition to two already published, he has given 26 cases of insanity which
seem to have originated in diseases of the ear or auditory nerve. He
observes that hallucinations of hearing often commence during the
night, or when the patient is alone, that is, when other auditory im¬
pressions were absent. Aurists have observed that patients who hear
noises in the ear are often much disturbed and oppressed, and some¬
times have suicidal tendencies. He asserted that hallucinations may
be produced by the action of electric currents upon the acoustic nerve.
Of Fiirstner’s 26 cases, 19 were troubled with subjective noises in the
ear. Many of these were old people. In the majority of cases there
was chronic catarrh of the cavity of the tympanum and alteration of
the membrana tympani. In these cases the prognosis was generally
unfavourable. In one case the patient recovered from a state of stupor
and melancholy through the sudden discharge of purulent matter by
the meatus. He cited a case from Schiile of the same character. In
one patient with melancholia there was chlorosis with anaemic noises ;
in another there was compression of the vessels of the neck through
an enlarged thyroid gland.
Experimental and Clinical Researches on Epilepsy (“ Archiv.,” xiv.
Band, 2 Heft).
In the introductory history of previous researches which, according
to the German custom, is appended to Dr. Unverricht’s paper, we are
informed that there has recently been a return to the old view that
the seat of epilepsy is in the pons and medulla oblongata. This was
owing to the experiments of Albertoni, who found that after extirpa¬
tion of the motor zone of one hemisphere general convulsions could
be produced through electrical stimulation of the remaining hemi¬
spheres. He saw general convulsions appear after the entire removal
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444 Psychological Retrospect. [Oct.,
of the cortex, when he applied stronger currents to the nerve masses
below. This induced him to conclude that the epilepsy produced by
stimulation of the hemispheres was really owing to the irritation being
conveyed to the medulla.
To elucidate these and other questions about the pathology of epi¬
lepsy, Dr. Unverricht has made some careful clinical observations,
and tried a number of experiments upon dogs, the result being com¬
municated in an elaborate paper which fills 87 pages of the “ Archiv.”
In his experiments Dr. Unverricht used weak electrical currents, con¬
sidering that strong ones are apt to be misleading. He found that an
electric stimulus applied to the grey matter of the hemispheres causes
epileptic attacks, whether the electrodes are applied to the so-called
motor regions or to those behind. The posterior lobe, believed by
Munk to be a visual centre, when stimulated, excites epileptic attacks.
The disposition to fits under this stimulus is, as a general rule, inde¬
pendent of the supply of arterial blood to the cortex, of the bodily
temperature, and of the reflex excitability. The duration of the elec¬
tric stimulus was found to have more efficacy in causing convulsions
than the strength of the current. The course or succession of the
convulsions was found to correspond with the arrangement of the motor
centre in the brain, so that only such groups of muscles come succes¬
sively into action whose centres lie near one another in the motor area.
For example, it is never observed that the klonus of one extremity fol¬
lows convulsions of the muscles of the ear passing over the orbicularis
whose centre lies between; nor does one ever see convulsions of the
muscles of the jaw follow those of the lower extremity. The author’s
researches have also led him to the following results That after con¬
vulsions have gone through one side of the body, when they pass over
to the other side, the muscles are affected in exactly the same order
as in the side first affected. The convulsions may either oscillate from
one side to the other, passing from one side of the body and then re¬
turning to the other side, and so on till general convulsions ensue;
or the same tract of muscle may be visited by a third and fourth con¬
vulsive attack, until general convulsions follow. Special muscular
groups sometimes take part in the convulsive fits, which shows that
their centres are fully excitable during the fits or are not excitable at
all.
In the course of his observations, Dr. Unverricht found two spots in
the cortex, from which he could excite isolated motions of both halves
of the tongue. At first he believed that only the left half of the tongue
received its nervous stimulus from the left hemisphere, and that the
motions of the right side of the tongue were passive, and vice versa.
In order to decide this question, he cut through the hypoglossal nerve
on the same side (the left) as the stimulated hemisphere ; he then saw
the movements of the left half of the tongue cease, while those of the
right half were continued. In the same way the innervation of the
retractive muscle of the tongue was decided. They were proved to de-
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rive their nervous supply from both hemispheres. By sawing the jaw
he was able to differentiate the action of the muscles on both sides.
He came to the conclusion that the masseter and temporal muscles al¬
ways receive their nervous supply from both hemispheres. The muscles
of the neck and trunk seem to get their principal nervous supply from
the hemispheres of the same side; but he thinks farther researches
are needed to determine whether they do not receive some fibres from
the opposite side.
Dr. Unverricht was able to make sections of the corpus callosum,
which generally caused death by bleeding into the third lateral ven¬
tricles ; but he was able to ascertain that division of this commissure
did not prevent the passage of convulsions from one side of the body
to the other. On a stimulus being applied to one hemisphere, con¬
vulsions attacked one side of the body and then the other, after a pause
between.
Extirpation of the motor zone in the status epilepticus was found
to cause the convulsions to cease on one side. If the motor zone were
removed on both sides the convulsions entirely ceased.
Dr. Unverricht considers the following experiment very decisive :
—He took a dog and excited convulsions on both sides of the body
by the application of the electrodes, after which he removed the whole
motor area of the left hemisphere, comprising the cortical centres for
the limbs, those for the muscles of the trunk, neck, jaw, and tongue,
leaving only the centre for the orbicularis muscle. On stimulating
this solitary centre, there followed a long-continued convulsion of the
right orbicularis, and of the muscles of the ear, while the other
muscular groups remained in absolute rest, save that on the left
risorius muscle, whose centre is probably not sufficiently ascertained,
there were some convulsive startings. Then followed rhythmical
turnings of the eyes to the right, which continued for some time, so
that one who looked on from a distance might think the convulsions
had ceased; but suddenly, and with great vehemence, there appeared
convulsions in the left hind leg, which soon spread upwards through
the body, involving the muscles of the tongue and jaw.
Dr. Unverricht holds that the convulsions caused by electric excita¬
tions of the cortex have a close resemblance to epilepsy, though he
will not allow that the spasms produced in Brown-Sequard’s experi¬
ments by division of the sciatic nerve or section of one half the cord do
actually constitute genuine epilepsy.
The author considers that many forms of the aura epileptica prove
that epilepsy originates in the cortex. Sometimes there are appear¬
ances of light and colour, or hallucinations. From all this he comes
to the conclusion that the integrity of the motor cortical region is
necessary to the evolution of a complete epileptic attack.
Sometimes the bodily heat increases during the fits by 1 or 2 degrees
centigrade. In one case the rise of temperature was observed to be as
high as 44*1 c.; but a sinking of the temperature to 34*8 was found
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446 Psychological Retrospect. [Oct.,
neither to hinder the excitibility of the cortex nor the appearance of
the status epilepticns. Anaemia will only check the appearance of fits
when pushed to a dangerous degree. This was also trne with asphyxia,
and a new supply of oxygen caused the convulsions to reappear. It
was found that morphia in large doses caused convulsions to cease;
but more effectual for this purpose were intravenous injections of
chloral and inhalations of ether, both of which promptly brought the
fits to an end. Atropine was found to increase the excitability of the
cortex so as to renew the convulsive attacks after they had ceased.
This was not what was expected, as atropine is a well-known remedy
in epilepsy. Dr. Unverricht, however, observes that different effects
may follow the long-continued administration of a drug in small doses
from the use of a single large dose.
Dr. Unverricht’8 experiments have led him to conclude that chloral
is the most valuable remedy in the status epilepticus. It has recently
been found very useful in the other motor neuroses, especially in
chorea (Mosler).
Progressive Hemiatrophy of the Body.
In the “ Neurologisches Centralblatt ” (No. 16, 1883) there is a
report of a remarkable case, described by Dr. Henschen, of Upsala.
The patient, who is now 43 years of age, lost his parents from con¬
sumption, and had a cousin who was insane. When 14 years old he
suffered a dislocation of the left ankle joint, which caused an inflam¬
mation rising to the knee. This was followed by pricking pains, for¬
mication, muscular startings, and feelings of rigidity in the affected
parts. After this there was headache lasting for some months; and
atrophy commenced in the left leg, and gradually became sensible over
the whole left side of the body. At the age of 19 the patient was
visited by an attack of melancholia, which passed away in a year, but
returned two and a half years ago. The man's condition is described
very minutely. On the right side he is strong and well-nourished,
while the left side is everywhere smaller. When he stands upon the
right leg his height is 170 c. When he stands upon the left leg his
height is 164 c. The cranium is well developed and symmetrical, but
there is a depression on the left temporal region, and the notch for the
supra-orbital nerve is somewhat deeper on the left side. The whole
left face from below the eyebrow is smaller, looking as if the upper
and lower jaw had been resected. The opening of the left eyelid is
smaller, but there is little appreciable difference in the size of the eye¬
ball, and the pupils are equal. The tongue, as well as the neck, are
symmetrical. In the trunk the left side seems, on the whole, some¬
what smaller, but the atrophy is confined to the following places :—In
the chest, between the fifth and seventh interspaces, there is a depres¬
sion about 20 centimetres in length, where the ribs may be felt under
the attenuated skin. In the umbilical region there is another depres¬
sion of 23 centimetres long and 3| centimetres broad, lying from the
Digitized by ^ooQle
1884 .] Psychological Retrospect 447
linea alba to the margins of the 10th aud 11th ribs. The skin over
these spots was thin as paper, and had fallen into folds; the muscles
were atrophied. The left arm is shorter than the right, and all the
muscles atrophied. The arm can be moved, though, owing to altera¬
tion in the elbow and wrist joint, the limb cannot be completely ex¬
tended. The left hip is atrophied, and there is another depressed spot
of from 3 to 4 centimetres broad between the anterior superior spinous
of the ileum and the first lumbar vertebra.
The whole left leg is atrophied, and 10 c. shorter than the right, but
part of this shortening is owing to the limb not being capable of
complete extension. The skin is thin as in the other atrophied parts,
and the muscles wasted. Along the quadriceps run two parallel lines
of ossification, about 10 or 20 centimetres long. The left leg below the
knee is about half the circumference of the right, and the calf has dis¬
appeared. Below the tibia and fibula are grown together, and the
ankle joint ankylosed; the bones of the foot are immovably connected
with one another, and the skin stiffly adhering to the hard parts. The
toes are atrophied. The sensibility of the skin is not diminished ;
indeed, it is rather increased on the left side. The reduction to the in¬
duced and continued current are somewhat greater on the left arm than
on the right, in other parts the reaction seems equal. The reflex action
is stronger on the left thigh and abdomen than on the right. Nothing
abnormal was discovered on the right side.
Dr. Henschen calls this a case of tropho-neurosis, arising from
chronic irritation of the nerves distributed to the parts around the
dislocated ankle, which the patient suffered from when 14 years old.
At last it affected the brain, as shovfn by the melancholia and spasms.
The patient is still alive.
Stuttering and Stammering.
Dr. Berkhan defines stuttering to be the incapacity to pronounce
consonants or vowels, which is only occasional, and brought on by
emotion ; and stammering, where the incapacity occurs without any
anxiety, and where the difficulty generally consists in pronouncing con¬
sonants. He finds these deficiencies of speech to be generally here¬
ditary, and to occur amongst poor families. He finds that amongst
children who stammer the circumference of the chest is very small; in
some cases he found it even less than the circumference of the head.
On looking over Dr. Berkhan’s tables, we doubt whether he has allowed
for the fact that the proportion of the circumference of the chest to
that of the head is less with younger children. Apparently Dr. Berk¬
han is better able to make original observations than to go through
the necessary task of ascertaining what has been done by previous ob¬
servers. At any rate, he cannot be acquainted with what has been
written upon idiocy in the English language, or he would never have
claimed as an original observation of his own that stuttering and stam¬
mering are common with idiots, or that a high palate is apt to occur in
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448 Psychological Retrospect . [Oct.,
those who are bom deaf, or that deafness and idiocy are commonest
with males. He has a better claim to the merit of the observation
which we have not read before, that the vaulted or saddle-shaped palate
is frequent with stammers.
Disturbances of Vision in General Paralysis .
Dr. C. Fiirstner, in two papers in the “ Archiv.” (Band viii., 1 Heft
and ix., 1 Heft), a resume of which was given in the German Retro¬
spect (Jan., 1879, p. 681), called attention to a peculiar disorder of
vision in general paralysis, which he thought to be dependent upon a
brain lesion. It seemed to consist in a loss of the power of recog¬
nising objects often confined to one eye only. Dr. Carl Stenger, in a
paper in the “ Archiv.” (Band xiii., Heft 1), continues the study. He
distinguishes two disturbances of vision. In the one there is a loss of
the power of perception (Wahrnehmungs-vermogen), in the other a
loss of the power of recognition, or forming an ideal representation
(das Erkennungs, das Vorstellungs-vermogen), the result of lesions
of the occipital lobe, which Munk calls soul-blindness (Seelen-blind-
heit), and Goltz visual weakness of the brain (Himsehschwacbe).
Wilbrandt thought that the confusion of vision might be owing to
hemiopia or defect of sight in one portion of the retina, so that the
individual might make false conclusions which his mental weakness
would render him less liable to correct. It ought to be carefully kept
in mind that sight requires not only the integrity of the apparatus of
the eye and optic tract and ganglia, but that the recognition of objects
and the ordinary exercise of vision require a number of mental pro¬
cesses of apprehension, recognition, comparison, memory, and judg¬
ment, which seem to many intuitive, since they have been acquired in
infancy. The mental nature of many of our acts of vision hasjbeen
demonstrated by Helmholtz. In a disease like general paralysis,
where the mental faculties slowly waste away, it seems likely enough
that the power of making correct inferences from the impression of the
senses may be lost before the senses themselves are weakened or de¬
stroyed. These considerations are certainly not always kept in view ;
and this is one of many instances where careful observations are viti¬
ated by want of psychological analysis, or by careless, though con¬
venient assumptions at the outset of the investigation.
It is clear that where derangements or weakness of sight and hear¬
ing occur in advanced general paralysis the weakened mind would
have great difficulty in correcting the sensory deficiencies, and that
the patient would give no assistance in analysing his sensations ;
hence, in a disease, with diversified lesions and diversified sensory and
mental deficiencies like general paralysis, it would be very difficult to
say if the patient were unable to recognise objects by sight, whether
the deficiency lay in the optic tract, in the corpora quadrigemina, or
in the hemispheres.
Wernicke observes that in general paralysis there is a rapid loss of
the memory of the images derived from the organs of hearing and
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Psychological Retrospect .
449
sight. Some of Dr. Stenger’s patients had evidently lost the power
of recognising the import of objects of sight and sound, and one had
lost the power of learning what objects were through touch. In
another, to use Dr. Stenger’s own words, the power of the mind to
elaborate the impressions of the senses seemed to be entirely lost.
Dr. Stenger, in describing one of his cases, says that after severe
convulsions ending in stupor, which lasted about ten hours, the patient
began to recover. He heard every sound, but when questions were
put to him he either did not understand them, or mistook the mean¬
ing, so that he gave wrong answers or no answer at all. In speaking,
he changed the words and letters, and when objects were held before
him he could not name them. He ran against things in his way, and
was not afraid of a lighted body held before his eyes. It was only
when he felt the burning heat of fire that he drew back, and when a
needle was held before his eyes he seemed to recognise what it was
only when it pricked him. He did not seem to recognise wine till his
lips were moistened with it, when he showed the desire to drink. In
fact, the power to gain the right import of the impressions of the
senses seemed to be lost. In all the five cases, save one, the defi¬
ciencies of the visual faculty were common to both eyes. The lesions
found in the brain of those cases which he examined were of the usual
character in general paralysis, and, as he admits, do not confirm any
particular theory of localisation.
Dr. Zacher (“ Archiv fiir Psychiatric,” xiv. Band, 3 Heft), in a
long contribution to the “ Pathology and Pathological Anatomy of
General Paralysis,” continues Dr. Stenger’s inquiries, accepting his dis¬
tinctions of Seelenblindheit and Rindenblindheit, or cerebral amaurosis.
The soul-blindness, which is not common, is always double, and
associated with aphasia, and some degree, more or less, of paralysis
of the right side. One of his patients, for example, failed to recog¬
nise objects held before him; when bread was put near his eye he did
not eat till it was placed between his lips. Formerly he was fond of
smoking, but now, when a cigar was put into his hands, he did not
recognise it. Nevertheless, he seemed to see, for he followed objects
with his eyes, and when anything got rapidly near, the eyelids were
closed.
In one case he describes a general paralytic seized with convulsions
which diminished motor power and sensibility on the right side, the
right pupil more dilated than the left. There was a complete loss of
visual power on the right side, so that there was no closure of the lid
when a burning light was rapidly brought near to the eye ; but the
reaction existed on the left side, in which the sight seemed unaffected.
In the next case the paresis and diminution of sensibility was on the
left side. There was the same loss of visual power in the left eye, the
visual power in the right eye being preserved. In both patients the
loss of vision disappeared in a few days. Twelve cases of a similar
kind fell under Dr. Zacher’s observation.
xxx. 30
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450 Psychological Retrospect [Oct.,
In the second category Dr. Zacher gives three cases as examples of
donble-sided hemiopia.
It was ascertained by careful examination that objects were not per¬
ceived on the temporal side by one eye, and on the nasal side by the
other. In cases like these total blindness would only be produced by
doable hemiopia. Dr. Zacher thus reduces the visual deficiencies
into two categories—
1. Pure soul-blindness. Further observations are required to make
out whether this blindness is always double with motor derangements
on the right side and aphasic symptoms.
2. Double-sided visual disturbances, which are probably true hemi-
opias, and are connected with lesions in the occipital lobes.
He acknowledges that some cases described by Fiirstner and Will-
brandt would probably require another class.
Tendon Reflex and Tdche Meningitique in General Paralysis .
Dr. Zacher, in his general paralytics, finds the tendon reflex always
heightened after convulsive attacks (even when the fits of motor ex¬
citement are followed by paresis). The greater the irritation the
greater the clonus. He has often repeated Nothnagel’s observation
that, by striking with the percussion hammer upon the paralysed leg,
startings are produced in the foot of the opposite limb. On the other
hand, when symptoms of paresis or paralysis alone appear, the clonus
is found to be diminished, so that sometimes it nearly disappears.
Dr. Zacher finds this result in accordance with the views of Schwartz,
who stated that if a process causing destruction of the motor and
sensory areas of the brain has a paralysing effect on more distant parts
of the nervous system, that even the reflex centres of the spinal cord
which stand in connection with these parts of the brain are more or less
paralysed, but when the process is of a stimulating or irritating cha¬
racter, that a stimulating effect is produced. He also found that where
the sensibility to pain was diminished, the reflex from cutaneous im¬
pressions was also diminished.
In some cases great disturbance of the muscular sense was observed,
so that the patient did not know the position of a limb, and kept it in
strange and inconvenient positions.
Dr. Zacher also directs attention to two cases of vaso-motor dis¬
turbance in general paralysis, in which there was transudation of a
serous fluid. When the surface was touched with a blunt point, the
spot first turned white, then red, and at last there was elevation of the
skin. After a prick there was no blood, but a raising of the surface,
owing to the transfusion of serous fluid into the injured parts. This
Dr. Zacher regards as an exaggerated form of the tache meningitique,
which he has observed after epileptic fits, and even after attacks of the
petit mal.
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1884,] Psychological Retrospect. 451
An Insane Mother Kills her Five Children.
Dr. von Krafft Ebing (in “ Friedreich’s Blatter fiir Gerichtliche
Medizin,” Band xxxiv., 1883, quoted in the “ Neurologisches Cen-
tralblatt,” No. 13, 1883), gives a tragical story of the result of the
delusion of suspicion. The subject had a strong hereditary neurosis,
and experienced hallucinations of a religious character when nine years
old, and which afterwards frequently returned. Her education and
moral training had been neglected in childhood. She was married
when twenty-seven, and lived happily until her thirty-second year,
when she lost all her property through an usurer, and had to suffer
great hardships. In the hope of regaining some portion for her
children, she involved herself in reckless lawsuits, and as she was
unable to obtain a favourable verdict, she abused the court in an un¬
measured manner. In spite of her violent language and imprudent
conduct, she was declared by the physicians employed by the court to
be sane, and was punished for defamation. About a year later, as she
continued to complain, and had become wilder and more senseless in her
language, threatening to kill her children, the question of her respon¬
sibility was again raised ; but the physicians said that, though she had
fixed ideas, she was not insane. But in consequence of her excited
state of mind, and her threats to kill her children, they recommended
her to be kept under supervision, which, however, was not done. The
poor woman’s distress became more pressing. She had frequent hal¬
lucinations, which seemed to point to heaven as the only refuge re¬
maining for herself and children, and strengthened by an old vow to
dedicate her children to heaven, she believed that she was entrusted
to kill them. After contending with despair and hallucinations for
nearly two years, the catastrophe took place, which could have been
avoided if the mother’s state of mind had been rightly understood.
On the 12th August, 1881, she at length resolved to kill her children
to save their souls. She prayed fervently that if God wished to pre¬
vent the deed to send someone to stop her. She waited at the door
to see if anyone came, but as no one appeared, she went into the house
and deliberately killed the five children with a pestle, at each blow
making the sign of the cross and calling the name of Jesus. After a
long prayer in the village church, she arranged the linen for the
corpses, and confessed the deed in a quiet and composed manner.
Then at length she was sent to an asylum.
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452 Psychological Retrospect . [Oct.,
2. English Retrospect .
Asylum Reports .
(Continued from p. 303.)
Newcastle . —The day-space of what may be called the “ refractory
ward ” for women has been increased and a similar improvement is
contemplated on the male side. It is also intended to warm the
single rooms.
Northampton (County). —Patients continue to accumulate in this
asylum with great rapidity. There are already 61 in excess of the
number for which it was originally constructed. Extensive additions
and alterations are about to be made.
We suppose this is the only pauper asylum in England where it
can be reported that “ No charge has been made upon the County
Rate for any purpose connected with the asylum during the past or any
year since the completion of the asylum.*'
Northumberland .—Concerning the discharge of harmless lunatics
to the care of their relatives, Dr. McDowall says : “ During the last
nine years, the duration of my official connection with this asylum, a
large number of patients have been so disposed of, to the great
saving of cost and the deferment of the necessity of asylum ex¬
tension. I have always acted on the principle that the happiest
place of residence is, or should be, a private dwelling. I have ac¬
cordingly encouraged applications to be made to you for the discharge
of harmless cases to the custody and care of relatives. You have been
able to accede to the majority of them, having first tried to satisfy
yourself as to the respectability of the applicants and their ability to
maintain their friends in comfort. Still it cannot be denied that the
practice may have drawbacks. Once a patient has left the asylum,
there is no guarantee that he or she will be properly cared for. If the
patient ceases to receive parochial relief, all official supervision is at
an end, and he may be restrained, secluded, improperly and insuffi¬
ciently clothed and fed, and ill-used in a variety of ways, before
public scandal attracts the attention of the police. Before county
asylums were built, patients were necessarily neglected and often ill-
used, not always wilfully so, but often through ignorance and
inability to do better. If such were the case so recently, it is greatly
to be feared that it is so still, for human nature changes little
in such a short time, and the supervision has not improved. Most of
the progress which has occurred in public asylums has been due,
amongst other causes, to improved supervision and greater publicity,
and it does not admit of a doubt that, were the inspection by Com¬
missioners and Magistrates to diminish in its thoroughness, the
general condition of asylums would deteriorate, and we might have a
Digitized by boogie
1884.] Psychological Retrospect . 453
renewal of the scandals which engaged public attention some 50 years
ago. If so much can be done in public institutions by official inspec¬
tion, it cannot be doubted that equally satisfactory results would
follow from the same care bestowed on cases in private dwellings. ,,
Norwich. —Great energy appears to be displayed in the removal of
various defects in this new asylum, and in bringing it as quickly as
possible into a thoroughly comfortable and efficient state.
Nottingham (County). —Precautions required to be adopted to pre¬
vent the introduction of small-pox, a disease prevailing in the neigh¬
bourhood. Only one attendant, non-resident, was affected.
An inquest was held in the case of a male patient who died from
injuries received before admission. Mr. Aplin very correctly says: “ In
many instances I fear sufficient inquiry is not made into the bodily
condition of the insane when about to be sent to the asylum. Their
mental aberration being proved, the bodily condition is often ignored ;
the result being that patients almost fatally exhausted by disease, pro¬
longed refusal of food, sleeplessness, or by injuries, are sent upon a
journey to the asylum for which they are totally unfitted, and from
the evil effects of which they have great difficulty in rallying.”
Such a case points strongly to the necessity of a thorough physical
examination of every patient on admission, and in the presence of
the relieving officer. Should the patient be too excited or otherwise
make a thorough examination impossible, it should be so stated in
writing and signed by the medical and the relieving officer. Such a
precaution may save much subsequent trouble.
A head attendant has been appointed to the male side, and the
results are reported to be very satisfactory.
The Commissioners notice the unfortunate position of this asylum.
Two hundred and sixty patients cannot be taken beyond the walls
for exercise. This is greatly to be regretted.
Nottingham (Borough). —This asylum, though opened so recently as
August, 1880, is reported to be already too small for its purpose.
An unfortunate dispute has arisen between the Visitors and the
Commissioners relative to the necessary enlargements. Plans had
been prepared and forwarded to London, but as the Commissioners
insisted that 20 acres should be added to the estate, the Visitors
have withdrawn the plans, and intend to limit the extensions to the
building of a hospital for contagious diseases.
Nottingham Lunatic Hospital. —At the cost of £9,000 this asylum
has been enlarged and various alterations and improvements intro¬
duced. The extra accommodation provided is for twenty patients of
each sex.
As some patients pay only 8s. per week for the admirable accom¬
modation and treatment to be obtained at The Coppice, it is evident
that this lunatic hospital is doing a good and admirable service to
the poorer middle-classes requiring asylum care. %
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454 Psychological Retrospect . [Oct.,
Portsmouth —Various improvements have been effected during the
year, and so much has been done to bring this new asylum into good
working order that the Commissioners express their belief that it will
ultimately take a high position among public institutions of a like
nature.
Richmond District Asylum .—Of 1,041 patients in the asylum at
the end of the year no fewer than 511 were considered probably
curable. This fact alone shows how different the types of insanity
are in Dublin and London. In most English county asylums only
some 10 to 20 per cent, of the patients are considered curable.
Dr. Lalor reports:—“ At the present moment we have only nine
single rooms for 500 female patients in the old house, and of these there
are rarely more than two employed. They are, I may say, used
altogether at night, and only for a short time, to prevent patients
who may become noisy from disturbing the repose of their fellow-
patients.
“ Such results .... are, I believe, mainly due to the judi¬
cious employment of the patients, which is, I may say, universal, and
has taken the place of directly repressive measures.
“ Refractory or disorderly wards are unknown here, as being out
of character in an institution where all are expected to be orderly.
In the few exceptional cases where patients, by noise or irregularities,
disturb or set a bad example to their fellows, such are at once re¬
moved either to the recreation ground, if the weather be fine, or to
one of the large dormitories, if it was not so, and they are then walked
about in charge of an attendant till the period of excitement has
passed away. Seldom are there two such cases at the same time.”
This reveals an amount of peace and tranquillity that is wonderful,
and probably does not exist in the general population. Possibly a
course of treatment under Dr. Lalor would be found to be highly
benehcial to those gentlemen who have caused so much political
excitement and noise during the last few years. We Englishmen and
Scotchmen certainly do not understand insane Irishmen, at least we
fail in soothing them as Dr. Lalor does. Speaking generally, it is
absolutely true that the most noisy, discontented, irritating and
troublesome patients in county asylums are Irish, and the same holds
good for ordinary hospitals. How is this to be explained ?
Roxburgh , <J*c.—The following remarks by Dr. Grierson on volun¬
tary patients are so true and so well put that we reproduce them in
the hope that all persons responsible for the management and the
reputation of public asylums will take warning and avoid such cases
as they would shun death. Our experience is that the more solemnly
a voluntary patient swears that he will reform the stronger is his in¬
tention of availing himself of the very first opportunity to become
hopelessly drunk.
Afty trying various hydropathic establishments, spas, &c., &c.,
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1884.]
455
Psychological Retrospect.
Dr. Grierson’s case placed himself under restraint voluntarily. “ As
is too often the case in our experience, and I believe in that of most,
little benefit is derived by the one, so little credit accrues to the
other of such contracting parties. "Thus it was in this. Under pro¬
mises readily given, but with no thought or intention of their being
other than purposeless and delusive, he or she prevails over the one
member of the family who has suffered least by his or her mis¬
doing, and all appeals—appeals to medical belief, appeals to a past
but sad experience—are set at nought; another chance must be given
in accordance with the better knowledge of the all-but stranger, and
that at once. The end is nearly unvaryingly the same, and soon
told. Before night, with the opportunity, which is rarely wanting,
he is .beyond hope, helpless for self-care, and if not an actual danger,
certainly an unbearable nuisance to the public. Lucky for him it is
if his disposition and antecedents are known in the neighbourhood—
on this account commiseration is felt for him, but often more for the
misplaced confidence of those in whose charge he is still believed to
be; friends are made acquainted with the danger, and to avoid a
scandal these appear, not in time to save another downfall, but an
unintentional self-death perhaps. No one wishes to deal with such a
case more than once, or at most twice, and unhappily, after
having tried and wearied every establishment by this playing at
treatment, while good was possible, fate, rarely baulked, now inter¬
poses and sentences him to a life of uselessness and unbroken
restraint.”
Salop and Montgomery .—Once the improvements and enlarge¬
ments are effected, those who formerly knew this asylum will scarcely
recognise it as the same place.
A second assistant medical officer has been appointed, to relieve
Dr. Strange of much extra work thrown upon him. Only 30 of each
sex go for walks beyond the asylum walls. We agree with the Com¬
missioners in the opinion that this seems a small number.
A fire broke out in the blacksmith’s shop, and at one time
threatened to become alarming. It is greatly to the credit of the
staff that it was extinguished by their unaided efforts, and so orderly
and quietly was everything done that not a single patient was aware
of the fire until the following morning.
Concerning beer in asylums so much humbug and nonsense has
been written that we warmly thank Dr. Strange for the following
remarks. We were tempted to say something very similar long ago,
but refrained from doing so simply to see how far the craze
would go:—
u The question of giving beer and stimulants in public institutions
as asylums and workhouses, has been forced before the public very
much of late years. As in most controversies the arguments used
for and against the use of alcohol in one or other form, are exag-
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456
Psychological Retrospect.
1
[Oct.,
gerated and misleading. It is not my province to deal with the
question in reference to workhouses, and my remarks apply solely to
asylums. When I see in the reports of asylums statements of the
excellent results arising from the disuse of beer, that greater quiet
and an altogether higher tone prevails, and almost an assertion that the
proportion of cases is relative to the use or disuse of beer, I am startled
to think of the mighty evil that must still be worked in those
asylums whose superintendents are not apostles of teetotalism ; but
calm reflection will, I think, show that the immense advantage
claimed from the disuse of beer cannot in common sense be credited.
Will any sensible person believe that half a pint or a pint per day
of asylum beer, the very weakest possible, can do any harm ? Even
grant that it does no real good, it is simply, in my opinion, absurd
to suppose it can work an evil. In this asylum, wishing to grapple
with the question fairly, after consultation with the Visitors, and
with their approval, the following regulation was adopted, viz., that
beer should only be given to real working patients and by medical
order. To deprive the artizans, farm workers, laundry women, &c., of
their beer would, I think, be unwise, but I see no reason for giving
beer to a lot of idle imbeciles and dements. ,,
St. Luke’s Hospital .—Surely an effort might be made to make this
report somewhat fuller and more interesting. The lists of officers
and governors occupy much more space than the medical report.
Somerset and Bath .—The Visitors have entered into a contract
for the erection of a separate building for 80 females, at a cost of
£7,957. The work is in progress. They report that much has been
done by Dr. Wade to reorganise the asylum.
Patients continue to accumulate in spite of all that is done by
sending the harmless to workhouses and to the care of their friends.
During the spring a severe outbreak of typhoid fever and erysi¬
pelas occurred. Twelve patients, two nurses, and the workmistress
were attacked by typhoid ; six died. Steps have been taken to
effect three most desirable objects: (1) to diminish the overcrowd¬
ing, (2) to improve ventilation, and (3) to rectify all defects in the
drainage.
The report by the Commissioners in Lunacy is not given.
Stafford. Stafford .—This asylum is also full. In anticipation of
the addition to the numbers on the opening of the new block for
females, another assistant medical officer has been appointed.
Mr. Pater’s report is an unusually short one, and extends to only
two pages.
Stafford. Burntwood .—The Commissioners report a substantial
improvement in the condition of this asylum. They also notice that
the number of attendants and nurses is low. On the male side it is
in the proportion of one to 16*2 patients; and on the female side
one to 16'8.
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1884 .]
Psychological Retrospect.
457
Surrey . Wandsworth .—Seven cases of typhoid occurred during the
year. Although the water was analysed, and the drains thoroughly
examined, no cause for the outbreak could be discovered. Although
the disease disappeared, it is probably only for a time, and it will
return when circumstances are more favourable. It may be con¬
sidered certain that typhoid does not break out in a public institution
without cause, and that the cause will be discovered if looked for long
and carefully.
The asylum is quite full. Although 59 patients were transferred
to other asylums, occasionally new cases were refused admission for
want of room.
Surrey. Brookwood .—The Visitors report that: 11 The whole of
what are termed the old cases have been re-investigated, that is to
say, the case of every patient (some of whom have been at the asylum
ever since it opened in 1867) has been gone into afresh, in order
that there might be no possibility of a patient being allowed to
remain merely because he had been considered to be incurable. It
is a matter of congratulation that no such case could be found ; at
the same time, it became evident that several had settled down into
perfectly harmless patients, who simply wanted a moderate amount of
care. Some of these we induced their relatives to take charge of,
and others we sent to the workhouses.” In spite of such discharges,
there has been a great pressure for accommodation.
Dr. Barton appears to be directing special attention to the out¬
door employment of his patients. The Commissioners state that
they cannot too highly commend the result of the management in
this direction. Leaving out those exclusively engaged as ward-
cleaners, 80 per cent, of the men and 49 per cent, of the women can
take part in the work of the asylum. Even some women, between
50 and 60, were employed in field work during the summer, and
although they did little, they benefited by the change.
Sussex .—To provide room for recent cases it has been found
necessary to get rid of a large number of patients (65) by sending
them to workhouses or by boarding them with their friends. By this
means the further provision for county patients admitted of post¬
ponement. The Visitors, however, are obliged to report that this
transfer of harmless cases to workhouses has necessarily produced a
marked deterioration in the general character of the patients, as they
are mostly replaced by those of a violent, maniacal, and suicidal
nature, thus involving increased anxiety and difficulty to the staff
in their management, and an increase in the expense of their
management.
Dr. Williams reports that the experiment has so far been success¬
ful. Out of 80 patients so discharged only eleven have returned.
He says further that he “ is fully conscious of the nice discrimination
required in carrying it out. He is unwilling to admit that any case
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458 Psychological Retrospect . [Oct.,
of insanity, unless involving organic changes in the brain, is hope¬
lessly incurable, and he therefore sees the impropriety of transferring
cases to the workhouse in whom there is any chance of recovery.
Such a step is wrong, both from a humanitarian and from an econo¬
mic point of view. At the same time he is convinced that it is a
mistake, ip many instances, to keep some cases too long in asylums,
as he has often seen much benefit accrue from change. There is no
point, however, in the whole range of medicine more difficult to
decide than which cases are best in asylums, and which will benefit
by change. It has occurred that discharged patients have been re¬
turned to the asylums respecting whom it was confidently anticipated
they would do without control, whereas, on the other hand, it oc¬
casionally happens that others, whose friends have removed them
contrary to medical advice, have derived decided benefit from the
change. It is only by a careful study of each case that a correct
prognosis can be arrived at.” And, we would add, not even then.
Wilts .—The estate has been enlarged by the purchase of 26 acres.
It is well known that the sanitary state has not been satisfactory.
Typhoid fever has been endemic for a long time. At last the cases
became so frequent and so serious that the Visitors had the drains,
&c., inspected by a competent sanitary engineer. So many and grave
defects were discovered that the Visitors applied to Quarter Sessions
for a grant of £2,000 to execute such drainage and other works as
may be found necessary.
Wonford House Hospital .—Under Dr. Philipps’s direction this
institution appears to be in the process of thorough renovation. The
progress already made and the results are so evidently satisfactory,
financially and otherwise, that the Governors have raised his salary
£150 per annum. The Commissioners report that the Wonford
House contrasts favourably in point of comfort with any hospital
which they inspect.
Worcester .—It is proposed to build an annexe to accommodate 210
patients but capable of extension for double that number.
In his report Dr. Cook enters at length into the cause which has
raised the asylum population from 210 in 1853 to 772 in 1882.
Yorkshire. East Riding .—Although this is a modern asylum, its
sewage arrangements appear to have received little attention from
the architect. It would have been difficult for matters to have
been in a worse state than they were when examined by Dr. Macleod.
He reports :—
" In February much trouble and annoyance was caused by the
drainage and sewerage of the asylum. The whole system broke
down at once. The sewerage in itself had many drawbacks. The sewers
were very inaccessible, and were placed in and across buildings.
Closets were situated where their presence could only be a source of
danger, and the lavatories and baths discharged their waste directly
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into the sewer, with only the intervention of an imperfect water trap.
The workmanship also of the drains, &c., was found in many places
very imperfect. Pipes were fitted loosely into each other without
clay or cement in the joints (and this inside the building) ; some of
the ends of the drain tiles barely touched the sockets of the next tile,
into which they ought to have fitted. Pipes from baths and
lavatories were pushed into sewer drains, and a few handfuls of
mortar roughly plastered round them. The main sewer is in many
places laid ten feet deep, in stiff clay, which had to be dug through,
a most disagreeable task, for the diggers had, while at work, often to
stand in two feet of water and liquid sewage. The tenacious and
unabsorbent character of the soil on which the asylum is built, alone
prevented an accumulation of sewage under wards and corridors.”
Fifty-one acres of land have been added to the estate, and a
walk of nearly two miles is to be made round the grounds.
Yorkshire , South .—Additions continue to be made to this already
great asylum. During the year its population increased by 77. The
work thrown on the medical staff must be enormous, for there
were 526 admissions, 325 discharges, and 124 deaths during the
year.
Dr. Mitchell reports favourably of sending chronic cases to
workhouses. He says :—“ In passing I may remark that this* plan
of removing the quieter sort of incurable cases to our union work-
houses has answered very well. In well-conducted wqrkhouses, which
(especially the larger of them) now constitute the greater
number, the imbecile inmates are well cared for—have such medical
care as they require, and are indeed as comfortable as they would be
in asylums. They enjoy many privileges they cannot look for when
confined in asylums—the chief of which is the frequent opportu¬
nities of visiting their friends, in whose neighbourhood they still, as
a rule, reside. When removed to asylums this point of interest in
their lives—to which they had accustomed themselves to look forward
—is withdrawn ; and in many instances I have found that no com¬
pensation an asylum can offer will weigh in the scale against this
lost and highly prized privilege.”
Yorkshire . West Riding .—The asylum at Wakefield is unable to
admit all the cases which should be sent there; the surplus being
admitted at Wordsley.
Sanitary arrangements receive continual attention. When they
are completed it is hoped that attacks of dysenteric diarrhoea, which
appear from time to time, will cease.
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460
[Oct.,
PART IV.—NOTES AND NEWS.
THE ANNUAL GENERAL MEETING OP THE MEDICO-PSYCHO-
LOGICAL ASSOCIATION, 1884.
The Annual Meeting of the Medico-Psychological Association was held
on Wednesday, 23rd July, 1884, at the Royal College of Physicians,
London, Dr. Rayner presiding. The following members and visitors were
present:—Drs. J. Adam, J. Bayley, Q. F. Blandford, David Bower, Stanley
Boyd, J, C. Bocknill, Fletcher Beach, David M. Cassidy, Crochley Clapham,
J. A. Campbell, T. B. Christie, T. A. Chapman, E. Maziere Courtenay, H.
Campbell, J. Langdon Down, F. Pritchard Davies, J. V. de Denne, G. S.
Elliott, J. E. M. Finch, Bonville B. Fox, J. R. Gasquet, J. Tregelles Hingston, W.
R. Haggard, Octavius Jepson, Henry Lewis, J. Murray Lindsay, H. Rook Ley,
J. A. Lush, Baron Mundy (Austria), H. C. MacBryan, W. J. Mickle, T. W.
McDowall, G. W. Mould, F. Needham, H. Hayes Newington, Chas. H. Nichols
(New York), J. H. Paul, S. Rees Philipps, G. H. Savage, H. Stilwell, J. Beve¬
ridge Spence, James Stewart, D. Hack Tuke, D. G. Thomson, A. R. Urquhart,
T. Outterson Wood, Francis J. Wright, Henry F. Winslow, D. Yellowlees, Ac.
Dr. Rayner, on taking the chair at the morning sitting (Dr. Orange being
unavoidably absent), said that they would be glad to learn from a letter
which he submitted that Dr. Manley, who they had at one time hoped would
have taken the chair that day, was improving in health.
Dr. Murray Lindsay moved a vote of thanks to Dr. Orange, the retiring
President, observing that they all remembered the very able and interesting
address which Dr. Orange had given them last year, and fully recognised what
an excellent President Dr. Orange had made.
Dr. Needham seconded the motion, which was carried by acclamation.
Dr. Hack Tuke submitted the minutes of the last annual meeting, which
were printed in No. CXXVII. of thiB Journal (October, 1883).
The minutes having been taken as read, were confirmed.
Dr. Campbell proposed a vote of thanks to the Editors of the Journal.
The Editors had very arduous and often thankless duties, and discharged them
in a most judicious way. If he might make a suggestion, he would venture
to say that he thought it would be very desirable if the names of the
members of any standing committees could be given after the minutes of the
present meeting. It would also be convenient to have the Index Medico-
Psychologicus so numbered and paged that it might be bound up as a whole at
the end of each volume.
Dr. Mickle said that the work of the Journal had increased each year with
the increased number of members of the Association, and the duties became
each year more and more difficult, requiring greater care on the part of the
Editors. He was sure they all felt that the Editors performed those duties in
the most efficient manner, and he had therefore very great pleasure in second¬
ing the motion.
The motion was then carried
Dr. Hack Tuke said that Dr. Savage and himself would very much ap¬
preciate the vote of thanks. It was a great help to them to know that
their efforts were appreciated by the members of the Association. He hoped
it was not at all implied that the editing of the Journal was perfect. The
Editors were well aware that there was room for improvement, and they
would only be too glad if at any time members would make suggestions. He
was very pleased that Dr. Campbell had made suggestions. As far as he
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1884 .]
Notes and News.
461
could see at present, they were good suggestions, and if his co-editor agreed,
he thought they might be carried out.
The Treasurer, (Dr. Paul) submitted the balance sheet of the accounts for
the past year, which will be found on the next page, the same having been
duly examined and certified as correct by the Auditors.
Dr. Langdon Down proposed a vote of thanks to the Treasurer, observ¬
ing that they could not be unmindful of the many years that Dr. Paul had
filled that office with great efficiency, nor could they omit to bear in mind
Dr. Paul’s kind efforts in introducing them to their agreeable annual dinners.
Dr. Phillips seconded the motion, which was carried.
Dr. Paul, in response, said that his work had always been a labour of love.
He had now been connected with them as their treasurer for 21 or 22 years,
and so long as he should be spared to fill that office it would always give him
very great pleasure to assist the members of the Association when they came
to London.
Dr. Jepson moved a vote of thanks to the Secretaries. The secretarial
duties were no doubt both onerous and irksome, and it was almost impossible
for a secretary, however well-meaning he might be, to please everybody but
the secretarial duties were most admirably performed, and their recognition of
this was especially due at the present time, when, in addition to the work of
the General Secretary, Dr. Rayner had, greatly to their satisfaction, under¬
taken the office of President.
Dr. Davies seconded the vote of thanks, which was put to the meeting
by Dr. Hack Tuke, and carried with acclamation.
Dr. Rayner thanked the Association most sincerely and heartily for the
vote of thanks, saying that it had been a great pleasure to him to carry out
his secretarial duties, which he should be pleased to continue to discharge
during his Presidency.
Dr. Rutherford, Secretary for Scotland, begged to thank the meeting
very cordially for the vote of thanks, adding that owing to the prompt way
in which Scottish members paid their subscriptions he could not say the
duties of his office were very onerous, but they were always agreeable.
Dr. Courtenay, the Secretary for Ireland, also acknowledged the vote of
thanks.
On the motion for the appointment of officers and Council for the en¬
suing year,
The President explained the mode of voting, and nominated, in accord¬
ance with the rules, the three following gentlemen to act as scrutineers, viz.:—
Drs. Yellowlees, Courtenay, and Hayes Newington.
The lists having been collected, the scrutineers retired to examine them,
and subsequently reported that the nominations of the Council had been un¬
animously supported with the exception of two suggestions as to alterations
in the names of members of Council, whereupon the following gentlemen
were declared by the President to be duly elected as
OFFICERS AND OTHER MEMBERS OF COUNCIL OF THE
MEDICO-PSYCHOLOGICAL ASSOCIATION.
YEAR 1884-5.
President-Elect
Treasurer .
Editors op Journal...
Auditors .
... J. A. Eames, M.D.
... John H. Paul, M.D.
f D. Hack Tuke, M.D.
1 G. H. Savage, M.D.
f J. Murray Lindsay, M.D.
I W. J. Mickle, M.D.
f E. M. Courtenay, M.B. For Ireland.
Honorary Secretaries J. Rutherford, M.D. For Scotland.
I H. Rayner, M.I). General Secretary.
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J. MURRAY LINDSAY, Auditor.
J. H. PAUL,
Royal College of Physicians. Teeasuree.
Notes and News .
463
MEMBERS OF COUNCIL.
David Ybllowlees, M.D. I D. M. Cassidy, L.R.C.P.Ed.
W. Bevan Lewis, L.R.C.P. | Henry Stilwell, M.D.
Dr. Ybllowlees said that now the election of officers and Conncil was
over he wished to refer to the balloting list sent out. He was not quite sure
that it could be accurately called a balloting list. Although members were
invited to alter any names, yet he thought they would not like to do this, from
the feeling that it might involve some supposed slight on the name struck out
or in some degree reflect upon the Council. He thought that much more
choice should be given to members than at present was the case, and with
this view he would suggest that—taking the post of President for example—
instead of giving only one name, the Counoil might submit three names In
the same way with the members of Council—instead of four names, eight
might be given. Thus, the members might be enabled to exercise their judg¬
ment on the balloting list without any invidiousness at all, and without ap¬
pearing to reflect upon anyone.
Dr. Let said he would second Dr. Yellowlees’ proposal.
Dr. Campbell having suggested that the rule bearing upon the point
should be read,
The President read Rule 2 in Chapter 9 of the Rules of the Association
viz :—“ Balloting lists of the members recommended by the Council for office,
shall be prepared and transmitted by the Secretary to each member with a
notice of the annual meeting. Opposite the names recommended by the Council
shall be a blank space for any other names which the member using the
ballot paper may prefer.” The President added that he thought the rule would
admit of the alteration suggested.
Dr. Ybllowlees thereupon moved that it to be a recommendation to the
Council that the lists be made up in the way suggested—the names to be put
alphabetically.
Mr. Mould asked Dr. Yellowlees to add to his recommendation that any
member of the Association who should send up a name should first ascertain
whether the member he suggested would serve.
Dr. Campbell said that he did not think it had ever been the rule to ask
members beforehand.
Dr. Yellowlees said he thought they must keep within the lines of the
rule. The rule definitely put it as the duty of the Council to prepare
balloting lists, and it was open to anyone to write to the Council saying—
“ Please put in such and such a name.” His suggestion was quite within the
rule, only giving the latter a wider application.
The President pointed out that the election must take place at the
annual meeting. If it should happen that the member elected as President
did not serve the election would then fall upon the Council.
Dr. J Epson said that if Dr. Yellowlees’ recommendation were carried out
he thought that the Council should have the privilege of saying— u There are
so many names. We suggest that those specified be elected.” What other¬
wise would be the use of the Council in the matter ? He thought the
Council should have that left in their hands.
Dr. Needham said that as he understood the proposal he thought it would
be exceedingly invidious to subject any of these gentlemen named to rejection
by the members. It would probably be the general feeling of everybody pre¬
sent that they would greatly prefer to remain in obscurity than to be dragged
into a position they did not seek.
Dr. Hayes Newington suggested that the opinions of the members might
perhaps be elicited by communications to the Council.
Dr. Campbell said that if so it would be best to issue a circular.
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Notes and News.
[Oct.,
Dr. Christie said he thought the proposal would involve change for the
worse. If three names were put forward they would be having committees
formed and canvassing, and the Association would degenerate. No one would
care to have his name put forward and circulars sent round asking nembers to
support him. They had had good men as Presidents, and the present proposal
was being brought forward without any grounds to support it. It would result
in Scotch members uniting for one purpose, English members for another
purpose, and Irish for another. The objections to the course proposed would
hold good also in regard to the other officers. Surely the editing of the Journal
would not be benefited by such a rule. He thought the matter was best left
in the hands of the Council. Moreover, ought not notice to have been given of
this ?
The President said that it would scarcely involve a fundamental alteration
of the rule, such as would require previous notice.
Dr. Down said that there were two methods of election : one being that fol¬
lowed at the Eoyal College of Physicians, where all present wrote down the
name of the gentleman they wished for President, and the other the method
adopted by this Association, as well as by some of the other Medical Associations.
Looking back upon the past, he did not think they had any cause to find fault
with their present system.
Dr. Ykllowlees said that they ought not to be dictated to by their own
Council. There was a blank line to write in, but members knew that they could
not alter the name if circumstances arose which should make them wishful to
do so. He therefore suggested that there should be given not one name, but
several names, and that those names should be given by the Council irrespective
of any canvassing of the popular vote. It was the business of the Council to
do this* but it was not their business to tie the hands of the members. He
therefore laid his suggestion as a formal proposition before the meeting.
Dr. Needham said he agreed with the principle but not with the method of
Dr. Yellowlees* proposal. He would propose as an amendment that the Secre¬
tary should, some time before the annual meeting, send out to the members of
the Association a request that they would send in the names of any gentlemen
whom they wished to propose as their President and officers, and that the Secre¬
tary should then frame a list to be presented to the annual meeting for con¬
firmation or otherwise; but that the names of those gentlemen who would then
become competitors should not be published.
Dr. Chapman said that if the Council recommended A, the Society would
take A, and when next time they recommended B, who would have been twice
on the list, B would be chosen. It would come to this—that the Council would
have to place names on the list in rotation, and decide on Presidents before¬
hand.
Dr. Lush said that they had better leave things as they were. He could not
vote for Dr. Yellowlees* proposition, nor could he vote for the very troublesome
amendment, so he would beg to move the “ previous question.**
This being seconded by Dr. Down, and the first amendment not having been
seconded, the “ previous question ” was put to the vote and carried.
The PRESIDENT brought under the consideration of the meeting the question
as to the place of the next annual meeting, and it was resolved, on the motion
of Dr. CAMPBELL, that the next annual meeting should be held at Cork, in Ire¬
land.
The election of ordinary members was then proceeded with. The balloting-
box having been sent round, and there being no dissentient vote, the list was
taken en masse, and the following gentlemen were declared to have been duly
elected ordinary members, viz.:—L. R. Cox, M.D., Med. Supt. County Asylum,
Denbigh; Ernest White, M.B. Lond., and M.R.C.P., Sen. Assist. Med. Off.,Chart-
ham, Kent j W. Beattie Smith, F.R.G.S. Ed., Yarra Bend Asylum, Melbourne,
Australia.
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Notes and News .
465
1884.]
The following gentlemen were elected honorary members of the Associa¬
tion, their qualifications being reported by Dr. Haok Take, viz.:—J. Workman,
M.D., Toronto, Canada; J. Corwen, M.D., Warren, Penn., U.S.A .5 Frederick
Norton Manning, M.D., Inspector of Asylums, Sydney.
The next business being as to Committees,
Dr. Hack Tuke reported that during the past year it had not been found
necessary to hold a meeting of either the Parliamentary or Statistical Com¬
mittees.
The President said that he had to submit a recommendation of the Council
that the Parliamentary Committee, if reappointed, should confer with the Par¬
liamentary Committee of the British Medical Association, with regard to pros¬
pective legislation, and report to the Council, so that the two Associations
might take combined action. After the conference, the Committee so appointed
would report to the Council, who, if necessary, would call together a general
meeting of the Association to confirm their resolutions.
Dr. Christie asked whether the Parliamentary Committee was still in ex¬
istence.
The President said that it was reappointed last year.
Dr. Christie said he thought it was too large. This time there would be
really work for them to do. He should propose that a Committee be appointed
of seven members to confer with the members of the Committee of the British
Medical Association.
Dr. Campbell was in favour of the Parliamentary Committee being re¬
appointed as it then stood. He thought legislation was not advancing at a very
rapid pace.
Dr. Down said he understood that action was likely to be taken, and it was
of vital importance that the Parliamentary Committee should be constituted at
once, and of the best material. He thought it desirable that the size of the
Committee should correspond with that of the British Medical Association,
which he believed was seven.
After some further discussion, it was agreed that the Parliamentary Com.
mittee should be constituted as follows, consisting of twelve members, the
names of whom were proposed and carried seriatim , five to form a quorum,
viz.:—Dr. Lush, Dr. Blandford, Mr. G. W. Mould, Mr. H. Hayes Newington, Dr.
William Wood, Dr. Savage, Dr. Clouston, Dr. Needham, Dr. Eingrose Atkins,
Dr. Paul, Dr. Stocker, Mr. H. E. Ley.
It was further resolved, on the motion of Dr. MURRAY LINDSAY, seconded by
Mr. HAYES Newington, that the Committee should appoint certain of their
numbers to confer with the Parliamentary Committee of the British Medical
Association, and report to the Council.
It was resolved, on the motion of the PRESIDENT, seconded by Dr. CAMPBELL,
that the Statistical Committee be reappointed, and add to its present functions
the consideration of the desirability of adopting a system of collective investi¬
gation of disease.
Dr. Hack Tuke reported that the adjudicators, consisting of the ex-Presi-
dent, the President, and the President-elect, had this year awarded the prize of
£10 10s., together with a bronze medal, to Dr. S. Eutherford Macphail, Assistant
Medical Superintendent of the Garlands Asylum, Carlisle, for his essay on “ Clini¬
cal Observations on the Blood of the Insane ” (see Original Articles, p. 378). Dr.
Hack Tuke submitted a letter from Dr. Macphail, who was unable to be present,
in acknowledgment of the award, and explained that the striking of the medal
had been hitherto delayed until such an essay appeared as would justify the
incurring of the expense. The first cost would ordinarily have been about £76
but as the Association already possessed a die for the stamping of diplomas, it
would be about £30 to commence with, and it would afterwards cost about a
pound for each striking.
The President said he was sorry that Dr. Macphail was not present to receive
xxx, 31
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466
Notes and News.
[Oct.,
the prize, whioh he very richly merited. He hoped the Association would con¬
tinue the prize and bronze medal in fntnre years, and that they would have a
still larger number of good papers from competitors.
Dr. Hack Tuke said that with reference to his inquiries concerning the use
of alooholio liquors in asylums, he had engaged to read a paper on the subject
at the Belfast meeting; but as so many of the members present that day would
not be at Belfast, he thought it was only due to them, after giving them so much
trouble, to read a summary of the results of his inquiries so far as he had been
able to obtain them. Dr. Tuke then gave the substance of a paper whioh be
subsequently read at the Annual Meeting of the British Medical Association.
The President said that Dr. Hack Tube’s very interesting summary would
no doubt call for observations from the members, but as their time had all but
expired, it would be beet to defer the discussion till the afternoon.
AFTERNOON MEETING.
The President read his Address, whioh will be found at page 337 of this
Journal (Original Articles, No. 1).
Dr. Maudslet moved a vote of thanks to the President for his Address,
remarking that so far as a general impression would go, he heartily coincided
with most of the suggestions made. In regard to any steps which might be
taken to bring about more careful proceedings for the admission of cases into
asylums, he might say that he felt sure that they would not result in a cessa¬
tion of the outcry against asylums. Taking the recent case of Gilbert Scott,
which was a case tried before a Judge of the Supreme Court, with a jury,
although, after a careful trial of three or four days, the jury were unanimous
and the judge expressed his entire agreement with them, yet the newspapers,
were not satisfied; and probably if every case were tried before a jury, still the
public would not be satisfied. He was glad to hear the President’s experience
as to the use of sedatives in regard to insanity. It agreed with what he bad
himself said when he occupied the chair, that they were seldom useful, and
sometimes positively mischievous. Before sitting down he might say that be
hailed with pleasure the presence of a distinguished foreign honorary member
of the Association, Baron Mundy. That gentleman would, he knew, have taken
great interest in many of the points contained in the Address, and particularly
in regard to the treatment of the insane out of asylums. In fact, when Baron
Mundy was in this country he was an apostle of the cottage-system of treat¬
ment, and he would no doubt be pleased to recognize a very considerable modi¬
fication of opinion since then.
Dr. Hack Tuke seconded the motion, saying that the Address was full of
information, and likely to lead to a practical discussion. As Dr. Maudsley had
referred to one distinguished visitor, he might be permitted to mention the
presence of another, viz., Dr. Chas. H. Nichols, of the Bloomingdale Asylum,
New York, who had been delegated to this Association from the Association of
Medical Superintendents of American Institutions for the Insane.
The motion was then put to the meeting and carried with applause.
The President, in thanking the Association for their vote of thanks, said
that he felt sure that it gave them all great pleasure to have their honorary
members present, and he hoped that Baron Mundy would not fail to express
some of his views in regard to the single care of patients.
Baron MUNDY said that, having to leave to attend another meeting, he would
take this opportunity of thanking them for the reference they had made to his
presence. He said that in France and other foreign countries the lunacy laws
were not nearly so well regulated as in England, but there were commissioners
appointed, partly from the Ministry of Justice, and partly from the medical
corporations, who visited patients after a fortnight. In regard to the “ cot-
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Notes and News.
467
1884.]
tage ’’ or “ family ** system, he said that Prance stood nearly where it did
twenty years ago, although there was much talk there about “ family ” treat¬
ment, and some attempt at it. Norway, Italy, and Sweden were as before ;
and he was sorry to say that Austria was still behindhand, except in Vienna.
In Germany progress had been made. He would call their attention to a re¬
port at the Copenhagen Congress relative to the system in question, which was
working well on an estate which had cost about £30,000, and which had been
bought for a lunatic asylum, but where the insane were living in the different
houses which had been built before the inhabitants left. There were central infir¬
maries, but the system was a separate one. Half of the oost of the estate had
already been repaid. It was proposed also to buy such an estate near Munich.
From his experience, however, he was obliged to say that he did not think such
a system could be carried out in England.
The President suggested that the adjourned discussion on Dr. Hack
Tuke’s paper might be taken at the same time as the discussion on the Address,
as the subject was referred to in it.
Mr. MOULD said that the system described by Baron Mundy had been in
existence at Cheadle for seventeen or eighteen years, where they had living in
cottages many patients out of the main building of the asylum. He should like
to bear his testimony to what Dr. Rayner had said with regard to the certifi¬
cates. He hoped and believed that in the eusuing year those certificates would
be modified or done away with—at all events in their present form. It was
impossible to shirk the question. It was all very well for them to be afraid of
a law which they knew to be bad i n its inception and still worse when carried
out. For several years he had, almost in defiance of the law, received patients
as boarders without certificates. He had always taken the Commissioners to
see them, and he must say that they had never interfered. The regulations
were constantly broken, and by no class of people more than by the rich. A
rich man’s friends would say, “ Cannot you allow a couple of nurses to come
into the house P ” or, “ Cannot you do this or that ? ” but when it came to the
legal question they would ignore all that, and help in the prosecution. Only
think of the harm which those certificates did ! In the case of a man in excel¬
lent business it actually took away his meaus of living. He could mention a
a case in which the friends interfered, fearing that the patient’s future would
be ruined, and the man died insane. He hoped that, when the Parliamentary
Committee met, some other mode would be hit upon of placing a patient in
an asylum. He fully agreed with Dr. Rayner’s suggestion, that a patient
should be sent to an asylum for a short definite period, and that in that period
he should be visited to see whether he should continue under care and treat¬
ment. That would do away with the disadvantages of the existing state of
things. He had felt the utter inutility and positive obstruction of the certifi¬
cates, and protested against treatment of patients by simple Act of Parliament,
instead of by common sense. He had, at the present time, the good fortune
to be indicted for a conspiracy. He had received a patient who was dis¬
charged and brought an action against the two medical men who signed the
certificates. The action was quashed, and because he had received that patient
he had been indicted for conspiracy. Of course it was for him to show bona-
fides, and he hoped to show also the absurdity of the law which allowed a public
officer to be indicted and put to a great expense simply for doing his duty.
Dr. Savage said he had always felt the great importance of having some
“ house of rest ” to which patients could be taken at once. There was no
doubt that Mr. Mould broke the law habitually, and the older he (Dr. Savage)
grew, the more he felt inclined to break it. Cases were brought in which he
thought humanity necessitated it. Only last week Dr. Maudsley sent a patient
to Bethlem, quite maniacal, without any certificates whatever, and said—“See
what you can do with this patient.” He took the patient in. Of course he
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468
Notes and News.
[Oct.,
got the certificates by that evening; bat consider the position. There was a
maniacal patient with only a feeble old woman in the cab with her. That
often happened. Unfortunately, there was another side to it. Even if they
had a house of rest, something also was required in the way of power to com¬
pel dangerous people to be retained. Two cases had occurred in his own ex¬
perience within the week, which were of grave import. A patient admitted
into Bethlem in consequence of acute mental disorder following upon delirium
tremens, got sufficiently well to understand his business relationship, and his
friends said, 44 We will take him out at once. His business is interfered with.”
I said, 44 It is a temporary calm. I am sure he will have a relapse.** The
patient was perfectly sane. His friends would not believe the medical opinion.
He was taken out: an indemnity was given by his wife, and within two or three
weeks he killed her. Another patient was taken out under almost precisely
similar circumstances. The friends were warned, but they would not believe
medical advice, because the patient answered so reasonably. An indemnity
was given, and that patient killed himself. Accidents of this kind would occur,
and he was afraid he was inclined to look rather easily upon suicidal ones; but
if they were to have a house of rest, they must have some arrangement giving
power of detention. As to special certifiers, that would be of the greatest
importance ; not because the man who signs usually loses a friend, but because
there were many cases in which ordinary medical men had no right to sign a
certificate. They were told so and so by the friends, but the symptoms put
down in an immense number of cases were worthless and misleading. Of
course, the Commissioners were doing their best, and they had much more to
do; but patients themselves complained that they were sometimes three or
four or five months in an asylum without been seen by the Commissioners.
Perhaps patients would never be satisfied ; but it was just that within a certain
time of admission—say within three or four weeks—patients ought definitely
to be seen by a State-expert. He could not agree with Dr. Rayner altogether
about the dietary. He did not believe—although Dr. Rayner spoke as though
he regarded it as likely—that Dr. Rayner thought that the dietetic value of
food was to be judged by the mere analysis of it. He should be very sorry to
see the time come when patients would be fed according to the amount of nitro¬
gen, hydrogen, or carbon which the food contained. There were some present
who felt strongly that there was scarcely a county asylum where the dietary
wa6 satisfactory. There would always be many difficulties, and he was afraid
there would always be some hotch-potch in the food. He quite agreed with
Dr. Rayner that the age of quieting patients by narcotics was coming to an
end, but he trusted that the pendulum would not swing too much in the other
direction. There were cases in which he believed that treatment of a very
severe kind was useful. They might see at Bethlem shaven scalps, and even
blistered scalps, and he remembered cases which had improved under that
treatment. The same with narcotics. If they had a sharp weapon it might
be either extremely useful or dangerous according as they knew how to use it;
and because it might be dangerous he hoped they were not going to exclude the
fact that it might be extremely useful.
Dr. Bucknill said that he thought the Address was a very able one, but he
never heard one with which he so generally disagreed. On certain points which
were being referred to when he entered the room, he would reserve his opinion.
In regard to the very interesting points touched on subsequently, he must say
first of all that he cordially agreed with what Dr. Savage had said with respect
to treatment. He was glad to hear him say that shaven scalps and blistered
scalps could be seen in his wards, for he (Dr. Bucknill) had seen them there,
and he thought he was, to some extent, responsible for that. It was one
of those things which, under certain conditions, did so much good; but they
were now so much afraid of responsibility that, as a rule, they had left off
Digitized by boogie
1884.]
Notes and News.
469
that and other treatment which was beneficial to recovery. They thought too
mnch of what the outside world thought, and were apt to forget that the
greatest benefit which they could confer upon a lunatic was to cure him by any
means available. He also begged respectfully to refer to the use of narcotics,
and especially of morphia. Judiciously used, morphia was one of the best of
remedies, and to have a kind of general discredit thrown upon it in the present
Address, and also in the Address by Dr. Maudsley on a former occasion, was, he
thought, a very mischievous thing. What was to be avoided was the giving of
narcotics for the piirpose of quieting patients; but to say that they should not
be given for curing patients, was a dangerous doctrine and a retrograde one.
He agreed as to certificates. The whole thing was wrong. As to the law of
“ two medical men separately , 1 ” what could be more absurd ? It was the entire
reverse of what took place in the case of bodily disease. There concurrent ex¬
amination was made j but in lunacy each medical man must examine separately,
and so the public lost the advantage and security which would be attained by
two or more conscientious men examining together. He agreed entirely also
with the suggestion that had been made that there should be an intermediate
house, as distinct from the asylum ; in fact, he thought that the more they
treated insane patients on the same lines as patients were treated in hospitals
the more they would be honoured, and the better the public would eventually
be satisfied.
Mr. Hayes Newington thanked Dr. Rayner for the kind opinion he had
given as regards private asylums. Examination by a Government official was,
on the face of it, a very wise thing, and would satisfy the public; but the ques¬
tion was—What was their duty ? Was it to satisfy the public, or was it to do
the best thing they could for the patient ? Would the proposed examination be
for the benefit of the patient? Such an examination would be called for only
in one case out of ten ; but taking that one case, what would be the result ? He
could honestly say, from his own experience, that the visits of the Commissioners
had much prejudiced the recovery of the patient. Suppose the somewhat doubtful
case of a lady who had the idea that she was well, and who was much worried
by the difficulty she had in getting the doctor to see that she was well. As long
as she had the hope of proving herself right and the doctor wrong, she would be
at great pains to benefit herself. The Commissioners would come, and would,
unfortunately, be obliged to think the same as the doctor, and the patient would
begin to rave at once. Then, too, what Government official would ever take the
responsibility of saying that two medical men were wrong ? He did not see how
any Government official in a fortnight would, in the face of two medical men
who knew the circumstances of the case, say that they were to be discredited,
and the patient set right. Then what was to be done ? Possibly he might be
thought foolish in saying it, but he did not see that anything had to be done.
Perhaps a few trifling alterations might be made in the law ; but the best cure
for ill-doing was to be found in the fear connected with the responsibility for
such ill-doing. Mr. Mould had taken great credit to himself for law-breaking;
but if his bona fides were not so well proven he would find it a very severe respon¬
sibility to break the law. He did not, however, think that they need throw on
one side the suggestion as to the magisterial inquiry. He had always held that
if the Commissioners were empowered to write confidentially to many of the
public servants of a town in the country—say to a Justice of the Peace—the very
Justice of the Peace before whom the examination took place—making inquiries
as to the family and other circumstances connected with the patient, and the
public knew this, it would go a very great way to allay dissatisfaction. He
thought they were all too much disposed to run after the “ liberty of the subject.”
This was, of course, sacred to every Englishman, and it required very serious
neglect of duty to cause a person'to be deprived of his liberty. It seemed, how¬
ever, to be forgotten that liberty was not a present made unconditionally to
every man, but that it had its duties as well as its privileges; and he thought
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470 Notes and News. [Oct.,
that the liberty of the friends of the subject was vastly more interfered with by
the insane patient than the liberty of the patient was by the friends.
In reply to inquiries by Dr. Bucknill and Dr. Hack Tuke, Mr. Mould said
that he had never broken the law in the sense of detaining patients, without
certificates, for profit. He had kept patients from going to an asylum, under
certificates, by treating them at their own homes with the aid of their medical
men. He had done this sometimes in order to prevent them being thrown out of
their business. Only the other day he saw a gentleman who would have been
thrown out of his firm if he had been certified. The law, as it at present stood,
allowed a person to be suspended at once from his business. He had gone even
further. He had frequently, with the full consent of his colleagues, allowed
patients to take such active part in their business as would prevent its being
lost. In hospitals they were allowed to take M boarders/* It was for the super¬
intendent to determine whether these persons were so insane as to need certifi¬
cates, or whether they required simply a certain amount of control and super¬
vision. He had at the present time something like forty or forty-two boarders.
All of them had been seen by the Commissioners, and ail were patients staying
on of their own free will. He referred also to a case of a lady whom he had
detained against her will for a little time.
Dr. Campbell said he was very pleased to hear Dr. Rayner*s remarks with
reference to imbecile children, whom it was very wrong and improper to send to
adult asylums. He had last year a child of eight years of age, and sent the
child away. He thought it very hard that an imbecile, who had the misfortune
to be epileptic, should be excluded from the imbecile asylum. He was also
pleased with Dr. Rayner’s remarks on dietary. He thought that the dietaries of
public asylums required very much improvement. There should be a summer
diet and a winter diet. The amount of fruit and vegetables given to pauper
patients was not enough, and the monotony was most wearisome. As to treat¬
ment, many might differ from the views expressed both by Dr. Rayner and Dr.
Bucknill; but the truth could be arrived at only by discussing the treatment,
and they ought all to oombine in inquiry as to its relation to recovery. They
had not enough data to come to any conclusion about it. In regard to blistering,
which Dr. Savage seemed to take to himself considerable credit for, many of
them had not as yet come to a conclusion as to the cases it was good for. He
thought that they should, at their quarterly meetings, put down some one sub¬
ject of practical value for discussion, and give their experience. That would
conduce very much towards their advancement in knowledge in regard to medical
treatment.
Dr. Fletcher Beach said he quite agreed with what Dr. Campbell had said
about their not being able to take into the imbecile asylum imbeciles who had
the further misfortune of being epileptics. It would be of very great advantage
if they were allowed to take in patients who were only or also epileptic. At
present they were obliged to return such patients. He believed there was a place
in the North of England for epileptics alone, but not in the South of England.
What happened now was that a child would be removed from one place to another,
and perhaps became an imbecile when he would not otherwise have become so.
Dr. Yellowleks said that they were supposed to have some peculiarities in
Scotland as to lunacy. Their certificates there were endorsed by a legal func¬
tionary, the Sheriff, and the result was that they had less grumbling on the part
of the relatives, and on the part of the patients themselves. It was his familiar
conclusive reply to a patient, “ The Sheriff has sent you here.’* That position
was one which shut up the patient, so to speak, and satisfied the friends, and he
did not believe that any subsequent examination by a certifier, no matter who
he might be, would equally satisfy patients or their friends. He thought that
the certifier would be suspected by the public. Some people were never
satisfied; and if the certifier were a medical man they would not be much
nearer to satisfying this section of the public. The Scotch method was really
Digitized by <^.ooQLe
Notes and News,
471
1884.]
therefore answering very well. The patient did not appear before the Sheriff at
all, and he must say that sometimes the Sheriff endorsed cases which he (Dr.
Yellowlees) would not have received. In Scotland the superintendent of the
asylum at once signed a certificate of emergency for the patient, which certificate
was valid for three days, thus allowing ample time to communicate with the
friends and make other inquiries. The emergency certificate was therefore most
valuable. Then the other difficulty, referred to by Dr. Savage, was provided for.
In Scotland the friends could not remove a dangerous patient without the con¬
sent of the medical superintendent. The mode in which the medical superin¬
tendent exercised that power was that he would communicate with the Pro¬
curator Fiscal to the effect that a dangerous patient was about to leave the
asylum, or rather he would say to the friends, “You may, if you please, take the
patient away; but I must acquaint the Procurator Fiscal, who will arrest the
patient.** That threat was, of course, enough, and he had in only one case had
to ask the Procurator Fiscal to arrest the patient. He was very pleased to hear
what Baron Mundy told them; but the same thing had been done in Scotland
and elsewhere. They would all recognise what Dr. Rayner had said about the
increasing requirements of accommodation for lunatics; but he believed they
were on the wrong tack, and that until they had got small curative asylums,
containing not more than 200 or 250 patients, they would not be able to fight
lunacy as they ought. It was only in that way that the curable patients would
get a fair chance of recovery, and that the terrible incubus of incurable patients
would be lifted away, so as to enable medical officers to do their best for the
cure of the others. He very much appreciated the energy and antithesis with
which Dr. Bucknill had spoken ; but he was not prepared to go that length.
He did not at all understand Dr. Rayner to speak of treatment by, but of the
misuse of, narcotics. He would very much like to hear more about another
point touched upon in the Ar I dress. If there was one bit of practice which had
assumed to him a greater definiteness than any other, it was that dipsomaniacs
should not get stimulants unless their physical condition absolutely required it.
He formerly thought that there were no conditions where alcohol was required,
but he now thought there were cases in which it was needed.
Dr. Stewart said that it was impossible to assume too decided a position upon
the last observation. He would ask what was meant by “dipsomaniac.” There was
no more misused term. Probably if he asked Dr. Yellowlees to give an absolute de¬
finition of that word he (Dr. Stewart) would not be satisfied with it. The majority
of the cases called “ dipsomaniac ** were not so at all. The term was very loosely
used by the general public, and they, as practical physicians, should set them¬
selves most decidedly against looseness of application of a term. What was
“ mania ? ” They generally accepted, as a fair definition of insanity, that it was
a disease of the brain which involved the mind. Now, was the ordinary dipso¬
maniac one who had got a disease of the brain ? And, until they were prepared
to say that the majority of the patients called “ dipsomaniacs ” had a physical
disease of that portion of the body which was called the brain, it was extremely
unscientific to speak of 99 dipsomania.” Nine-tenths of so-called “ dipsomaniacs ”
were not so at all, and no psychologist of scientific repute would class them as
such. A dipsomaniac, in the ordinary sense of the term, was only a person who
was in a chronic state of drink. Was that a brain-disease? Was a constant
desire of a man to give way to his carnal passions a disease of the brain ?
Were all the vices he could name diseases? He maintained that there was not
one case in a thousand of so-called “ dipsomaniacs ” in which it was at all neces¬
sary, or even good practice, to administer stimulants in any form whatsoever.
It had been remarked that they were too careful to regard what the outside world
said, and what the Commissioners said. He endorsed this in both ways. A
typical case had been brought under his notice the other day, in which an in¬
dividual, who was decidedly of unsound mind, was brought before a physician
who had a great fear of the Commissioners. He (Dr. Stewart) had no such
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472
Notes and Nem.
[Oct.,
fear. Hie first duty was to look upon the case individually, and. having come
to a conclusion upon it, he thought the other gentleman might consider it
separately, and apart from his fear of the Commissioners. “ No,” he said, “ I
will not. The Commissioners may upset the case in a few days.” He thought
they were bound to do their duty in spite of what the Commissioners might
say, and he commended Mr. Mould for the way in which he acted upon his
opinions. He was quite sure that an intermediate home would do good; but
there was a great practical difficulty in the way, and that was the bugbear of
the Commissioners.
Mr. Bonville Fox said that as to the place of rest which had been proposed,
he should like to ask what would be the legal status of the individuals treated
therein ? by whom would they be transferable thereto and therefrom ? by whose
authority and at whose discretion would they be kept there ? who would deter¬
mine whether they should be kept there or sent on ? aud, while there, at whose
risk were they there ? He was bound to say he had that afternoon heard one
or two things which had rather astonished him and opened his eyes. He
heartily endorsed what had fallen from Mr. Hayes Newington, that the fear of
the law was the great protection of the freedom of action of the individual.
Anything that would relieve the proprietors of private asylums from their re¬
sponsibility and onus would be welcomed by them as freeing them from the
unpleasant position in which they were often placed ; and if patients were con¬
signed to them by such an order as that of the Sheriff in Scotland their position
would be a very different one from what it was. He would point out especially
that, as far as the freedom of the patient was concerned, he would be precluded
for ever from bringing any action against a person who had signed that
order, when once it had been endorsed by a sheriff or magistrate. With re¬
ference to what Mr. Mould had said, he might say that about a month ago
a patient was brought to his asylum at ten o’clock at night. The order
had not been signed, but the certificates had been. It would have been con¬
trary to their idea of anything legal to have received the patient, so the
only thing they did was to send up to the nearest magistrate, who, after a good
deal of compunction, signed the necessary order. He found now that they might
have received that patient.
Mr. Mould explained that what he had said referred only to boarders in
hospitals.
Mr. Bonville Fox said he did not quite understand what Mr. Mould had
said about the dipsomaniac lady.
Mr. Mould said that he was only stating what was the law upon the subject
as to voluntary boarders. That lady was received under her own hand. He
enforced his bond, saying, “ No ; you agreed to stay with me.” The Commis¬
sioners saw her, and they said, “ Give her another chance.” He did so, but she
came back again. The Commissioners had sent round a circular saying that all
hospitals could receive voluntary patients. No sanction had to be got what¬
ever.
Mr. Bonville Fox asked whether they were kept when they wanted to go
away.
Mr. Mould replied that they could be kept for a definite period.
Dr. Nichols, of New York—Mr. President and Gentlemen : I heartily thank
you for the cordial manner in which you have received my introduction to you
as a member of the American Association of Superintendents. Though well
aware that an introduction to your body by such a distinguished and esteemed
member of it as Dr. D. Hack Tuke affords ample warrant for your cordiality, I
regret that I forgot to bring with me this morning from my distant hotel in this
great city a certificate accrediting me to this Association as a delegate from the
like Association on the other side of the water. I shall, however, embrace an
opportunity to hand it to your Secretary as a sort of official evidence that I am
the man that, upon Dr. Tuke's authority, you have kindly taken me to be. That
Digitized by v^ooQle
Notes and News.
473
1884.]
document authorizes me to offer you the cordial greetings of the body I repre¬
sent on this occasion. If I am correct in my recollection, our Association takes
precedence of yours in age, but as a people we do not forget our national origin,
which we consider exceedingly respectable, and still, as I trust we always shall,
notwithstanding occasional differences in past times, have a filial regard for the
mother country, and a family pride in the grandeur of its institutions and the
happiness of its people. The able and practical Address of your President, and
the discussion that has followed it, have deeply interested me, partly because of
the views expressed, and partly because I find that most of the subjects
brought to your attention by the Address are the very same that are now
engaging the attention of practical alienists in America. It is true that two or
three of them may be said to be res adjudicate with us. For example, a large
proportion of our patients come to us both in an anaemic and neuraesthenic con¬
dition, and we are quite agreed that they generally need a generous diet; and,
with few exceptions, I think they get it. The variety of food they get is con¬
siderable, the quality is generally at least fair, and the quantity is practically
unlimited. We everywhere experience the difficulty of cooking and serving the
food in the best manner, for large numbers, that has been before referred to in
this discussion ; and while the cooking and table service in our institutions have
been greatly improved in the last twenty-five years and is in the majority of
them now fairly well done, without doubt it is in many of them susceptible of
much improvement. We give our patients milk and fruits freely. In many
institutions malt liquors are more or less used, but I think they are generally
prescribed as a tonic rather than used as a beverage or article of diet. Again,
so far as I am aware, there is not any sentiment among our practical men in
favour of the family care of the dependent insane. We have not suitable fami¬
lies suitably situated, nor does it seem practicable for us to make provision for
the requisite supervision. But with respect to what is known as the cottage
treatment of the insane, alluded to in the Address, I may say that there is with
us a growing tendency to disintegrate our patients, most of the latest asylum
edifices having been built in separate sections or blocks connected by corridors.
In the State of Illinois a public institution has been built, and organized dis¬
tinctly on the cottage or quite-separate-buildings plan, but the desirability of
public provision for the insane upon this plan may be said to be with us an
open question. I think we do pretty generally favour detached buildings for the
chronic and other special classes, but connection with an ordinary asylum or
hospital edifice, suitably furnished and fitted up, for the treatment of the recent
and active cases. The Government Hospital for the Insane at Washington, and
the Willard Asylum for the Chronic Insane in the State of New York, are
examples of such an arrangement of buildings. We have, as you know, in
America nearly forty States, each of which is independent of all the others, and
of the general government, in the management of its interior concerns, among
which is the provision it makes for the care of its dependent classes, including
its insane. The natural consequence of this governmental arrangement is that
the laws of the different States relating to certification for the purposes of treat¬
ment in their institutions vary very greatly. In some States they are much too
lax, allowing a patient to be sent to an asylum upon the simple certificate of
one physician ; in others they are too rigid, not to say barbarous, requiring a
verdict of insanity by a public jury, as if the patient were under a criminal
charge, before he can be placed under proper treatment. In some States, as in
New York, legislation has been enlightened and prudent, and their laws relating
to certification are pretty much all that can be desired, being sufficiently rigid
to amply protect the personal liberty of the citizen and satisfy popular sensi¬
bility upon this subject, while they allow reasonable promptitude in getting
patients under treatment. It may be said that, whatever views may be enter¬
tained by individuals on our side respecting the restraint and treatment of the
insane upon the responsibility of their friends and the medical men having the
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474
Note* and News.
[Oct.,
care of tbem t it is not probable that any one of 'the American States would
tolerate suoh a practice. I know of no law in America that stands in the way
of the admission to our institutions of strictly voluntary patients, but our diffi¬
culty in such cases is that they will rarely remain under treatment long enough
to receive lasting benefit. It has never come to my knowledge that a physician
has lost his attendance upon the family by eertifying to the insanity of a
member of it, precedent to his treatment in an institution or asylum. Except
in the case of the poor, supported on the public charge, certificates are usually
given at the request, or at least with the concurrence, of the nearest relative or
guardian of the patient. While there has not been any material change in our
views respecting the nature of insanity, I believe there has been, in a practical
way, a more general recognition that it has essentially a physical pathology
than was formerly the case, and that the general aim among us is to place the
patient in a sound physiological state, and at the Bame time to give the cerebral
disorder and the mental derangement such special treatment as appears to be
indicated in each case. We probably resort to medical treatment as often, per¬
haps oftener, than we formerly did, but I am glad to believe that it is muoh
more delicate and discriminating, and less gross and routine than it formerly
was. The views and practice of our superintendents are not altogether uniform,
as, from the Address and discussion, they do not appear to be here; but the ten¬
dency is, I believe, towards what I have stated. For myself, after a pretty long
experience, I am an earnest believer in the value of medicines in the treatment
of insanity, but hold that, in this as in all other diseases, they should be pre¬
scribed with careful reference to an important end that the physician believes
can be attained by their administration, or in conjunction with it, but which'
can not be as well or certainly attained without their use. It is clear to me
that opium is curative in a limited number of cases of mania, and that it may
be administered with advantage in some cases of melancholia ; also that opium,
the bromides, chloroform, hyoscyamus, if discriminatingly used, are so advan¬
tageous in allaying excitement and procuring sleep that it at times becomes the
duty of the physician to prescribe them, but that their long-continued use in
individual cases should generally be avoided. Warm, graduated baths, with
the application of cold water—sometimes of ice-water—to the head when the
latter is hot, taking great care not to frighten or distress the patient, and follow¬
ing the bath by rubbing the whole surface with alcohol or whiskey, as a swelling
is rubbed with liniment, will often procure sleep more satisfactorily than any
drug administered internally, while it allays the fever and saves the strength of
a feeble patient. Our climate is malarial, and we have occasion to use a good
deal of quinine, both as an anti-periodic and tonic. We also use the mineral and
speoial tonics freely. Counter-irritation to the shaven head has gone almost
altogether out of practice in American institutions for the insane, from the
same feeling that appears to have influenced British practice in this respect,
viz., that if it is of doubtful advantage, as we think it is, then it is scarcely
justifiable. We have felt that, when such treatment appeared to be indicated,
its ends can be substantially as well attained by cups and blisters over the nape,
temples, and behind the ears, as by applications to the shaven head. I forbear
to further traverse the Address, wishing to confine my remarks strictly to a few
subjects of common interest on both sides of the water, and thank you for the
patience with which you have listened to what I have said.
Dr. Campbell said that allusions had been made to the boarding-out system.
That was a matter he should like to hear about. There was at one time a very
great deal written about this in the official records of the Scotch Commis¬
sioners, but during the last seven years he had noticed that there had been a
gradual diminution in the numbers boarded out, and, as it was a matter in¬
volving many points for consideration, he might, perhaps, be allowed to throw
out the suggestion that it would form a most admirable topic for a paper from
the other side of the border.
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The President, in reply, said that the discussion on the Address had been so
prolific that he could not but feel thoroughly satisfied in having thrown his net
as widely as he had done to catch subjects which had excited interest. As re¬
gards “treatment,” he would only say that he thought Dr. Bucknill misunder¬
stood him to a certain extent. His observations on that head might be summed
up by saying that he considered it necessary to be a good physician to be a suc¬
cessful alienist. He spoke of the use of narcotics as a means of restraint as
one of the things of the past ; but he left it quite an open question whether the
brain could not be satisfactorily influenced by narcotics, as some in the profes¬
sion held that it could be, although he, for one, had not been successful with
them. He did not say narcotics were not of use, or might not be of use, but at
present his own reliance as to treatment was on bodily health and external ap¬
plications to the head, which he had found very successful in certain cases of
stupor, and even in some cases of hallucination in which there was reason to
suspect a localized lesion of the brain. With regard to the treatment of dipso¬
mania, he could say only that he had been much more successful in the cases
he had treated by training the patient in habits of self-control than in those
caseB in which he had tried to get the patient to abstain altogether. He could
quote one case of a man whose grandfather and father were dipsomaniacs. The
patient himself became insane from drink at the age of 49. He was under re¬
straint for some years, and recovered. After leaving the asylum he lived for ten
years, not as a total abstainer, but as a moderate user of alcohol at his meals.
With respect to the general question of dietary, he was pleased to find that, his
remarks were approved of. He trusted that Dr. Campbeirs suggestion as to a
forthcoming paper on “ boarding-out ” would bear fruit.
A paper by Dr. Newth, “ On the Value of Electricity in the Treatment of In¬
sanity/’ was taken as read.
A vote of thanks was unanimously accorded to the Royal College of Physicians
for the use of the room, and the proceedings then terminated.
The members of the Association afterwards dined together at 41 The Ship,* 1 at
Greenwich.
ANNUAL MEETING OF THE BRITISH MEDICAL ASSOCIATION AT
BELFAST, JULY 29th to AUG. 1st, 1884.
SECTION II.—PSYCHOLOGY.
Officers
President . Dr. Savage, Bethlem Royal Hospital, London.
SICBE“IB. j St p!p“”pk.'l™“ 8.. ta'. n«tb, Cli«rt«r.
There was a fair attendance of members, nearly 60 taking part in the meetings.
Proceedings
30th July.—The President delivered an able Address on 44 The Pathology
of Insanity.”*
The discussion was opened by Dr. Deas, who remarked with what pleasure
he had listened to Dr. Savage’s able and suggestive Address, and said it was
particularly interesting to find that he had taken up the subject of the relations
* Published in exUnso in the “ Brit. Med. Journ.” Aug. 2nd, 1884, p. 239.
>OQLC
476 Notes and News . [Oct.,
between bodily and nervous diseases in a way which might be considered cognate,
or complementary, to those so ably brought forward by Dr. Ord in his Address
on medicine. The latter had discussed the causation of certain bodily diseases
through the influence of the nervous system; while Dr. Savage had shown how
profoundly the nervous system and mental conditions may be modified by the
existence of certain bodily states or disorders. He pointed out, in reference to
an etiological classification of insanity, that though it was, as Dr. Savage said,
imperfect, still it was very important to view insanity clinically in connection
with co-existing bodily diseases. He alluded also to the interest of those cases
in which the occurrence of acute bodily disease appears to modify profoundly
the mental symptoms, even in long-standing cases of chronic insanity.
Dr. Stewart remarked—We cannot, as practical physicians, be too careful
in our sanction of the use of medical terms. The term “ insanity ” does not
commit us to a theory, and, therefore, is not objectionable if used in its broadest
sense—that of non-sanity. But we find most people applying it in a restricted
sense, implying that they believe there exists a pathological lesion of a portion
of the brain. There may be no pathological change of cerebral tissue, and yet
there may be mental disorder—not such as one could associate even in theory with
any alteration of the kind. Functional disorder, as the President has wisely
emphasised, is a recognizable abnormal condition, and ought to be studied by us
as practical physicians.
Dr. Tuke mentioned two cases of suicide, followed by complete blank in one
case and partial blank in the other. He referred to the distinction between
functional and structural disease, and was glad that Dr. Savage had brought this
out so prominently. It seemed to him most important to recognize that mere
change of position of the minute constituents of the brain is sufficient to cause
insanity without any pathological change being discoverable after death, or,
indeed, being present at all. Then there were cases of what he might call
physiological insanity, in which there is a constitutional disproportion of
portions of the brain, so that without there being a change of character due to
disease, there might be an abnormal state in which the individual was not
responsible for his actions. He referred also to the cure of insanity by an
appeal to reason, and mentioned the case of a woman who after being silent
for years, and regarded as incurable, suddenly recovered on considering the
improbability of her delusion, which was that she had been all this time in hell.
Dr. Conolly Norman remarked—It is a little point, but it must be said
that the absence of good cases in asylum case-books is very often due, not to
want of intelligent interest on the part of medical officers, but really to want of
time. In general hospitals the staff of physicians, assistant physicians, house
physicians, and clinical clerks—all more or less skilled observers—form quite a
large percentage in proportion to the patients, but in Ireland it often happens
that one man alone has to do all the medical, administrative, and social duties
belonging to the management of a large asylum. In England, of course, things
are better, and in America, as one is glad to notice from the reports, better still;
but even in the best-manned asylum, the staff is insufficient to give to every case
that minute scientific care that is so desirable for the extension of our know¬
ledge by minute observation.
Dr. Woods —The great difficulty, rendering it almost impossible to keep a
case-book of any value in the Irish asylums, is due to the very imperfect entry
obtained with the patients ; the certificates are meagerly and inaccurately filled,
and no one comes to the asylum with the patients save the police, who are total
strangers. The second cause is the want of sufficient medical staff. I believe it
is absolutely necessary that an assistant should be appointed to every asylum,
and a representation on this subject, either from the Psychological or British
Medical Association, might do much good.
Dr. Isaac Ashe said he thought that Dr. Savage’s remarks on monotony as a
factor in the production of insanity were of much importance. He had lately
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Notes cmd News,
477
1884 .]
had a case that pointed to the view that this monotony might be that of physical
exertion on mechanical occupation as well as mental monotony. It was that of
a carpenter who had seemed to make a very good recovery until he was caused
to resume his usual occupation in the asylum, when immediately there was
another outburst of insanity of a severe and prolonged character. As regards
extravagance of expenditure, he almost thought that in acute mania it might be
regarded as the whole thing, and that excessive' change in the cerebral nerve-
cells might be due rather to change in the composition of the blood circulating,
or in the rate of its circulation through the organ, rather than to original
change of a nervous character. He thought that in general paralysis there was
ground for believing that the cerebral changes were an expansion in that one
direction of changes affecting the whole system, and characterized by the
removal of the basic salts, the calcic salts being abstracted from the osseous
system, the potassic from the muscular, and the sodic from the nervous, the
result being fatty degeneration in each case, the sclerotic degeneration of the
cord found after death being possibly of secondary character.
Later, on July 30th, papers were read by Dr. Norman Kerr, “ On Inebriety, a
Disease Allied to Insanity,” and by Dr. D. Hack Tuke, “ On Alcoholic Beverages
in British Asylums.”
The papers on Thursday, July 31st, were : “ The Care of Suicidal Patients,*’
by Dr. Yellowlees,* “Insanity Complicated with Asthma,” by Mr. Conolly
Norman.
On Friday, August 1st: “On Moral Insanity,** by Dr. D. Hack Take ;
“ Suggestions on the Treatment of Epileptic Dementia,” by Dr. Harkin.
Dr. S. Rees Philipps has been so kind as to supply notes of the discussions on
the above papers, but it seems useless to publish them until the papers them¬
selves have appeared.
At the conclusion of the business of the Section, a very hearty and unani¬
mous vote of thanks to Dr. Savage for his valuable services as President of the
Section was proposed by Dr. Yellowlees, seconded by Dr. Agar, and carried
by acclamation.
ANNIVERSARY MEETING OF “AFTER-CARE” ASSOCIATION, 1884.
The “After-Care” Association—whose meetings have been frequently re¬
corded by the “Journal of Mental Science”—held its anniversary on 3rd July
for 1884, at 83, Lancaster Gate, by kind permission of Lord and Lady Brabazon.
The Earl of Shaftesbury, President of the Association, occupied the chair, for
the fourth year in succession.
The minutes of the last meeting, and a review of the Society’s history during
the five years of its existence, were read by the Rev. H. Hawkins, Hon. Sec.
Dr. T. C. Shaw (the Hon. Treasurer) having made a statement about the funds
in hand, moved the following resolution :—‘‘ It is desirable to establish a Home
for the temporary reception of females who have left the county asylums cured.
Such Home to be under the charge of a resident matron, and subject to the con¬
trol of a Committee of 12 ladies, appointed by the General Committee, and to in¬
clude the Hon. Sec. and Treasurer.*’
Seconded by Reverend J. W. Horsley.
This resolution was, however, withdrawn, and a proposition by Dr. D. Hack
Tuke, seconded by Dr. James Adam, adopted—“To refer the matter of a Home
for the Committee to report upon at a general meeting called for the purpose.”
This meeting, it was agreed, should be held on the first Thursday in November.
Among other speakers were Dr. Bucknill—whose judgment was not in favour
of a special Home—Rev. F. H. A. Hawkins, and Mrs. Ellis Cameron, Hon*
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478
Notes and News,
[Oct.,
Secretary of the Ladies’ Committee, who has evinced mnch interest in the Asso¬
ciation, and who raised an earnest plea on behalf of the establishment of a
Home.
Thethanluof the meeting—among whom were Miss Twining, Miss Agnes
Cotton, Miss Fremantle, Lady Cotton, and others—were conveyed to Lord and
Lady Brabazon and to the Earl of Shaftesbury, who remarked that homes for
mental convalescents appeared to him to be a necessity; and, in acknow¬
ledging the thanks of the meeting, said that he had been for more than fifty
years (as Commissioner in Lunacy) connected with kindred work. Dr. Savage
having invited the After-Care Association to hold their anniversary for 1885
at Bethlem Hospital, the meeting separated.
THE REPATRIATION OF FOREIGN LUNATICS.
Copies of Dr. Mercier’s resolution on the above subject, brought forward and
carried at the May meeting of the Medico-Psychological Association, having
been sent by the Hon. Secretary to the Commissioners in Lunacy and other
authorities, the following replies (abridged) have been received
Office of Commissioners in Lunacy,
19, Whitehall fclace, 8.W.,
July 9th, 1884.
Bia,—I am requested by Lord Shaftesbury to acknowledge the receipt of your letter of the
3rd instant, with reference to a resolution of the Medico-Psychological Association, relating
to lunatics in asylums of nationality foreign to their own. Your letter was communicated
to the last Board, and the Commissioners in Lunacy directed me to say that they presume
that a copy of the resolution has been sent to the Home Office. They believe, however, that
the conclusion arrived at by the Government some years since is unaltered, viz., that it
would be inexpedient to institute any international scheme of “ repatriation ” of lunatics.
Iam, Sir,
Your obedient Servant,
Charles Bp. Perceval,
H. Bayner, Esq., M.D. Secretary.
Foreign Office,
July 29, 1884.
8nt,—I am directed by Earl Granville to inform you that your letter of the 3rd instant,
enclosing a resolution passed by the Medico-Psychological Association, respecting the re¬
patriation of pauper lunatics, was referred to the Lords Commissioners of the Treasury, who
state that they would not be averse to a reciprocal arrangement of the kind with foreign
Governments.
From past experience, however, their Lordships anticipate that there would be a great
difficulty in making any such general arrangement, and they are of opinion that it would
probably be impracticable to confine the arrangement to lunatics, and not to extend it to
all distressed foreigners.
I am, Sir,
Your most obedient humble servant,
H. Bayner, Esq., M.D., J. Paunckfote.
Middlesex Lunatio Asylum, Hanwell.
Local Government Board,
Whitehall, B.W.,
11th July, 1884.
Sir,—I am directed by the Local Government Board to acknowledge the receipt of your
letter of the 3rd instant, transmitting a copy of a resolution passed by the Medico-
Psychological Association, that it is desirable that arrangements should be made for the
transference of persons confined in lunatio asylums of nationality foreign to their own to
the country to which they belong.
I am directed to inquire whether the Association are in a position to furnish the Board
with any facts as to the number of English lunatics in asylums in foreign countries.
I am, Sir,
Your obedient servant,
0. N. Dalton,
To H. Bayner, Esq., M.D., Assistant Secretary.
Middlesex Lunatic Asylum, Hanwell, W.
Digitized by <^.ooQLe
1884 .]
Notes and News.
479
INDEX MEDICO-PSYCHOLOGICUS.
(Continued from page 178.)
Lunacy Law Reform (Another failure of). Joum. of Psych. Med., 1883, part
viii., page 187.
Lypemania. Unusual form of Epilepsy ; treatment by Prof. Ball’s method; re¬
covery. EncSphale, 1883, part iii., page 204.
Marriage in Neurotic Subjects. Dr. Savage. Joum. Ment Science, April, 1883,
page 49.
Medico-legal. On concussion of the spine, nervous shock, and other obscure
injuries of the nervous system, in their clinical and medico-legal aspects.
By John Eric Erichsen, F.R.S. Longmans, Green, and Co., London, 1882.
-A murderess of five children, from religious mania, etc. Dr.
Krafft-Ebing. Friederichs Blatt. f. Gerichtl. Med., Niimberg, 1883, xxxiv.,
155.
-Case of Diedrich Mahuken, the insane murderer of Diedrich Steffens.
Dr. Gray. Amer. Journ. of Neurol, and Psych., New York, 1883, ii., 505.
--Case of murder (Charles Stockley) ; plea, temporary insanity. Dr.
Andrews. Amer. Journ. of Insanity, Utica, New York, 1883, xl., 145.
-Sir James Stephen’s History of the Criminal Law of England (A Review
of). Journ. Ment. Science, July, 1883, page 258.
-The Factors of unsound mind and the plea of Insanity. By Dr. Guy,
F.R.S.
Melancholia Attonita (or Acute Dementia, pathology of). Journ. Ment.
Science, Oct., 1883, page 355.
- ■ (in Children). Dr. Kovalevski in St. Petersburg Med. Journ., 1883,
part xxii., page 17.
-On causes of. Dr. Bayles. New York Med. Joum., 1883, xxxviii., 171.
-with Dementia. De la Demence Melancolique, contribution a l’dtude de
la periencephalite chronique et a l’dtude des localisations cdrdbrales d’ordre
psychique. Dr. A. Mairet. Paris, ] 883.
Memory (Case of Acute loss of). Dr. G. H. Savage. Journ. Ment. Science,
April, 1883, page 85.
Mental Diseases (Clinical lectures on). By T. S. Clouston, M.D.Edin, Churchill
and Co., London, 1883.
Mental Disease (The medical and legal theories thereof in criminal cases).
Edin. Med. Journ., 1883, part xxviii., page 673.
Mental Symptoms (Precursors of Apoplexy). Dr. G. H. Savage. Journ. Ment.
Science, April, 1883, page 90.
Miliary Sclerosis. Dr. J. W. Plaxton, Joum. Ment. Science, April, 1883, page
27.
Moral Insanity (Commentary on cases of). Dr. Manley. Joum. Ment Science
Jan., 1883, page 531. 1
-What is it? Amer. Journ. of Insanity, 1882-3, part xxxix , page 334.
Medico-legal. Moral Insanity. Guiteau a case of alleged, a reply to Dr.
Spitzka. Dr. Elwell, Alienist and Neurologist, St. Louis, 1883, iv., 621.
-Guiteau. The mental status of Guiteau; a review. Dr. McBride,
Alienistand Neurologist, St. Louis, 1883, iv., 543.
Moral Insanity, Case of. Dr. Goldsmith. Amer. Joum. of Insanity Utica. New
York, 1883, xl., 162. .
“ Monasterio ” Case. Joum. Ment. Soienoe, July, 1883, page 253.
Digitized by viooQle
480
Notes and News.
[Oct.,
Moral Insanity, The Germs of, in Children (I germi della pazia morale nei
fanciulli). Drs. Marro e Lombroso. Archiv. de Psychiat., etc., Torino.
1883, iv., 7.
Morphia Craving. Die Morphiumsucht und ihre Behandlung. Dr. Erlenmeyer.
2 Auflage, Neuwied, 1883, 8o., 3m„ 60.
-De la Morph6omanie. By Dr. Zambaco. Paris, 1883, 91 pages, 8o.
-(Die Morphiumsucht und ihre Behandlung, etc.). Dr. Erlenmeyer.
Neuwied, 1883, 8o., 2 mark.
Murder (during temporary Insanity due to Drink or Epilepsy). Dr. D. Yellow-
lees. Joum. Ment. Science, Oct, 1883, p. 382.
Netherlands, System for Insane in the. Dr. Piper, in Amer Journ. Psych.,
Phi lad., 1883, i., 60.
Nervous Families (Ueber nervose Familien). Dr. Mobius. Allg. Zeitschr. f.
Psychiatrie, Berlin, 1883, x., 342.
Nervous System, Treatise on the diseases of. Dr. Boss. 2nd ed., 2 v., London,
1883, 8o., 52s. 6d.
Nitro-Glycerine, The chemical nature and physiological action of. Dr. Hay,
Practitioner, London, 1883, xxx., 422.
Onanism. De l’onanisme, causes, dangers, et inconvenient* pour les individus,
la famille et la soci6t£; rem&des, 3e. ed. Paris, 1883, 18o. Dr. H.
Fournier.
Patients* surroundings (importance of investigating). Dr. Samuel Wilks.
Journ. Ment. Science, Jan., 1883, page 549.
Periodical Insanity. Ueber die Gesetze des periodischen Irreseins und ver-
wandter Nervenzustande. By Dr. Koster. Bonn, 1882.
Permanent Baths, on the use of, in the gangrenous bed-sores of General Para¬
lytics. Allg. Zeitschr. f. Psychiatrie, xxxix., 6 Hft.
Phthisical Insanity (three cases of). Mr. A. Campbell Clark. Journ. Ment.
Science, Oct., 1883, page 391.
Posture of Hand, as indication of condition of Brain. Dr. Warner, in Brain,
1883, xxiii., page 342.
Post-Febrile Insanity. Zur Casuistik der Psychosen im gefolge febriler
Erkrankungen. Dr. Kirn in Allg. Zeitschr. fur Psychiatrie, 1883, part
xxxix., page 739.
Prevention of Insanity after Cranial Injury. Dr. W. J. Mickle, in Amer.
Psych. Journ., Philad., 1883, i., 46.
Presidential Address (Annual). Dr. W. Orange. Journ. Ment. Science, Oct.,
1883, page 329.
Prevention of Insanity in nervous and hysterical women. Amer. Joum. of
Psych., Philadelph., 1883, i., 24.
Private Asylum. A Neapolitan. Dr. Nicholson, in Lancet, 1883, i., 704.
Production of Insanity, On some of the conditions of life which influence the.
Dr. Chas. Mercier, in Amer. Psych. Journ., Philad., 1883, i., 28.
-Do perversions of assimilation play any part in ? Dr. Fothergill, in
Amer Psych. Journ., Philadelphia, 1883, i., 48.
Prolonged Baths, in the treatment of the Insane. Des Bains prolong^* chez les
Alienes. Dr. Millet. Encephale, 1883, iii., 287.
Prognosis (In cases of refusal of food). Dr. Sutherland. Journ. Ment. Science,
July, 1883, page 178.
—-(in Insanity). Dr. D. G. Thomson. Journ. Ment. Science, July, 1883,
page 188.
Progressive meningo-cerebritis of the insane. Dr. Deecke. Amer. Journ. of
Insanity, Utica, New York, 1883, xxxix., 391.
Psychical Conditions in young chi'dren. Dr. Cohn. Archiv. fur Kinderheil-
kunde, Stuttgart, 1882, Yol. iv., page 28.
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Notes and News .
481
1884 .]
Psychiatry in Russia, history of. Archives de Psychiatric, etc., Charkov, 1883,
i., 203 (in Russian).
Punishment of the Insane. Editors Journ. Ment. Science, April, 1883, page 93.
Pupil, The, in emotional states. Dr. Wilks, F.R.S., in Brain, 1883, xxi.,
page 1.
Recoveries (slow, in Insanity). Dr. Luys. EncSphale, 1883, iii., 266.
Religious excitement, epidemic. Brit. Med. Journ., Lond., 1883, ii., 343.
Report of Annual Meeting of German alienist physicians at Eisenach in 1882,
Sept. 16th. Allg. Zschrift fur Psychiatrie, 1883, part xxxix., page 607.
Restraint (Philosophy of). Dr. Cameron. Journ. Ment. Science, Jan. 1883, page
619.
Rousseau. Etude sur l'etat mental de J. J. Rousseau et sa mort a Ermenou-
ville. By Dr. Bongeault. Paris, 1883.
Saturnine Lunacy. Dr. Goodhart. Guy’s Hospital Reports, London, 1883,
xxvi., 177.
Cerebral Sclerosis. Sur un cas de cirrhose atrophique granuleuse diss£min4e des
circonvolutions c6r6brales, note pour servir a Thistoire de la sclerose du
cerveau chez les Ali&i4s. Dr. Pozzi, in l’Enc4phale, 1883, part iii., page
155.
Solerosis of the Central Nervous System, etc. Ueber Sklerose des Central-
nervensystems und ueber fleckweise glasige Entartung der Himrinde. Dr.
Greiff. Archiv. f. Psychiatrie, Berlin, 1883, xiv., 286.
Sclerosis. Weiterer Beitrag zur herdweisen sklerose des Centralnervensystems.
Dr. Chvostek. Allg. Wein Med. Zeitung, 1883, xxviii., 369.
Multiple Sclerosis. Dr. Friedman, in Jahrbuch fur Psychiatrie, Wien, 1883,
iv., 69.
Self .mutilation (Cases of, in the Insane). Dr. James Adam. Journ. Ment.
Science, July, 1883, page 213.
Senile Insanity. T. S. Clouston, in Edinburgh Med. Journ., 1882-83, xxviii;,
1067.
-Dr. Geo. H. Savage. Journ. Ment. Science, July, 1883, page 231.
Simulation of Insanity by the Insane. Dr. Hughes, Alienist and Neurol., St.
Louis, 1883, iv., 355.
Signs of Recovery in the Insane, their value (Essai sur la valeur des signes de
la gufcrison chez les Alienas). Dr. Guillemin, Paris, 1883, 57p., 4to.
Sunstroke (Epidemic of, in Cincinnati during the summer of 1881). American
Health Association Reports, Boston, 1883, part vii., page 293.
Suicide. Journal Psych. Med., 1883, part viii., page 82.
Syphilitic Gumma of Brain (case of). Dr. Nelson, in Alienist and Neurologist,
1883, part iv., page 190.
■-Disease of the Cerebral Arteries, etc. Dr. Bristowe. Lancet, 1883,
ii., 1.
—-Gummata of Brain. Asylum Journal, Berbice, British Guiana, 1883,52.
Syphilis (case of delirium) produced by cerebral. l’Enc^phale, 1883, part iii.,
page 103.
—■ The influence of hereditary Syphilis in the production of Idiocy and
Dementia. Dr. Bury, in Brain, 1883, xxi., 44.
Treatment of Insanity, four years of, at Garlands Asylum. Dr. Campbell,
Lancet, 1883, i., 497.
Trial by Jury as a means of ascertaining the mental state of alleged lunatics,
and as a pre-requisite to the seclusion of lunatics. New York Med. Record,
1883, part xxiii., page 400.
Tumour, tubercular encephalic, with epileptic convulsions, recovery after 16
years. Dr. Luys. EncSphale, Paris, 1883, iii., 517.
xzz. 32
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482
J Votes and News .
Tubercular Meningitis in Insane Adults. Dr. Julius Mickle. Journ. Ment.
Science, July, 1883, page 219.
Twins (Melancholia in). Dr. Geo. Savage. Journ. Ment Science, Jan. 1883, p.
539.
-(Mania in). Mr. Clifford Gill. Journ. Ment. Science, Jan., 1883, page
540.
-(Imbecility in). A. F. Mickle, M.B. Journ. Ment Science, Oct, 1883,
page 400.
Variola and Insanity. Dr. Kiera&n. Amer. Journ. of Neurol, and Psychiatry,
New York, 1883, ii., 365.
Vioe (hereditary and pathological aspect pf). Dr. Lydston. Chicago Med.
Journ. and Examiner, 1883, part xlvi., page 131.
Appointments .
Batten, Gsorgk B., M.B,, C.M.Edin., appointed Assistant Medical Officer,
Fife and Kinross District Asylum.
Beatley, W. Crump, M. D. Durh., M.B.C.S. appointed Senior Assistant
Medical Officer, Somerset and Bath Lunatic Asylum, Wells.
Durrus, George, M.B., C.M. Aberd., appointed Assistant Medical Officer to
the Cheshire County Lunatic Asylum, Macclesfield.
Greenlees, J. Duncan, M.B., C.M. Edin., appointed Junior Assistant Medical
Officer, Cumberland and Westmorland Asylum, Garlands, Carlisle.
Lopthousx, Arthur, M.B.C.S. and L.8.A., appointed Assistant Medical
Officer to the County Lunatic Asylum, Snenton, Nottingham.
Robkrt8on, Alex., M.D., of the City Parochial Asylum, Glasgow, has been
elected Physician to the Glasgow Royal Infirmary.
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THE JOURNAL OF MENTAL SCIENCE.
[Publishedhy Authority of the Medico-Psychological Association]
No. 132. JANUARY, 1885. Yol. XXX.
PART 1-ORIGINAL ARTICLES.
Practical Remarks on the Use of Electricity in Mental Disease.
By A. de Watteville, M.A., M.D., B.Sc., Physician to the
Electro-therapeutical Department, St. Mary's Hospital,
London.
“ II n’y a point de parit6 entre la responsabilit^ d’un rruSdecin et son
pouvoir ; l’nne est grande et l’antre petit, et c*est jnstement k cause des
limites oil ce pouvoir est resserrd que, bien qu’il soit facile d’ en laisser
perdre une parcelle, la moindre parcelle perdue cause une poignante
anxi&td.”
LlTTRfi.
The application of electricity to the treatment of insanity is,
I am happy to observe, beginning to occupy the attention of
alienists in this country. From the perusal of some papers
recently published,* and letters of inquiry received on the sub¬
ject, I gather that many of those anxious to test the efficacy of
the current in certain forms of mental disturbance are some¬
what in the dark as to the instrument required for, and the
manipulations required in, the rational application of the agent.
I propose here to give a short outline of the principles which
ought to guide the physician, and a few hints as to the best
way of putting the theory into practice.
First, let us consider the question of instruments. In treat¬
ing insanity our main object is to improve the circulation and
nutrition of the brain, and this we may endeavour to effect
either by the direct permeation of that organ by currents, or
through a reflex influence exerted by certain excitations of the
peripheral nerves. In order to secure an effectual permeation
* See Dr. Newth’s paper in the last number of this Journal.—[E ds.]
xxx. 33
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484 The Use of Electricity in Mental Disease , [Jan.,
of deep organs we must have resort to the Galvanic (or con¬
stant) current.
The first point to be taken into account is the average
strength of current required, in other words the number of
cells needed. Experience has shown that six to fifteen cells of
sufficient electromotive force are the number usually required.
But it will be convenient to have thirty at hand. Then, again,
the applications are to be made to the head; this necessitates
a contrivance for regulating the strength of the current with the
utmost precision and smoothness. Thirdly, it is convenient to
be able to reverse the polarity of the electrodes without re¬
moving them from the body or battery. A commutator has
to be provided. Finally, the strength of the current used has
to be noted ; such a measurement is effected by means of a
galvanometer.—The thirty cells must be small if portability is
a necessary condition to be fulfilled by the battery. The size
of the cells has no perceptible influence on the strength of the
current obtainable from them through such a high resistance
as that of a portion of the human body; but it is to be remem¬
bered that small cells are less durable, more liable to accidental
fluctuations than big ones. Whenever, therefore, patients can
be made to go to the battery the latter had better be made up
of good-sized Leclanch6s, which, if well made and put together,
will work for several years without recharging or any further
trouble.—There are two kinds of portable cells to be re¬
commended—first, the small Leclanches (those I have obtained
of Mr. Schoth, of 232, Euston Road, have given me most
satisfaction); second, the sulphate of mercury elements (made
by Mr. Thistleton, 1, Old Quebec Street, W.). The advantage
of the first is that they require no attention until exhausted—
an event which depends upon the care taken in carrying the
battery about, and the amount of work done with it. The
average duration of a small Leclanche is eighteen months,
when (and this is the drawback of their kind) it must be
returned to the maker for recharge. The advantages of
the new sulphate of mercury cell are that the owner of the
battery may keep it going himself; the drawbacks being that it
requires some amount of nursing—far less, however, than the
clumsy, antiquated Stohrer's acid element, which is further ex¬
posed to the dangers of being easily spilt.
A collector is a contrivance by which any given number of
cells may be thrown into action; it affords us the means of re¬
gulating the strength of the current. The collector is usually
Digitized by Google
1885.]
by A. de Watteville, M.D.
485
made in the shape of a dial. A circle of metallic studs, num¬
bered and connected with the successive cells in the battery,
surrounds a central pivot on which revolves a switch, the peri¬
pheral extremity of which comes successively in contact with
each of the series of studs. It is important, as I have already
observed, for cephalic electrisation that the current should be
gradually increased and diminished, for otherwise, in the case
of nervous patients especially, the vertigo and phosphenes
produced by the sudden shocks accompanying sudden changes
in the current-strengths, are a source, if not of positive danger,
at least of more or less serious discomfort. It is therefore
advisable to have as many studs in the dial as there are cells
in the battery, so as to proceed by increments of one cell only
in bringing the current up to its required strength, and vice
versa to diminish it by one cell at a time in reducing its strength
before the removal of the electrodes from the body.
Of the Commutator and Galvanometer I shall say little here.
The former is a simple instrument which will be found attached
to every complete battery. With reference to the latter I have
strongly advocated its use for - many years, with a modifi¬
cation (graduation in milliamperes, or units of absolute current
strength) which makes of it a truly measuring instrument. My
arguments will be found elsewhere * by the reader interested in
the rational application of electricity to medicine; I need only
add here that since the late International Congress of Elec¬
tricians in Paris the milliampere has generally been adopted by
electro-therapeutists, and graduated galvanometers may be ob¬
tained from most Continental makers, and in this country from
Thistleton, whose name has already been mentioned in the
course of these remarks.
Of the electrodes required two should be made in the shape
of well padded plates of flexible metal, by 5 inches in size,
which adapt themselves accurately to the shape of the part of
the body to which the current has to be applied. A third
should consist of a carbon disk, 3 inches in diameter, also
padded, fixed to the extremity of a strong wooden handle.
The padding consists of a good thickness of wash-leather,
with or without a layer of sponge. When the patient's
skin is a bad conductor—a fact shown by the galvanometer—
the electrodes are to be well moistened with warm salt-and-
water; otherwise plain water is sufficient.—With reference to
* “ A Practical Introduction to Medical Electricity ” 2nd Edition, page 28.
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486
The Use of 'Electricity in Mental Disease , [Jan.,
faradic (or induction) apparatus, I need not describe here the
various models now in use. Any well-made instrument of
sufficient size and power will fulfil the special requirements of
the alienist.* The battery should consist of a couple of
Leclanche, or chloride of silver, cells, f Sulphate of mercury
cells are convenient only when the apparatus has to be used at
intervals, as they require a small fresh charging on each
occasion. The secondary coil should be made of wire suffi¬
ciently long and fine to give a good spark when its current is
applied to the skin with a metallic conductor; the primary coil
should yield an extra-current sufficiently powerful to produce
good muscular contractions when applied through the large
electrodes already described. A wire brush is required for
the faradisation of the skin.—I now pass to the modus
operandi. It would be impossible within the limits of this
article to describe in detail the operations required for the
successful application of the current. I have done this in the
manual already referred to, and the reader anxious to fami¬
liarise himself with them will require not only to read the
rules, but to practise them faithfully, remembering that it is
not " Electricity *' which cures, but “ Electrisation ”—a process
requiring far more technical skill than the uninitiated generally
believe. I shall content myself here with giving some general
directions based upon the rationale of electrisation in the treat¬
ment of mental disturbances. The chief indications which
govern our applications here obviously are :
1. To promote the equilibrium of the cerebral innervation
by acting directly on the nutrition of those centres which are
deficient functionally or organically, through molecular, vaso¬
motor, or other influences. Experience shows we can do this,
in some cases, by direct galvanisation of the head and neck.
2. To rouse up the peripheral and spinal innervation, and
to indirectly restore their necessary equilibrium by supplying a
deficiency in the afferent influxes upon which it partly de¬
pends. Here galvanisation of the spine, and general faradisa¬
tion (with the moist electrode or wire brush according to the
requirements of the case) will be of service.
3. When the cerebral troubles are connected with some
* With reference to the cost, I may say that eight pounds for a complete
galvanic battery of forty cells, and two for a good induction apparatus ought to
be sufficient. For details the reader is referred to the catalogues of the makers
already named.
f Schoth’s iteiypattern. Gaiffe’s are not to be recommended.
Digitized by
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487
1885.] by A. de Watteville, MJD.
disturbance of the abdominal or pelvic viscera (visceral
paraesthesise, torpidity, and the like), to correct or mitigate
the latter by the application of either current, or better still,
by the method I have described under the name of galvano-
faradisation.* The value of electricity in visceral neuroses is
very great, though hitherto unrecognised.
4. To relieve certain symptoms as they arise according to
the rules laid down in the usual treatises. It must not be for¬
gotten, for instance, that general faradisation is a good tonic
and excitant of general nutrition. In some cases, again,
appropriate electrisation acts as a promoter of sleep.
Such are, stated in general terms, the principles which ought
to guide the physician in the electro-therapeutics of mental
disorders.f It will have been observed that in this article I
have not made any allusion to the direction of the currents
through the body, or what comes to much the same thing, to
the relative position of the anode and kathode (positive and nega¬
tive pole) on the body. My reason for departing from these
time-honoured traditions is this. All the rules given by the ad¬
herents of the “directional 9} and the “ polar ” school of electro¬
therapeutists are based on physical errors or on aprioristic con¬
siderations ; experience has not confirmed the former; advance
of knowledge has ruined the basis of the latter. If there ever
appears to be a therapeutical difference between the action of
the two poles, it has to be established and defined empirically,
for it rests on some idiosyncrasy of the particular patient under
observation. The doctrine of electrotonus J has no place in
treatment. We may state as a general rule that the best results
are obtained by using both poles successively to each point of
application, remembering only that the kathode has a greater
local action, both chemical and stimulant.—I refrain from
* “ A Practical Introduction to Medical Electricity,” pp. 161 and 190.
f The psychical effects of electrisation should be remembered, and may, in
the hands of a judicious experimenter, be turned to good use in appropriate
cases.
t The conditions under which electro-physiological phenomena are observed
in the laboratory render them inapplicable to the explanation of phenomena ob¬
served in the living human body. Here what is above all required is a thorough
mastery of the questions connected with the resistance of the tissues, and the
diffusion of the current in them. Electro-physics, not electro-physiology, must
for the time being form the basis of electro-therapeutics ; much remains to be
done before it can be otherwise. (Cf. loc. dt. f chapter ii, and the paper by Waller
and myself on the effects of the galvanic current on the motor nerves of man,
in the “ Philosophical Transactions of the Royal Society ” for 1882.)
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488
The Use of Electricity in Mental Disease. [Jan.,
committing myself to any positive statements concerning the
forms of mental derangement in which electrisation is most
likely to prove successful. It has not yet been tried on a
sufficiently wide scale to furnish us with the data necessary for
such generalisations. States of depressed nerve-action seem,
however, to have hitherto yielded most successes. Certain
sensory parmsthesi© hallucinations have likewise been stated
to be amenable to appropriate galvanisation. Symptoms of
excitement indicate that the utmost prudence is required in, if
they do not forbid, the application of galvanic treatment. But it
is obviously among those who are still hovering on “ the
borderlands of insanity,” rather than among those who have
for years passed the limits and have become confirmed inmates
of our asylums, that the most fruitful field for electro-therapeutic
activity will be found. An interesting field, too, the very
paucity of implements for whose cultivation, should make the
physician loth of allowing a single one, however humble, to
escape him; a field the fruits of which—human reasons re¬
claimed—even if scanty in number are sufficiently valuable to
stimulate us to the utmost efforts. It was with this thought
in my mind that I ventured to offer these remarks to the
readers of the Journal; for, as Littr6 so truly remarks, if the
responsibility of the physician is great, his power is limited;
whilst the narrower these limits, the more sacred is his duty to
explore every inch of ground within the fatal precinct.
Clinical Observations on the Blood of the Insane . By S.
Butherfobd Macphail, M.D.Edin., Assist. Med. Supt.,
Garlands Asylum, Carlisle; being the Essay to which the
prize of £10 10s., together with the bronze medal of the
Association, was awarded in 1884.
(Concluded from p. 389.)
in.
While the condition of the blood vessels in General Paralysis
has been a subject of discussion by many observers, and the
state of the pulse, including sphygmographic tracings, has en¬
gaged the attention of Thompson* and others, I have been
* Vfest Riding Reports, Vol. i.
Digitized by Google
1885.] Clinical Observations on the Blood of the Insane . 489
unable, in the literature to which I have had access, to find
reference to any observations on the state of the blood in this
disease.
With the object of ascertaining the condition of the blood in
General Paralysis, I selected five typical examples of male
general paralytics at three different stages of the disease, and
examined their blood. The three periods selected were (1) on
admission, (2) in the demented and lethargic condition, and (3)
in the bedridden and completely paralysed stage. The results
are given in tabular form (C).
0. Tables showing the Quality of the Blood in Male General
Paralytics at three different stages of the disease.
I. Five General Paralytics on Admission.
No.
Age.
Probable Duration
of
Disease.
Percentage
of
Haemoglobin.
Percentage
of
Haemacytes.
Proportion of
White to
Bed Corpuscles.
mm
40
6 mos.
68
89*3
1 to 380
86
13 mos.
63
88*1
1 to 350
8
33
9 mos.
66
88*4.
1 to 360
mm
45
3 mos.
70
90*3
1 to 310
■1
48
4 mos.
65
87*6
1 to 340
Averages
40*3
6*8 mos.
66*3
88*7
1 to 308
II. Five General Paralytics over Six Months after
Admission.
No.
Age.
Period
of
Residence.
Percentage
of
Haemoglobin.
Percentage
of
Haemacytes.
Proportion of
White to
Bed Corpuscles.
—
33
Over 3 years
75
89*9
1 to 350
B
54
„ 9 mos.
65
87*6
1 to 130
B
67
„ 1 year
73
85*3
1 to 180
B
53
»> 1 year
70
84*4
1 to 180
5
38
„ 9 mos.
68
85*3
1 to 140
Averages
48*6
Over 15 mos.
70
86*5
1 to 176
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490 Clinical Observations on the Blood of the Insane , [Jan.,
m. Five General Paralytics in List Stage, Bedridden
and Paralysed.
No.
Age.
Period
of
Boaidenoe.
Percentage
of
Haemoglobin.
Percentage
of
Haemacytes.
Proportion of
White to
Bed Corpuscles.
1
40
Over 18 moa.
68
77*6
1 to 140
3
61
„ 16 mos.
64
81*1
1 to 140
f •
43
„ 8 moa.
66
68*9
1 to 110
n
60
» 6 moa.
66
83*6
1 to 130
H
46
„ 0 moa.
60
80*4
1 to 110
Averages
47*4
Over 11 moa.
60*6
78*1
1 to 134
From an analysis of the first of these tables we find that the
average percentage of haemoglobin is 30 per cent, below the
normal standard, and that in individual cases, with one excep¬
tion (No. 5), the longer the probable duration of the disease the
lower is the percentage. The percentage of haemacytes is also
diminished, though to a less extent; and as in the case of the
haemoglobin, with one exception (No. 5), this decrease is coin¬
cident with the duration of the disease. The proportion of
white to red corpuscles is increased, but this increase does not
appear to vary in the same ratio as the haemoglobin and haema¬
cytes with the duration of the disease.
The second table is composed of patients in the quiescent
stage of the disease, who have resided in the asylum for an
average of over fifteen months. The most noteworthy features in
this series are an increase in the percentage of haemoglobin and
in the proportion of white to red corpuscles, and a decrease in
the percentage of haemacytes. An interesting point in this
table is that, contrary to what one might expect from the pre¬
ceding table, the percentage of haemoglobin is higher, and the
proportion of white to red corpuscles is lower in relation to the
length of residence of the individual patients. There is also a
similar increase in the relative proportion of haemacytes, but
there are two exceptions (Nos. 2 and 4) to this. The average
percentage of haemoglobin is higher, and the average per¬
centage of haemacytes is lower, than in the case of ordinary
demented patients at the same age.
The thinl group is selected from advanced cases of paresis.
In two instances (Nos. 1 and 3) the patients died on the day
succeeding the observations, and in both these cases the per¬
centages of haemoglobin and of haemacytes are very low. In
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491
1885.] by S. Butherfobd Macphail, M.D.
all the five cases the relative proportions of hemoglobin and
haemacytes are much below the percentages in either of the
preceding groups. The proportion of white to red corpuscles
is much increased.
In the last group the blood in each instance was dark, venous
in character, and drawn with difficulty from the finger. In the
haemacytometric observations the individual corpuscles were so
irregular in outline and deformed that it was deemed advisable
to examine the blood on a slide in the ordinary way. The
white corpuscles were much increased; there was little tendency
of the red corpuscles to form rouleaux; in all the cases the
individual corpuscles were crenated; in two they were irregular
in outline, and in one observation many of the corpuscles were
tailed or had processes. In two cases in the second group the
blood contained a large number of corpuscles of small size; in
two the larger proportion of the corpuscles were crenated; and
in one their outlines were irregular. In both the first and second
groups the blood was darker than normal. Small granule cells
were observed in four instances in the first series, twice in the
second, and not at all in the last series.
These observations may be summarised thus :—
(1) The percentage of haemoglobin is low on admission, it
improves in the quiescent stage of the disease, and falls again
in the paralytic stage.
(2) The red corpuscles deteriorate both in quality and quan¬
tity coincident with the progress of the disease.
(3) Small granule cells are not present in the blood during
the last stage.
(4) The relative proportion of white to red corpuscles is in¬
creased, and this increase is coincident with the progress of the
disease.
Defective nutrition of the body, including anaemia, has long
been recognised as a predisposing cause of epilepsy. In idio¬
pathic epilepsy no constant anatomical lesion has been dis¬
covered, and it may therefore be inferred that the lesion is a
molecular one. According to Nothnagel’s theory, continued
excitation of the vaso-motor centre is the necessary pathological
condition of the epileptic paroxysm. In other words, he
believes that irritation of the vaso-motor centre causes contrac¬
tion of all the arteries of the body, including those of the
brain; and that the anaemia caused by the contraction of the
vessels of the brain is the active factor in producing epilepsy.
He has not, however, so far as I am aware, supplemented this
theory by recording a series of observations on the blood of
epileptics.
Digitized by Google
492 Clinical Observations on the Blood of the Insane , [Jan.,
In this asylum all the male epileptic patients, with three ex¬
ceptions, have, as part of their routine treatment, continuous
doses of Bromide of Potassium (grs. xxx thrice daily), and many
of the patients have had this treatment with occasional inter¬
mission for a number of years.
With the object of determining whether the blood is deterior¬
ated in patients suffering from epilepsy, as NothnagePs theory
suggests, I have examined the blood in a series of epileptics.
As all the patients were being treated with continuous doses of
Bromide oi Potassium, I have taken as the bases of my obser¬
vations the length of time this treatment had been carried on.
D. Tables showing Condition of the Blood in Male Epileptic
Patients treated with 90 grain doses daily of Bromide of
Potassium for different periods.
I. Five Epileptic Patients on Admission.
No.
Age.
Percentages
of
Hemoglobin.
Percentage
of
Hemacytes.
Proportion of
White to
Bed Oorpusoles.
1
46
65
87*9
1 to 320
a
20
68
82*4
1 to 350
88
68
82*9
1 to 220
as
60
76*9
1 to 200
Bfl
27
62
81*3
1 to 410
Averages
81'2
64*6
82*28
1 to 300
II. Five Patients who have taken Bromide of Potassium con¬
tinuously FOR MORE THAN TWO AND LESS THAN FlVE YEARS.
No.
Age„
Percentage
of
Hemoglobin.
Percentage
of
Hemacytes.
Proportion of
White to
Bed Corpuscles.
1
29
68
88*6
1 to 360
2
27
70
92*7
1 to 220
3
29
72
93*8
1 to 190
4
34
72
88*2
1 to 380
5
22
76
89*4
I to 400
Averages
28*2
71*4
90*62
1 to 308
Digitized by Google
493
1885.] by S. Rutherford Macphail, M.D.
III. Five Patients who have taken Bromide of Potassium con¬
tinuously FOR MORE THAN Two AND LESS THAN FlYE YEARS.
No.
Age.
Percentage
of
Haemoglobin.
Percentage
of
Haemaoytes.
Proportion of
White to
Bed Corpuscles.
mm
23
75
87*9
1 to 500
1
44
60
85*4
1 to 380
■
33
74
89-2
1 to 380
33
75
90*8
1 to 310
H
31
80
93*2
1 to 240
Averages
32*8
72*8
69*3
1 to 362
IY. Five Patients who have taken Bromide of Potassium con¬
tinuously FOR MORE THAN Ten AND LESS THAN FIFTEEN YEARS.
No.
Age.
Percentage
of
Haemoglobin.
Percentage
of
Haemacytes.
Proportion of
white to
Bed Corpuscles.
■■
36
60
85*3
1 to 400
33
75
96*3
1 to 340
3
49
70
90*1
1 to 360
4
32
80
93*2
1 to 360
5
35
72
89*6
1 to 340
Averages
37
71*4
90*9
1 to 360
Y. Five Patients who have taken Bromide of Potassium con¬
tinuously for over Fifteen Years.
No.
Age.
Percentage
of
Haemoglobin.
Percentage
of
Haemacytes.
Proportion of
White to
Bed Corpuscles.
Bj
53
70
89*6
1 to 440
41
70
86*2
1 to 480
32
60
85*7
1 to 560
53
75
90*6
1 to 380
5
66
65
90*7
1 to 220
Averages
49
68
88*56
1 to 416
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494 Clinical Observation* on the Blood of the Insane, [Jan.,
Clonston * states that patients gain in health and weight
while taking average doses of Bromide of Potassium, and his
observations are corroborated by Hughes Bennett f in a recent
paper on the prolonged administration of the Bromides in
Epilepsy.
Analysing the tables (D) we find:—(1) As to hmmoglobin,
that on admission the average percentage is considerably below
the normal standard; that the blood improves in this respect
during the first 10 years of treatment, after which there is a
slight decrease; and that the percentage of haemoglobin
in eplileptic dements is slightly higher than in ordinary
dements at the same age. (2) That the average amount of
haemacytes in the blood of Epileptic patients when admitted is
almost 20 per cent, below the normal standard; that with
slight fluctuations the blood improves during the next 15 years,
after which there is a slight deterioration; and that the per¬
centage of haemacytes is a fraction higher in epileptics than in
dements at the same age. (3) That the proportion of white to
red corpuscles diminishes in ratio to the period of residence.
(4) That the quality of the blood improves during treatment
with bromide of potassium, and that the prolonged use of the
drug exercises no deteriorating influence in decreasing the per¬
centages of haemoglobin and of haemacytes.
There was considerable variation in the size of the individual
corpuscles. In two instances more than one-fourth of the
haemacytes were of large size. These cases were Nos. 1 and
2 in Table III., and probably this fact influenced the average
percentage in this group; for, as I have already stated, the
larger the individual corpuscles, the fewer can be counted in
the square of the haemacytometer. In Nos. 2 and 4 in Table
IV. the larger proportion of the corpuscles were small in size,
and this, of course, would affect the general average in the
opposite direction. In several other instances the blood-cells
were of varying size, but not to such a marked extent as in
any way to affect the results. Crenated corpuscles were
observed in about half the cases, and cells with irregular out¬
lines were occasionally met with. Small spherical bodies were
noticed in a large proportion of the cases, especially in the first
three groups.
In order to ascertain what variations occur in the blood
of patients subject to periodic attacks of excitement, I selected
* “ Journal of Mental Science,” Oct., 1868.
f “ Lancet,” 1884, Yol. i, page 883i
Digitized by Google
495
1885.] by S. Kutherfobd Macphail, M.D.
six female patients of this class and made a series of observa¬
tions on their blood. The number of observations was 68.
As it is difficult to represent the results in a tabular form
without taking up more space than the limits of a short paper
will allow, I shall not attempt to do more than summarise the
series of observations as briefly as possible.
In two instances the observations represent a period of one
year. Twenty-three observations in the case of one, and 20 in
that of another patient. In other two the observations were
taken over a period of nine months, eight in one case, seven
in another. In the two remaining cases five observations were
made on each, within a period of six months. The ages of the
patients varied from 18 to 44 years, and with one exception
they had resided in the asylum for over a year. The observa¬
tions were made on each patient in all the various stages of the
attacks of excitement, and also in the intervals between the
attacks when the patient was either in a quiescent, partly
demented condition, or on the other hand was to all appear¬
ance in a normal mental state.
In- the two patients in whom the observations were continued
periodically for a year each passed through seven attacks of
excitement, varying in duration from 80 hours to two months.
In the cases where the observations represent a period of nine
months' duration, and in one of those during a period of six
months, there were three attacks of excitement in each. In
the remaining case there were two outbursts of maniacal excite¬
ment. Of these six individuals two have been discharged
recovered, one has drifted into dementia, and three continue to
have periodic attacks of excitement.
The weights of the patients were taken periodically. Con¬
siderable variation occurred in each instance. One patient
lost 121bs. in one month during a prolonged attack of excite¬
ment, while another gained 81bs. in three weeks of freedom
from excitement between two attacks. Short periods of
excitement had little effect in altering the weight, but when a
maniacal outburst lasted over a fortnight there was usually a
sensible diminution in weight. The two cases which recovered
were those which showed the least depreciation in weight even
during the periods of excitement, and were likewise those in
which the greatest gain in weight took place.
The percentage amount of haemoglobin varied from 56 to 80.
The lowest percentage occurred during the fifth week of an
attack of excitement, the highest was registered when the
patient had kept free of excitement for 28 days, and two days
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496 Clinical Observations on the Blood of the Insane , [Jan.,
before the commencement of another maniacal outburst. The
greatest variation in an individual case was from 58 per cent,
to 80 per cent. In the earlier period of the attacks of excite¬
ment the hemoglobin in many instances did not diminish in
quantity, and in two instances the patient passed through an
attack of excitement of a week’s duration, leaving the percen¬
tage of hemoglobin higher at the end of the attack than it was at
the commencement. This, however, was exceptional, and in 14
of the 25 attacks of excitement represented by these six
individuals, the amount of haemoglobin diminished during the
attack; in the remaining nine attacks no change in the per¬
centage of haemoglobin was recorded. With a few trivial
fluctuations, the decrease in the percentage of haemoglobin
progressed in apparent ratio with the length and severity of the
attack of excitement.
The lowest percentage of haemacytes recorded was 79*7, and
the occasion was the 13th day of an acute attack of excitement
which rapidly followed a similar attack lasting one month.
The highest percentage (93*6) occurred in the same patient
during convalescence from a third attack of excitement. This
patient had no further relapse, and has since been discharged
recovered.
The greatest fluctuation in the amount of haemacytes in the
three cases which remain in statu quo is also worthy of remark.
In one case the highest percentage (9 T8) was registered on
the seventh day, after an attack of excitement had passed off;
the lowest (81*3) on the 19th day of an acute maniacal attack.
In the second case the highest percentage (88*7) occurred on
the second day of an acute attack of excitement, the patient
having been quiet for three weeks • previously, the longest
period of freedom from excitement during the year; the lowest
percentage (80*7) on the third day after settling down from an
attack of excitement which had lasted two months. In the
third case the highest percentage was 89*6, and the lowest
84*5; the one occurred during a period of freedom from excite¬
ment, the other during a prolonged maniacal seizure.
In the 68 observations with the hsemacytometer 30 were
taken when the patients were free of excitement, 38 while they
were in an excited state. The average of the first observations
was 87*8, that of the second series 84*8 per cent. Thus we
see that, taking the cases in bulk, there was a decrease of three
per cent, in the observations made while the patients were ex¬
cited. Though there are a few exceptions, this fact is brought
out in an examination of the individual cases and of the
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497
1885.] by S. Rutherford Macphail, M.D.
individual attacks. As in the case of the haemoglobin, the
decrease apparently progresses in relation to the length and
severity of the attack of excitement. Another noteworthy
point is that the decrease in the percentage of haemacytes
during an attack of excitement progresses more rapidly than
the increase during convalescence or between attacks. For
example, in one case the percentage of haemacytes decreased in
14 days during an attack of excitement from 87*5 to 81*3 ;
for the next fortnight the patient kept free of excite¬
ment, and during that time the percentage only increased
to 84*4.
The proportion of white to red corpuscles varied from 1 in
170, to 1 in 480. The average of the 68 observations was 1 in
312. There were considerable variations in the proportions in
each of the six cases, the proportions in one individual fluctuat¬
ing between 1 in 210, and 1 in 410. These fluctuations,
however, did not occur in any constant ratio to the mental
condition of the patients at the time of the observation.
Although the proportion of white corpuscles was higher in the
observations during the periods of freedom from excitement
(30 observations, 1 in 317; 38 observations, 1 in 308), the
variations were so numerous and irregular that no general con¬
clusion was possible. Crenated corpuscles were observed more
frequently in the periods of quiescence than when the patients
were excited. Small and irregular forms were more numerous
during the excited stage, while small granule cells were
observed with equal frequency at both periods.
A more extended series of observations and greater frequency
of examination in individual cases are necessary before one is
justified in forming many deductions from the foregoing re¬
searches on the blood of female patients subject to attacks of
periodic mania. There is one possible source of fallacy to
which my attention was not drawn till I had completed my
observations, and which in a great measure detracts from the
scientific value of this portion of the subject. I refer to the
influence of the catamenia in lowering the percentage of the
blood corpuscles. Hunt * in a large number of observations on
chlorotic anaemia, has shown that a definite numerical fall in
the number of haemacytes occurs shortly before the onset of the
menstrual flow, and other observers, notably Gowers f and
Willcocks' J have made similar statements. It would be
* u Lancet,” July 17th, 1880. f “ Practitioner,” Yol. xxi, p. 11.
\ “ Practitioner,” Vol. xxxi, page 103.
e
498 Clinical Observations on the Blood of the Insane , [Jan.,
advisable, therefore, in view of this statement, to pay attention
to the menstrual period in any further observations.
I therefore submit the following deductions, recognising that
the results may possibly be fallacious :—
(1.) Prolonged periods of excitement cause a reduction in
weight.
(2.) The percentage of haemoglobin is less during an attack
of excitement than in the periods of quiet preceding and fol¬
lowing the attack.
(3.) During an attack of excitement the average amount of
haemacytes is less, and small forms are more numerous than in
periods of freedom from excitement.
(4.) Maniacal attacks do not appear to influence to any
great extent the relative proportion of white to red copuscles.
(5.) The more prolonged and severe the attack of excitement
the greater is the deterioration in the quality of the blood.
V.
The tables in this section (E 1 and E 2) represent fifteen
consecutive admissions of either sex. These may, I think, be
regarded as fairly typical examples of the class of patients
admitted to asylums. None of the cases were transfers from
other asylums.
The points in the tables which call for special comment are—
(1) The ages of the male patients vary from 20 to 58 years,
average 36*5 years; the females from 21 to 63 years, average
35*4 years. There appears to be no uniform relation between
the ages of the respective individuals and the quality of their
blood. (2) The weights also show considerable variation,
between 108 lbs. the lowest and 164 lbs. the highest for men;
and 83 lbs. and 154 lbs. for women, the respective average
weights being 136*7 lbs. and 110*2 lbs. The relation of the
weight to the quality of the blood is by no means constant,
although the blood of the larger proportion of the heavier
patients is richer in haemoglobin and in haemacytes than in the
case of the male patients whose weights are below 128 lbs.,
and the female patients below 100 lbs. (3) The duration of the
mental symptoms on admission varies from one week to four
years in men, and from three days to two years in women.
There appears to be some connection between the duration of
the attack and the amount of haemoglobin and haemacytes in
the blood. In the male series, of six cases with a percentage of
haemoglobin of 70 or over, in five the symptoms had lasted
under a month, while in three of the four highest percentages
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1885.] by S. Kutherford Macphail, M.D. 499
of haemacytes the mental disease was of short duration (ten
days and under). A prolonged duration of attack does not
however necessarily cause a deterioration, for in the four cases
where the symptoms had lasted a year and upwards the average
amount of haemoglobin is 68, and the average of haemacytes 87
per cent., or a fraction above the averages in the tables. While
the exceptions are more numerous in the female group, in these
also the hlood appears to deteriorate in quantity of haemoglobin
and haemacytes pari passu with the length and severity of the
attack. (4) The quality of the blood varies considerably in
the different types of mental disease. In the three epileptics
in Table E. I., the average amount of haemoglobin is 2 per
cent, below the average for the fifteen cases, while the average
percentage of haemacytes is reduced to 80*7. General Paralytics
also have a low percentage of haemoglobin, while the amount
of haemacytes is above the average in the table. In the
melancholic type the haemoglobin is below, and the haemacytes
are above the general averages. The highest percentages of
haemoglobin and haemacytes are found in the three cases of
acute mania, and in one patient suffering from delirium
tremens . In the remaining cases of mania there are con¬
siderable fluctuations in the quality of the blood. In Table
E. II., the average percentages of haemoglobin and haemacytes
in the eight cases of mania are 61 and 78 ; in the five cases of
melancholia 59*2 and 81*5. In other words, the haemacytes
are below the average of the fifteen cases in mania, while the
haemoglobin is decreased and the haemacytes are increased in
melancholia. (5) Seven men and seven women are stated to
be in weak bodily health. Only three of these had active
physical disease, viz., one man convalescing from an attack of
pneumonia, and two women in a very feeble state suffering
from bronchitis. The bodily health does not appear to affect
the quality of the blood in a uniform ratio, for the three
patients, physically ill, occupy a middle position in the series
in this respect, and one female in good bodily health has a low
percentage of haemoglobin and haemacytes. (6) In males the
percentage of haemoglobin is almost 30 below the normal
standard, the average of the fifteen cases being 67*2, the same
amount as registered in the case of dements of the same age.
In females the percentage varies in individual cases from 50 to
70, with an average amount of 61, or 24 per cent, below the
normal standard. (7) The average amount of haemacytes is
86*9 per cent, for men, and 80*4 for women. In no case does
the amount reach the normal standard, and in the male series
xxx. 34
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E. II.—Table of Fifteen Consecutive Female Admissions.
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F. I.—Table of Ten Consecutive Male Kecovebies.
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Average of seven observations.
F. II. —Table of Ten Consecutive Female Recoveries.
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Average of seven observations.
504 Clinical Observations on the Blood of the Insane , [Jan.,
the average is 3 per cent, below that of dements at the same
age. (8) The average proportion of white to red corpuscles is
increased, especially in the male admissions. In individual
instances the fluctuations appear to bear no definite ratio either
to the duration of attack or to the mental disease, although,
speaking generally, the increase is more obvious when the
attack is of short duration, and in the types of mental disease
represented by Acute Mania, General Paralysis, and Epilepsy.
The individual corpuscles in this series were regular, and, for
the most part, uniform in size, though cells of small size were
seen in several of the observations. Small granule-cells were
seen in less than a third of the cases.
VI.
An examination of the blood of ten consecutive recoveries of
either sex, as represented in the foregoing tables (P. I. and
F. II.), furnishes us with some interesting and very uniform
results :—The average age of the men is more than 10 years
over that of the women. With two exceptions, one male who
remained stationary and one female who lost 2 lbs., there is a
uniform gain in weight in these patients during their re¬
sidence in the asylum. The average amount gained by men is
12*3 lbs. in 5*7 months; by women 16 lbs. in 8*6 months.
Some of the gains in weight are very remarkable, one man
gaining 24 lbs. in three months, another 20 lbs. in five months,
and a third 15 lbs. in two months, while one woman gained
46 lbs. in nine months, another 36 lbs. in five months, and
a third 18 lbs. in four months. In seven cases of either sex the
blood was examined on admission, the remaining six cases
having been admitted before I commenced the series of
observations. Without an exception, the blood in these cases
is richer in haemoglobin and in haemacytes on discharge than
when the patients were admitted. In males the average per¬
centage of haemoglobin on admission is 66*8, that of these
seven cases on discharge 77*4, while the average for the ten
cases is 79. The average percentage of haemacytes is 85*1 on
admission, that of the seven cases on discharge 92*4, while the
average of the ten cases is 93*82. In females the respective
percentages are haemoglobin 60*4 on admission; 77 for seven
cases and 76*7 for ten cases on discharge; haemacytes 82*8 on
admission, 92*2 for seven cases and 91*8 for ten cases on dis¬
charge. We thus see that there is an individual and a
collective gain in the richness of the blood among patients
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505
1885.] by S. Rutherford Macphail, M.D.
who recover. The improvement is more noticeable, and the per¬
centages of haemoglobin and hasmacytes approach more nearly
the normal standard, in the case of female recoveries than in
those of males. In neither sex does the period of residence or
the type of mental disease appear to affect the quality of the
blood in any uniform ratio.
The proportion of white to red corpuscles is rather higher
than normal, the average being 1 to 344 in men and 1 to 329
in women. The individual corpuscles were regular in outline,
and large and small cells were observed with greater frequency
than in normal blood. Small forms especially were numerous.
Clusters of hsematoblasts were seen in all the cases.
Of the 20 patients, eight men and seven women had tonic
treatment. The average per cent, of haemoglobin in these 15
cases was 80 for men, 76'8 for women; the average percentage
of haemacytes, men 94*5, women 92*3. In other words the
blood showed greater improvement in those who had undergone
a course of tonics than in those who had no medical treatment.
VII.
The influence of tonics on the quality of the blood of patients
during the early period of residence in asylums is an in¬
teresting and important study. I hope on some future occa¬
sion, after making a sufficient number of observations, to treat
this subject at greater length than I am able to do at present.
The following remarks are based on a series of 1.30 observa¬
tions on 22 individuals—15 men and seven women. The
number of observations on individual cases varied from three
to ten, and the period of time represented by each series from six
weeks to eleven months. Of the 22 cases, eight have recovered,
six are convalescing, one has died, and seven have not improved.
Tonic treatment was administered to the patients on ordinary
general principles, and their blood was examined while they
were undergoing the particular line of treatment. By this I
mean that the patients were not selected and then given special
treatment with the view of collecting data for this enquiry.
For the sake of comparison, I examined the blood of three
patients who were not receiving any tonic treatment; these
represent 20 of the 130 observations. One case was treated
with cod-liver oil, extract of malt, and quassia respectively,
two with arsenic, three with iron, seven with iron and quinine,
and four with a combination of iron, quinine, and strychnia.
The ages ranged from 16 to 62 years. The only remark
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506 Clinical Observations on the Blood oj the Insane , [Jan.,
which calls for comment under this head is that the improve¬
ment in the quality of the blood was more pronounced in the
young, and in those advanced in years, than in the middle-aged.
In the aggregate the 22 patients gained 179 lbs in 78 months,
or an average of 8 # 1 lb. in 3*5 months; 18 gained an aggregate
of 188 lbs., three lost an aggregate of 9 lbs., and one re¬
mained stationary. The average percentage of haemoglobin
in the first observations on each individual, t.e., before the
treatment was commenced, was 61; in the last observations, or
when the treatment was discontinued, 70. In 18 cases there was
a definite increase varying from six to twenty per cent., in two
a diminution—eight per cent, in one case, nine per cent, in the
other; while two cases did not vary. The average amount of
haemacytes was 81*1 for the first observation, 89*2 for the last.
The percentage was increased in twenty cases, the gain fluctuat¬
ing between 1*9 the lowest and 26*3 the highest amount gained.
In two cases there was loss, but in neither instance did this
exceed two per cent. The proportion of white to red corpuscles
showed considerable variations, but not in any definite direction.
The average of the first observation was 1 to 384, of the last
1 to 320. Haematoblasts were seen in nearly all of the obser¬
vations, the exceptions being the first observation in three
cases, and the last observation in the individual who died.
Many of the red-blood corpuscles throughout the series were of
smaller size than normal, and in addition were feebly coloured.
In no case did the blood show any marked deterioration after
the tonic treatment was discontinued.
The cases which had no medical treatment, and those treated
with cod-liver oil and a bitter tonic (quassia), differed from the
rest of the series in that there were considerable fluctuations in
the quality of the blood at the different periods. In the
instances where an increase in the amount of haemoglobin and
haemacytes was recorded this did not take place uniformly, and
the total increase did not amount to 10 per cent, in either case.
On the other hand the blood of those in whom iron, either
alone or in combination, formed part of the treatment, varied in
a definite and particular way. For the first fortnight the
haemoglobin remained stationary, while the amount of haema¬
cytes was largely increased. In the third and fourth weeks the
haemoglobin continued stationary and the haemacytes were
diminished. During the second month the haemoglobin was
slightly increased in all the cases, while the percentage of
haemacytes increased in the patients progressing towards
mental recovery, but diminished in the others. In each
instance improvement in the amount of haemacytes preceded
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507
1885.] by S. Rutherford Macpha.il, M.D.
the increase in the percentage of haemoglobin. The greatest
increase was observed in the cases treated with iron, quinine,
and strychnia, next in those treated with iron and quinine, and
a less though quite a definite improvement in quality in those
treated with iron alone. The blood in the two patients treated
for two months with arsenic showed slight variation in the
quantity of haemoglobin and haemacytes; in both cases the
treatment was changed to iron and quassia when a definite
improvement took place. Considerable improvement was
observed in the case treated with extract of malt. The increase
in the amount of the haemoglobin and haemacytes was gradual
and progressive, and, as in the cases where iron was given, the
blood improved in haemacytes before the percentage of haemo¬
globin was much increased. In every instance where there
was a marked increase in weight the quality of the blood
improved. While this improvement was more noticeable in
cases which improved, or were mentally convalescing, it also
occurred to some extent in the others.
I have not sufficient data to discuss the effect of mental
relapses and maniacal outbursts in these cases, and I regret
that the limits of the paper prevent my giving the whole series
of observations in tabular form. The influence of large and
small doses of the various tonics on cases of recent admission
must be omitted for similar reasons. Indeed I feel diffident in
attempting to discuss the subject of blood-tonics in a fragmen¬
tary form before my observations have been completed, and
my only excuse is that the paper should contain at least an
introduction to this, the practical outcome of the whole subject.
The observations I have made so far are encouraging, and
sufficiently uniform to enable one to anticipate valuable and
accurate results if this method of clinical research is persevered
in, and engages the attention of several observers.
VIII.
Summary .—I have endeavoured to approach the subject
from an unbiassed and scientific standpoint, to avoid theorising
and to arrive at my deductions only from observed facts.
Each series of observations has been summed up and com¬
mented on separately, but the following general conclusions
seem warranted:—
(1.) While there is no evidence to show that anaemia in itself
is a cause of insanity, yet an anaemic condition of the blood is
undoubtedly in many cases intimately associated with mental
disease.
(2.) The blood in the demented class of asylum patients is
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508 Clinical Observations on the Blood of the Insane. [Jan.
deficient in haemoglobin and in hasmacytes, and the deteriora¬
tion progresses as age advances.
(3.) 'Hie blood in patients known to be addicted to mastur¬
bation is deteriorated in a marked degree.
(4.) The blood is below the normal standard in General
Paralysis, and the deficiency is greater in the active and com¬
pletely paralysed stages of the disease than in the intervening
periods of inactivity and quiescence.
(5.) While there is a deficiency in the quality of the blood
in Epileptics, the decrease is not so pronounced as in ordinary
dements at the same age.
(6.) Prolonged and continuous doses of Bromide of Potassium
do not cause deterioration in the quality of the blood.
(7.) Prolonged attacks of excitement have a deteriorating
influence on the quality of the blood.
(8.) The blood of the average number of patients on admis¬
sion is considerably below the normal standard.
(9.) In patients who recover, the quality of their blood
improves during residence in the asylum, and on discharge is
not much below the normal standard.
(10.) There appears to be a close connection between gain
in weight, improvement in the quality of the blood, and mental
recovery.
(11.) While there is a definite improvement in the condition
of the blood during mental convalescence in all cases, the im¬
provement is both more pronounced and more rapid in those
who have had tonic treatment.
(12.) The four tonics which either alone or in combination
proved most efficacious in restoring the quality of the blood as
shown by these observations may be classed in order of value
thus (a) iron, quinine and strychnia ( b ) iron and quinine ( c)
iron alone (d) malt extract.
(13.) Arsenic proved of little value as a blood tonic in these
cases, and the observations with quassia and cod-liver oil did
not give satisfactory results.
(14.) The close connection which exists between improve¬
ment in the quality of the blood, increase in weight, and mental
recovery, the converse which exists in cases of persistent and
incurable dementia, and the marked improvement which is
effected by certain remedial agents, show that this line of
clinical research, more especially with reference to the curative
treatment of the insane, should have more attention paid to it
than has hitherto been the case.
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1885.]
509
On Uterine Disease and Insanity .—By Joseph Wigleswobth,
M.D. Lond., Assistant Medical Officer, Rainhill Asylum.
The question of the relation between Uterine Disease and
Insanity is one which, though at different times it has attracted
much attention, is yet very far from being thoroughly elucidated.
On the one hand the subject is mixed up with so-called
“ Hysterical Insanity,” and on the other with “ Amenorrhceal
Insanity,” concerning the former of which it may be said that
but little evidence has been advanced to prove its dependence
upon distinct physical disease in the internal organs of repro¬
duction; and, as regards the latter, it needs but little observation
in an asylum to show that in the majority of cases in which
Amenorrhcea is associated with insanity, the suppression of
the menses is merely a symptom, and in no sense the cause of
the disease.
Again, under the head of “ Ovario-Mania,” Dr. Skae
described a form of insanity connected with the sexual organs,
in which delusions as to intercourse were common. He says *
“ I have long believed that all such cases were connected with
diseases of the ovaries or neighbouring parts, acting on them
by direct irritation, and by reflex action on the nervous centres.
I have uniformly found such disease in every case where I have
had an opportunity of making a post-mortem examination/’
Dr. Clouston, following Dr. Skae, refers f to the same disorder
under the head of “ Old Maid’s Insanity,” and the same sub¬
ject is alluded to by Drs. Bucknill and Hack Tuke, who say,t
“ A form of disease has been described by Dr. Skae under the
head of Utero-Mania or Ovario-Mania, to designate cases of
insanity in old maids associated with delusions as to sexual
intercourse.” The general aetiological relation, however,
between diseases of the internal organs of reproduction in
women and insanity, is a subject to some extent outside of
those enumerated above.
It may be impossible to say, indeed, of any individual case of
Uterine or Ovarian disease, that it was the cause of the insanity,
but by the systematic examination of the uterus and its append¬
ages in a large number of insane individuals error may be elimi¬
nated, and the relative frequency of disease of these parts in
lunatics may be approximately ascertained. The subject does not
* “The Morisonian Lectures on Insanity for 1873,” by Dr. Skae and Dr.
Clouston. “Journal of Mental Science,” Vol. xx, p. 10.
t “ Clinical Lectures on Mental Diseases,” p 478.
J “A Manual of Psychological Medicine,” 4th edition, p. 348.
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510
[Jan.,
On Uterine Disease and Insanity ,
appear to have been much investigated on these lines in this
country; at least, I have not come across many records of obser¬
vations. On the continent, however, it would seem to be
otherwise. By a reference to the “ German Retrospect ” in the
“Journal of Mental Science” for October, 1883, it will be
seen that, as there stated* “ there is great variance of opinion
about the frequency of diseases of the genital organs in insane
women,” one author placing it as low as 6 per cent., and another
as high as 80 per cent.
A lady physician in the United States, Dr. Cleaves, found
that “of eighty-five patients admitted under her care at
Harrisburg in a period of twelve months, twenty-nine suffered
from utero-ovarian disease of some kind, and in a large pro¬
portion of those who so suffered, improvement in mental health
followed rapidly on the treatment of the local disorder.
In the Commissioners’ Blue Book for the year 1882 “ Uterine
and Ovarian Disorders ” figure as causes of insanity in 1*9 per
cent, of the female admissions. I should myself be disposed
to think that their influence was here much understated.^
Theoretically we might suppose that uterine or ovarian
disease might produce insanity in two ways—either by the
direct irritation such disease might set up, in which case the
symptoms would not improbably have a maniacal character—or
by the wearing out of the system by prolonged pain and
exhausting discharges, when melancholia would be the more
likely form of mental alienation. That such diseases are
common enough in the population at large without giving rise
to insanity, is no argument against their having this effect in
persons with unstable nervous organisations, and thus pre¬
disposed to attacks of mental disorder. Indeed, in every case
of insanity, no matter what the cause assigned be, the personal
predisposition of the individual is obviously a factor of the first
importance. But theories are of very little use unless they stand
the test of experience, and it is the main object of this paper
to bring forward certain data which may assist us in forming
correct conclusions on the question. The subject, then, here
resolves itself into a record of observations made by myself, in
part pathological and in part clinical; in the former case the
result of a series of post-mortem examinations being described,
* p. 426.
f ** British Medical Journal,” Vol. i, p. 123. 1883.
} Dr. Tuke says, “ The proportion of admissions from uterine disorders ap¬
pears to be about 6, or taking female admissions only, 10 per cent. Among
asylums for the opulent classes exclusively, the ascertained proportion would
be higher, the real proportion higher still, among both poor and rich.— Op. cit
p. nc *.
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511
1885.] by Joseph Wiglesworth, M.D.
and in the latter, that of a number of bedside examinations.
The cases observed are given in detail in two tables, the first of
which deals with the pathological aspect of the question, whilst
the second approaches it from the clinical stand-point. The
cases quoted in the one table are altogether distinct from those
in the other. (For tables see pp. 520 et seq.)
I will now proceed to analyse the cases under these two heads.
I. Pathological.
Table I. gives the condition of the uterus and its appen¬
dages, as they were noted to be in 109 post-mortem examinations,
made by myself, of patients who died in the asylum. The cases
were altogether unselected, and were recorded just as they came
under notice. Of these 109 cases, in 42—38’53 per cent.—the
uterus and its appendages were perfectly normal, or at the most
showed very trivial changes; whilst in the remaining 67—
61*46 per cent.—the parts in question showed a greater or less
degree of departure from the normal. From this latter category,
however, important deductions have to be made in estimating
a connection between the uterine disease and the patient’s
mental alienation. (1) In 15 of the abnormal cases—Nos. 8,
14, 15, 16, 17, 39, 46, 59, 68, 69, 82, 85, 97, 105, 108-the
changes were very slight, and consisted in trivialities, such as
very small fibromata, ecchymosis of mucous membrane of
fundus, etc., which could have had no bearing on the mental
symptoms. (2) In three cases—Nos. 2, 5, 8—the changes
noted were secondary to parturition, and were, therefore, not
abnormal as regards the then condition of the individual. (3)
In one case—No. 4—the uterine affection was a purely
secondary involvement, and of very recent origin. (4) In
three cases—Nos. 12, 45, 63—the abnormalities were due to a
general constitutional taint—tubercular—and were associated
with tubercle in the lungs and other organs.
Deducting, then, these 22 cases from the 67 abnormal ones,
we get 45—a percentage of 41*28—in which cases there was
either congenital defect, or a degree of acquired abnormality
requiring further investigation. First as regards congenital
abnormalities. In one case—No. 21—the uterus was absent.
In eight cases—Nos. 32, 50,57,59, 63, 77,89,92—the condition
known as conical cervix, with pin-hole os, was present; in four
of these cases, however, this condition was associated with other
abnormalities, which brought them under the category of
acquired abnormal cases; in the remainder the defect may,
perhaps, be considered of little moment. It is indeed common
enough in the community at large, but it would seem to be
worth while to take note of it in connection with other possible
Digitized by <^.ooQLe
512 On Uterine Disease and Insanity , [Jan.,
developmental defects, and when it is remembered how fre¬
quently this abnormality is associated with dysmenorrhoea and
the constitutional disturbance so frequently dependent thereon,
and that it is a direct cause of sterility, it is quite conceivable
that in some cases it may be a factor in the production of
insanity. If, however, we were to exclude these cases of
developmental defects (when not associated with other lesion)
we should narrow our total of abnormal cases to 40—36*69 per
cent. This total includes very different cases and very different
degrees of abnormality; whilst in many of them a connection
with the mental symptoms would be at the most very pro¬
blematical ; in others it would be quite legitimate to infer such
a dependence. It will be convenient to consider these 40 cases
of acquired abnormality under the following heads:—
(1.) Simple Displacement .
Eleven cases—10-09 per cent, of the total number of cases
—came under this category. They were divided as follows:—
(a.) Retroversion. —Four cases—Nos. 47, 64, 77, 78.
(6.) Retroflexion. —Five cases—Nos. 25, 37, 62, 80, 102.
(c.) Retroflexion combined with Retroversion .—One case—
No. 44.
(d.) Prolapse. —One case—No. 70.
This last case was complicated with hypertrophy of the
cervix. The patient was the subject of senile mania, and it is
possible that the uterine affection may have been a factor in the
production of the insanity. As regards the other cases, however,
I should not be disposed to attach too much importance to
them. Displacements are, as is well known, among the most
common of uterine affections, and probably often receive at
the hands of gynaecologists greater attention than they deserve.
It cannot be denied, however, that they may occasionally be
factors in the production of insanity.
(2.) Enlargements of the Uterus.
It may be difficult in any given case to say whether we have
to deal with a simple enlargement, a genuine hypertrophy,
or a subinvolution. I think, however, we shall not be far
wrong in the case of a woman who has borne children, and in
whom the uterus weighs 3oz. or more (tumours being, of
course, excluded), in putting the case in the last category.
No. 87 appeared to be a case of simple enlargement, but as it
was associated with a pin-hole os, it would, perhaps, be more
appropriate to include it under the head of congenital defects.
I have marked five cases as examples of subinvolution—Nos.
9, 24,27, 30, 84—(4*58 per cent, of the total number of cases).
This condition, as is well known, is very common in the com-
Digitized by
Google
513
1885.] by Joseph Wiglesworth, M.D.
munity at large, but because a condition is often met with
without mental disorder, that is no reason why, in the case of
a person predisposed to it, this may not be an important factor.
I should myself be disposed to think that in certain cases it
may prove an efficient cause of insanity ; and this, not so
much by the annoyance which the condition often entails, as
by reason of the exhausting haemorrhages, which are the too
common concomitants of the affection. That frequent and
considerable losses of blood may, by lowering the general tone
of the system, predispose to insanity, can hardly be doubted.
In case No. 30, these copious losses of blood had, indeed, taken
place j and the impression conveyed to my mind, by the history
of that case, was that the subinvolution was a not unimportant
factor in the production of that patient’s mental disorder.
(3.) Uterine Fibromata .
Excluding very small tumours, six cases belong to this
category, viz., Nos. 81,34,41,58, 75,93—5*50 per cent, of the
total number of cases. In Nos. 31 and 58 alone, however, did
the tumours reach any very considerable size ; but in these two
cases there was evidence derived from the history of the patients,
and the mental symptoms, that the tumours were important
contributory causes in the production of the melancholia from
which both patients suffered.
(4.) Old Pelvic Inflammation .
This was evidenced by the presence of old fibrous adhesions
in Douglas’ pouch, the fundus of the uterus being thus more
or less adherent to the rectum and pelvic walls ; the cases
were mostly complicated with retroflexion. Six cases—Nos.
13, 19, 23, 60, 72, 90 (5'50 per cent.)—came under this cate¬
gory. It is, of course, impossible to say that the attack of
pelvi-peritonitis or cellulitis, from which the patients must have
suffered, may not in certain cases have had an influence in the
production of the insanity, but I should not myself be disposed
to rate that influence high.
(5.) Hypertrophy and Induration of Lips of Cervix .
One case, No. 53, came under this category. The condition
pointed to a chronic inflammatory state of the cervix, which
might during life have caused symptoms out of proportion to
the small change noted after death, but the condition was
probably of no moment whatever.
(6.) Cancer of the Uterus .
Only one case—No. 20—was of this character. The case
was one of melancholia of five months’ duration, and the im¬
pression conveyed by the observation of the case during life
was that the uterine disease was an important factor in the
Digitized by Google
514 On Uterine Disease and Insanity , [Jan.,
production of the patient’s mental symptoms ; these certainly
got worse with the progress of the disease.
(7.) Diseases of the Ovaries and Fallopian Tubes .
Nine cases—8*25 per cent.—came under this heading.
In only one case—No. 89—was there uncomplicated cystic
disease of the ovaries, and that was in a very early stage.
In one other case—No. 82—there was present a small
dermoid tumour of the left ovary.
In three cases there was evidence of old chronic inflam¬
mation—cirrhosis in fact—of the ovaries. In No. 52 the
affection was confined to the right side ; whilst in Nos. 26 and
42 the condition was double.
In four other cases the affection of the ovaries was compli¬
cated with dilatation of the Fallopian tubes, and effusion of
fluid into these. In some of these four cases the affection
was clearly inflammatory, whilst in others it seemed impossible
to pronounce definitely whether the collection of fluid was the
result of imflammation or a simple dropsy. In No. 40 there
was evidence of old perimetritis, together with peri-oophoritis
and salpingitis. In No. 57 there was evidence of old inflam¬
mation both in ovaries and tubes. In Nos. 99 and 107 one or
both ovaries were cystic, with effusion of fluid into the tubes.
As regards the mental symptoms in these four cases. No. 40
was a case of subacute mania, with frequent outbursts of im¬
pulsive violence ; No. 107 might be described as a moral
imbecile, who was subject to violent outbreaks of temper ;
whilst No. 99 was an epileptic, who had pretty frequently very
acute maniacal attacks ; on the other hand. No. 57 presented
an example of a quiet, demented, general paralytic. It cannot
be denied that in the three first-mentioned cases the irritation
that must almost certainly have been occasioned by the con¬
ditions described, may have had something to do with the
violent maniacal outbreaks ; and I think it a matter for
consideration whether, had the disease been recognized during
life, prompt removal of the uterine appendages might not
have been attended with considerable benefit.
A condition to which I may just draw attention, which was
several times met with, was a deep congestion or ecchymosis of
the mucous membrane of the fundus uteri in old people . I am
at a loss to account for the condition, which appeared to be
due to an effusion of blood into or around the uterine follicles;
Nos. 18, 15, 44, 62, 82, 108 were the cases met with. The
lesion had clearly no clinical significance, as regards the mental
symptoms at any rate, if only for the reason that it must cer¬
tainly have been of very recent origin. These cases are, there-
Digitized by Google
1885.]
515
by Joseph Wiglesworth, M.D.
fore, not included in the list of abnormal ones, of which an
account has just been given.
II. Clinical .
Table II. gives the condition of the uterus and appendages
in 65 insane individuals, as ascertained by examination during
life. Clinical memoranda are clearly of more importance than
pathological in determining the question of the frequency of
uterine disease in insane women, for the latter dealing only
with the conditions noted at the termination of what may be a
long period, any disease existing at the commencement of the
insanity may have had time to subside. Again, a uterine
affection might spring up after the insanity had become con¬
firmed, and no indication being afforded of the period of its
commencement, might lead to the drawing of erroneous in¬
ferences. For the same reasons, the examination of cases in
which the insanity is recent is of more importance than that of
those in which it has become confirmed. Taking a “ recent 93
case, to indicate that in which the insanity is of not more than
a year’s duration, the table before us deals with 27 “ recent ”
cases of insanity and 31 “ chronic ; 99 whilst in seven the dura¬
tion of the insanity has not been recorded. Before proceeding
further with the analysis, however, I must say a word or two
about the method of examination. In every case an anaesthetic
—ether—was given. This is absolutely necessary in the great
majority of cases, and advisable in all; and I may say at once
that in no recent case of insanity have I seen any bad effect
produced on the mental condition of the patient, either by the
administration of the anaesthetic, or by the subsequent ex¬
amination (of which, indeed, the patient is usually quite
unconscious). In one or two chronic cases of mania there
seemed for two or three days subsequently to be a little increase
in the patients* noise and turbulence, but this was all; and,
therefore, whilst not being prepared to deny that in certain
cases the effect of these proceedings might be injurious, I
think the experience here gained shows that they may be
resorted to with much less hesitation than is, I think, commonly
thought. As regards the examination itself, I made it a
practice to give a dose of aperient medicine on the afternoon
of the day preceding the examination, and on the morning of
the examination a simple enema, to make sure of the rectum
being thoroughly empty. Then, in addition to the usual
methods of investigation by vaginal touch, speculum, and
uterine sound, the bipolar method of examination has in all
cases been resorted to—that is, two fingers of one hand were
xxx. 35
Digitized by Google
516
On Uterine Disease and Insanity , [Jan.,
introduced into the rectum, whilst the opposite hand pressed
upon the abdominal parietes immediately above the pubes; by
these means the contents of the pelvic cavity can be explored
with a completeness which leaves little or nothing to be de¬
sired.
For obvious reasons, most of the cases examined have been
married women. The majority of the cases were unselected,
being taken just as they came under notice. A few cases,
however, were specially singled out for examination, owing to
the fact of sexual delusions, or other circumstances, causing a
suspicion to fall upon the uterus. These cases, though few, have
rendered the percentage of abnormal cases somewhat higher
than it would have been had all the cases been taken at
random.
To take the normal cases first. If we were only to take
those which presented not the smallest trace of abnormality,
we should only have nine out of the 65 to place in this
category. In 26 other • cases, however, the abnormalities
present were so slight, that they might be considered practi¬
cally normal. Such abnormalities consisted of trifling epithelial
erosion of the lips of the os uteri, slight displacement, either
forwards or backwards, etc., the departure from the normal
being in all these cases so trivial, that to include them under
the head of disease would be altogether misleading; I have,
therefore, thought it best to include them under the head of
i( normal cases,” which would cause 35 out of the total 65 to
be placed in this category—a percentage of 53 84. In the
remaining 30 cases, 46*15 per cent., some distinct abnormality
or congenital deformity was present, though the amount and
importance of this, as will be seen as we proceed, has varied
considerably.
The abnormal cases may be classified under the following
heads :*■—
I. Congenital Defects.
Four cases were of this class. In one—No. 11—there was
an imperfectly developed uterus, with absence of the os ex¬
ternum. Two cases, Nos. 2 and 44, were examples of conical
cervix, with a very small os, the latter of these two being
complicated with anteflexion of the fundus. No. 10 was an
example of conical cervix without contraction at the orifice.
Eemarks were made on this abnormality in the Pathological
Section. All these four patients were nulliparae.
* Where a case presented two or three different abnormalities, it is classified
'tinder the head of that which seemed the most important.
Digitized by <^.ooQLe
517
1885.] by Joseph Wigleswobth, M.D.
IT. Acquired Abnormalities .
(1.) Displacements .—These, as might be expected, are most
important from a numerical point of view, no less than 13 of
the abnormal cases coming under this category; of these, seven
—Nos. 9, 15, 23,38, 63, 64, 65—were examples of anteflexion,
and one—No. 46—of anteflexion combined with anteversion;
four—Nos. 16, 54, 56, 57—were cases of retroflexion, and one
—No. 61—of prolapsus. This last case was complicated with
hypertrophy of the cervix. As previously stated, all cases of
slight displacement are excluded from these numbers, those
only being here enumerated in which the condition was well-
developed. We have, therefore, a percentage of 20*00 cases of
displacement in an examination of 65 cases. This is doubtless
a high percentage, but it would be easy to exaggerate the im¬
portance of it. It will be seen that the majority of the displace¬
ments were cases of anteflexion, and it is now known that this
condition is very common in unmarried, nulliparous, women,
without, in the majority of cases, any symptoms being pro¬
duced.*
(2.) Ulceration or Erosion of the lips of the os uteri.
The condition here referred to is that in which the surfaces
in question are stripped of epithelium, raw, red, and granular-
looking j it is described as “ erosion ” in the table. After ex¬
cluding all quite trivial cases, five are left in which the con¬
dition was present in a marked degree—Nos. 18, 30, 35,42,48.
The affection is, as is well-known, enormously common in
women of all ages, who are often energetically treated for an
“ ulcerated womb/ 5 which it would sometimes have been better
for the patient had it never been discovered. In its minor
degrees the condition is sufficiently unimportant, and even
when present to the extent met with in the five cases enu¬
merated above, but little significance can be attached to it from
our present point of view.
(3.) Uterine Fibromata .
Two cases—Nos. 4 and 33—were examples of fibroid
tumours of the uterus; in the former sexual delusions were
present, which will be referred to hereafter, but whether the
tumour in this case had any aetiological relation to the patient’s
insanity cannot be determined, the mental alienation being of
some years 5 duration.
(4.) Subinvolution.
One case—No. 1—was an example of this condition. The
patient presented strongly-marked delusions as to sexual in-
* See a Leading Article in the “ Lancet, 0 1883, Vol. ii, p. 286 .
Digitized by <^.ooQLe
On Uterine Disease and Insanity,
[Jan.,
tercourse. The uterine affection was treated by the introduc¬
tion of solid nitrate of silver into the fundus, by scarification
of the os, etc., by which means the size of the uterus was
much diminished, the length being reduced from 3^ to 2£
inches. Correspondingly with this improvement, the mental
symtoms seemed for a time in abeyance, but they soon returned
in their pristine vigour, and no permanent improvement has
resulted in this respect. Indeed, this could perhaps hardly
have been expected, since the insanity was of at least years’
duration, and probably much more; and even supposing that
the insanity had been started by the uterine disease, the delu¬
sions had had plenty of time to get organically registered in
the brain, and were thus probably in a position to exist by
themselves, independently of the cause which started them.
(5.) Hypertrophy of cervix rcith contraction of os.
One case—No. 3—presented these characters in a slight
degree.
(6.) Old pelvic inflammation.
In No. 31 it was inferred that old adhesions were present
in Douglas’ pouch, the uterus being deflected to the left, and
showing deficient mobility in this situation.
(7.) Diseases of the Ovaries.
Thus far we have dealt with uterine affections only; the
small number of cases in which the appendages were at all
involved is somewhat striking; such lesions as were noted
were confined to the ovaries.
Nos. 39 and 43 were examples of Prolapse of the Ovaries in
Douglas’ pouch where they would at least have been in a
position to produce irritation; both cases were complicated
with some displacement of the uterus.
In No. 58, the right ovary was a little enlarged. It may be
remarked that in three other cases—Nos. 27, 38, 48—a
slight enlargement of one ovary was met with; but as in these
three cases the examination was made shortly after the men¬
strual period, the swelling was probably the usual physiological
engorgement, etc., and these cases are therefore not considered
abnormal.
Sexual Delusions.
It will be well to consider under a separate heading those
cases of insanity which presented delusions having reference
to the sexual organs. Nos. 1, 4, 16, 38, 46 were of this
character; they all presented certain uterine abnormalities, and
I may here remark that they include all the cases presenting
sexual delusions, which have recently come under my notice.
Digitized by boogie
519
1885.] by Joseph Wigleswobth, M.D.
In Nos. 1 and 16 the patients suffer from very prominent
delusions as to sexual intercourse; they are both firmly per¬
suaded that men cohabit with them at night. No. 1 has been
already commented on, under the head of subinvolution. In
No. 16 there was complete retroflexion of the uterus; this was
reduced, and the organ maintained in its place by a Hodge's
pessary; and it is interesting to note that the patient spon¬
taneously remarked, two or three days after this was done,
that she had not been so much troubled at night since she had
been examined; she, however, subsequently removed the
pessary, and refused to wear it any more, and her delusions
now continue as before; her insanity is of many years' dura¬
tion.
No. 4 presents very strong delusions as to torture being in¬
flicted on her; she often complains bitterly that she is practised
upon by instruments being put into her womb, and declares
that her womb is tom out, etc.; these delusions have existed
for two or three years at least, and appear clearly to depend
upon the growth of a fibroid tumour in the fundus of the
uterus. Though this tumour is not at present producing any
marked physical effects, it is legitimate to enquire whether
operative interference might not be justified, in order to rid
the patient of what seems to be such a source of misery to
her.
Nos. 38 and 46 both had whilst menstruating strong de¬
lusions that they were in labour, and in both of them the
uterus was found to be anteflected, the anteflexion in No. 46
being combined with some amount of anteversion; the delusions
were only manifested during the menstrual period, and were
frequently and spontaneously expressed; they appear to have
had a physical basis in the flexion of the uterus, which clearly
(especially in No. 46) would have offered some obstacle to the
free flow of the menstrual fluid ; the increased contractions of
the uterine fibre thus set up, being conducted to the uterine
cerebral centre, gave birth to an idea—in this case erroneous,
on account of the general disturbance and want of co-ordina¬
tion in the cerebral plexuses. Of the two cases No. 46 cer¬
tainly, and No. 38 probably, had experienced the sensations
connected with labour, and had therefore presumably organised
connections established in their brains dependent thereon;
both patients were general paralytics.
This subject indeed—the connection of visceral disease with
special delusions—is a very interesting one, and one which will
doubtless repay further investigation.
Digitized by Google
Table I. —Showing the Condition of the Uterus and its Appendages in 109 Insane Individuals;
as Ascertained by Examination after Death.
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Table II.—Showing the Condition op the Uterus and its Appendages in 65 Insane Individuals,
as Ascertained by Examination during Life.
* In this, and all cases where no special mention is made of the condition of the ovaries, no abnormality of these parts was detected .
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Digitized by <^.ooQLe
On Uterine Disease and Insanity . 531
Conclusion .—From the study of these cases, the general con¬
clusion which appears capable of being drawn, is, that uterine
abnormalities are of more frequent occurrence amongst the
insane, than is commonly supposed. Though I am unable to
bring forward any cases in which the recognition and treat¬
ment of uterine disease has been followed by the cure of the
patient’s insanity, this is perhaps hardly to be wondered at,
since the investigation has embraced a much fewer number of
recent cases of insanity than I could have wished, and it is
sufficiently obvious that it is only to recent cases, that we can
look for results of this nature. Many of the cases, however,
given in the tables, and commented on in the text, are, I think,
very suggestive. I cannot but think it very probable that in¬
stances must occasionally occur in which the non-recognition
of uterine disease must result in a case at one time curable,
eventually passing beyond this category, to assist in swelling
the large total of permanent asylum-residents. The only way
in which this danger may be guarded against, is by the more
frequent resort to uterine examinations on the patient’s ad¬
mission, and I would venture to suggest that if greater atten¬
tion were paid to this subject in asylums than is, I think, now
generally the case, results of practical value might be expected
to accrue.
Some Relations of Delirium Tremens to Insanity . By
Geo. H. Savage, M.D.
(Paper read at the Quarterly Meeting of the Medico-Psychological Association ,
held at Bethlem Hospital Nov . 6,1884.)
At the last moment I have been asked to fill up a gap in the
programme of to-day, and if my paper be short and uninterest¬
ing, I must crave your indulgence.
The most interesting territories are either those which are
quite untracked, or those which may be called historic, from
the frequency with which they have proved battle-grounds on
which fights for great objects have taken place.
I cannot claim any interest for delirium tremens as an un¬
tracked morbid territory, but I think it deserves further notice,
and must continue to arrest attention from its importance as a
boundary-land, where insanity exists on one side and marked
physical disease is met with on the other. There are several
most important points upon which I should like to hear the
expressed opinion of this meeting:—
xxx. 36
Digitized by <^.ooQLe
532 Some Relations of Delirium Tremens to Insanity , [Jan.,
1st. Is delirium tremens more common among persons of a
neurotic type than among the ordinary run of people ?
A similar question has been asked, but not fully and satis¬
factorily answered, as to the frequency and the degree of
delirium met with in fevers—whether, in fact, a patient with
insane inheritance or with a misshapen head is more likely to
be wildly delirious than those with no physical or mental
defect ?
The question requires very careful consideration, and can¬
not be answered from the experience of any one man.
Our experience necessarily brings us most in contact with
the illness of insane people and of their near relations; there¬
fore, for the complete answer to this question, we must seek
help from the general physician. To conclude the first part of
this discussion we must admit that delirium tremens is at least
a common affection with neurotic persons, and next we must
consider in detail the other points.
2nd. Does a neurotic tendency affect delirium tremens either
in its form, its duration, or its results ?
Recent experience leads me to think that nervous inheri¬
tance has a distinct effect, first of all on the causation of deli¬
rium tremens , so that a smaller amount of alcoholic stimulant
or stimulant of a weaker kind will cause delirium tremens in
the neurotic than in others.
This is, I believe, true for many of those who come of ner¬
vous stock, but it is true also of those who are neurotic from
other causes.
Very few cases of delirium tremens arise from drink unac¬
companied by some nervous shock or cause of nervous depres¬
sion. The surgeon is used to cases following injuries, and the
gaol-surgeon is used to cases following nervous shook resulting
from detection in crime.
I have met with several cases in which social trouble has
produced the nervous depression which was sufficient to start
the morbid process.
Besides this very general nervous depression which may
lead to delirium tremens we often meet with cases in whom
a blow on the head has predisposed to nervous instability, so
that very little stimulant will make a man <c mad drunk.” In
some of these cases a very little drink either sets up a craving
for drink or so removes the power of self-control that drunken¬
ness is indulged in, which soon develops delirium tremens or
some other form of mental disorder.
In general paralysis of the insane we sometimes meet with
Digitized by <^.ooQLe
1885.]
by Geo. H. Savage, M.D.
533
cases very easily disturbed by stimulants, the tottering nervous
structure being easily upset. In such cases the repetition of
indulgence in alcohol may set up delirium tremens or a state of
delirium which may mark the early symptoms of the decay.
It is noteworthy that general paralytics will rarely tolerate
the same dose of powerful remedies, such as hyoscyamine or
chloral, as will other patients suffering from mental excitement
apart from general paralysis.
To sum up this part of my subject, then, I would say in my
experience, delirium tremens or an allied state of mental dis¬
order is more readily produced in the neurotic by inheritance,
in the nervous from injury or from decay, than in less unstable
people. In the specially neurotic persons referred to above
alcohol may produce insanity in several distinct ways, but at
present I intend to allude only to the cases which develop
delirium tremens first.
In these a bout of drinking may be followed by some moral
shock, such as loss of reputation, loss of situation, or loss of
fortune; and this may produce very brief depression, which
may be followed by the acute symptoms of delirium tremens.
The attack of delirium tremens may either run its ordinary
course or it may rapidly change in character. In either case
in the individuals under consideration the ordinary “ horrors ”
pass off, and are replaced by boisterous mania or simple melan¬
cholia. The mania is generally of a very acute type. The
patients are boastful and benevolent, and in very many parti¬
culars resemble general paralytics in the early stages of the
disorder.
The appetite is often very good, and the patient says he
feels himself quite another man.
Acute mania of the type described may last for a few weeks,
to be then slowly replaced by perfect sanity, or the mania may
for several months be present ns general incoherence.
The real danger arises from misunderstanding the nature of
these symptoms, and allowing the excitement to go on till the
patients sink rapidly from exhaustion.
In some such cases food is obstinately refused, the tongue
becomes dry and brown, the bowels are confined, and the
bodily temperature rises.
If very energetic measures in the way of constant forced
feeding are not followed, death will result. In cases in which
the mania appears to be becoming chronic repeated blistering
of the scalp is useful.
After delirium tremens there may be exaggeration of the
Digitized by <^.ooQLe
534 Some Relations of Delirium Tremens to Insanity. [Jan.,
natural depression following the great mental excitement.
This may be associated with both suicidal pnd homicidal
symptoms. Those cases having delusions of poisoning or of
conspiracies, require very careful supervision and treat¬
ment, and should, if possible, be kept some months under
observation.
Repeated attacks of delirium tremens may gradually pro¬
duce mental instability, which may pass into delusional in¬
sanity. I have seen several cases in which neurotic patients
have had acute attacks of delirium tremens of the ordinary
type. Later attacks of delirium tremens have been followed
by slight mental perversion, which has rapidly passed off, but
as age increased and the attacks of delirium tremens recurred
the mental disorder became more pronounced, so that these
persons had to be secluded in asylums.
In one case a third seclusion proved to be the last, as the
patient never recovered from his insanity, which was charac¬
terised by hallucination of all his senses, with ideas of perse¬
cution and of poison.
To sum up, the result of my experience among neurotic
subjects is that partial weak-mindedness may follow on an
attack of delirium tremens, and this, too, is most commonly
well marked if insanity exist in the family.
Delirium tremens in neurotic patients may be but the first
symptom of nervous disorder which may assume either of the
forms common in ordinary insanity, the delirium being the
active cause or “ motor ” in producing the disorder.
Repeated attacks of delirium tremens, especially in those of
nervous inheritance, tend to create chronic forms of insanity.
Each attack makes the person less stable, and causes insta¬
bility to be most marked along certain lines. Thus I have
seen neurotic patients suffering from ordinary delirium tremens.
These, later, have had delirium tremens followed by certain
prolongations of the disorder, which were got rid of on several
occasions, but on still more recurrences of delirium tremens the
tail of the disorder remained as a permanent mental appendage.
Digitized by Google
1885.]
535
On Alcohol in Asylums, chiefly as a Beveraqe. By D. Hack
Tuke, P.B.C.P.
(Paper read at the Psychological Section of the British Medical Association,
held at Belfast, July, 1881.)
My object in this paper is to elicit the opinions of asylum
superintendents in regard to the use of some form of alcohol in
the ordinary dietary of institutions for the insane, and to state
at the same time what I already know in respect to this
question, thanks to the very general replies I have received
from medical superintendents to a troublesome circular which
I recently issued. It was not without much hesitation that I
sent round these queries, well aware as I am of the multitudi¬
nous duties already devolving upon the heads of asylums; but
the importance of the subject induced me to overcome this
reluctance, and I take the earliest opportunity of expressing
my appreciation of the kindness of those gentlemen who have
taken the trouble to fill up the circular. A s to those who have
not done so, I readily take the will for the deed.
That this subject is, as I have said, an important one, I sup¬
pose no one, whatever opinion he may hold about it, will for a
moment deny. It is of importance to the patients on the one
hand, and as respects pauper asylums, may be so to the ratepayers
on the other. I hasten to say, however, that the decision arrived
at as to asylum diet must be determined by what is really the
best for the administration of the asylum and the good of the
patients, physically, mentally, and morally, and not by what is
most economical from the ratepayer’s point of view; although,
of course, I do not deny that if what is best for the order of the
house or the health of the inmates is also the best financially,
added force is given to the conclusion.*
I issued the subjoined circular to the County and Borough
Asylums and to the Registered Hospitals of Great Britain and
Ireland. These are 129 in number, 80 in England and Wales,
26 in Scotland, and 23 in Ireland. The replies amounted to
100, namely, 66 in England and Wales, 18 in Scotland, and 16
* An indication of the practical importance of the question is afforded by a
letter received from a medical superintendent, in which he writes :—“ Publio
opinion in the county is pressing me to make a change, but I cannot yet make
up my mind on the question, and am awaiting with interest the result of your
debate.”
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536 On Alcohol in Asylums, chiefly as a Beverage , [Jan.,
in Ireland. The total number of patients in these asylums is
53,855 :—
1. Average number of Patients resident during last year (1883).
2. Persons having their Meals in Asylum in addition to Patients.
8. Do you give Beer or any Alcoholio other than medicinally F and if so,
what is the allowance ?
4. If not, do you give any substitute ?
6. What was the average weekly cost, per Patient, in 1883, for supplying
Alcoholics (including cost of Brewery, when Beer is brewed in Asylum) ?
6. What was the expenditure during the above year, in (1) Beer, (2) Porter
and (3) Wine or Spirits, respectively.
7. Are your Attendants and Servants allowed Beer ?
8. If not, what, if any, substitute or equivalent do you give ?
9. If Beer and other Alcoholics have been disused as a beverage in your
Asylum, will you briefly state your views as to the result upon the health of
the Patients and the discipline of the Wards ?
Of the 100 asylums, the superintendents report in 50 in¬
stances that alcohol is not used for patients in any form or
for any use except as a medicine,
I proceed to enumerate them.
England and Wales .
Birmingham Borough Asylum, Winson Green.
Ditto, ditto Bubery Hill.
Bristol Borough Asylum.
Cornwall County Asylum.
Cumberland and Westmoreland County Asylum.
Carmarthen County Asylum.
Derby County Asylum.
Durham County Asylum.
Denbigh, Anglesea, Carnarvon, Flint and Merioneth.
Devon County Asylum.
Glamorgan County Asylum.
Hull Borough Asylum.
Hereford County and City Asylum.
Ipswich Borough Asylum.
Kent County Asylum, Barming Heath.
Lancashire County Asylum, Lancaster.
Monmouth, Brecon, and Radnor County Asylum.
Northumberland County Asylum.
Somerset County Asylum.
Surrey County Asylum, Cane Hill.
Yorkshire West Biding County Asylum, Wakefield.
Ditto ditto ditto Wadsley.
Note, —At the York Retreat stimulants are not provided. They are, how¬
ever, used and charged to the account of the patients requiring them.
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Scotland .
Argyll District Asylum.
Ayr District Asylum.
Dumfries Asylum, Pauper Department.
Fife and Kinross District Asylum.
Glasgow. District Asylum, Bothwell.
Ditto Barony Asylum, Woodilee.
Ditto City Asylum.
Ditto Govan Asylum.
Greenock Asylum.
Mid Lothian District Asylum.
Paisley Asylum.
Perth District Asylum.
Roxburgh District Asylum.
Ireland .
Belfast District Asylum.
Ballinasloe.
Castlebar.
Clonmel.
Carlow.
Down.
Dundrum Criminal Asylum.
Ennis.
Enniscorthy.
Killarney.
Londonderry.
Limerick.
Omagh.
Sligo.
Waterford.
Before I state the opinions of the superintendents of those
asylums in which alcoholics have been discontinued, I must cite
the opinions of those who continue their use and decidedly ob¬
ject to make a change. The number, out of the 50 superinten¬
dents of alcohol-using asylums, who express their opinion is
unfortunately very few, but they are none the less worthy of
respectful consideration.
1.—Mr. Symes, the medical superintendent of the Dorset
Asylum, says :—" All the beer given to those who are not ill
never causes any excitement or breach of discipline. Just as
with tobacco, many persons like it. Should patients have such
a trifling luxury withheld ? ”
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2. —Mr. Kooke Ley, who, although he has discontinued the
use of beer in the recently-added annexe where the bulk of the
epileptics are located, allows its use in the asylum generally,
thus writes :—“ Of course patients will get on without beer
as they would do without tobacco or snuff, but that, in my
opinion, is no reason for depriving them of these little luxuries.
Patients do not find an asylum a pleasant place to five in, and
it will not add to their contentment to cut off their beer and
tobacco. I should like to hear from some superintendent who
indulges in beer or wine himself what harm he thinks the
asylum beer will do his patients/’
3. —Dr. Jepson, of the London City Asylum at Stone, ob¬
serves :—“ I am strongly opposed to the plan of enforcing
teetotalism, but I am always willing to consider the feelings of
those who are abstainers/’
4. —I ought in this place to quote the testimony of Dr.
Harris, the superintendent of the Norwich Borough Asylum,
where beer is allowed. He is to be congratulated for being
able to speak in these glowing terms of the state of his
asylum :—“ Tranquillity,” he says, “ invariably reigns in the
wards, and the discipline is considered good. I have not seen
any patient excited in this asylum from alcohol, and should be
sorry to see the beer allowance cut off. This simply shows that
beer does not excite any patients as allowed here.”
This is certainly a very modest deduction.
5. —In similar terms writes Dr. Tate, of the Nottingham
Lunatic Hospital, where there are 76 patients :—“ During the
25 years I have been superintendent of this asylum I have
never observed any ill-effect either amongst patients or ser¬
vants from drinking the beer allowed to them, viz., two pints
daily for males, one pint for females, for both patients and
attendants.”
6. —Dr. Wild, superintendent of the Netley Lunatic Asylum,
writes :—“ The giving of beer, &c., rests entirely with myself,
and my opinion is that a pint of moderate beer or porter taken
with the food is, as a rule, decidedly beneficial. I may say
that I rarely use any other form of alcohol, and as such allow
it in every case unless there are special reasons against it.”
7^-Dr. Spence, superintendent of the Stafford Asylum,
writes :—“ Happily I am supported strongly by my Com¬
mittee in adhering to the good old plan of giving the
patients one of their very few pleasures, a glass of beer.”
Dr. Spence, however, does not give beer to “ the imbeciles
and the grosser epileptics.”
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8.—One superintendent expresses himself strongly in favour
of giving beer, but is one of those who feel themselves placed
in a difficult position. On the one hand they feel a strong
repugnance to introduce any sweeping rule into the diet allow¬
ance which appears unsocial and opposed to an Englishman’s
notion of good cheer, while on the other hand they are dis¬
turbed by the abuse of the privilege in the form of patients
becoming intoxicated from obtaining much more than their
allowance of beer. This superintendent, warmly opposed as he
is to the discontinuance of beer in the asylum, observes that
after one of these unpleasant occurrences he exclaims, “ I wish
to goodness there was no beer at all in the house.” In cooler
moments, however, he cannot bring his mind to favour the de-
prival of the patients of what he contends has the effect of
making the asylum population happier for a few hours every
day than they otherwise would be.*
Returning now to the superintendents of asylums in which
alcoholics have been discontinued, I find it convenient to divide
them into three classes :—
I. —Those who have found the disallowance of stimulants
(except as a medicine) to be injurious.
II. —Those who have not observed any effect, whether
favourable or unfavourable.
III. —Those who regard the experiment as successful.
I will cite all that has been communicated to me under the
first and second heads. The returns under the third head are
the most copious, and I am afraid time will not admit of my
reading them all.
I.
The returns from superintendents who have found the dis¬
allowance of stimulants (except for medical treatment)
to be injurious.
Under this head I have to give the observations made by
Dr. Ashe, of the Dundrum Criminal Asylum.
“ Beer,” he says, a was formerly used as an extra for work¬
ing patients. A severe deterioration took place in the health
of the inmates just about the time when it was disused, but
though at first inclined to attribute it to the withdrawal of the
* The steward of an asylum where alcoholics are used thus expresses him¬
self :—“ If there is beer in the way it goes I can’t tell you how. Men will take
it as they breathe the air. The great difficulty is to keep a hand on the beer
barrel. It is extraordinary what dodges and schemes there are to get at the
beer barrel.” He does not, however, approve of the practice of disallowing
beer altogether.
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540 On Alcohol in Asylums , chiefly as a Beverage , [JarL,
mild stimulant tonic, I afterwards thought that other circum¬
stances had at least as much to do with it. The deterioration
consisted in a tendency to develop phthisis, which proved fatal
in several cases, the house up to that time having been remark¬
ably free from such diseases.”
The only other superintendent I can quote under this head
is Dr. Claye Shaw, of the Middlesex Asylum. Dr. Shaw’s
experience, however, does not touch the question whether dis¬
continuance of beer is injurious. He simply failed in his
attempt to make a change. He writes:—“ We tried the
discontinuance of beer in one of the wards on each side for
a few days, but we very nearly had a riot in consequence.”
II.
The returns from Superintendents who have not observed any
effect, whether favourable or unfavourable.
1. —Under this head I refer to an asylum in which the experi¬
ment has been partially tried, namely, the Leicester Borough
Asylum, where, out of 457 patients, only 79 patients have beer,
and these only half a pint. The rest have tea or coffee. The
superintendent, Dr. Finch, observes :—“ The change in the
dietary has had no perceptible effect upon the health of the
patients.” He adds that “ it has occasioned scarcely any com¬
plaint among the patients.”
2. —I would refer here also to the Northampton County
Asylum, inasmuch as although beer is given to workers* as a
reward, it forms no part of the ordinary diet. Dr. Greene
reports :—“ Some years since the beer was discontinued to the
non-workers without any appreciable effect.”
3. —Again, at the Northumberland County Asylum, where
beer has been partially allowed and is about to be wholly dis¬
continued, Dr. McDowell states that “In 1876 beer was re¬
moved from the dietary of some patients as an experiment.
The result was absolutely negative in every respect. Its use
was further limited in 1-879 ; result the same. Next month it
will be discontinued altogether.”
* The number in the list of non-alcoholic asylums would have been larger,
had I not excluded those in which beer is given to workers. Returns have also
oome to hand since |this paper was written, reporting the non-use of alcohol
in the Armagh, Maryborough, and Haddington Asylums.
As is well-known Dr. Strange, of the Salop Asylum, holds strong views against
disallowing beer in asylums. He, however, says “ I see no reason for giving
beer to a lot of idle imbeciles and dements.” It is “only given to real working
patients and by medical order
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541
4. —At the Worcester Asylum, where a partial trial has been
made. Dr. Cooke writes :—“ Not the slightest alteration either
as to improvement or deterioration in the health of the patients
or discipline of the wards has occurred in those wards where
alcohol as a beverage has been disused.”
5. —Dr. Mitchell writes from the West Riding Asylum,
Wadsley :—“I have not noticed any difference either in the
health of the patients generally or in the discipline of the
wards since beer was discontinued as an article of diet. The
beer formerly given was of too weak alcoholic strength to have
any effect in any way upon the patients, unless it may have
had a slight mild diuretic effect upon the more feeble of
them.”
6. —Dr. Skae, the superintendent of the Ayr Asylum, writes:
—“ I have found no appreciable result upon the health of the
patients or the discipline of the wards since beer was disused
as a beverage. The quantity which was at any time allowed
was so small, and the quality of the beer so feeble, that its
withdrawal was apparently never felt.”
7. —Dr. Cameron, of the Mid Lothian Asylum, writes :—“ I
believe no appreciable change can be discovered either in dis¬
cipline or in health that can be fairly attributed either to the
moderate use or the disuse of beer or porter, but I do not
favour the system of giving stimulants to attendants, at least in
this county, where whisky is the popular drink.”
8. —Dr. XJrquhart, of the Murray Royal Asylum, Perth, says:
—" I have served in teetotal and beer-drinking asylums, and
do not believe that this question has any appreciable influence
on the state of the patients as regards discipline. For myself, I
order wine and other alcoholics for medical reasons, but I also
meet the wishes of my patients themselves, and do not refuse
what they ask for, except for medical reasons. For instance, I
would never allow a glass of beer to a patient whose insanity
depended on or was interwoven with alcoholism, though I con¬
sider it a needless hardship to deny it to a chronic case of, say,
monomania. It is to be remembered that I have to deal with
private patients only. Were I managing an English pauper
asylum I should unhesitatingly knock off the beer, secure an
ample dietary, and offer the attendants an equivalent money
allowance. I would be inclined to bribe workers in the
fields, &c., with a lunch of bread-and-cheese and beer, and
to serve out a ration of currant loaf and beer at the usual
dance.”
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542 On Alcohol in Asylums, chiefly as a Beverage , [Jan.,
m.
The returns from those Superintendents who, from their expe¬
rience of its disallowance, regard the experiment as
successful.
1. —Mr. Whitcombe, the medical superintendent of the Bir¬
mingham Borough Asylum, Winson Green, writes :—“ Disci¬
pline has improved; less discontent and quarrelling. Health
of patients has certainly not suffered. The effect of abstinence,
on drinking cases especially, appears to have a good influence.
All acknowledge they can get on just as well without drink.-”
2. —Dr. Lyle, the superintendent of the other Borough
Asylum, Birmingham (Rubery Hill), writes :—“ The health of
the patients has in no way suffered. I think there is more con¬
tentment among them, and no quarrelling as to certain patients
getting more than their share. Indeed, I am well pleased with
the result of giving no beer.”
3. —Dr. Thompson, of the Bristol Borough Asylum, where
beer was only discontinued September (1883), says :—“I see
no evil result upon the health of the patients; and the disci¬
pline of the wards, both as to patients and attendants (espe-
pecially as to the latter), is much more easily maintained.”
4. —From the Cumberland and Westmorland Asylum, where,
from the opening, under the superintendency of Dr. Clouston,
to the present time, beer has not been used in ordinary diet, a
very strong expression of opinion comes in favour of the course
pursued. Dr. Campbell’s conclusions, as given in his annual
reports, are so well known that I will only quote one passage
contained in a letter to myself :—“ I use really good liquor for
those who need it, and give it when I think it useful. I have
always thought it foolish to give dements, criminals, and imbe¬
ciles, beer as an article of diet. If you do give it, call it by its
proper name—a luxury.”
5. —Dr. Hearder, of the Carmarthen Asylum, thus writes :—
“ The change has been entirely satisfactory. It caused no dis¬
content either among patients or attendants. The general
health has not been affected. The discipline has certainly im¬
proved.”
6. —I come next in alphabetical order to the Derby Asylum.
Dr. Lindsay writes :— u In my opinion the health of the patients
has certainly not suffered, nor their comfort, whilst at the same
time the discipline and comfort of the wards have without doubt
been improved. The attendants, too, are satisfied, and have
never once attempted to bring beer in. They prefer the money
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543
1885.] by D. Hack Ttjke, M.D.
compensation ” (£3 5s. a year to male attendants and servants
and £2 15s. to female ditto).
7. —Dr. Smith writes from the Durham County Asylum : —
“ Both the health of the patients and the discipline of the
wards have improved.”
8. —The superintendent of the Denbigh Asylum, Dr. Cox,
says : — a Since the discontinuance of beer in the ordinary
dietary of the patients, their health has been very satisfactory,
their conduct quieter, and general disposition on the whole
more contented and more easily satisfied, especially among
those who are fit to undertake some form of employment.
Tea, coffee, and butter-milk are given to the latter class as a
substitute for beer. Their physical condition appears to be
maintained provided the diet is abundant and of good quality.
The discontinuance of beer among the attendants and staff, and
the substitution of beer money, has improved their general con¬
duct. Discipline can be more readily maintained, and their
general health could not be more satisfactory.”
9. —Dr. Saunders writes from the Devon Asylum :—“ The
disuse of beer, &c., has been in every way satisfactory.”
10. —At the Glamorgan County Asylum Dr. Pringle thus
expresses himself :—“ The health of the patients has been in
no way impaired, and there has been marked improvement in
the discipline of the wards.” “ Beer to ordinary patients was
never given here unless as a reward for work. Now workers
f et milk instead of beer. Before stopping the attendants' beer
got the head attendants to enquire as to whether'beer or its
money value would be preferred, and out of 65 attendants and
servants 63 chose the latter.”
11.—Dr. Merson, superintendent of the Hull Borough
Asylum writes :—“ The result has been altogether favourable
both as to health and discipline.”
12.—At the Hereford Asylum Dr. Chapman reports the re¬
sult to be, although not very marked, still on the whole for the
better. “ This is perhaps marked,” he says, “ in some indivi¬
dual patients, and in the absence of the quarrelling that often
resulted from the desire to obtain an undue supply.”
13.—Dr. Chevallier, of the Ipswich Asylum, reports that the
practice “ has been altogether satisfactory.”
14.—Dr. Pritchard Davies, the medical superintendent of the
Kent County Asylum, Barming Heath, writes very strongly
“ Since we abolished beer as an article of diet the general
health of the patients has improved, and the wards have been
much quieter. I attribute much of this to the fact that the
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544 On Alcohol in Asylums , chiefly as a Beverage , [Jan.,
patients eat more food now than they used to. When we gave
beer, the first thing a large majority of the patients did, when
they sat down to dinner, was to drink all the beer. After that
they had not good appetites, and the consequence was that a
great quantity of the food supplied was wasted and went to the
farm for the pigs. As a proof of the correctness of this idea I
may mention that since we abolished the use of beer the aver¬
age weight of the patients has increased, and we have had to
buy food for the pigs in very much larger quantities than for¬
merly. I can speak strongly of the good effect total abstinence
has had upon several of my patients. Many have told me how
very hard they found it during the first few weeks they were
forced to go without their beer or the usual ‘ spirits ’ at night;
yet after awhile they felt better ; and without any attempt to
get favourable evidence from them I have been over and over
again assured that they were now convinced they were better
without ‘ drink/ I do not wish to be considered as an advo¬
cate for universal teetotalism.”
15. —Dr. Cassidy (Lancaster), states that there has been “ a
greatly improved condition of the asylum generally,” but he
does not attribute this to the disuse of beer alone, but to this
conjoined with a life of more freedom in the open air and in¬
doors.”
In referring to the Lancashire asylums I would remark that
although I do not include the Rainhill Asylum in the non-alco¬
holic list. Dr. Rogers has discontinued beer in certain wards,
and states that this has been done with advantage, and that he
shall therefore very probably discontinue its use altogether
eventually.
16. —From the Monmouth Asylum Dr. Glendinning writes s
— u The discipline of the wards has undoubtedly been greatly
improved, and the officers have been relieved from the per-
* petual requests for beer on all sorts of pleas. I do not think
that the health of the patients has been in any way affected by
the discontinuance of beer.”
I have not included the Norfolk County Asylum as properly
belonging to the non-alcoholic list, because workers are allowed
a little beer, but I will quote Dr. Hills’ opinion of the with¬
drawal of beer from the ordinary diet: — “ The health of
patients,” he says, “ is better. They are quieter, less quar¬
relsome, eat more, and their habits are not so faulty.”
17. —Dr. Wade, of the Somerset County Asylum, has
favoured me with a very full and explicit statement of his
experience, premising that he is one of those who believe
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by D. Hack Tuke, M.D.
545
that the evil influence of alcohol in the production of in¬
sanity has been grossly exaggerated. I should also say that
no inference can be drawn from the death-rate in this
asylum now” and before the trial was made, seeing that,
although it has fallen during the non-alcoholic period, this
may be well attributed to improved drainage coincidently
with the discontinuance of beer. He writes :—“ The beer
dietary acted, in my mind, injuriously in the discipline of the
asylum, for there were always a large number of patients who
did not care for the alcoholic beverage, and who bartered it
away to others who had a craving for it, and who thus had too
much. Again, attendants have frequently indulged useful
patients with extra beer at the expense of others who did not
work, thus causing much squabbling. Indeed, the universal
testimony of the best among my attendants is that the non-use
of beer saves much fighting in the asylum, and the wards are
certainly much quieter here, where we use no beer, than they
were in the first asylum where I was assistant, where the beer
was used. But besides this, I have come to the firm convic¬
tion that the quantity of beer given to working patients in
asylums is most iniquitous in principle, e.gf., a labouring
man, comes in, who earns, say, 14s. a week. He gets for his
ordinary diet half a pint at dinner and half a pint at supper.
As he gets better he is sent out to work, and then is given half
a pint extra at eleven and four o'clock. So when doing very
easy work he gets two pints of beer daily. Is not that enough
to justify the man in saying when he goes out in the world
again that he requires two pints daily ? for the doctor at the
asylum gave it to him when he worked, although he did not
work as hard as he has to do outside. And besides, the iniqui¬
tous principle is maintained of paying in liquor for work done,
a custom that has led to much intemperance. As a fact, I
never have any complaints from any patient about the disuse
of beer, except from those who are manifestly the better for
being without it, and for whom a short period of compulsory
total abstinence is highly beneficial. The attendants them¬
selves unanimously requested to be allowed money in lieu of
beer, and in two years I have not had a single case of drunken¬
ness in nearly 100 attendants . 99
18.—Next in order comes the East Riding Asylum, Bever¬
ley. Dr. McLeod writes that “ the health of the patients has in
no way suffered since beer was disused. The discipline of the
wards has improved. Beer is, on the whole, a mistake in
asylum dietary."
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546 On Alcohol in Asylum , chiefly as a Beverage, [Jan.,
19. —At the West Riding Asylum, where the experiment has
been only recently tried, Dr. Major observes in his annual re¬
port :—“ Upon the whole I am of opinion that, given a satis¬
factory dietary in other respects, the balance is in favour of the
omission of beer in ordinary cases as being at least unnecessary,
and where large numbers of the insane are together under care
a frequent source of inconvenience and trouble.”
20. —Dr. Rutherford’s views on the disallowance of beer are
so well known that I need not do more than quote his observa¬
tion that “ the discipline and general tone of an asylum are
vastly better where stimulants are disused/’
I have not included the Edinburgh Royal Asylum in the
non-alcoholic list, because half a pint of very weak beer is
given to workers at lunch; but, as Dr. Clouston observes, this
asylum may be regarded as not giving beer as a part of the
ordinary dietary, and upon this his verdict is—“ We certainly
do not suffer in consequence.”
21. —From the Fife and Kinross Asylum, Dr. Turnbull
writes : —“ My opinion is strongly against the use of beer. The
disuse of it here has not had any prejudicial effect on the health
of the patients, and my impression is that the discipline of the
wards is better when alcoholics are not given.”
22. —Dr. Yellowlees writes very strongly in favour of a non¬
alcoholic dietary :—“ Here it is given either for purely medical
reasons or as a mere luxury on the table of the wealthier
patients (the gentlemen only; the ladies have none). I give
no alcoholics to anyone as a luxury unless in the cases where
it would be depriving the patient of what has been a lifelong
and harmless'indulgence—the glass of wine at dinner.”
23. —Dr. Merrick reports of the Belfast Asylum that,
although no stimulants are given to the patients or attendants
other than medicinally, the health of the inmates is good. No
substitute or equivalent is given.
24. —From the Ballinasloe Asylum, Dr. Fletcher writes :—
“ I am decidedly against stimulants save as medicine in aslyums,
and consider it much more easy to maintain discipline without
than with alcoholics.”
25. —From Ennis, Dr. Daxon, the Superintendent writes that
the general health is good, and the death-rate below the ave¬
rage. Milk is given at the rate of 1,000 gallons per month.
26. —Dr. Drapes, the medical superintendent of the Ennis-
corthy Asylum, writes :— u I believe on the whole that the dis¬
continuance of alcohol has had a salutary effect on the health
of the patients and the discipline of the wards.”
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by D. Hack Tuke, M.D.
27. —Dr. Oscar Woods, Killarney Asylum, says :—“ I think
alcoholics as a beverage not only useless but injurious, both as
regards health and discipline.”
28. —Dr. Hetherington, Londonderry Asylum, says “The
health of the patients is remarkably good. Stimulants are
only used when ordered by the medical officers. There is no
limit attached thereto. The attendants were never allowed
beer, and my opinion is that a large majority of them would
be against its introduction.”
29. —Prom the Waterford Asylum, Dr. Ringrose Atkins
writes :—“ The female patients working in the laundry used to
have porter. This I stopped early last year, and I find that
the working and discipline of that department have not been in
the smallest degree injuriously affected thereby. On the male
side I have found it very difficult to effect the same change
suddenly.”
30. —Dr. Conolly Norman, the medical superintendent of the
Castlebar Asylum, where alcoholics are not given, is in favour
of this course.
I would here observe that in some instances superintendents
who report that alcoholics are used only medicinally do not ex¬
press any opinion as to the effect on the patients, because no
other practice has prevailed since the opening of the institution.
Thus from the Greenock Asylum, where the expense of stimu¬
lants does not exceed a farthing a week, Mr. Hardie simply
states, in reply to my query :—“ Never were in use. We
give officials and patients plenty of sweet milk.”
Several of my Scotch and Irish friends smile at the idea
which some appear to entertain that there is something new in
the disuse of stimulants in an asylum, whereas they have been
disallowed by them for many years. They think the matter
has long passed the stage of experiment. An English super¬
intendent takes the latter view also, very strongly.
Summary and Conclusion.
1. —Out of the 129 County and Borough Asylums and Regis¬
tered Hospitals in Great Britain and Ireland, I have been
favoured with replies from 100. These returns comprise
53,855 patients out of 64,103, the total number in the asylums
of the description just mentioned.
2. —Of the 100 returns received, one-half report the non-use
of alcoholics other than medicinally.
3. —Among the 50 in which alcohol continues to be used,
eight superintendents express themselves strongly in favour of
xxx. 37
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548 On Alcohol in Asylums , chiefly as a Beverage, [Jan.,
the retention of alcohol as a beverage, and, doubtless, many
hold the same view who have not expressed it. The presump¬
tion, indeed, is that in those asylums in which alcohol is used,
the superintendent approves of it rather than otherwise.
4. —In regard to the 50 in which alcohol is disused, one
superintendent has had his suspicions that this course has
proved injurious, and another found the attempt endanger the
peace of the household.
Eight superintendents have observed no result favourable or
unfavourable.
Thirty superintendents hold that they have observed very
beneficial results from the course pursued. The improvement
usually refers to both the patients and the discipline of the
asylum.
We have now 11 left who make no comment, and in most of
these cases the superintendent could not make any comparison,
because alcoholics had never been given in the asylum.
5. —With regard to a point of secondary but not altogether
insignificant importance, the cost of alcoholics in asylums, I
find that the cost per patient per annum (calculated upon the
total expenditure for alcohol, and the average number of
patients resident) is 12s. for Great Britain and Ireland, being
at the rate of 14s. for England and Wales, 8s. 8d. for Scot¬
land, and 4s. 8d. for Ireland. The total expenditure in alcoholic
drinks is about £32,000.
This shows a marked decrease since 1878, when Dr. Brush-
field made a similar calculation for England and Wales and found
it to be close upon 30s. per patient per annum [£1 9s. llfd.].
6. —If we take the British Asylums in which beer is given as
a beverage, and no substitute is given to those patients who do
not take it, and no money allowance is granted to the attend¬
ants, the average annual cost per patient is £1 11s. 2d.
7. —Taking on the other hand the asylums (12) in which
neither patients nor attendants are allowed alcoholics as a bever¬
age, and where no substitute or allowance is given, the average
annual cost per patient is 2s. Id.
8. —The cost of alcoholics is 3s. 9d. per annum per patient in
the 50 asylums where they are not allowed as a beverage, but
where substitutes are given to patients and allowances to
attendants, and including several cases in which beer is occa¬
sionally given to attendants* This also includes the 12 asylums
appearing above where no alcoholics are allowed and no sub¬
stitute or allowance is given. In 16 of the non-alcoholic asylums,
* i.e. The beer thus given to attendants makes the difference between 2s. and
3s. 9d.
, Google
1885.]
by D. Hack Tuke, M.D.
549
milk, tea, coffee, cocoa, or beef tea are given to the patients and
attendants, and in 15 of these Asylums, a money allowance, and
in 2, uniform are granted to attendants.
In estimating the cost of substitutes and allowances, in order
to ascertain the relative cost of an asylum in which alcoholics
are given and one in which substitutes are provided, it may be
of use to append the relative cost of beer or porter, and of milk,
as calculated several years ago by Dr. Brushfield :—
per
gallon.
d
Beer at 16s. per barrel .
0
5-35
Porter at 29s. 8d. per barrel.
0
9*88
Milk, supplied from the farm, valued at
0
10
Ditto, by contract
1
0
Skim Milk (only half the cream removed) ...
0
6
Dr. Pringle (Glamorgan Asylum) found that the cost of beer
supplied to his patients was £260 a year, and that this sum
would purchase rather more than 14 gallons of milk daily in
addition to what the patients then had. He believed, however,
that 10 gallons were quite sufficient, which would cost £159,
thus effecting a saving of £100, which Dr. Pringle proposed
to devote to the attendants.
One thing seems to me to be very clear, viz., that it is a mis¬
take to have a different diet in the matter of beer with regard
to patients and attendants. If the patients do not take any
beer as a beverage, it may answer to offer an inducement to the
attendants to receive a money equivalent for their own beer;
but so long as the patients have beer, it is a great mistake to
pay anything to the attendants in lieu of beer.
I would here say that I do not see how any distinction can be
made in the dietary between those who are of intemperate
habits and those who are sober. It would be to make the
former a marked man, and would be most undesirable. This,
however, will appear to many to be some reason for disallowing
beer altogether at meals.
It is, indeed, impossible to ascertain accurately the number of
patients who have been of intemperate habits. Dr. Brushfield
gives proof of this, for of 70 readmissions, in only one was in¬
temperance stated to be the cause j whereas he found on strict
enquiry, especially just before the patient’s discharge, that in
no less that 18 this was the cause in a greater or less degree.
Hence, when least wishing to give a patient alcohol, it may be
made part of his dietary.
In presenting the facts now detailed, I have chiefly in view,
as I said at the beginning, the provocation of a discussion. The
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550 On Alcohol in Asylums, chiefly as a Beverage . [Jan,,
materials are before you, and you are as competent to draw
your conclusions on the evidence as I am.
For myself, I confess I was not prepared to find that so many
asylum superintendents in England and Wales had discon¬
tinued stimulants other than medicinally. Still less was I pre¬
pared to receive such strong expressions of opinion in favour
of this course, both as regards the health of the patients and
the increased order and discipline of the asylum.
The counter expression of opinion comes from those who
have not tried the experiment, with the exception of Dr. Clay©
Shaw, who, having made it, promptly retired before the insur¬
rection which menaced him; and with the exception (to a
qualified extent) of Dr. Ashe, who, however, continues to dis¬
allow beer at Dundrum.
I can sympathise with the feeling that it is rather hard lines
to cut off a poor man’s beer who has been accustomed to it all
his life. On the other hand, we must remember that in the
administration of an asylum, a balance must often be struck
between conflicting interests; and I do think, in this beer
question, that if the health of the patients does not suffer and
the discipline of the asylum is better maintained, asylum
authorities are fully justified in discontinuing the use of stimu¬
lants other than medicinally, even if a few patients feel it to be
a hardship. I am glad that hitherto the change has been
almost always made at the instance or with the full concurrence
of the medical superintendents themselves and not their com¬
mittees. I hope that pressure will never be put upon the
former to make a change, and that they will not adopt it unless
they honestly think that it is on the whole for the good of the
institution they superintend. I would here make one obser¬
vation arising out of the remark frequently made in the Returns,
that the beer is so weak in its character that it cannot possibly
do any harm to the patients. Well, if that be so, one cannot
suppose that much good can come of it either; and while I
wish to keep the question of expense in a subordinate place, I
should be disposed to query whether the present large outlay on
beer alleged to be too weak to have any effect, is altogether jus¬
tifiable. I do not think the substitutes given and the money
allowance will often equal the amount spent at present in
asylums where alcoholics are freely allowed; but I should be
very glad to know that, where they are discontinued, the
dietary is proportionately increased, and the wages of the
attendants and the cook raised.
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1885.]
551
CLINICAL NOTES AND CASES.
Clinical Cases .—By Joseph Wigles worth, M.D.Lond.,
Assistant Medical Officer, Rainhill Asylum.
I. Case of Apoplectiform Cerebral Congestion , or Serous
Apoplexy .
Annie P., set. 35 years, had been an inmate of Rainhill Asylum for
12 years. She was subject to attacks of recurrent mania, in the
intervals between which she would be quiet, orderly, and rational;
the attacks usually lasted some months, and were attended with great
restlessness and loquacity, but not with much incoherence. She was
at these times very mischievous and destructive, and was indeed a very
troublesome patient — generally appearing to have a very good
notion of what she was about, and seeming to commit many of her
destructive acts on purpose to give trouble, though this apparent
capacity for self-restraint was doubtless illusory. In April, 1883, she
had been for upwards of 18 months in a maniacal condition, which
attack had thus been not only unusually prolonged, but had also been
in some respects exceptionally severe. On May 1st following she
did not appear very well, but exhibited at that time no special symp¬
toms beyond a little mental dulness and some delay in responding to
questions. These symptoms gradually increased, and though there
were no physical signs of disease, patient called out at times when
moved ; she took her food fairly well, but had to be fed, and her bowels
were freely relieved after medicine. At 2.15 p.m., on the 5th inst.,
a great change was observed in her ; her face was noted to be livid,
conjunctivas insensitive to touch, pupils much dilated, being each
about 6 mm., and did not respond to light; respirations slow; pulse
80, full; temp, about 95° (the index did not rise at all, and the
thermometer did not register lower); limbs flaccid; plantar reflex,
very slightly marked, as also were the knee jerks. She was, in fact,
deeply comatose, and presented all the symptoms of cerebral hemorr¬
hage, a diagnosis of which was, with some confidence, made. Two
drops of croton oil were given, and an enema, but neither had any
effect. At 5 p.m., in addition to deepening coma, there was distinct
drawing of the angle of the mouth to left. The eyes were directed
straight forwards, or with a very slight external deviation in each.
At 10 p.m. every muscle in the extremities appeared absolutely flaccid,
and the reflexes were completely abolished. Pupils as before. Re¬
spirations irregular, with mucous rattling in throat. Pulse 110,
bounding. Temp, about 95° (the index, as before, would not rise at
all). 11.45 p.m., died.
7th. Autopsy (38 hours after death).
Cranium . Calvaria normal; dura mater not abnormally adherent
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552
Clinical Notes and Cases .
[Jan.,
thereto. A little black clot at posterior part of longitudinal sinus.
No excess of fluid in subdural space; no bagging of the dura-mater,
the surface of the brain being everywhere closely pressed against it.
Veins of meninges fairly distended, but by no means abnormally so.
Arachnoid a little thickened over lower surface of pons, but not else¬
where. Marked injection of pia-mater over convex surface of brain,
giving it a slightly rosy appearance. Pia-mater a little difficult to
strip on account of its tenuity. General pink-staining of surface of
cortex. Gyri not at all wasted, but everywhere firmly in contact, the
subarachnoid fluid being absent, or nearly so. Cortex apparently
normal, not diminished in depth, and striation distinct. Ventricles
somewhat dilated, and distinctly distended, with clear fluid. Puncta
cruenta numerous. Brain generally of fair consistence—a little wet.
Basal ganglia decidedly soft; fornix very soft. Cerebellum, pons,
and medulla healthy. Basal vessels healthy.
Brain (immediately after removal) 1,318 grammes.
Right hemisphere... bos') stripped of membranes
Left ... 555j to great extent.
Cerebellum . 141
Pons . 15
Medulla oblongata 8
1,287
Thoracic and abdominal viscera normal.
Remarks .—The pathology of this case appears to me by
no means clear. Idiopathic cerebral congestion , terminating
fatally, is an affection which, though described in text books,
is one about which no little obscurity rests; whilst as regards
serous apoplexy we are told that this term ought to be discarded
from our nomenclature. As will have been seen, the symptoms
presented were so strikingly those of brain pressure, and, in
their pronounced form, came on so rapidly, as to lead to a con¬
fident diagnosis of cerebral haemorrhage, probably ventricular.
The conditions noted after death, namely, distension of the
ventricles with clear serum—convolutions pressed together,
with absence of subarachnoid fluid—harmonised with the
clinical symptoms, and might be supposed to favour the view
of a primary effusion of serum into the ventricles—a serous
apoplexy.
On the other hand, whilst signs of venous congestion were
absent, those of arterial hypersemia were manifest, as instanced
by the injection of the pia mater, and the pink staining of the
surface of the gyri.
I should myself favour the view of a primary arterial
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1885.]
Clinical Notes and Cases.
553
hypersemia of the brain, the effusion of serum into the
ventricles being purely a secondary phenomenon, but why such
hyperaemia should have taken place I am quite at a loss to
understand.
The case suggests some reflections, both as regards diagnosis
and treatment. How is such a case to be distinguished from
cerebral haemorrhage, especially when this occurs in the
ventricles ? In connection with which point let me emphasize
the fact that the temperature was, and remained, sub-normal.
Then as regards treatment: possibly active treatment in the
form of bleeding, ice to the head, &c., might have resulted in the
recovery of the patient; but the resemblance of the symptoms
to those of cerebral haemorrhage prevented a resort to what, in
such case, would certainly have been nugatory.
II. Four Cases of Melancholia in One Family.
Elizabeth B., set. 47, single, domestic servant, was admitted into
Rainhill Asylum Oct. 28th, 1879. She had been nursing a sister
who was suffering from what was called “ religious mania,” and had
lost her rest in consequence. Two days before admission she hung
herself in a wash-house with a rope, but was discovered and cut down
in time to prevent serious consequences. On admission she was noted
to be a thin, spare woman, but, with the exception of slight pulmonary
emphysema, her viscera appeared sound. She had a very depressed
appearance and manner, but her conversation was collected and
rational, and, beyond the abnormal depression, there did not appear to
be anything wrong. She rapidly improved, and in three weeks’ time
was quite cheerful, and working well in the ward. She was dis¬
charged, recovered, on December 19th.
She lias been seen at intervals since her discharge, and had re¬
mained well up to the time she was last heard of, about a year ago.*
Margaret B., aet. 33, single, housekeeper, was admitted Jan. 6th,
1880. She was the sister whom Elizabeth B. was nursing when she
(the latter) broke down. Her history was simply to the effect that
she had got despondent without obvious cause some seven months pre¬
vious to admission—thought she could not be saved, &c. She was a
rather short, dark-featured woman, fairly nourished, with healthy
thoracic and abdominal viscera. She had an aspect of great depres¬
sion, and a nervous, frightened manner. She sat all day with her
hands before her doing nothing; she seldom spoke, unless when ad¬
dressed, and then gave utterance to various melancholic expressions
and self-accusations, such as that she was the greatest sinner on the
earth, that she had committed adultery, &c. ; in fact she presented
the symptoms of typical melancholia. She improved somewhat in the
* Since the above was written this patient has committed suicide by drowning
herself in a reservoir.
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554
Clinical Notes and Cases .
[Jan.,
coarse of the first month, and occupied herself with needlework,
though she kept very low and desponding. After this, however, she
relapsed, became exceedingly depressed, and threatened more than
once to commit suicide. By the beginning of July she had improved
very much, having got fairly bright and cheerful, and w appeared to
have lost all her old gloomy thoughts and delusions. This improve¬
ment was maintained, and she was discharged, recovered, on August
16th.
She had remained well up to the time she was last heard of, abont
a year ago.
Margery G., set. 87, was admitted July 26th, 1881. She had been
married 18 years, and had had two children and two miscarriages.
The la6t child had been born 4£ months previous to admission ; she
suckled this child for about a fortnight, but then had to wean it on
account of getting an abscess of the breast; this suppurated for 13 or
14 weeks, and required frequent incisions. This long continued drain
had pulled her down a good deal, and appeared clearly to be the ox¬
citing cause of her illness, which commenced about two months pre¬
vious to admission, with symptoms of depression. She said she was
a sinner, and that the devil had got hold of her; she then tried to
strangle herself. Though continuing depressed, she improved some¬
what for a time, but relapsed again, and shortly before admission got
very excited, and attempted to kill one of her children. On admis¬
sion she was noted to be a thin-featured, dark-complexioned, little
woman, of spare habit, but fairly nourished. Viscera normal. Her
case, though substantially similar to that of the sister last described,
proved much more severe and prolonged. She was at first very quiet,
but appeared distressed and terrified, had a nervous, fidgety manner,
about her, and it was difficult to get her to speak. She continued’
quiet and depressed for the first month, but subsequently got very
agitated, and for about three months presented, more or less typically,
the symptoms of “ melancholia agitans.” She was full of the most
mournful self-accusations, constantly repeating that she was the most
wicked woman in the world, that she ought to be locked up, that she
had turned against her husband and children, &c.; and she at times
threatened to commit suicide. She was all day long giving utterance
to these expressions, and was at the same time very restless, rubbing
the top of her head with her hands until she had made it quite bald.
She then improved for a time, though continuing depressed, she was
more settled, and was got to occupy herself with needlework. By the
end of December, however, she had relapsed again, and was almost as
bad as ever. She continued very restless and agitated, with occasional
intermissions, during the first few months of the following year ; but
gradually the acute symptoms diminished, and by the autumn had
quite subsided, though she still kept depressed. In January, 1883,
she was very much better; she had entirely given up all her old self¬
accusations, was quite rational, and, with the exception of some slight
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555
1885.]
depression at times, was quite well. The improvement continued, and
she was discharged, recovered, on March 19th.
The sequel to this case was melancholy. In June of the present
year, about 14J- months after her discharge from the asylum, she left
her home one evening ostensibly with the object of visiting a relative,
taking with her her two children, aged respectively 15 years and three
years. Whilst walking along a canal bank she suddenly jumped into
the water, and thus committed suicide. She draggedher two children
into the water with her, and the younger of the two was drowned with
her mother, the elder managing to scramble out. It came out in evi¬
dence at the inquest that she had been in a low state of mind for some
months, and had said that she wished someone would put an end to
her misery, and whilst in the water she exclaimed to her daughter
that it was better they should all die together than be parted again.
She was daily expecting her confinement, which was doubtless the
cause of the relapse which had obviously occurred.
Ellen, the fourth sister, did not come under personal observation,
but, as will be seen by the history, she had obviously suffered from
melancholia.
Family history .—Both parents were natives of Lancashire, in no
way connected before marriage, and said to be steady, hard-working
people. Father still living, set. 77 ; mother died, set. 56, of “ soften¬
ing of the brain.” She was paralysed for three years before her death,
but her mental faculties are said not to have been affected. With
this doubtful exception there was no history of mental disease or
neurosis of any kind on either side of the family.
There were eight children in the family, of whom the following is an
account:—
1. John, the eldest, got into a very depressed condition about nine
years ago, after the death of his second wife. That there was here an
adequate cause for depression is patent, but from the account given,
stating that he was at home for some time and so depressed he could
do nothing, it is probable that he also suffered in some degree from
melancholia.
2. A son, who died in infancy.
3. Thomas, died set. 18 of “ typhus fever.”
4. Elizabeth (case described above).
5. Ann, set. 44 ; single ; never mentally affected.
6. Ellen, died of consumption, set. 37. Was married 10 years
before her death, and had three children. She became insane for a time
after the birth of her first child, “ getting very dull and stupefied ; ”
she was treated in the workhouse, and recovered from this attack, but
had a second attack before her death.
7. Margery (case described above).
8. Margaret (case described above).
RemarTcs .—These cases are interesting, not individually, but
collectively, such a series occurring in one family being cer-
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Clinical Notes and Cases .
[Jan.,
tainly unusual and, more particularly so in the absence of
clearly marked hereditary taint. The case of the mother must
of course be looked upon as doubtful. From the accounts
given this would seem to have been an ordinary case of cerebral
haemorrhage, or thrombosis, and, if so, it would lie outside the
neurotic diathesis. As above noted, her mental faculties were
said to have been clear; but we know how unreliable are the
statements of patients 5 relatives on this point, even when there
is no intention to deceive, and the nature of the case must
therefore remain doubtful. It will be seen that of the six
members of the family who attained to adult life, all but two
suffered at different times from melancholia of greater or less
intensity, and two of these cases eventually terminated fatally
by suicide; in fact, if we take the depression manifested by the
eldest son to have been pathological—and from the account of
this furnished I should myself be disposed so to regard it—only
one adult member of the family has hitherto escaped. This un¬
usual consensus of cases is, I think, worthy of being placed on
record.
Notes of a Case of Addison's Disease Associated with Insanity.
By S. Rutherford Macphail, M.D.Edin., Assistant
Medical Superintendent, Garlands Asylum, Carlisle.
(Read at the Quarterly Meeting of the Medico-Psychological Association held
at Perth , November 2lst , 1884).
The rarity of cases of Addison’s Disease, and the want of
accurate knowledge alike of the clinical features and of the
pathology, justify the record of the following case.
John F., aet. 42, carter, admitted to Garlands Asylum Jan. 10,
1883.
History .—The Relieving Officer who brought the patient could
only give a very meagre account of the onset of the mental symptoms,
and was unable to furnish any definite information respecting the
state of his previous health.
He is said to have been a hard-working, healthy, and fairly tem¬
perate man, in constant employment. Two years ago he sustained an
injury to the right knee, which necessitated rest and confinement to
bed for a few weeks. There was a hereditary predisposition to in¬
sanity, his mother having been an inmate of an asylum. The exciting
cause of this attack was said to be attending revival meetings. At
one of these gatherings symptoms of mental aberration first became
apparent, and he had been excited a week previous to his admission
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Clinical Notes and Cases.
557
1885.]
to the asylum. Some years ago he had two short and slight attacks
of excitement, but got well at home.
Present Condition .—He is a short, thick-set, well-developed and
muscular man, with dark shaggy eye-brows, and black hair. His
complexion is muddy and sallow, and the general appearance of the
man gives the impression that he has not been washed for a consider¬
able time. He has an anxious, wistful expression ; eyes wide, con¬
junctivas white and glistening ; pupils equal and contractile; tongue
moist, slightly furred ; pulse 108, soft and full; temperature 98‘2 ;
weight 1701bs. The special senses and sensibility to pain are normal;
cutaneous and tendon-reflex excitability increased. He walks lame.
The right knee-joint is swollen, tender to the touch, and the sur¬
rounding tissues are indurated, but there does not appear to be any
active inflammation. The patient is in a restless, excited, emotional
state, continually shouting, preaching, praying, and talking in the
most flippant manner on religious subjects. Owing to his great
restlessness it was impossible to make a thorough examination of the
chest and abdomen, but as far as the examination went, it was nega¬
tive, no active physical disease being detected.
Progress of Case :—Jan. 12. Since admission he has been noisy,
restless, sleepless and perfectly incoherent in conversation. He
cannot answer questions, and he carries on an incessant rambling
talk, either counting numerals rapidly, or talking to imaginary horses.
Appetite bad ; he requires much coaxing to be induced to take any
food at all. Temperature and pulse have both been slightly over normal
for the last two days. Soap and water have only partially removed
the dark and muddy colour of the skin. The duskiness is general,
but is more pronounced on face and in flexures of arms and thighs.
Jan. 14.—During the last two days he has been more settled and
rational, and this morning he gives coherent answers to questions.
Last night he was* sick and vomited after supper. The bronzing of
the skin is now more marked. It appears to affect the whole
cutaneous surface and the mucous membrane of the lips. In some
places the colouration is very distinct, and on the face, neck, axilbe,
hands and loins, the pigmentation occurs in dark brown patches.
Jan. 21. —Temperature normal, pulse quickened, small and soft.
He has an anxious expression and looks ill; conjunctivas yellowish ;
complains of no pain but says he feels sick ; has a slight cough, a
few bronchitic rales heard over sternum; urine pale, acid, non-
albuminou8; liver dulness extends one inch below margin of ribs;
slight tenderness on pressure over epigastrium. He has had several
attacks of vomiting during last week; after these gastric attacks,
the bronzing of the skin becomes intensified.
Jan 26.—Mental symptoms vary. He is one day excited and the
next depressed, and it is only very occasionally that he can be induced
to answer simple questions about himself. There is marked asthenia,
and he is now so weak that he is kept in bed. The vomiting and
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558
Clinical Notes and Cases.
[Jan.,
retching are very distressing, and he retains little except cold water,
for which he has a great craving. Bismuth, hydrocyanic acid and
sinapisms have been tried with little effect. Nutrient enemata were
given for a couple of days, but were not retained. He complains of
pain in the loins and abdomen, chiefly after vomiting.
Feb. 8.—Vomiting continues occasionally, but is checked by ice
and sinapisms to epigastrium. His diet consists of small quantities
of milk and water;; be rejects everything else almost immediately.
March 2.—Mental condition worse. He is emotional, cries like a
child, and has a very miserable appearance. During the last three
weeks be has been steadily growing weaker and losing ground ; weight
1151b8. On some occasions he seemed better, but the improvement
never lasted more than two days at a time, and the relapse was
always ushered in by a severe attack of vomiting. He takes no
food, but drinks a fair quantity of milk and whiskey. Bowels con¬
stipated ; have to be moved by occasional enemata. He has a very
cachectic appearance; the conjunctiva? are yellow,and present a marked
contrast to the dark hue of the face and lips ; tongue clear and moist.
Bronzed patches can now be distinctly recognised on the lower ex¬
tremities from the knees downwards.
March 10.—He is now quite childish and weak-minded, can exer¬
cise no self-control, and will scarcely answer the most simple ques¬
tions. His habits have become very filthy, and he daubs himself and
his bedclothes with faeces.
March 19.—For the last few days he has been so weak that no
physical examination was possible. On several occasions he appeared
to be dying of asthenia. Last evening he had a fainting fit and lost
consciousness for some minutes, pulse scarcely perceptible. He
shortly rallied, however, passed a fair night, and appeared to sleep.
He died this morning at 9.15 in a syncopal attack similar to the one
last evening.
Autopsy 55 hours after death. Body thin, much emaciated, of a
uniform yellowish brown colour, no definite patches of pigmentation
observed. Bight knee-joint swollen; synovial membrane thickened
and indurated.
Brain .—Cerebral sinuses and meningeal vessels filled with dark
semi-clotted blood ; brain firm on section, nothing abnormal detected.
Heart .—Bight side dilated, muscular substance flabby.
Lungs. —Bound to chest wall at apices by old adhesions, nodules
of miliary tubercle sparsely scattered through both lungs.
Stomach normal.—In the large intestine the faeces were in yellowish
nodules of the size of marbles.
Liver. —Slightly enlarged and congested ; capsule thickened ; old
adhesions to stomach and diaphragm ; structure normal.
Spleen and Kidneys normal.— Supra-renal Capsules both enlarged,
weight of right over an ounce; of left three quarters of an ounce. They
were nodulated and irregular in outline, firm to the feel, and lay em*
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Clinical Notes and Cases .
559
1885J
bedded in a mass of cicatricial tissue. The increase was chiefly in
breadth and thickness rather than in length. On section they consisted
of a whitish, translucent, semi-cartilaginous material with yellowish
patches.
Microscopical sections of one of the supra-renal capsules were made
for me by my friend Dr. E. Baily. The outer coat was thickened and
made up of dense fibrous tissue. The stroma consisted of a fibro-
nuclear growth close to the outer portion of the organ, and this small
cell infiltration could in places [be traced into the formation of fine
fibrous tissue. The interior was made up of an undefined structureless
material containing large cells of an irregular shape, hyaline masses,
and many large giant cells. Several of the cells had undergone
caseous degeneration. The blood vessels, especially those near the
periphery, showed great thickening of the muscular coat, and endar¬
teritis with proliferation of the epithelium.
The solar plexus and the semilunar ganglia were not examined.
Remarks .—The clinical history and pathological appear¬
ances all point to this being an undoubted case of disease of
the supra renal capsules, commonly known as Addison’s
Disease. Although several isolated cases had been reported
previously, Addison, in his original monograph,* was the first
to discriminate, in the living patient, this remarkable train of
symptoms, and associate them with a definite morbid condition
of the supra-renal bodies. Wilks has added to our present
knowledge of the disease by a succession of papers published
from time to time in u Guy’s Hospital Reports,” while Green-
how, in the Croonian Lectures for 1875, has summarised all
that is at present known of the disease, and collected the
statistics of over 300 reported cases. He also read a paper on
Addison’s Disease at the International Medical Congress (1881),
which lead to an interesting discussion.
I am not aware that this condition has ever been reported
in association with insanity. If so, I have been unable
to find any reference to the fact in the ordinary text books,
and in tins respect the case would appear to be unique.
Griesinger,f a recognised authority on mental disease says :
“ In Addison’s Disease there is generally great depression of
sentiment, but no case of actual mental disease is known
to me.”
It is unfortunate that the previous history of this case is so
incomplete, but the clinical features after the patient came
* “ On the Constitutional and Local Effects of Disease of the Supra-renal
Capsules/’ London, 1855.
•f u Mental Diseases,” New Syd. Trans., p. 198.
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Clinical Notes and Cases .
[Jan.,
under observation are very typical and correspond accurately
with the description given by Jaccoud, quoted by Trousseau,* * * §
from an analysis of 127 cases:—“ An asthenia which goes on
increasing up to death, a melanodermia presenting special
characters, gastric disturbances and pains in the loins and
abdomen.” Indeed, the only anomalous symptom in the case
was the persistent yellowish tint of the conjunctivas, which
are described in the text books as retaining their normal pearly
lustre throughout. The injury to the knee is an interesting
point, for Bristowef says that the first symptoms, are often
attributed to local injury. The varying character of the
bronzing is also worthy of remark, for the apparent increase
in the pigmentation following a gastric attack does not appear
to have been observed by any writers on this subject. The
disease appears to be uniformly fatal, and treatment can only
attempt to be palliative. Iron, quinine, and stimulants were in
turn administered in this case without appreciable benefit,
while the gastric symptoms were only in a slight degree
amenable to treatment. Little is known of the causation of
Addison’s Disease, and it is still a moot point whether disease
of the supra-renal capsules is a primary affection, or whether
it is secondary to changes in the sympathetic nervous system.
Physiologists have hitherto been unable to ascertain the accu¬
rate functions of these organs, but that they are necessary to
life is proved by the researches of Brown Sequard,J who
found that death occurred in animals very quickly after their
removal. Some authorities, notably Virchow and Greenhow,
believe that Addison’s Disease is intimately connected with
structural alterations in the sympathetic, and that the de¬
generation of the supra-renal capsules is secondary. Eulen-
burg and Guttmann have collected 32 cases in which the
pathological appearances are detailed. In 12 the supra-renal
capsules alone were diseased, and no change was observed in
the sympathetic, while in 20, in addition to degeneration of
the capsules, lesions were detected in the solar plexus, semi¬
lunar ganglia, and in the nerves supplying the supra-renal
capsules.§ Therefore it appears that the results of examination
of the sympathetic are antagonistic to one another, at one time
negative, at another positive. It has also been suggested that
* “ Clin. Medicine,” New Syd. Trans., Vol. v., p. 158.
t “ Practice of Medicine,” 4th Ed., p. 559.
j “ Comptes Rendus,” 1857, Tome xliv., p. 246.
§ “ Sympathetic System of Nerves,” " Journal Ment. Science,Vol. xxiv.,
p. 531.
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1885.]
Clinical Notes a/nd Cases .
561
the supra-renal bodies exert some important influence on the
condition of the blood, and so cause the train of symptoms
found in A ddison’s Disease, in other words that it is a disease
of anaemia. Unfortunately for this theory, however, the
observers who have examined the blood have hitherto not
found any constant departure from the normal state.
There is no evidence to prove any relationship of cause and
effect between the physical and mental symptoms in this parti¬
cular case. Undoubtedly there is an intimate correlation between
changes in the skin and changes in the higher nerve centres,
and these are frequently of a permanent, as well as of a tem¬
porary nature ; but as far as our present knowledge goes, we
are only justified in considering the occurrence of a maniacal
seizure in the course of Addison’s Disease as a mere coincidence.
OCCASIONAL NOTES OF THE QUARTER.
Over-pressure in Schools .
Although we have no reason to suppose that the storm
that has been raised on the subject of over-pressure in
Board Schools has altogether subsided, but, on the con¬
trary, think there will be much more said, written, and,
above all, done, we nevertheless are disposed to glance at the
present aspect and position of the movement, and to endea¬
vour to ascertain whether definite conclusions have been
reached, and whether any practical course of action is called
for. We put aside as irrelevant to the general question at
issue such questions as whether Dr. Crichton Browne as¬
sumed a more official position than was ever intended by Mr.
Mundella, whether the Report* branches out into disquisitions
not germane to the subject in hand, whether the tone of the
Report is altogether befitting a scientific investigation, or
whether, as the critics say, its style is open to the charge
brought by Lord Beaconsfield against that of his great rival,
however unjustly. Nor is it relevant to the main question
whether Mr. Mundella acted rightly in occupying the time
and thought of a public servant required to devote the whole
of his energies to his own department, and already “ ab-
* Report of Dr. Crichton Browne to the Education Department upon the
alleged over-pressure of work in Public Elementary Schools, July 24, 1884.
Also the Memorandum relating to this Report by Mr. Fitch, one of Her
Majesty’s Inspectors of Schools, August 4,1884.
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562 Occasional Notes of the Quarter. [Jan.,
sorbed [in his own official duties ”—duties understood to
be very onerous, in spite of the Act of 1882, which, by miti¬
gating in some respects the irksome rigour of certain regula¬
tions respecting the visitation of Chancery lunatics, rendered
the demand upon the time of the Visitors less open to the
charge of “ over-pressure.” Some may say, indeed, that Mr.
Mundella, not content with his inhumane proceedings in his
own department, has extended them into another, and sanc¬
tioned what is analogous to keeping boys in after school
hours and setting them lessons to learn at home. It is not
surprising under these circumstances that Dr. Browne apo¬
logises for any imperfections there may be in his work by
stating that his “ observations have been made in such brief
intervals of leisure as I have been able to obtain from my
official duties, and have been necessarily fragmentary and
limited in extent.” All these are matters of indifference to
those who simply wish to ascertain whether over-pressure in
schools is a serious evil at the present time, and who do not
intend to be diverted from their object by the critics.
The detention in school of large numbers of children
beyond the school hours is the first evidence of over-pressure
which is adduced. While in some schools this rarely exceeds
a quarter of an hour a day for two months in the year, and
only applies to some of the children, in others it has been
protracted to an hour and a half, and has been applied to all
the standards for six months in the year. It must be ad¬
mitted that the ordinary school hours, from 9 a.m. till noon
and from 2 p.m. to 4.30 p.m., are long enough for children
from seven to fourteen years of age.
Home-lessons constitute the second proof, and the evidence
appears to us conclusive. To this we shall return.
The emphatic testimony of the teachers themselves is
the third and very important proof of over-pressure. Out of
sixty teachers questioned by Dr. Browne only two denied its
existence. It should also be added that since this Report, a
very large number of the teachers of Board Schools have met
together to consider it, and have strongly endorsed it. Mr.
Fitch defends the setting of home-lessons, and states that
he always looks at the home-exercises and makes inquiries
of the teacher in regard to his practice. We are, however,
still jealous in regard to the abuse of this custom, nor can
we affect to be sorry to learn that recent public discussions
have tended to discourage teachers from what Mr. Fitch
regards as the " legitimate use of home-exercises.”
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Occasional Notes of the Quarter .
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A fourth source of evidence is derived from the condition
of the children themselves as seen by an ordinary observer,
who would be able with a little attention to pick out the
backward children, those, namely, on whom over-pressure
tells most, and to divide these into the dull, the starved, and
the delicate. It is strongly urged that if these backward
children are expected to do just as much as the bright and
clever children, there must be a considerable amount of over¬
pressure. Does not the reputation of the school demand that
they shall be forced to meet the requirements of the exami¬
nation ? In reply to these objections of Dr. Browne against the
system of forcing backward and clever children alike through
the same examination, Mr. Fitch asserts that considerable
exemptions are made, and that an inspector “ never examines
for the standard a child who for any reason is placed by the
managers on the exemption list.” We are glad to learn that
u in practice the rule permitting exceptions and withdrawals
has been used by managers and teachers generally, though on
the whole very carefully and judiciously ; and the inspectors
have been instructed in cases of doubt to allow freely all
such exemptions which are claimed on the ground of the in¬
terests of the scholar; although, of course, they do not permit
indiscriminate withdrawal of children on the ground that
the teacher fears that they may not pass.”
That the effect on half-starved children of cramming their
minds with lessons must be injurious seems too obvious to
require proof. Mr. Marchant Williams is quoted as having
found in one of the Board Schools in London that 36 per
cent, of the parents were out of work, that 40 per cent, of
the children came to school sometimes without a breakfast,
and 28 per cent, to afternoon school without any dinner.
When Dr. Browne has to answer the question whether
over-pressure causes insanity, he comes into collision with
the Commissioners in Lunacy, who maintain that the in¬
crease of insanity in England is apparent and not real, a view
which, as is well known, has been ably supported by Dr.
Lockhart Bobertson in the columns of this Journal. It must
be admitted, we think, that even if the proportion of the in¬
sane to the population is stationary, there may be fresh
causes of insanity, such as over-pressure and worry, which
take the place of some of the malign influences which have
received a check from the social reforms of the last twenty
years. We doubt, however, whether Dr. Browne strengthens
his argument by referring to malaria, small-pox, and fevers
xxx. 38
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Occasional Notes of the Quarter.
[Jan* 3
as formerly prolific causes of mental disease. The chief, if
not the only, change for the better in the way of lessening
the production of insanity would seem to he in the reduction
of the amount of alcohol consumed. We are surprised also
that Dr. Browne should find any cause for congratulation in
the change of the emotional atmosphere of the country,
which is now, we are assured, “ calm and settled,”\ and “ free
from those violent storms of political and religiouB excite¬
ment which invariably leave a large quantity of mental
wreckage behind them.” We should have thought, taking
the periods chosen (1862 and 1882), that the former hacPt^e
advantage of not having been invaded by .the excited fol¬
lowers of Messrs. Moody and Sankey and the uproarioute
proceedings of the Salvation Army, who are surely respon\
sible for a much larger “quantity of mental wreckage” than 1
are any of the religious agitators of twenty years ago.
If, however, we are correct in this view of the relative in¬
fluence of the various factors of insanity now and at tlie
earlier date, we should still leave an ample margin for the
effect of over-pressure in schools in inducing nervous affec¬
tions and increased liability of the brain to become affected
with disease evidenced by insanity. This may be taken as
the equivalent of what has been gained by the spread of
temperance.
We next come to the alleged influence of over-pressure in
inducing hydrocephalus, in which is included tubercular men¬
ingitis, as well as “ water on the brain.” Dr. Browne meets
the objection that in spite of the diffusion of education the
death-rate of hydrocephalus has been steadily falling, by
showing that this is attributable to the diminished prevalence
of hydrocephalus in infants under five, while at all ages above
five the death-rate has greatly risen. The former is explained
by the influence of sanitary reforms, while in the rise of mor¬
tality in later life, Dr. Browne finds anew factor at work,
namely, brain excitement and fatigue consequent upon school
work. On this point there will be a difference of opinion) for
however probable it seems that excessive mental work should
cause tubercular meningitis, there is no scientific proof that
this really occurs, and those who regard the question irrom a
purely clinical point of view will probably deny that they
have ever been able to connect the action of mental pro¬
cesses of any kind with a single case of meningitis. So o:i
cephalitis, in regard to which Dr. Browne gives a table show¬
ing that between 1861 and 1880 the death-rate from this
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Occasional Notes of the Quarter.
565
1885.]
disease has nearly doubled. One difficulty, moreover, which
attaches to this table is the much greater recognition by
medical men of brain diseases, in consequence of which more
cases would be credited to cephalitis* now than formerly.
With a view of escaping this fallacy, Dr. Browne takes
diabetes, about which it is probable there would not be the
same difference of opinions at different periods. As this
disease is largely due to nervous conditions, and as it has
increased in children and young persons, Dr. Browne makes
use of the fact in support of his position, although he does
not maintain that the increase of diabetes is connected directly
with over-pressure.
We pass over the tables showing the increased mortality in
nephritis, Bright’s Disease, and rheumatism, and pass on to
the liability to headache in the elementary schools of Lon¬
don. Of 6,580 children examined, 3,334, or 46 # 1 per cent.,
professed to suffer habitually from headache. Here again all
will not be able to follow Dr. Browne in his conclusions, for
in the first place, in spite of the precautions he assures us
he took, an uncomfortable impression is left upon the mind
that a part at least of the result obtained was due to
the familiar pitfalls of Suggestion and the Imagination.
Mr. Fitch, who was present on some of the occasions when
the children having headache were requested to hold up
their hands, appears to have been much struck with the
probability of this source of fallacy,f and his well-known
intelligence and his long familiarity with the habits of
children ought, we feel bound to admit, to count for some¬
thing. We fail to see how “the promptness, simultaneity,
with which a little grove of hands was held up ” was any
* The returns under this head must be vague and untrustworthy in the
extreme, but this does not affect the argument, as they point to some disease
of the nervous system.
t In justice to Dr. Browne, we should add that the statement that “ Dr.
Browne’s questions were in all cases clearly suggestive of the kind of answers
he desired or expected to receive ” of course only applies to those schools in
which Mr. Fitch was present and observed, “with some amusement, the
peculiar methods by which Dr. Browne sought to verify the conclusions he had
already arrived at and publicly set forth.” Or, again: “I confess that I
witnessed with astonishment the manner in which the data for remarkable
statements were got together. When 1 visited a pupil teacher’s centre-class
with Dr. Browne, leading and highly suggestive questions were put; hands
were held up and counted ; impressions and opinions were asked for and
apparently accepted as facts; and there seemed to me to be a lack of the most
ordinary precautions for distinguishing between what was typical and habitual
from what was only occasional.” We repeat, Mr. Fitch’s criticism only applies
to what he himself alleges to have observed.
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566
Occasional Notes of the Quarter .
[Jan.,
presumption in favour of a genuine experience. We should
have been inclined to draw a contrary conclusion. Again, if
there were any who regarded headache as “ a moral delin¬
quency, the confession of which would be followed by caning
or keeping in/’ about which we are very sceptical, we should
suppose that far more held up their hands in the hope of
procuring a holiday on the ground bf headache, for which so
charming an opportunity presented itself of obtaining a cer¬
tificate from a medical visitor.
The other objection to these cephalalgic tables arises from
the entire absence of a similar enquiry among the same class
of children not subjected to school work. Such a table may
not in the nature of things be procurable, but none the less
is the conclusion arrived at lacking in the conditions of scien¬
tific evidence. It is psychologically interesting, apart from
the question of over-pressure, that a very able head-master
of one of the Board Schools found that the attention which
the enquiry had drawn to subjective sensations had largely
increased “ the number of complaints of headaches, giddi¬
ness, faintness, sleepless nights, &c., and these complaints
form strong reasons for absence from school. Complaints
never before heard are now too frequent, of over-pressure
causing these attacks.”
We next come to the very important question of whether
sleeplessness is of frequent occurrence among Board children.
Dr. Browne found it difficult to obtain definite information,
but he says: “ My statistics and the inquiries made in col¬
lecting them, have borne in upon me forcibly two or three
general conclusions, viz., that there is really a great deal
of sleeplessness amongst the children attending elementary
schools in London; that some of this is caused by over¬
pressure ; and that some of it, which is attributable to en¬
tirely different causes, conduces to over-pressure by keeping
the children in a state of nervous exhaustion in which they
are particularly liable to be detrimentally affected by their
school works.” Beduced to figures, the procurable informa¬
tion showed 41*04 per cent, of the boys and 35*09 per cent,
of the girls suffered from sleeplessness, and that the lower
standards suffered more from it than the upper, which is a
fact which at first sight seems opposed to the idea of the
influence of over-pressure, but is referred by Dr. Browne to
the effect of muscular action and fatigue. Dr. Browne
found that talking in sleep and somnambulism are common.
Of 381 boys, 129 were sleep-talkers, and 28 were sleep-
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567
1885.] Occasional Notes of the Quarter .
walkers; of 432 girls, 17 were sleep-walkers, and out of
382 in another school there were 20.
Chorea was sought for, but not found, probably in conse¬
quence of cases of this disorder being at once removed
from school. However, out of 6,580 children 48 exhibited
peculiar movements; at any rate, when agitated. It is found
that the death-rate from chorea is almost exactly the same
as it was twenty years ago. Our own experience is certainly
in favour of a causal relation between over-pressure and
chorea, but it applies to those of older growth.
Stammering appears to be benefited instead of aggravated
by schooling, and it is only fair to place this to the credit
of the Educational Department. The prevalence of neu¬
ralgia and toothache is exhibited in a table giving a per¬
centage of 54*2 per cent. Toothache, however, is not
separated from neuralgia, and is so common a trouble with
all children, and is so indefinite a malady, that we cannot
attach any importance to this element in the count brought
against the London Board Schools. Besides, when present,
is it not at least as likely to have been caused by sweets as by
over-pressure ? Dr. Browne's enquiries do not appear to have
been directed to this distinction in the etiology of odontalgia.
Short-sightedness was found to be present in 5*6 per cent.,
and exhibits a steady rise from the lowest to the highest
standard, in which among the girls there was a percentage
of 10*7. Here, however, the value of the table, as of so
many, in this report, cannot be secured until a parallel series
of observations are made upon children in regard to whom
the question of over-pressure does not arise.
Before leaving the evidence collected in regard to school-
children in relation to over-pressure, we cannot omit a
reference to Dr. Browne's visit to his native county in
Scotland, where he made similar inquiries in some of the
schools on his way. Here he found a state of almost
Arcadian health and happiness, which even his vocabulary
fails adequately to depict. Very few suffered from head¬
aches, only one knew what it was to be sleepless, and just
one was short-sighted. Somnambulism was unknown. With
very few exceptions “ the children were pictures of health,
sturdy, rosy, well-nourished. I looked round in vain for
the sad, sickly faces to which I had become accustomed in
Metropolitan schools, and saw smiles and dimples on every
side." This is, no doubt, a charming picture. All, how¬
ever, that it proves to our minds is the superiority of
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568 Occasional Notes of the Quarter . [Jan.,
Dumfriesshire over Middlesex,—the great inducement
which it offers to immigrate rather than to emigrate. It
does not touch the question of over-pressure, for it is
obviously unfair to compare the children in London Board
Schools with those in schools “all situated in a purely
agricultural district/’ the children themselves being “ well
fed on porridge and milk as the staple articles of diet, with
broth, potatoes, butter, tea, and occasionally a bit of meat
or bacon, warmly clad, and much in the open and uncon¬
taminated air,” and having “ comfortable homes, where they
keep good hours.” Where the conditions are so entirely
different, how is it possible to enforce by a reference to the
Dumfriesshire schools the contention that the aspect and the
diseases of the London School Board children are due to
over-pressure? A good cause is here injured, for the
alleged diseases become explicable by environment.
It is in regard to the pupil teachers in the Board Schools
in London that Dr. Browne is more successful in demon¬
strating the injurious influence of over-pressure. The
returns refer to 388 persons, and it appears that the average
time given to school service by them was nearly four hours
overtime per week. A table is given showing the hours at
which they leave off study on those nights when they attend
“ Centres,” i.e., schools in which the pupil teachers in certain
districts meet for instruction, and from this it appears that
94 cease study at 8.30 p.m.; 26 at 9 p.m.; 81 at 9.30 p.m.;
121 at 10 p.m.; 50 at 11 p.m.; and 16 at 12 p.m. Another
table shows the hours at which pupil teachers leave off study
on non-centre nights, and we find as many as 56 working
till midnight, 142 till 11 p.m., and 131 till 10 p.m. In
addition to this, nearly one-half of the pupil teachers pro¬
fessed to devote more than three hours of their Saturday
afternoon holiday to further study, and we fear with only
too much truth. Of 416 female pupil teachers, the whole
number said they were on their feet more than five hours a
day, and 87 stated that they were not allowed to sit during
school hours.
As might be expected, irregular and hasty meals were
found to be very frequent. Out of 424, 257 asserted that
this was their constant experience. Dr. Browne asked 526
pupil teachers and ex-pupil teachers to state how many
pupil teachers had died, or so broken down as to have to give
up their work, and 72 cases were reported to him, in which
the result was attributed to the following causes : to con-
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569
1885.] Occasional Notes of the Quarter .
sumption in 22 cases, to brain fever in 13, to nervous
exhaustion and headaches in 9, to general debility in 9, to
loss of eyesight in 4, to epilepsy in 3, to insanity, heart
disease, and loss of voice in 2 each, and to neuralgia, St.
Vitus’ dance, dyspepsia, uterine disease, and spinal curva¬
ture in 1 case each.
As to absence of work from sickness—an important point
—it was found that out of 456 pupil teachers, 333 had been
so absent during the previous twelve months, 62 of whom
had been off work for more than a week, and 271 for more
than a day. On the other hand, Mr. Fitch made enquiry at
certain schools in London, having in all a staff of 220 female
teachers, and found that on the day of the visit not a single
head teacher, assistant, or pupil teacher was absent, and that
only three had been kept away for a week in the year from
over-work. It would be fairer, however to say seven, as
three were detained by nervous debility and one by neuralgia,
which probably arose from over-work.
Headaches were found to prevail more frequently than
amongst scholars, viz., in 64-5 per cent, of the pupil
teachers. Much is said in detail in regard to these head¬
aches, but as we feel sceptical in regard to the trustworthi¬
ness of the replies, in consequence of the inevitable fallacies
arising out of suggestion and leading questions, we pass over
this portion of the evidence.
It is a noteworthy fact in regard to insomnia that only 24
out of 388 pupil teachers suffered from it. And here again
the explanation of this unexpected result is sought in
muscular exhaustion. Short-sightedness was found present
in 16*7 per cent. We pass over the statistics of toothache as
not convincing, although probably more reliable than in the
case of children.
On the whole, we are very much inclined to believe with
Dr. Browne that “only a radical change in our pupil
teachers’ system, a change which shall relieve pupil teachers
from the excessive burdens under which they now groan,
and give them leisure for thought, digestion, and recreation,
can ward off so undesirable a state of affairs,” namely, the
evils to themselves and their children, which must inevi¬
tably follow the infraction of the physiological laws of our
being.
We are led to this conclusion by what we have seen in
taking part in the management of elementary schools, and
by what we have observed in hospitals to which teachers
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570 Occasional Notes of the Quarter . [Jan.,
have been brought, labouring under affections of the nervous
system attributed to over-work.
It might have been well, as Mr. Fitcb says, had Dr.
Browne referred to the exceptional character of the present
system of pupil-teacherism in the London Board Schools,
but we are very sure that the evils arising out of the system
are, and long have been, in operation, not only in London,
but the provinces.
We have seen too much of “the examination fever” to
doubt its existence, although it has been more conspicuous
among the head teachers, the assistants, and the pupil
teachers than the scholars. Still, it is to some extent reflected
upon them. Mr. Fitch is himself one of those admirable
inspectors who is not only exceedingly able in the perfor¬
mance of his duties, but who is sympathetic with the staff
and the children on examination day, so that all feel
encouraged instead of frightened and disheartened by his
inspection. But unfortunately all are not like him. We
have known an inspector who, although painstaking and
accurate, was so utterly destitute of consideration to the
teachers, and of sympathy with the children, that the effect
was most prejudicial to all concerned.
Objection may fairly be made to the term “over-pressure,”
and we should prefer that of over-work. “ One naturally
looks,” says Mr. Fitch, “ to a scientific expert to give greater
exactness to the connotation of an indefinite term, to indi¬
cate at what point human effort, whether mental or physical,
ceases to be legitimate and healthy, and becomes mischievous;
and either to verify or correct by careful induction the loose
general statements which pass current in the Press or in
public meetings. But Dr. Browne does not do anyone of these
things; on the contrary, he accepts anecdotes, rumours, and
resolutions of local meetings, pieces them together with
remarks and conjectures of his own, and then describes
himself as accumulating ‘ evidence/ ” We cannot altogether
acquit the writer of this sentence from the charge of the
exaggeration and rhetorical statement which he brings
against Dr. Browne, for after making a liberal deduction for
assertions unsupported by evidence, there remain important
facts, obtained from the schools and statistical results, which
cannot be disposed of without countervailing facts. Nor
can we set at nought resolutions passed by teachers at
public meetings, especially when it is considered that their
coming forward to make complaints requires, we should
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571
1885.] Occasional Ifotes of the Quarter.
suppose, some moral courage. With a good case, it is all
the more to be regretted if Dr. Browne has allowed himself
to fall into any inaccuracies. The description of an ordinary
day's school-work is, according to Mr. Fitch, inaccurate in
every particular. “ Though in all well-ordered schools the
members of the staff are in their places a few minutes
before the opening, work does not begin till nine. The
school is dismissed at twelve, not at one. The evening class,
even under the London School Board, meets only two even¬
ings a week, and three hours of private study on the same
evening are, according to Dr. Browne's own calculations,
entirely unnecessary."
In conclusion, we would say that we believe that good
will be done by the enquiry already instituted. “ Super¬
ficial " it may have been. The number of children examined
is, doubtless, infinitesimal compared with the total number.
A dominant idea, to which expression had been previously
given in somewhat sensational terms, may have coloured
some of the observations. Still, we hold that there is sub¬
stantial truth in the allegation that over-pressure exists, and
to such an extent as to cause a serious evil, especially among
pupil teachers, and the masters and mistresses themselves.
We trust and believe that greater care will be taken in
future not to force children to perform mental work beyond
their capacity, that keeping-in will be rarely if ever resorted
to, and that home-lessons will be sparingly enforced. We
believe one great evil lies in the character of the knowledge
which children in elementary schools are expected to master.
With regard to payment by results, the evil effects are really
not disputed, but the difficulty is to find a substitute. We
hope some better means may be discovered, but the tax¬
payers have a right to demand that £3,000,000 of the public
money shall not be paid to schools which are inefficient,
and of this efficiency, what are the proper tests ? Mr. Fitch
has shown that mere book knowledge is not the only thing
considered; and, still more, we trust, may be done in this
latter direction.
Finally, we consider that service would be rendered to the
interests of school children and teachers by the appointment
of a Committee empowered to collect evidence on a suffi¬
ciently large scale to form a reliable basis for conclusions,
and with ample allowance of time. We certainly cannot
object to Mr. Fitch’s demand that those who undertake such
duties shall “ have some perception of the true nature of
Digitized by v^ooQle
672 Occasional Notes of the Quarter . [Jan.,
scientific inference, and will take some pains to understand
the system which they propose to criticise,” or, rather, to
investigate. Calm investigation, conducted in a scientific
spirit, with scrupulous accuracy, and with parallel tables of
disease in the school and the non-school workers, might then
be carried out, and the results would be proportionately
trustworthy, and would command the assent of the public.
Weldon v. Winslow .
We refrain from offering any comment upon this trial, as
it is understood that the defendant will appeal against the
verdict. It is important, however, to place on record the
substance of the summing up of the Judge (Mr Justice
Denman) so far as it relates to his laying down of the law,
and his instructions to the jury.
Queen’s Bench Division of the High Court of Justice.
Nov. 28 and 29, 1884.
(Before Mr. Justice Denman and a Special Jury.)
Mr. Justice Denman, in summing up, directed the jury that all the
issues raised would for the purpose of the day be ruled by whether
the jury believed that the defendant had or not in the course of what
he had done been actuated by some improper motive and had not acted
honestly and bond fide in the performance of a duty. The burden was
upon the plaintiff to prove affirmatively that the defendant had been
actuated by some improper motive, or, in other words, that there was
malice. There were three substantial questions which the jury would
have to decide. Was the letter of the 14th of April a libel ? That
was, was it written in the honest and bond fide belief that Mrs. Weldon
was a person in whose case proceedings ought to be taken of the
character that were taken in reference to her confinement, or to super¬
vision, or restraint of some sort; or was it written regardless of the
real merits of the case as to that, and from some bye or sinister
motive, such as to get her into an asylum in order to gratify the
husband, or for gain or profit ? Secondly, as to the letter that was
published by the defendant in the " British Medical Journal,” was
that written in self-defence, or with the intention of further libelling
the plaintiff, by calling her an insane person, with the knowledge that
she was not that sort of person ? And, thirdly, was the assault which
was committed with the assent of Dr. Winslow when he sent persons
to arrest, the plaintiff committed in the bond fide belief that there was
good ground for taking her to an asylum, or was it a case in which the
Digitized by boogie
1885 .] Occasional Notes of the Quarter . 573
defendant, not honestly believing this, was anxious that she should be
confined from some improper motive ? These were the issues which
the jury would have to decide. In case they should find for the plain¬
tiff, he would say a word or two upon the question of damages. In
a case involving malice of any sort the question of damages was one
that was very much at large for the consideration of the jury. They
were entitled to consider the amount of malice, the sort of malice, and
the conduct of the party who charged the defendant with malice, and
how far the conduct of that party might have induced the defendant
to take an unfavourable view of the case ; how near it was to a bond
fide belief, and how far it was from a bond fide belief; everything was
for the jury, and should be taken into account in case they should give
a verdict for the plaintiff. There would be a disadvantage in running
riot as to damages ; and he was sure that the jury would not do that
unless they felt that the case was one in which on public grounds they
should mark their very strong sense of the wrong that was done.
Their verdict must not be influenced in any way by their dislike of the
lunacy laws, which gave very large powers to doctors, for it would be
highly unjust to visit any individual with additional damages merely
in order to express an opinion that the law should be altered. This
would be very wrong indeed, and he did not think for a moment that
the jury would act in that way. If the defendant had been actuated
by no sinister motive, then the verdict would be for him ; but if there
had been an improper attempt to carry this lady into an asylum,
then, of course, there must be damages for the plaintiff, and very
considerable damages.
The jury said that they found a verdict for the defendant in re¬
ference to the alleged libel in the letter of the 14th April, 1878. In
reference to the libel of the 8th January, 1879, in the “ British
Medical Journal,” they found for the plaintiff, upon the ground that
in it the defendant justified the proceedings taken against the plain¬
tiff, including the assault made upon her with a view to her confine¬
ment, when from the information at his command he had ample
opportunity of discovering that he was wrong. Upon this part of
the case they assessed nominal damages. As to the assault, they
found for the plaintiff, upon the ground that the defendant allowed
himself to be unduly influenced by other motives than the interests
of justice. Upon this they assessed the damages at £500.
Mr. Justice Denman upon this finding said that he should give
judgment for the plaintiff, damages £500, and one shilling; but upon
the application of the defendant, he said that he would stay
execution.
Digitized by <^.ooQLe
574
Occasional Notes of the Quarter .
[Jan.,
Assault by a Patient on a Superintendent .
Dr; Murray Lindsay, the Medical Superintendent of the
Derby County Asylum, was attacked in a very dangerous
manner by one of the patients under his care on Nov. 25th.
The man was regarded as harmless and inoffensive, and had
been in the asylum twelve years. He worked in the joiner's
shop, and on Dr. Lindsay entering, wounded him with a chisel
in three places, causing the flow of blood in the left groin, the
abdomen, and the chest near the heart. It was so quickly
and quietly done that another patient at work in the room at
the time, with his back towards the man, was unaware that
anything had occurred, and went on with his work as usual.
Dr. Lindsay, fortunately, did not faint, and, deeming it
prudent to avoid a struggle, left the shop, and gave orders
about the patient, who at once parted with the chisel, and,
without exhibiting any agitation, walked quietly to the ward
with the engineer, remarking, however, that he regretted that
he had not done for the doctor, and that he would yet, if he
had to wait twenty years. Dr. Lindsay was attended by
Mr. Dolman, senior surgeon to the Derby Infirmary. The
wounds happily proved much less dangerous than it was at
first feared they would be, and no alarming symptoms have
arisen.
All our readers will, we are sure, join with us in con¬
gratulating Dr. Lindsay on his escape from such an alarming
attack, and rejoice that he is spared—we hope for many
years—to carry on the work in which he is engaged, with so
much credit to himself and advantage to the asylum.
This event raises the question of compensation for injuries
to the officers of asylums, and we hope that an improvement
of the present provisions of the law will be the result. We
shall return to the subject in a future number.
In this instance, the occurrence cannot be adduced as an
argument in support of mechanical restraint, for as the
patient had been employed for years in the workshop, and
had been regarded as so very inoffensive a man, he would
not have been restrained in even an asylum in the Province
of Quebec.
Digitized by Google
PART II-REVIEWS.
Thirty-Eighth Report of the Commissioners in Lunacy. —17th
July, 1884.
This report, which is no less voluminous than its imme¬
diate predecessors, contains a large amount of interesting
and valuable material.
The total number of insane persons included in the returns
to the lunacy office amounted on the 1st January, 1884, to
78,528, as compared with 76,765 on the first day of the pre¬
vious year, showing an increase of 1,763, and a proportion of
insane persons to population of 1 in every 345.
Of these 8,058 were of the private class and 70,470 paupers.
The private patients had increased in the year 135, and the
paupers 1,628, as compared with an annual average increase
in the 10 preceding years of 90 private and 1,557 pauper
patients. The distribution and classification of these
patients is as follows:—
Where Maintained
Private.
Pauper.
on 1st January 1884.
M.
F.
T.
M.
F.
T.
n
In County and Borough Asylums
317
369
686
20,301
24,863
45,164
20,618
25,232
45,850
In Registered Hospitals .
1,548
1,451
2,999
95
52
147
1,643
1,503
3,146
In Licensed Houses :
Metropolitan .
973
844
1,817
229
476
705
1,202
1,320
2,522
Provincial.
710
854
1,564
249
444
693
959
1,298
In Naval and Military Hospitals,
Jk
and Royal India Asylum
295
19
314
295
19
In Criminal Lunatic Asylum
(Broadmoor) .
163
66
229
229
77
306
392
J
In Workhouses:
/
Ordinary Workhouses .
Metropolitan District Asylums
...
5,107
2,461
6,949
2,860
12,056
5,321
5,107
2,461
F
Private Single Patients .
180
269
449
Y
Out-door Paupers .
...
2,333
3,745
6,078
1
Totai.
4,186
3,872
l
8,058
31,004
39,466
70,470
The private patients have increased
borough asylums by 32, in registered
576
Reviews.
[Jan,
and at Broadmoor by 11, but they have decreased in
licensed houses by 28, in naval and military hospitals by 12,
and as single patients by 1. The pauper patients have in¬
creased in county and borough asylums by 1,753, in licensed
houses by 4, at Broadmoor by 11, and in the Metropolitan
District Asylum by 215. This class has, however, decreased
in registered hospitals by 10, in ordinary workhouses by 168,
and as out-door paupers by 177.
As we have frequently pointed out before, the statistics of
relative increase in private and pauper patients are probably
entirely misleading, the pauperizing influence of insanity
in persons, especially of the lower middle class, causing
numbers of them to gravitate to the pauper asylums and to
be included in the list of pauper lunatics.
The proportion of paupers to population still goes on
steadily decreasing, so as to be little more than half what it
was 20 years since, but the percentage of pauper lunatics to
paupers has increased almost threefold in the same time,
and shows, and is likely to show, no sign of abatement.
While the decreasing pauperism, and the accumulation from
various causes of pauper lunatics, are producing these results,
it is the opinion of the Commissioners, as a necessary de¬
duction from their statistics, that there is no appreciable
increase in occurring insanity, and that there has been none
during the last 8 years.
There was an apparent increase in the year under review,
but this arose mainly from the unaccountable, and apparently
unnecessary and unwise, transference of a large number of
chronic imbeciles from the workhouses to asylums in Lanca¬
shire.
The Commissioners say, “The proportion of persons
lually attacked with insanity and actually placed in
’urns and kindred institutions had not risen perceptibly
1875 to 1882, at which latter date the annual propor-
fresh cases was 5 # 15 per 10,000 ; but for 1883 there
^ance in the new admissions to 5*41 per 10,000 of
^ation.”
ance is in a great measure due to exceptional and
tions, particularly to the admission into the
asylums of a large number of imbeciles and
ies, previously under care in workhouse wards,
«^t fresh cases of insanity.
annual admissions into the Lancashire
lr years 1879 to 1882 inclusive (excluding
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Reviews.
577
1885.]
transfers) were 1,192, whereas for 1883 the total admissions
were 1,860, an excess of 668 over the average. If this
number (668) be deducted from the total number of admis¬
sions into all asylums during the year, it brings the ratio of
total first admissions in 1883 down to 5-15 per 10,000 of the
population, which is the same as for 1882.
“ The large annual addition to the number of insane persons
under care has produced, in some quarters, an impression
that insanity itself is much on the increase. On examina¬
tion, however, of the figures now under consideration, it
will be found that the increase is almost entirely due to
accumulation of chronic cases of the pauper class, so that
the community at large would not appear more liable than
formerly to be attacked with insanity. This should tend
to allay public anxiety; but those to whom the law has
entrusted the responsibility, should not disregard the im¬
perative necessity of making the accommodation for such
additional and accumulated cases keep pace with the require¬
ments of their respective districts. 55
The increase in the percentage of patients in asylums, as
compared with those in workhouses and private dwellings, to
which reference was made in our notice of last year’s report,
has continued, and the proportions in comparison with those
at previous periods are as follows:—
In Asylums. In Workhouses. With Relatives, &c.
1873 59-81 26-32 13*27
1883 65-74 25-17 9*09
1884 66-72 24-66 8*62
These figures, although they show that public confidence in
asylum care is increasing, also point to an increasing absence
in workhouses of suitable provision for the cheap mainten¬
ance of persons for whom such provision should, in the
interest of public economy, be made, as well as the con¬
tinuously augmenting influence of the mistaken 4s. grant, to
which attention has already so frequently been directed.
The number of patients admitted into the several classes
of asylums and into private care during the year under
review was 16,000, of whom 1,319 were transfers. The re¬
coveries were 5,574, and the deaths 5,135.
Excluding transfers and the admissions into idiot asylums,
the percentage of stated recoveries to admissions was, for
men 34-79, for women 42-00; total 38*50, as compared with
an average during the last 10 years of 39*38. The per¬
centage of deaths to the average number resident was 11-67
Digitized by Google
578 Reviews . [Jan.,
for men, 7*60 for women; total, 9*47, as compared with the
average for the previous 10 years <Jf 9 # 91.
The elaborate series of tables, which form so valuable a
part of the Commissioners* report, tell us that 67*4 per
cent, of the non-congenital patients admitted into asylums
in 1883 were the subjects of first attacks of insanity; that
9*4 per cent, of the whole of the admissions were epileptics,
and 8*0 per cent, general paralytics; that the epileptic
paupers exceeded the private patients threefold, and the
pauper general paralytics those of the private class by one-
fourth ; and that 28*6 per cent, of the patients admitted
were credited with a suicidal propensity.
4,128 patients stated to have a suicidal tendency and 1,359
epileptics were admitted into asylums during 1883, to swell
the very large numbers already under care; but only 21 of the
former succeeded in committing suicide, while 11 of the latter
were believed to have died from suffocation in epileptic fits.
These figures show that, however possible it maybe to take
greater precautions against these accidents, those which are
already in force are attended by remarkable success.
The Commissioners report with much satisfaction a con¬
siderable increase in the proportion of post-mortem examina¬
tions to the total number of deaths. Nearly 69 per cent, of
the deaths have been thus verified, a matter which the Com¬
missioners consider reflects great credit upon the Medical
Superintendents of asylums as a body.
We repeat, on page 579, our table of last year showing the
assigned causes of insanity in three classes of patients.
In the following table are shown the proportion per cent,
of recoveries and deaths in the several classes of asylums
and in private care, transfers and admissions into idiot
asylums having been omitted:—
Proportion per cent, of
Recoveries to Admissions.
Proportion per cent, of
Deaths to the Average
Numbers Resident.
M.
F.
T.
M.
D
a
County and Borough Asylums
35*28
42*20
38*88
12*40
7*76
9*85
Registered Hospitals.
38*56
45*70
42*56
11*07
5*14
7*76
Metropolitan Licensed Houses
27*75
38*60
3325
11*00
6*34
8*48
Provincial Licensed Houses.
28*42
43*89
37*31
10*29
9*56
9*86
Private Single Patients .
6*25
50*31
14*28
7*47
7*77
7*66
Digitized by LiOOQle
1885.]
Review 8,
579
Proportion
'per cent.] to the
Total
1
1
Number of Patients in each Class
Ditto to Number of
General Paralytics
CAUSES OF INSANITY.
1
PRIVATE
PAUPER
M.
F.
T.
M.
F.
T.
M.
F.
T.
MORAL :
Domestic Trouble (including loss
of relatives and friends)
Adverse Circumstances (includ-
4*4
11-8
7*8
37
10*0
70
4*1
10*7
5*5
ing business anxieties and
pecuniary difficulties).
Mental Anxiety and “ Worry ”
(not included under the above
8*4
2-7
5*7
7*2
4*0
5*5
9*6
5-8
8-8
6*8
two heads and Overwork ...
16-6
9-0
131
4*8
53
5-0
7*4
4*5
Religious Excitement .
Love Affairs (including Seduc-
2*0
4-8
3*3
3*2
2-8
30
•9
•8
1*2
1*2
•9
*9
tion) .
1-0
4-3
2*6
•8
2*4
1*6
Fright and Nervous Shock
•8
1-8
1*3
1*1
17
1*4
•8
•8
•8
PHYSICAL:
Intemperance, in Drink.
17*0
6*8
12-2
20-2
6*3
12*9
23'3
11*6
20‘9
„ Sexual.
1*8
•3
11
•6
•5
•5
2*4
41
2*8
Venereal Disease.
*7
•1
.4
•5
•2
•3
1*2
•4
1*0
Self-abuse (Sexual) .
37
•9
2*4
1-8
•1
•9
•2
...
•2
Over-exertion .
1*2
•2
*7
•5
•5
•5
1*5
1*7
1*5
Sunstroke .
1*6
•2
•9
2-0
•2
11
2*6
•8
2*2
Accident or Injury .
4*1
1-2
2-7
5-9
1*1
34
9*3
3*3
8-0
Pregnancy.
Parturition, and the Puerperal
...
*5
•2
...
•7
•4
...
2-5
...
State .
•••
7‘4
3*4
...
64
3*3
...
*5
Lactation .
...
•8
•4
...
24
1*2
...
*4
•1
Uterine and Ovarian Disorders
•••
6*0
2*8
...
1-8
*9
...
2*1
•4
Puberty .
•2
•1
1
•2
•5
*4
...
...
...
Change of Life .
73
3*4
...
3*4
1-8
4*5
•9
Fevers .
i : 3
•4
•9
•6
•4
•5
*2
...
*2
Privation and Starvation
...
•2
•1
1*4
2*4
1*9
*7
4*1
1-4
Old Age .
Other Bodily Diseases or Dis¬
2*2
34
2*7
3*7
4-8
4*3
•1
...
•1
10*7
orders .
9*4
10*1
9-7
11-4
10*2
10*8
10*6
11*2
Previous Attacks.
13*5
16*1
14-7
143
196
17*0
3‘9
6*2
4-4
Hereditary Influence ascer¬
tained .
23-2
26-1
24*5
18*5
21 3
19-9
15*5
20-2
16*5
Congenital Defect ascertained...
8-0
1-8
5*1
4*5
35
4-0
...
•8
•2
Other ascertained causes
76
2-9
5-4
1-9
•8
1*3
1*4
...
1*1
Unknown .
121
12*0
12*0
24-0
22*2
23*1
32*2
33*9
32 6
The following table, from which transfers and the admissions
into idiot asylums have been excluded, has an interesting
bearing upon the questions whether insanity is becoming
more or less curable, and whether the crowding together of
large masses of lunatics is producing a gradually increasing
or a gradually decreasing recovery rate, or having no appre¬
ciable effect:—
XXX
39
Digitized by <^.ooQLe
Number of stated Becoveries to 100 Admissions.
Digitized by boogie
40*06 I 39 66 52*74 46*81 I 28*69 36*48 32*84 I 30*69 39*30 36*37 I 16*26 17*60 16*67 I 36*68 43*28
Reviews .
581
We again record the percentages of patients admitted
into asylums in whom there was epilepsy or general
paralysis.
Tear.
Epileptios.
General Paralytics.
Private
Pauper.
Private.
Pauper.
1878
7*7
2*8
5*0
12*3
8*0
10*4
11*1
0*8
0*5
14*4
3*7
9*0
1879
7*9
3*5
5*9
12*1
80
10*0
8*8
1*0
5*2
13*0
3*0
8*4
1880
6*0
3*4
4*7
11*1
8*0
9*5
79
2*2
5*1
12*5
3*5
7*7
1881
5*4
3*0
4*5
11*9
8*3
10*1
9*4
2*0
5*9
12*4
3*3
7*7
1882
5*2
2*8
4*0
12*5
8*1
10*2
109
1*4
0*3
14*4
3*0
8*9
1883
4*9
2*8
3*9
12*4
8-8
10*4
10*2
1*7
0*2
1?*7
3*5
8*3
The Commissioners continue to report additions to county
and other asylums throughout the country, and in some
instances a failure to provide the accommodation which has
for some time been known to be required, whereby serious
injury in inflicted upon the ratepayers, the patients, and
their friends.
They also give a list of the casualties which have occurred
during the year.
Under the head of licensed houses they make the following
remarks, which are interesting in their relation to recent dis¬
cussions and approaching legislation:—
“ The statutory visits have been regularly made by us to all
these establishments, and we can report that on the whole they
continue to be well managed.
“ No cases of anything approaching to illegal detention have
come under our notice, nor have we had occasion to investigate
any serious charges of ill-treatment of patients by attendants
in licensed houses.
u While saying this, it must not be thought that we are not
fully alive to the fact that the insane are exposed (though cer¬
tainly not more in licensed houses than in public asylums and
lunatic hospitals) to rough usage and unkind treatment at the
hands of those to whom their immediate care is confided.
Against this evil one great safeguard is the exercise of extreme
care in the selection of attendants, a matter rendered more easy
by attracting a superior class by liberal wages and considerate
Digitized by Google
582
Reviews.
[Jan.,
treatment, and, above all, by the constant personal supervision
of these by employers themselves. Towards this end we have
consistently worked, and, though by no means content, we
think it safe to conclude from our own observations, and from
the comparatively small number, of late years, of established
cases of brutality or ill-usage, or of suspicious cases not ad¬
mitting of proof, that decided improvement in the treatment of
the insane by their attendants, as well in licensed houses as
elsewhere, has been effected.”
The average cost of maintenance in county and borough
asylums during the year under review was as follows :—
s. d.
In County Asylums ... ... ... 9 2f
In Borough Asylums. 10 4|
In both taken together . 9 5J
showing a decrease of fd. upon the previous year.
The report enters at length into the details of the fatal
fire at Southall Park, and publishes a code of suggestions
which has been issued to superintendents and proprietors,
which may be very serviceably reproduced here:—
“ General Suggestions applicable to Lunatic Asylums, Hos¬
pitals, and Licensed Houses, as to the Precautions to be
taken against Danger from Fire.
“ Three objects must be kept in view:—
“ 1. The prevention of fire.
“ 2. The safety of the patients in the event of an outbreak.
u 3. Extinguishing the fire, and saving the building and
property.
“Of these the two first are of paramount importance.
“1. As regards the prevention of fire.
“ The utmost caution in the use, by attendants, servants,
and others, of fires, lights, and matches should be inculcated;
the position and safety of gas-brackets, stoves, &c., should
be considered, and, where necessary, altered and improved;
the condition of chimney flues and hearths examined and
made safe; and a careful and frequent supervision of all
these matters exercised by some person in authority.
“ A careful examination of all the premises should be made
nightly by a trustworthy person after the hour of retiring
to bed.
“In all Licensed Houses, except a few in which the number
of patients is very small, and in all County and Borough
Asylums and Hospitals, a night patrol, or more than one
Digitized by Google
Reviews .
583
1885.]
when requisite, should be established, with mechanical means
for testing vigilance. The patrol should have the chief duty
of watching for indications of fire, and giving the alarm
should any be discovered.
“ An adequate staff of attendants should sleep at night in
the wards, or in close proximity to the sleeping rooms of
patients.
“ 2. As regards the means of securing the safety of patients
in the event of an outbreak of fire.
“ Ample means of escape, especially from the upper floors of
buildings, must be provided. Every floor on which patients
sleep should have two staircases for exit, so placed that one
at least would be in all probability available in case of a
fire. Where staircases are insufficient, others should be
constructed, internal where possible, otherwise external. In
addition, escapes of some approved form should be provided,
and windows should be adapted to their use. Doors of sleep¬
ing rooms should be so secured as to be readily opened from
the outside.
a 3. As regards the extinction of fire.
“ This must be a secondary object, except when the fire
is discovered at its first beginning, in which case, with means
immediately at hand, it may be possible at once to extin¬
guish it, and so ensure the patients’ safety.
“ Nevertheless sufficient apparatus should be provided,
having regard to the public means for extinguishing fire
existing in the neighbourhood, and particularly some means
of dealing with a fire in its early stages. Such means are
hydrants, hand-pumps, 6 extincteurs,’ fire buckets kept
constantly filled with water, &c. Where there are hydrants,
proper lengths of hose, nozzles, and spanners should be kept
in close proximity to them, and frequently examined as to
their condition. Care must be taken to secure an ample
supply of water.
“ It is of vital importance to the safety of the patients that
attendants and others in Asylums, Hospitals and Licensed
Houses should be carefully instructed and practised in the
duties which would devolve upon them in case of fire. For
this purpose a code of regulations, which must necessarily
vary in different establishments, should be drawn up and
printed, and all attendants, male and female, and other
persons engaged on the premises, should be required to make
themselves fully acquainted therewith. In such instructions
the steps to be taken, first, for securing the safety of the
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patients, secondly, for extinguishing the fire, should be
clearly indicated, and specific duties should, as far as possible,
be assigned to specified individuals. Copies of the code
should be hung up in conspicuous positions, and distributed
to the officers and servants.
u In all establishments means, electric or other, should be
provided for conveying the alarm of fire, arousing the inmates
and neighbours, and summoning public assistance.
“ The various apparatus provided should be frequently tested
to ensure its efficiency, and attendants and others should be
thoroughly instructed and practised in its use.”
The Commissioners thus describe their action with re¬
ference to the statutory “ statement:—”
“ At some Asylums a practice had arisen under which the
important duty of examining each patient, and reporting to
us on his condition of mind and body soon after admission,
was occasionally, or indeed always delegated to an assistant
medical officer, instead of being performed by the Medical
Superintendent himself.
“Finding some doubts as to the Construction of Section
55 of the Act 16 & 17 Viet. c. 97, which imposes on * the
Medical Officer ’ this among other duties, we laid a case in
March last before the Law Officers of the Crown, and their
opinion is as follows:—
“ Opinion of the Attorney and Solicitor-General on the
construction of the Act 16 & 17 Viet. c. 97.
“ 1. The Medical Officer mentioned in the different sec¬
tions of the Act appears to refer to ‘ the Medical Officer 9
appointed as such by name under Section 55. He is not
more or less ‘the Medical Officer ’ because he is also ap¬
pointed Superintendent. If there be a Medical Officer
appointed to different divisions, they can act as € Medical
Officer 9 in respect of the division to which either of them is
respectively appointed.
“ 2. Assistant Medical Officers are not Medical Officers
within the Act. They cannot perform any discretionary
duty imposed upon the Medical Officer, nor sign any docu¬
ment which has to be signed by him; but they may make
entries under the direction of the Medical Officers.
“ (Signed) “ Henry James.
“Royal Courts of Justice, “Farrer Hersohell.
“14 March, 1883.”
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Twenty sixth Annual Report of the General Board of Com¬
missioners in Lunacy for Scotland: Edinburgh, 1884.
The Report of the Scotch Lunacy Commissioners for 1883
is, as usual, distinguished for minuteness, and a kindly sort of
prolixity which is not altogether out of keeping with the
personal attention to details for which that Board has long
been noted.
There were on the 1st of January, 1884, 10,511 insane
persons in Scotland, known as such to the Board, and there
seem, in addition, to have been 228 imbeciles who were in¬
mates of training schools under the jurisdiction of the Board.
8,572 patients were accommodated in public and private
asylums, lunatic wards, and in the lunatic department of the
Perth Prison, leaving 1,939 in “ private dwellings.” Of
these last, 128,48 males and 80 females, were private patients,
and 1,811, 720 males and 1,091 females, were pauper. During
the year 1883, there had been 1,220 discharged recovered , 604
discharged not recovered, and 697 deaths. The percentage
of recoveries on the admissions, of all classes, except those
sent to the prison, seems to have averaged 27, from 43 in the
public and parochial asylums, to 11 in the private. The
deaths represent a percentage of 7 # 4 in the same classes,
from 5*2 in 66 lunatic wards ” to 10 in the private asylums.
The Board makes some remarks on the subject of what are
called in Scotland “ certificates of emergency.” In that
country, as is well known, no patient, private or pauper, can
be received into an asylum (except as a voluntary patient)
without a Sheriff’s order, and this is granted on the presen¬
tation of a petition accompanied by two medical certificates.
This must prove extremely cumbersome in practice, for
patients do not always go insane while the Sheriff is sitting,
and even if they did they might be at some distance from
one. That it is cumbersome is practically proved by the
fact that the u certificate of emergency ” is very frequently
resorted to. Under this certificate, signed by a medical man,
and generally by one of those signing the other certificates
in the case, a patient can be received and detained for three
days, and during that time the Sheriff’s order maybe procured.
It may possibly happen that the Sheriff declines to sign the
order, or that the patient recovers within the three days, or
that for some other reason he is discharged without an
order having been procured; and, with the view of ascer¬
taining whether in such circumstances the patient had had
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reason to complain of the deprivation of his liberty on
sncli terms, the Commissioners u had an examination made
for the years 1880, 1881, 1882,” during which time there
were 67 such cases, with the result of showing that no
injustice had been done to anyone.
It has been proposed to meet popular clamour in England by
copying the Scotch law in these particulars, as regards private
patients. We have not the slightest faith in the order of
the Sheriff. It is a complete farce, for he never, we believe,
sees the patient. At any rate he is not obliged to. Nothing,
however, can be more ingenious, for it relieves doctors and
friends alike of responsibility, and acts on the public mind
as a convenient opiate. It may, therefore, be introduced into
England as a placebo , and to satisfy those whimsical people
who fancy that anything must be good so long as it is im¬
ported from the other side of the Tweed.
Changes in the English lunacy statutes will very possibly
soon be made, and though it is not likely that, be the change
what it may, there will be much real improvement, a modi¬
fication of the English system can be made in this direction
as well as in any other. We need not expect the public to look
at the nice and delicate points of the question; all they think
of is this: under any Lunacy Act you must deprive a man of
his liberty, and we intend to see that the dangers of such a
system are minimised as much as possible. It is no doubt
well for those who have the care of the insane, such as those
whom we more directly address, to recognise the existence
of this sentiment, to meet it and aid in guiding it into those
channels by which the most good and the least ill to the
insane may be secured. They may depend upon it that they
will not be able to check the current altogether, however
unreasonable it may be. It is said that actions at law for
improperly confining a patient in an asylum are extremely
rare, if not unknown, in Scotland, and this does not arise
from any special care on the part of the doctors, or from want
of boldness in certifying the more obscure and doubtful cases,
such as those of dipsomania, but from the fancied security
given by the order of the Sheriff.
With reference to the changes amongst the attendants, the
Commissioners state that there have been no less than 603.
They do not state how many of these servants there are in
the Scottish asylums, but we can get an approximation to the
number. There were 8,519 patients in all the asylums and
poorhouse lunatic wards on the 1st of January, 1884, and it
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is on the whole probable that there are in all 10 patients
to 1 attendant. This gives 852 attendants for the asylums,
&c., of Scotland, and if so the proportion of changes is very
startling. It must be borne in mind that of the supposed
852, 603 were not necessarily new to the work on the 1st of
January, 1884, because it is probable that the total of changes
is made up of a comparatively small class. Thus, an asylum
with 6 attendants for instance, might have 12 changes in one
year, at one per month, and still have retained the services
of 5 old servants. But, with every favourable explanation,
such an evidence of a desire to quit the Scottish asylum
service is worthy of a careful inquiry into the cause. It
will probably be found to be, at any rate, partly due to the
fact that these asylums have no powers of granting pensions
whether for long service, ill-health, or injury contracted in
the service. We can speak from personal experience of the
additional attractiveness given to asylum employment in Eng¬
land, where an attendant gets a pension. But whatever be the
cause, a suitable remedy should be discovered and applied,
for nothing is more detrimental to asylum management than
a constant change of servants.
The Board has a good deal to say of the “ present con¬
dition of establishments/’ but much of what they say is
only a repetition, frequently in the same words, of the entry
made by the Visiting Commissioner at his statutory visit,
and the impression given of extending this portion of the
report unnecessarily would be removed were the practice
relinquished in future. Thus, of the Banff District Asylum
it is said, in the report, that the patients “ have good food,
good clothing, comfortable beds, abundant open-air exercise,
and the means of healthy action and useful work; they are
treated with skill and kindness, are not subjected to irksome
discipline, and they live in bright, cheerful, and well-fur¬
nished wards.” Turning to the entry, we find:—“The
patients are well fed and well clothed; they have comfortable
beds; they have abundant exercise in the open-air; a large
number of them engage in active, healthy, and useful work;
they are treated with kindness, and are not subjected to any
irksome discipline; and the wards are well furnished, and
have a bright and cheerful look.” This repetition is objec¬
tionable, but, if it be necessary, we would suggest that the
passages should in future be placed in the report within
inverted commas. In connection with one of the Banff
asylums, we note that it is called a “ Succursal ” asylum.
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This word, evidently used instead of “ auxiliary,” is sug¬
gestive of, and renders it difficult to repress, a malediction.
The chief interest of the Scotch Lunacy Report has, for
many years, centred in the remarks the Commissioners have
to make on the subject of lunatics in private dwellings.
Aided by the natural advantages of a country which, in
many districts, is sparingly populated, the people of these
districts being strange to town life, and retaining many
primitive customs, they have utilized these and other forces
to excellent purpose, and the result is a system of boarding-
out lunatics which, though not without its inevitable evils,
has its advantages. In the more crowded England, with its
busy centres, and far and wide-spreading feeders of those
centres, such a system on a proportionate scale would be
impossible, and its establishment has not been attempted.
Of the 10,511 insane persons in Scotland on the 1st of
January, no less than 1,939, or nearly 20 per cent., were
accommodated in “ private dwellings/’ These are startling
and interesting figures, and if they be supported by the fact
that these persons are in every way as well provided for as
they would be, were they aggregated together in one kind of
establishment or another, their importance could hardly be
over-estimated.
It is matter for regret that Dr. Fraser does not confine him¬
self to a record of the excellent work done by him, and leave
the conclusions to others. His work must take up a great
deal of time, and involve much expenditure of energy, for he
paid no less than 1,306 visits during the year. A simple
account of where he went and what he saw would be suffi¬
ciently interesting, and more in keeping with the proper style
of a formal report.
• Dr. Lawson, the other Deputy-Commissioner, writes
thus :—“ During the course of my visitation I am frequently
asked—‘ Can lunatics be properly dealt with in private dwell¬
ings?’ One who was inclined to advocate as a partizan
the system of dealing with the insane otherwise than in
asylums might, with a certain amount of fitness, meet this
inquiry by proposing the corresponding question — i Can the
insane be properly dealt with in lunatic asylums ? ’ At first
sight the question appears to be absurd,” and so on; and
Dr. Lawson concludes that asylums “ apart from their re¬
sources, are absolutely prejudicial to the interests of the acute
lunatic.” “ The acute lunatic, whose friends could place at his
disposal the especial shill , appliances , amd organisation which
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are the real advantages of an asylum, transferring them for the
occasion to the patient’s private dwelling , would place him
under the most favourable conditions for being cured.” We
give these two sentences as passages which are so completely
qualifying as to render them substantially an argument
against his proposition. And what, may we ask, is the
grammatical position of “ the acute lunatic ? ”
We think that in the following paragraphs Dr. Lawson
practically ends by admitting what he begins by denying:—
“ Evidently then, so far as the curing of insanity is con¬
cerned, lunatic asylums are not unexceptionable institutions.
They are only a necessary evil for which there is as yet no
practicable substitute. Both the separation and the aggre¬
gation which they involve are disadvantageous. It is one of
the most afflicting features of insanity that to all except the
very wealthy it involves a violent and sometimes a permanent
disturbance of domestic relationships. Even the pauper can
wait for the issue of his simple bodily disease on his own
hearth, or in his own bed. He has the companionship of his
own little society and it has the pleasure of his company,
which is often none the less valuable to them or valued by
them on account of the softening effects of sickness. On
the other hand, there is often an inherent necessity in disease
of the brain and derangement of the mind, for the removal
of the victim from the family circle. Other maladies may
simply destroy or impair a man’s usefulness; insanity may
make him a positive enemy to society. Unless he is very
wealthy, he cannot be treated in isolation, and an asylum is
the only alternative. Insanity is the leprosy which takes
him without the camp. Undoubtedly insanity has an ad¬
ditional horror in thus being a double affliction—a terrible
malady and a domestic disruption. Yet, it is almost im¬
possible that it can ever be otherwise than that, in the vast
majority of acute cases, treatment in an asylum will be a
painful necessity. Practically, efficiency in management and
treatment can be arrived at only by the aggregation of
lunatics. This, however, is an argument in favour not of
asylums but of efficiency, as we submit to the disadvantages
of aggregation in order to secure the advantages of efficiency.
“When, therefore, we ask whether acute cases can be
properly dealt with in private dwellings, we are in a position
to answer, that only the want of abundant means prevents
their being so dealt with, and that, that obstacle being re¬
moved, no method of treatment is more likely to be satis-
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factory. When again, the same question is asked regarding
asylums, the answer is unavoidable, that there is much in the
nature of an asylum which makes it unsuitable for the treat¬
ment of acute insanity, and that whatever improvement is
made in our method of dealing with the acutely insane,
must be in the direction of keeping the individual who has
just become mad away from the society of those who are
already confirmed lunatics, as long as it is possible to do so.
This can be effected only by the treatment in cottages or
other isolated dwellings of all recent cases which may be
judged to be curable. Till such a method of treatment is
made possible, the vast majority of the acutely insane must
be dealt with in asylums; and there they should be sent
without a moment’s delay.”
Practically, then, the question is answered in favour of
asylums, and against the private dwelling system, so far as
Dr. Lawson’s arguments affect pauper maniacs. He seems to
have quite lost sight of the fact that a thing must be possible
in practice as well as good in theory. The reason of the
institution of asylums is just the very reason that he gives
why acute cases cannot be properly dealt with in private
dwellings, namely, the “ want of abundant means; ” and
this is so obvious, and so universally acknowledged, that we
wonder it should have been thought worth while to publish
such 'arguments over again. The climate of Madeira, for
instance, is believed to be of much benefit to the phthisical,
and that of many parts of Britain is extremely inimical to
them; but that would not be a good reason for devoting
several pages of a Blue Book to amplifying this statement,
and arriving in the end at the conclusion that until the
obstacle of the want of abundant means can be removed, we
must cease to wish to be able to deport all the phthisical
poor to that island, but instead of that do the best we can
for them at home. No one will deny that there are serious
disadvantages to contend with in asylum treatment. To our
own mind, living as we have done for many years amongst the
insane, and endeavouring to the best of our own poor ability
to ascertain their wants and to lighten their annoyances,
none of the latter has ever appeared to us more grievous to
bear on their part, and more difficult to combat on ours,
than absence of stillness at night. But what can be done in
such a case ? Abolish the asylum ? Surely not.
In connection with this subject it is interesting to refer
to the table giving the cost of pauper patients in asylums,
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and in private dwellings, and to the causes of death under
the different systems. In the asylums the average cost
appears to have been Is. 5£d. per day, or 10s. 0|d. per week
per head, and in the private dwellings 9£d. per day, or 5s. 6£d.
per week. It is not specified whether this sum of 5s. 6^d.
includes the cost of lodging as well as of maintenance, but
from a table given by Dr. Lawson at page 148, we are in¬
duced to believe that it does. Table XXII. gives the specified
causes of death in establishments, but not those in private
dwellings, and why this should be we are quite unable to
understand. We are, however, able to draw some comparison
between the two systems by the help of a table by Dr. Fraser
at page 132, giving the causes of death in the asylums for
twenty-jive years, and in the private dwellings for three years,
a rather remarkable mode of comparison, by the way. The
deaths in the asylums were due to the causes usual in such
institutions, and in the private dwellings they were due to
precisely the same series of causes, except that there was
none from general paralysis. That is to say, cases of
maniacal and melancholic exhaustion, of paralysis, of fever,
dysentery, phthisis, and of organic diseases of the brain,
such as tumours, were treated to the end in these places, at
an average cost of say 4s. per week, which is probably all
that is left out of 5s. 6£d. for maintenance after the rent,
coal, lighting and clothing have been paid for. Asylums
may be “not unexceptionable institutions,” but, on the
other hand, it is not pleasant to dwell on the contemplation
of the treatment of a case of dysentery, or of fever, or of
maniacal exhaustion, at an outlay of 4s. per week.
It is much to be regretted that these reports of the Deputy-
Commissioners should become Essays, and partisan Essays
too, and we have criticised them more minutely than usual,
but with no unfriendly feeling towards the system which they
are defending (so long as it is applied with great care to the
proper cases), in the hope that these remarks may induce
them to adopt a more judicial and impartial style in future.
We have watched the growth of the Private Dwelling scheme
with great and increasing interest. The conditions which
exist in Scotland are favourable to its being tried on an
extensive scale, and the Scotch Commissioners have not
failed to take advantage of this, and for doing so they are
to be commended. We consider that by their praiseworthy
efforts and indefatigable exertions many lunatics are suitably
provided for at a cheap rate, who in a more densely popu-
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lated country would have to be sent to an asylum. But the
system is quite strong enough to speak for itself without
there being any necessity for surrounding it with a torrent
of arguments which might be as readily used for swamping
as for irrigating it, and it is weakened by an attempt to
advocate its extension to totally unsuitable cases.
Thirty-third Report of Inspectors of Irish Asylums. 1884.
The Annual Report of the Inspectors of Irish Lunatic Asylums
commences by stating that, from some unexplained reason, they are
unable to publish the “ more elaborate tables,” given for the first time
in their last report. On comparing their Blue Book for this year
with that of last the following statistics will be found omitted:—
Tables showing the percentage of Recoveries and Deaths.
„ showing the Form of Mental Disease.
„ showing the Causes of Insanity of those admitted into District
Asylums.
That these statistics are of great importance in the study of psy¬
chology must be admitted. Especially it is to be regretted that the
attempt made to introduce one uniform system of tabulating the
different causes of insanity should have been thus early laid aside.
Any attempt to elucidate the origin of mental disease must be a matter
of interest not alone to those engaged in the care of the insane, but
to those occupied in the preservation of the public health, and even
to those who contribute to the public taxes.
For years past this Journal has pointed out the importance of the
publication of statistics on Insanity in the three divisions of the
United Kingdom, which might supply dates for the future comparison
of the ever-changing phases of Insanity. Even should these statistics
at first be of doubtful value from the difficulty of obtaining authentic
information, nevertheless the very habit of compiling them from year
to year must of necessity cause greater care to be taken in acquiring
the knowledge necessary for this publication. The Blue Books pub¬
lished in the three divisions of the United Kingdom cpntain a vast
mass of facts on the subject of insanity. If the statistics thus
obtained from the various institutions for the treatment of the insane
could be produced in forms admitting of comparison, surely a step
would be made in the advancement of science. Much has
been done in the English and Scotch reports to further the study of
psychology and medicine ; there surely can be no reason, either from
expense or trouble, why Ireland should not follow the same good
example.
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At the end of the years 1882 and 1883 the numbers of insane in
Ireland under supervision were as follows :—
1883.
1884.
In District Asylums on January 1st.
9,271
9,542
„ Criminal „ „
173
172
„ Stewart Inst. (Gov. Patients) ...
16
12
„ Private.
651
636
„ Workhouses ... .
3,711
3,726
Total
13,822
14,088
The increase in District Asylums amounts to 271.
The increase
during the same time in English County Asylums has been 1,753,
and in Scotch Royal and Parochial Asylums 58.
The total increase of the insane under supervision has been 266—
that for 1882 being 377. No evidence would appear to exist from
these returns that any increase had taken place in the ratio of the
insane to the population. A certain addition of the number under
supervision will of necessity take place from year to year owing to
the numerous cases of mental fatuity and old age which are drafted
into asylums, there to finish their career.
According to the Inspectors, the proportion under treatment in
district asylums was about one to every 540 of the general popula¬
tion, the males exceeding females by about 18 per cent. The number
of recoveries, amounting to 1,079, gave a percentage of 40 on the
admissions. The Inspectors seem, however, still determined to hold
to their own view, that this percentage is more legitimately calculated
on the daily average under treatment. This they gave as fully 11
per cent. The discharged relieved, or actually benefited, 372, in
like manner gives a percentage of 3£ per cent.; both together a per¬
centage of 15 per cent. It is, however, a difficult matter to under¬
stand how the Inspectors can group the Recovered and Relieved
together, as the latter involve such very different results. An
epileptic may be discharged relieved, who has recovered from an
attack of excitement—a maniac may have passed into a state of quiet
dementia and be given to his friends, but it can only throw doubt on
the statistics of insanity to lead it to be supposed by the general
public that*bases discharged relieved are, as a general rule, curable.
The mortality was one degree higher than in 1882. It included
five cases of suicide. “ In each an exculpatory verdict on a coroner’s
inquest was returned.”
The sanitary condition of all the district asylums is spoken of in
the highest terms, having been particularly exempt from epidemics
and diseases of an acute character, deaths in them in almost all cases
being referable to advanced age or to pre-existing debility of
constitution.
The Government Auditors were stated to have reported favourably
on the mode in which the various books pertaining to expenditure
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were kept. In one case, however, the Auditor disallowed the outlay
of £33 for a lift supplied for the use of a Medical Superintendent in
one of the district asylums. It seems hard to understand how a
medical man, in charge of a large institution, should be denied even
the means of supplying himself with food.
It is gratifying, however, on the other hand, to find in the next
paragraph that the practical efficiency of district asylums in Ireland
has been sustained by a cordial co-operation between Boards of
Governors and their staffs—that resident and extern medical officers
have been sedulous in the discharge of their duties—that there is a
general absence of complaints against subordinate servants and atten¬
dants, and almost no instance of any on the score of harshness or
immorality.
This is certainly a most gratifying and happy condition of affairs
to all concerned in the management of Irish asylums. But perhaps
we might suggest that the Inspectors should consider that this state
of things is not quite in accordance with the result of experience
elsewhere; that there may be no complaints, and that quietude may
have been made and called peace, which may hide a very bad state of
affairs behind; that perhaps, if discipline were a little more severe, if
a more careful watch were kept, the rosy hue of the existence of the
insane in Ireland might not look quite so bright.
But what appears more extraordinary is that these immaculate
attendants, against whom no complaint is found, are under-paid. It is
easy to understand that a high class of officials can be procured at
high wages; but the opposite proposition is difficult to believe, that,
at low wages, candidates can be found for these posts, whose morals
are perfect and who are free from any suspicion of cruelty. Never¬
theless, the Inspectors repeat that their remuneration admits of much
improvement, and point out the result that attendants, as soon as they
become educated to their duties, emigrate, and are succeeded by others
quite uneducated, who, in turn, on acquiring some experience, seek a
like engagement wherever they can get better pay; or, on earning
the cost of their passage, emigrate to America. Happy the country
which can supply a continual flow of young men with such perfect
morals 1 We advise all American and Canadian Superintendents to
be on the look out for them.
But however indispensable the professional knowledge and experience of the
superior officers attached to lunatic asylums must be for their successful
management, it is not the less requisite that attendants in immediate and con¬
tinuous charge of the insane should be suited to their respective duties. Coin¬
ciding in the opinion so often expressed by the English and Scotch Commis¬
sioners on the remuneration of some subordinate staffs within their supervision,
we cannot but repeat that in this country it admits of much improvement.
Superannuation is said to hold forth very little attraction.
No doubt a retiring pension is recognised at the end of a certain number of
years, but the amount on which it is calculated is so uncertain that, as a rule,
very few remain to benefit thereby.
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A more likely reason would appear to be that the period of service
(forty years) under the Lunatic Asylums’ Superannuation (Ireland)
Act, 1856, is so long that it is the lot of few to enjoy human exist¬
ence lengthened to such advanced age.
Oar district asylums have been already fifty years in existence; at present
there are nearly eight hundred individuals of the class adverted to in them, while
on retirement after a full length of service there are probably not a dozen
receiving pensions. Thus the emoluments of place, calculated to a considerable
extent on allowances, and so obtaining prospectively a fictitious character or
monetary value, interfere with a reasonable payment for services while being
rendered.
The meaning of the last sentence and its connection with the con¬
text is so doubtful that we must leave it to our readers to explain it
for themselves.
The balance-sheet of the expenditure of district asylums stands
thus
£ s. d.
Balance in hand . 37,459 0 0
Rate in aid. .89,424 12 0
District rates . 114,953 2 3
Self-supporting patients . 4,750 9 6
Produce of farm and incidents ... 5,974 13 8
Total .£252,561 17 5
On the other hand the expenditure amounted to £200,267 13s. 9d.,
and included—
£
Provisions . 94,300
Salaries . 47,000
Clothing, furniture and bedding ... ... 29,500
Fuel and washing ... 16,000
Repairs and alterations . 11,200
The average cost per head amounted to £22 16s. 3d. Subtracting
from this the Treasury rate in aid, the cost to the ratepayers amounted
to £12 8s. 5d. for each Irish lunatic.
We would here suggest the wisdom of assimilating the statistics of
expenditure and cost of maintenance with that of other countries by
giving the cost of maintenance, medicine, clothing, and care of
patients in asylums by week and not by year, and so making Table
No. 19 correspond with a similar table in Appendix E. of the English
Commissioners’ Blue Book.
Indoor amusements and agreeable occupations—reading, music,
dancing, scenic entertainments and the like—with outdoor games
and occasional excursions into the country, have been liberally afforded
to patients capable of their enjoyment, during the year under con -
sideration, by the various Boards of district asylums, in which we are
glad to notice a growing tendency to dispense, as far as possible, with
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all arrangements “ of a restricted character” although, in truth,
what the precise meaning of “ arrangements of a restricted char¬
acter ” may be y it is difficult to understand. Whether it means that
the governors of asylums have given up all ideas of economy and have
become lavish in their expenditure, or have laid aside all forms of
restraint, strait waistcoats, locks, bars, airing courts, high walls, or
have removed all restrictions as to the admission or discharge of the
inmates, their dietary or treatment, we are left in doubt.
Next follows a series of short statements on the condition of
the twenty-two district asylums; they are all of a most laudatory
character, but contain little of interest to the general reader, except
the ratio of the insane to the general population in each district. A
more systematic mode of reporting, by which one institution could be
fairly compared with another, is much to be desired. We would
suggest to the Inspectors the scheme of reporting proposed in Yol.
xviii., p. 352 of this Journal.
In these reports on the various asylums, references are made to the
indebtedness of lunacy districts to the Treasury. The advances by their
lordships, since the passing of the 1 and 2 Vic., s. iv., amounted
altogether to close on £1,540,000, out of which a balance of
£240,974 remained due at the end of last March. A table, giving
the different items and dates under this head, will be found in
page 110 of the Report.
With reference to the distribution of insanity in the various
counties, the Inspectors point out the small number of the insane
to be found in Mayo, so that in a population of 240,000, the asylum
accommodation only amounts to 280 beds, and in the various work-
houses throughout the county 82 comprise the whole number of
idiots, imbeciles, epileptics, and lunatics. This remark holds good to
almost the whole province of Connaught. Comparing, on the other
hand, the prosperous County of Down, with an asylum containing
460 patients, there are 139 insane paupers in its workhouses, in
an existing population of 260,000. Again, in the rich and fertile
district of Limerick, amongst 173,000 inhabitants, in addition to 480
lunatics in the asylum, the number of insane in poorhouses amounts
to 245.
The reason given for this is that destitution was far more severely
felt in Connaught during the famine years than elsewhere, at which
time the unprotected and unhoused insane suffered most severely in
the struggle for existence.
The report of the resident physician of Dundrum Criminal
Asylum is given as usual in extenso. He points out that the
health of the inmates has been much improved by sanitary arrange¬
ments, especially by the adoption of a self-acting apparatus for
flushing the closets. When speaking of the farm, he regrets much
the sum which had to be paid for plough labour. This, he states, is
due to the inmates refusing to work owing to the system of rewards
having been put a stop to. In urging the alteration of this, he states
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that the system of rewards for work done is in full operation at Broad¬
moor, and is found to work well. The Inspectors, however, decline on
principle to establish an injudicious precedent on behalf of idlers well
supplied with food of the best description. At the date of the report
172 insane prisoners were in the asylum, and had it not been for the
unusual mortality in 1882 and 1883, averaging eight per cent., the
buildings would not have afforded accommodation for the number
admitted, amounting to forty-nine in the last eighteen months.
The mentally affected inmates of Union Workhouses in Ireland on
December 3l6t, 1883, amounted to 3,726—1,488 males and 2,238
females—an increase of 15 on the year before.
As a rule the Inspectors believe them to be treated with con¬
sideration, located in detached buildings, and placed on a more
liberal and nutritious dietary than that given to ordinary paupers.
From personal observations they believe that their comforts, as
a rule, are practically progressing. The most notable deficiencies
are referable to restricted airing grounds, the want of separate day
rooms, and congenial modes of occupation under responsible attendants.
The Guardians of the Belfast Workhouse are, according to the
Inspectors, deserving of every praise for their appreciation of the
wants of the idiotic and epileptic inmates, having erected a spacious
pile of buildings, with a fair acreage around, for their pauper insane.
The number of private patients in Ireland seem to have fallen off
considerably. On 1st January, 1884, the inmates of private asylums
amounted to 636, as against 651 on like date in 1883. Here we may
again repeat a suggestion made a long time ago in this Journal, viz.,
that those institutions kept wholly for profit should be distinguished
from the hospitals which are supported, to a very large extent,
from special funds, and are not kept for any individual gain. Many
of these exist in Ireland, viz., Swift’s Hospital, St, Vincent's,
the Friends’ Betreat, and the Stewart Institution.
The Keport concludes with the usual statistics to be found ip
the Irish Lunacy Report, omitting, in addition to those referred to in
the beginning of this article, the tables giving the salaries and
emoluments of officers and attendants.
Body and Will. By Henry Maudsley, M.D. Kegan Paul,
Trench, and Co. 1883.
Prolegomena to Ethics. By the late T.H. Green. Clarendon
rress: 1883.
(Concluded from July , 1884.)
We alluded in the closing sentences of the earlier part of
this review to the interesting work that is included in Part
III. of Dr. Maudsley’s book, which he entitles the Pathology
of Will. It opens with a chapter “ concerning degenera¬
tion,” and from that opening to the final dirge, entitled
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" What will be the end thereof?” it reflects throughout a
startling pessimism. The author thinks, for example, that,
“ in order to have a theory of cosmogony that shall cover all
the facts, it has always been necessary to supplement a good
principle by a bad principle, a god of creation by a god of
hate and destruction.” And he is so staunch a Manichsean
as to predict that it will always be so, that to believe in the
survival of good over evil is as foolish as to persuade ourselves
that repulsion will one day survive attraction, and that, in
fact, there is always good reason to believe that “ the sum of
the respective energies of good and evil remains a constant
quantity.” Into these dark depths of despair we decline to
follow him, for indeed they are in no wise necessary deduc¬
tions from his scientific data, but rather an offspring of his
own metaphysics. It is of more value to follow his progres¬
sive study of moral degeneracy as it appears in actual prac¬
tice. He starts, for simplicity, with the case of children
morally but not intellectually defective; and he summarises
the lessons of such a case in this way:—
"One might represent the stages of descent in this fashion :
1. Absence of exercise, and through disuse decay, of the
highest social sensibilities and powers, moral and volitional,
in one generation: therewith lifelong unchecked exercise of
the secondary or social developments of the egoistic passions
in the conduct of life: consequent moral degeneration, which,
by its nature, goes deeper into character than intellectual
degeneration. 2. In a succeeding generation some form or
other of positive mental derangement; or such a development
of vice in character as falls a little short only of madness or of
crime. 3. In the third generation moral imbecility or
idiocy, with or without corresponding intellectual infirmity.”
This is an excellent statement of the broad lesson, deducible
from the whole range of hereditary degenerations in human
life, that the “ acquired infirmity of one generation will
become the natural deficiency” of a succeeding one. Two
reflections occur to us, however, when we look closely into
the case as it is stated here. In the first place, does not the
very possibility of " acquiring an infirmity ” by moral choice
and persistent repetition of voluntary acts which we know to
be wrong, imply exactly that freedom of the will which Dr.
Maudsley would deny ? And again, is it quite true that a
"natural deficiency” cannot, at least in all the lesser
degrees of it, be improved out of existence by a contrary
moral exercise of the will ?
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We pass reluctantly over Dr. Maudsley’s careful discussion
of the various kinds of moral perversion in disease, as in
hysteria, epilepsy, injuries to the head, and alcoholism.
They are a tempting subject of discussion; but it is more
tempting still to consider his views on the “ Moral Sense and
Will in Criminals,” which forms his Section IV.
“ Habitual criminals,” says Dr. Maudsley, “ are a class of
beings whose lives are a sufficient proof of the absence or
great bluntness of moral sense.” In spite of the great
authority of the writer, this strikes one as too sweeping a
generalization. It is perfectly true, of course, as he goes on
to explain, that a certain proportion of them are of obviously
weak intellect, and that many, perhaps most, are malformed
or deformed in part or whole of body. But it seems to us
not to be true that “ the organization of the wicked is com¬
monly defective.” Surely some of the grandest criminals—
the great swindlers and forgers, the successful villains of
good society—are men of rather favourable and efficient
organization, who have gone wrong because it seemed to
them preferable to do so, and because they trusted in their
talents to conceal their crimes and to achieve social success
by what Dr. Maudsley calls “ anti-social ” means. In any
case, it is worth notice that Dr. Maudsley protests strongly
against the present methods of criminal punishment, and
also that he reminds the world that “it is small profit to
teach a child the distance of the sun from the earth, if he be
not taught at the same time to know, and not taught to know
only, but trained to feel, the distance between its higher and
lower natures.” It is to be regretted that he did not incor¬
porate with this section of the work, some clear statement, as
it appears to him, of the bearing of these questions upon the
whole theory of a criminal law and of judicial responsibility.
It is all very well to say that society must punish crime,
whether it was the fault of the criminal or no. In certain
cases that may be true; yet the existence of any such thing
as the legal defence of insanity implies that at a certain point
the doer of a criminal deed must be held to be irresponsible.
Dr. Maudsley seems to drift towards a theory in which all
criminals would be in justice irresponsible, since it is their
organization that fatally condemns them to be what they
are. It is one of the most difficult of the many matters con¬
cerning the law, as it is related to mental disease, to say
how and where the boundary line is to be drawn.
In passing on to trace the relation of mental derangement
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in general to Will, Dr. Maudsley discusses for a time the
moral degeneracy of modem society; and his verdict will
startle most of his readers. There is no hope, he says, save
in revolution. Evolution, beyond a certain point, breeds an
egoism, which is worse than the primitive egoisms out of the
escape from which society arose, because it has itself put on
a quasi-social shape. Men of evil ends have learned to find
in association the best means of preying on society. Trades
are organised to defraud and cajole the public. A swindle must
needs be a joint-stock company, and every phase of wicked¬
ness has its own appropriate solidarity. The complexity of
the social organism swamps the simple ideals and the direct
aims which give “ the radical principles of human associa¬
tion ; ” and it is only by the tragic events of an “ uprising
from below ” that Dr. Maudsley sees any hope of bringing
the perverse generations back to the stem realities of their
existence.
From these wider discussions, however, we return at once
to the fundamental point of all psychology, when the author
proceeds to discuss what he styles “ the disintegrations of
the ego” in mental disease; and here we find ourselves
again in the range of questions on which the schools repre¬
sented by Prof. Green and Dr. Maudsley are fundamentally
in conflict. Dr. Maudsley refers, of course, to the various
cases of so-called u circular insanity ” or “ double conscious¬
ness,” comparing them to the phenomena of hypnotism, and
the conclusion he draws is that “ the consciousness of self,
the unity of the ego, is a consequence, not a cause—a sub¬
jective synthesis or unity based upon the objective synthesis
or unity of the organism: as such it may be obscured, de¬
ranged, divided, apparently transformed, for every breach of
the unity of the united centres is a breach of it” To those
who have followed our earlier criticism, it will not seem
strange that we should place alongside this dictum the pro¬
nouncement of Mr. Green (best stated perhaps at p. 85), that
the “ distinction by man of himself from events is essentially
different from any process in time, or any natural becoming,”
that “ it is through it that he is conscious of time, of be¬
coming, of a personal history ; and the active principle of
this consciousness cannot itself be determined by these rela¬
tions in the way of time or becoming, which arise from con¬
sciousness through its action,” and that “human action is
only explicable by the action of an eternal consciousness,
which uses the process of brain, and nerve, and tissue, and
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1885.]
the functions of life and sense as its organs, and reproduces
itself through them.” In a word, Mr. Green would reply to
Dr. Maudsley’s phenomena of double consciousness that it is
strictly and logically inconceivable that a man, so long as he
is a man, should be anything but an ego—in the sense of an
entity uncaused by, and unsubject to, the bodily processes
of which the pathologist takes account. Human life and
knowledge are, as the idealist offers to show, inexplicable on
any other hypothesis. No “ ego,” so-called, which was merely
“a subjective synthesis based on the unity of the nerve
centres,” and which was therefore a result of organic func¬
tions, and at the mercy of them, could ever be a conscious
being at all. It is as impossible as that water should run up
hill, or that the stones should speak. To ask why , in the
constitution of the world, the ego in us, which is in itself
transcendent and not a result of natural causes, should yet
be limited strictly to express itself only in and through
organs which are under the general limitations of matter,
and are therefore subject to disorganization and death, is
like asking why that mind, which the universe implies,
should have manifested itself in a world at all? It is a
question unanswerable, until we are beyond the range of all
the limitations which these same organisms imply. But it
is for all that an evident fact, and, being so, it must serve for
the explanation of the phenomena of madness, as well as a
hundred other not less difficult problems of human life.
Whether it is in any sense conceivable that there may be a
sane ego behind the mask of a diseased brain, is another and
a very difficult question, to which perhaps some of our
readers, who are interested in the ulterior problems of mental
science, might help to find the answer.
There is no doubt, for example, that in many cases of
aphasia the patient’s mental health is good enough to enable
him evidently to know what he wants to express and to be
annoyed, often to paroxysms of rage, at the impossibility of
getting his disorganised centres of speech to formulate in
outward shape the thing he desires to say. He may be able
to write and yet not to speak. He may be able to do neither,
and yet may have some power of expressive gesture. All this
may fail, and yet when his impatience is interpreted aright,
he may show by his pleasure that his mind knew what it
wanted, and could, as far as the mental effort went, have
normally expressed it. If the facts, in a case where we can
so closely and accurately observe them, carry us so very far,
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[Jan.,
may it not be that when other forms of mental disease are
studied further, we shall find other instances in which also
traces of the sane mind can be detected, in spite of the re¬
fusal of the brain organs to convey any coherent thought into
expression or action, or in spite of a persistent distortion
and perversion by the same diseased centres of volitional acts
and impulses, whose inception, as far as the mental act went,
was rational all the while ?
As Dr. Maudsley and Prof. Green are at odds in their con¬
ceptions of the starting point of all philosophy, it is natural
that they should differ also as to the end. The materialist
closes his book with a pessimism, beautifully and powerfully,
even poetically, stated, but absolute and hopeless. “The
common law of life is slow acquisition, equilibrium for a
time, then a gentle decline that soon becomes a rapid decay,
and finally death/* To this law nations and humanity are
as surely doomed as any individual life. “ Once the dissolu¬
tion of things has got full start and way, it will be vastly
quicker than the evolution has been/* Humanity in its
retrograde process will produce new savages, but they will no
longer be the simple, childlike, relatively harmless savages of
the beginning: they will be “ new and degenerate varieties,
with special repulsive characters—savages of a decomposing
civilization/* What takes place in the life of senile indi¬
viduals daily “ will one last, long day take place in the life
of the race/* The ideals of the world, ever rising till now,
will not only not be realized, but will themselves decay, and
“ give place to ever-worsening ideals of ever-worsening states
of things/* Not only this, but the daring author even goes
on to hint that the disillusioning process has already begun.
For himself, he suggests that it is not “ so certain as it is
assumed to be that a higher moral evolution, should it take
place, will tend necessarily to the greater happiness of man¬
kind/* For the world around him, he finds in its “ maladies
of self-consciousness** many forewarnings of its destiny,
when it shall come to the old conclusions of Solomon and Job,
but in a wider earnest, as to the vexation, and vanity, and
littleness of life. And thus, by way of final conclusion, he
comes down to the annihilation even of his own philoso¬
phising—for after holding that it is presumptuous to forecast
the future of the world, and better to hold one*s peace, he
adds the words which touch the Ultima Thule of pessimistic
scepticism—“ But be the words spoken those of folly or of
wisdom, they are in the end alike, vanity. All that which is
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1885.]
past is a Dream: and he that hopes or depends upon Time
coming, dreams waking.” To what good end then, if this he
so, is any preaching, or study, or energy at all ? Two courses
only are open, if we may speak as if we could choose courses,
for that also is taken from us. Yet if we could choose, we
should either say, “ Let us eat and drink, for to-morrow we
die ”— or we should make our quietus with a pistol or a
pill. We confess that it seems to us that the very fact that
a materialist theory of life and nature leads to this result is
a sufficient proof that that theory is wrong from the be¬
ginning. The explanation of life which stultifies it cannot
be the true explanation. There may be delusions and illu¬
sions here and there, from local and relative causes in the
complexity of every life ; but life itself cannot be thought to
be a delusion, any more than we can carry scepticism to the
point of believing that we do not exist. On Mr. Green,
indeed, the phenomena which discourage the optimist in the
history of the world and of ourselves, press almost equally
hard. But he denies that they are any real guide. He con¬
fesses (at p. 196) that “ the facts of human life and history
put abundant difficulties in the way of any theory whatever
of human development. If it were not for certain demands
of the spirit, which is ourself, the notion of human progress
could never occur to us. But these demands, having a com¬
mon ground with the apprehension of facts, are not to be
suppressed by it. It is the consciousness of possibilities in
ourselves, unrealized, but constantly in process of realization,
that alone enables us to read the idea of development into
what we observe of natural life, and to conceive that there
must be such a thing as a plan of the world.”
It is the same method of argument over again. Our
guarantee of these ultimate truths is not an induction from
observed facts, which are all the children of a consciousness,
without which no perception can be, but is an analysis of
the precedent conditions implied in knowledge, or in self, or
in the world. That there should be a fact at all, is the first
marvel; and in the unravelling of all that this implies, we
find the key to the mystery of the Universe. It is the only
key that has yet seemed able to unlock the hiding places of
selfhood and moral duty, of the present and the future life,
of the Human and the Divine. It is worth a better trial
than it has yet obtained in England. If it holds, all is well.
If it breaks, it will be time enough for Pessimism then.
Ox ON.
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Lectures on Mental Disease . W. H. 0. Sankey, M.D.
London: Lewis, 1884.
Those who remember with pleasure the originality and
shrewdness exhibited in the first edition of these lectures,
will not be surprised to find that, though so much altered
and enlarged that it may be considered a new work, the
book before us displays some of the most distinctive and
original peculiarities of the earlier issue.
The present edition is divided into five parts. The first
deals with Mental Science or Physiology. On the meta¬
physical side Comte’s doctrines, as expounded by Lewis,
are accepted on the more strictly physiological, the teaching
of Spencer and the English school. Modern physicians wifi
scarcely quarrel with this, but it may be observed that the
paramount importance of heredity as solving certain difficul¬
ties which have always arisen with reference to a priori
mental products, &c., has not yet received proper recogni¬
tion.
Part IL, consisting of nine sections, deals with Mental
Disease, or Pathology. The most striking feature here,
as in the earlier edition, is the mode in which classification
is treated. The following is the arrangement the author
adopts:—
A. Idiopathic
f
Morbid
{?:
Ordinary Insanity.
General Paresis.
2. | Developmental ^Sy.
B.
Symptomatic
§
5. Epileptic Insanity.
Alcoholismus.
Spinal Diseases.
Organic Cases.
The reader will perceive that the greater number of all
the cases we meet with are here comprehended under the
general term “ ordinary insanity.” “ Cases of mental disease
vary much in their course and progress. At one period the
subject will present phenomena totally different from the
symptoms presented at a different period. 1 maintain, how¬
ever, that the case must be considered to be of one species
throughout; such is the rule in general pathology, and there
are no grounds for having a different system in insanity,
however long the case may last. For a case to be placed
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1885,] Reviews.
under a different name it should differ from all other cases,
as distinctly as acute rheumatism from typhoid fever/ 5 Thus
it appears the author's opinions as to classification are based
chiefly on his opinion as to the course and progress of an
“ ordinary 55 case of insanity. In this point he is very
decisive and original, and his views are worth careful
examination. “ The disease has its well-marked and definite
symptoms, and runs its course in a manner which observa¬
tion enables us to describe. . . . Thus, a case in the
primary attack commences by symptoms of melancholy;
these may . . . pass off ... or the melancholic stage may
be aggravated and the patient die; or if the patient does
not die, the disease may exhibit symptoms of violence and
become acutely maniacal. ... A patient without becom¬
ing maniacal, however, may continue melancholic, and the
disease become chronic. The case of the patient who has
passed into a condition of mania may also become chronic
in that stage, and he may recover or die. Next, the chronic
case may alternate in different ways between a melancholic
and maniacal condition; and, lastly, if the patient does not
die in this stage, or recover, the chances of which would be
slight, he may pass into a condition of imbecility or
dementia. 55 Accordingly the author proceeds to describe,
(Section 1) under the name of the first stage, the various
symptoms of what would be ordinarily called melancholia;
under the name of third stage (Section 2), chronic melan¬
cholia, chronic mania, and alternating forms. No one can
deny that this is a striking view, and no careful observer
can doubt that in some points it is very noteworthy, but the
question arises. Has not the author’s reasonable dislike
to the over refinements of classification led him too far ?
Does he not generalise too much ? In fine, is this course of
insanity, as he strictly lays it down, truly in accordance
with clinical experience ? We think few of our readers will
endorse Dr. Sankey's view in its entirety. The variety of
symptoms which any case of insanity may exhibit during its
course is not more remarkable than the variety of ways
in which it may commence. Hard-and-fast classifications
have often before now been compared to the bed of Pro¬
crustes—and with justice—but by what process of lopping
or stretching can we make all ordinary cases of insanity
begin with melancholia? That a prodromal stage of depres¬
sion is very common is undoubtedly true, and one of the
most valuable points in Dr. Sankey’s earlier work was his
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insistance on this fact, but the universality of this first
stage we traverse, and we think it is possible to exaggerate
its importance where it does occur. For in many cases
where something resembling melancholia precedes an out¬
break of mania, it is certainly rather of the nature of dulness
arising from the retardation of activity in the normal mental
functions than a truly depressed emotional state.
Dr. Sankey denies the existence of acute dementia
altogether, not distinguishing between it and melancholia
cum stupor e. While strongly objecting to the term, we still
hold that there are certain cases of “ Mental Stupor ’’ (a
much better name) which are not based upon melancholia,
exceptional as they doubtless are.
In a Section on Recurrent Insanity the author states that
the second attack differs from the first by the sudden advent
of symptoms and general absence of a melancholic stage.
Section 4 discusses “ the various so-called kinds of In¬
sanity,” and Section 5 contains clinical cases, “ examples of
Insanity Proper.” These five sections contain much that is
valuable and original. The author gives due prominence to
the remarkable disturbance of digestive faculties that almost
always occurs in the earlier stages of melancholia, and
which has not elsewhere received by any means the notice
and practical attention its importance calls forth. In this
point also the author develops the views expressed in his
earlier edition. In the description of symptoms there is
much accuracy and acuteness, though sometimes, perhaps,
the author’s theoretical opinions have interfered with their
completeness. For example, though Puerperal Insanity may
not be logically or pathologically separable as a distinct
form, yet there are two symptoms that occur so frequently
in puerperal cases, that they seem to call for differentiation,
namely, sexual excitement and mistakes on the patient’s
part as to identity.
The value of a patient’s acknowledgment that he has
been insane as a proof of his presept recovery is rightly
insisted upon.
We miss any mention of the frequency of a certain kind
of small constant restlessness as an indication of the
suicidal tendency in melancholia.
Intense flushing after eating is noted as a common
symptom in ordinary insanity. It has been descrioh^by
a German author as common in the preliminary (melahs^
cholic) stage, and as it occurs in dyspepsia without insanity.
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1885.]
it is probably connected with the same condition of tbe
nervous system that causes the digestive troubles in melan¬
cholia. The frequent accompaniment of melancholic ap¬
prehensions by a “ physical sensation of dread at the prse-
cordia or region of the aortic arch ” is not overlooked.
The oft-noted association of erotic and religious excite¬
ment is confirmed by our author.
The value of a gain in the body-weight is referred to, but
it is not stated that this symptom must be carefully scruti¬
nized, seeing there is an unfavourable as well as a favourable
gain in weight.
On the subject of Moral Insanity Dr. Sankey quotes,
with apparent approval, a well-known passage from Bland-
ford. His own opinion clearly is that cases described under
this head are really cases of Recurrent Insanity. “ It is not
only important to know that the propensity exists in certain
morbid conditions to break out into these criminal acts, but it
is equally of importance to know that when one of these ap¬
parently motiveless acts is committed by a lunatic , there
will always be found a history of insanity in the accused’s
life; for such outbreaks in a lunatic are only met with as
phenomena of second or subsequent attaclcs; this fact is im¬
portant.” Very important, indeed, if true !
Section 6, on the Etiology and Pathology of Ordinary
Insanity is a good summary of what is known of these
rather obscure subjects. Here and there the author’s
style wants some elucidation—as at p. 218, where we
read that the prominent remote cause seems to be of a
moral kind, “when a man becomes insane after a long
course of hard drinking.”
Section 7 and 8 contain an account of General Paresis,
of that excellence which we should expect from this
author. As to etiology, he seems to have somewhat
modified the views cautiously expressed in the first edition
as to the importance of sexual excess. Having pointed
out the undoubted existence of strong sexual propensity
in paretics, he comes to the conclusion that this is less
to be regarded as a cause than as an effect of disease.
The pathological portion contains a good description of
the varicose condition of the small arteries previously noted
in the author’s earlier work. There is an ingenious con¬
jecture as to the cause of the frequency of broken ribs
in paretics. A man in health will receive a powerful blow
on the chest if he sees it coming, or will without injury
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bear great weights on his chest, because the intercostals
back up the ribs so as to form a powerful arch. This does
not take place! in paretics, owing to stupidity, dulness of
sensibility, and slowness of reflex movement. The last
condition would not, however, exist in all cases.
In the ninth and final Section of this Part, idiocy and
senility are described under the head of “ States of Mental
Weakness.”
Part III., on “ Symptomatic Mental Diseases,” contains a
description of Epileptic Insanity, Alcoholismus, Spinal Cases,
and Organic Brain Disease. Dr. Hughlings Jackson’s views
are adopted as explaining the phenomena of the epileptic
seizure. The question of diet is touched upon: “ Epileptics
are enormous eaters, and the fits are induced by too great
distension of the stomach. I have met more than one case
where the first attack was traced to the patient’s over
eating.” It may be remembered that the first oncome of
Swift’s epilepsy was attributed to this cause. The description
of alcoholism is good, and there is a useful analysis from
a French author of the diagnostic distinctions between
this affection and general paresis.
Many hints as to treatment are found in Part II., and
Part IV. is devoted altogether to this topic. The author
prefers chloral to opium as a hypnotic, and does not seem to
have found any evil result from the use of the former. He
has seen much benefit in mania from cod-liver oil, and
recommends among tonics the potassio-tartrate of iron,
particularly for females. With regard to moral treatment,
we are rightly told that mental rest is emphatically the
object to be attained; therefore, to change the patient’s
environments is the first indication. This can only be
carried out by early systematic treatment—not necessarily
always asylum-treatment, however.
Part V. is devoted to the legal relations of Insanity, of
which a useful summary, both for general practitioners and
specialists, is given.
On the whole these Lectures form a valuable addition
to the literature of the subject. They are characterized
by much individuality and strong common-sense, together
with a laudable avoidance of verbosity and “ fine writing,”
while the author steadily refuses to be guided by the
authority of previous writers to paths where his own ex¬
perience and judgment do not lead him.
C. N.
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PART III.—PSYCHOLOGICAL RETROSPECT.
Colonial Retrospect .
By D. Hack Tuke, F.R.C.P.
Under this head I propose to give my impressions of the condition
of the insane in Canada, derived during a visit made to the Dominion
in August last.
The Insane in Ontario .
There were, on the 30th September, 1883, 2,825 patients in the
Provincial Asylums of Ontario. This is an increase of 83, or 3*02
per cent, over the previous year. There were two less in the Insane
Wards of the Kingston Penitentiary, and the insane in jails, awaiting
removal, were fewer, viz., 34 instead of 47. There were 23 patients
at home on trial. In all there were 3,070 insane and idiotic persons
officially recognised, being 137 more than in the previous year.
They were thus distributed :—
M.
F.
Total.
Toronto Asylum .
358
... 345
... 703
London Asylum .
440
... 455
... 895
Kingston Asylum .
230
... 219
... 449
Hamilton Asylum .
246
... 301
... 547
Total insane in Asylums
1,274
1,320
2,594
Asylum for Idiots at Orillia *
122
... 109
... 231
Total
1,396
1,429
2,825
Insane Convicts in Kingston
Penitentiary .
29
2
... 31
Insane Idiots in Common Jails
21
... 13
... 34
Total
1,446
1,444
2,890
If to the above numbers are added the patients whose names
are on the files for admission into the above asylums, viz., 157, and
the number of patients out on probation, viz., 23, we obtain the total
number known to the authorities at the above date, viz., 3,070.
Dr. O’Reilly, of Toronto, the Inspector of Asylums, who provided
me with this information, states that there were 2,837 beds in the
asylums of the Province ; so that as 2,825 patients were resident at the
time of this return, and a certain number were out on trial, it is clear
that at that period the capacity of the institutions was pretty fully
reached. More recently additional buildings have been erected, but
* On Lake Simcoe. Dr. Beaton is the superintendent.
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as the number of insane has increased, the relative proportion of
supply and demand is probably aboat the same. It may be stated
that the admissions during the year ending September, 1886, were,
as regards the asylums mentioned, 543 ; the number discharged re¬
covered was 174 ; and improved, 52 ; and the number of deaths, 183.
The ratio of recoveries to admissions, viz., 33*52 per cent.,is stated by
Dr. O’Reilly to be higher than any year since 1877. The idiots are,
of course, excluded. The mortality, calculated upon the average
number resident, was 6*31 per cent., which is lower than for some
years previously.
The total annual cost per patient in 1883, in the four asylums for
the insane, varied from 127 dollars 16 cents (Hamilton) to 145
dollars 12 cents (London); the weekly cost being respectively 2
dollars 44 cents and 2 dollars 79 cents. Dr. O’Reilly contrasts
the low rate of expenditure in the Canadian asylums with that of the
United States, where the lowest average is 227 dollars 75 cents per
annum per patient; while in Ontario the average is 134 dollars 68
cents. And he quotes the saying of one of the superintendents of
the asylums in Ontario that this scale is “ nearly poor-house rates.”
The 6ame contrast has struck me as very remarkable, and the ex¬
planation is not altogether creditable to the Canadian Government.
The salaries of attendants and servants are lower in Canada, but the
explanation of the difference is to be found, according to the In¬
spector, in the relative character of the lodging, clothing, and, he
proceeds to say, more especially the food. The quality is said to be
good, but it is “ plain and unattractive,” so as to become extremely
distasteful to many patients. It is difficult for a stranger to form an
opinion on this subject, because he is unacquainted with their diet at
home; but the asylum dietary is as good as in our county asylums.
The revenue from paying patients, of whom there were 538 in the
asylums, amounts to a very considerable sum, viz., 59,922 dollars
(£12,485) during the last year. This certainly points to the
probable success of a private asylum which has recently been estab¬
lished at Guelph, and of which Dr. Lett is the superintendent.
I find, from a return made of the number of patients employed in
the asylums of Ontario, that 52*57 per cent, of the patients were
engaged in some occupation ; being 1,479 out of an average popula¬
tion of 2,813. The largest percentage was at the London Asylum,
viz., 6989.
The authorities in Ontario are not blind to the difficulties con¬
nected with the accumulation of incurable patients, for whom the
question of separate accommodation arises. I am glad to observe that
tbe latter difficulty is being met by the erection of small buildings;
these being sometimes devoted to the curable class of cases, while the
larger buildings are retained for the incurable. In some instances,
however, small buildings or cottages are, and may properly be,
devoted to the chronic insane; while the recent cases are treated in
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the old and more expensive building. Dr. O’Reilly believes that the
general feeling is entirely in favour of detached wards or annexes,
and I certainly found this to be the case at the asylums which 1
visited.
It will be advantageous to state here a few of the leading provisions
of the existing statute relative to lunatics enacted in 1871 by the
Legislative Assembly of the Province of Ontario, entitled “ An Act
Respecting Lunatic Asylums and the Custody of Insane Persons”
(chapter 220).
The Public Asylums are established and acquired under a grant
from the Legislature of the Province, and are invested in the Crown.
The Lieutenant-Governor has the appointment of the Medical
Superintendent.
Among the duties of the Medical Superintendent are those of re¬
porting the condition of the asylum to the Inspector of Prisons and
Public Charities at each visit, and also to report annually to the
Inspector upon the affairs of the institution. The financial affairs of
asylums are conducted by the “ Bursar,” who is appointed by the
Lieutenant-Governor.
The salaries of these officers are fixed by the Lieutenant-Governor,
and do not exceed 2,000 dollars for the Superintendent, and 1,200
dollars for the “ Bursar.”
In regard to admissions, no patient can be admitted (except upon an
order by the Lieutenant-Governor) without the certificates of two
medical practitioners, each attested by two witnesses, and bearing date
within three months of admission. Each certificate must state that
the examination was made separately* from any other practitioner, and
after due inquiry into all necessary facts; the medical practitioner
specifying the facts upon which he has formed his opinion, and dis¬
tinguishing those observed by himself from those communicated to him
by others. Dangerous lunatics may be committed to jail by a Justice’s
warrant on his receiving the necessary information, and after evidence
given with reference to the prisoner’s state of mind. He remains in
jail until removed to an asylum by the Lieutenant-Governor, where he
remains until discharged by the same authority.
The Inspector of Public Charities is ex-officio the Committee of every
lunatic having no other, and who is detained in any public asylum
of the Province. The Court of Chancery may at any time appoint
a Committee of any such lunatic, if it considers it expedient, in place
of the Inspector. The Chancellor, who may call experts to his assist¬
ance, decides the question of mental unsoundness and incapacity to
manage his affairs, without a jury. I understood that the number
under the legal guardianship of the Chancellor is somewhat under 400.
They are placed in confinement under his warrant. For this class, the
legal checks are much more stringent. They are subjected to more
* Curiously [enough the previous Aot required the examination to be made
by the physicians together. “ Three months ” is a long period.
XXX, 41
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Psychological Retrospect .
[Jan.,
official recognition, and they cannot be discharged without the sanction
of the Inspector. The ordinary patient, whatever may be his social
position, is admitted into an asylum on two medical certificates, and
he may be discharged by the Superintendent without reference to the
Inspector.
In regard to Private Lunatic Asylums , Justices of the Peace
assembled in General Sessions may grant a license to any person to
keep a house for the reception of lunatics within the county. The
regulations of private asylums are moulded upon those of the
English Lunacy Laws, and need not, therefore, be given.
Returns are made monthly by the asylums to the Inspector in regard
to admissions, discharges, and deaths. It is obvious that if these
returns are made with a view to prevent improper admissions, or to
allow of an inquiry in alleged deaths from violence, far too long a period
elapses before the Inspector has cognizance of an admission or death
at an asylum. It is argued that in the case of the private institution
at Guelph, a Committee has general oversight over it, and that this
constitutes a sufficient guarantee against abuses. But however good
it may be, and doubtless is, it does not supersede the necessity of an
independent Government official receiving immediate information in
regard to the admissions and deaths of patients in every asylum, for
whose inspection he is responsible to the public. And, before dismiss¬
ing the subject of inspection, I would say it is a great defect in the
law which enacted it, that it is not made imperative to have one of the
Commissioners a medical man.
Passing to the asylums themselves, I will first refer to the asylum
at Toronto , which I visited on the 20th of August last. The contrast,
as I have elsewhere intimated, between the asylums of the Province
of Ontario and those of Quebec is really astonishing. The system is
essentially different. The Legislature of Ontario recognises the duty
not merely of discovering institutions to which it can send its insane
poor at so much a head, but of providing the institutions themselves,
and making the State responsible for their proper management. I do
not maintain that all has been done that can be done, or in all instances
on a sufficiently liberal scale, nor yet that the asylums are perfect in
their organization and management, still less that the system of in¬
spection is the best that can de devised; and I object to any alleged
dangerous lunatic who has not committed a crime being in the first
instance sent to jail, and thereby branded as a criminal, but I have no
hesitation in saying that there is a sincere endeavour to make adequate
provision for the insane of the Province ; that the inmates of the
asylums are carefully treated, and that there exists among the superin¬
tendents a real interest in their work, and a desire to do their duty to
their patients.
At the Toronto Asylum, superintended by an active administrator
(Dr. Daniel Clark), there are 710 patients, the sexes being almost
equal. The spacious corridors (15 feet in width) and rooms are
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613
carpeted, and altogether well furnished, and in those used by the
destructive patients there is not the dismal bareness too often wit¬
nessed. There is strong evidence of the great care and atten¬
tion paid in this asylum to cleanliness, the dress and the general
comfort of the inmates. There was hardly anything deserving the
name of mechanical restraint. On the female side there has been
practically none for two years, and as regards the men patients there
has been none whatever, Dr. Clark informed me, for seven years. No
patient was in seclusion at the time of my visit. Indeed, Dr. Clark
strongly objects to its use. There is one feature in the construction
of the asylum which attracts the notice of the visitor at first sight, not
very pleasantly, it must be admitted, and that is the succession of
semi-circular spaces or verandahs at the end of the corridors, pro¬
tected and enclosed as they are by strong iron palisades. A glazed
wooden frame partitions off these spaces from the corridor. On
the areas of these projecting spaces the patients stand or sit on
chairs, gazing on the outer world through the vertical bars. On
those who look up to them from below, the impression of a cage in a
zoological garden may be, and indeed has been, produced. At
the same time it is surely much better for the patients to be able
to step outside the corridor into such an enclosure and breathe the
fresh air, than not. The view over the Lake (Ontario), etc., is
extensive, and affords variety, while the objection which may be made
in regard to the effect produced upon other minds is rather sentimental
than practical. In a new building no doubt this precise construction
would be avoided, or an ornamental guard would be constructed in
place of simple bars.
The pay of the attendants, with whose appearance I was pleased,
both as regards personal expression and dress, is liberal—18 to 26
dollars a month for males, and 10 to 12 for females. In the wings
there is 1 attendant to 12 patients ; not so many in the central
large wards. There are also six night watches, three on each side of
the house. There are six galleries for private patients. They pay
from three to six dollars a week. There are also six free wards. Four
hundred patients pay nothing. The weekly cost per patient is a
little more than 2£ dollars a week, or 134 dollars (£27 6s) a year,
exclusive of the capital account or repairs.
The patients are employed to a considerable extent, namely, about
60 per cent, of the free class, from whom alone work can be obtained.
All the vegetables required for the asylum are raised on the grounds.
There are 140 acres. Dr. Clark, however, states in the report he
favoured me with that the last potato crop had proved a failure, but
that the other crops were about the average. As there are about 29
acres under crop, the potato failure was a serious one for the asylum.
As there are no crops of hay and oats, the cultivation of roots is mainly
attended to, and Dr. Clark calls attention to the need of more arable
land. The value of the produce of the present small farm was 13,763
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dollars in 1883. Buildings, including a prison, have grown up in the
vicinity ; a regrettable circumstance, especially if, as I understand,
land belonging to the institution has been sold for building purposes.
There are, distinct from the main buildings, three cottages, in which
120 female and 50 male patients are accommodated. One is cheaply
built, and is well adapted for the purpose. There are good day-
rooms and dormitories. The floors are partly carpeted, and there are
a few pictures on the walls.
The separation of cases which these annexes furnish, affords advan¬
tages which here, as elsewhere, are fully appreciated.
This, as well as the other Ontario Asylums, is inspected by one of
two Inspectors of Public Charities and Prisons in the Province. He
visits four or five times in the course of the year, and oftener if he
sees fit. The Grand Jury have the power of visiting the asylum if
they wish, and when they do so they make a presentment to the
Court. Their visits, however, are, I believe of a somewhat formal
character.
This asylum was opened in 1843, and was at that time the only in¬
stitution for the insane in the Province. Indeed, this was the case
when the well-known and universally esteemed Dr. Workman became
superintendent in 1853. At that time there were only 300 patients.
What the condition of the asylum was two years after it was opened
(and I have reason to believe up to the time Dr. Workman became
superintendent) I have the means of stating, on the authority of my
brother, Mr. J. H. Tuke, who, on visiting it in 1845, made the follow¬
ing entry in his diary :—
“ Toronto , Sept. 30, 1845.—Visited the lunatic asylum. It is one
of the most painful and distressing places I ever visited. The house
has a terrible dark aspect within and without, and was intended for a
prison. There were, perhaps, 70 patients, upon whose faces misery,
starvation, and suffering were indelibly impressed. The doctor pursues
the exploded system of constantly cupping, bleeding, blistering, and
purging his patients; giving them also the smallest quantity of food,
and that of the poorest quality. No meat is allowed.
“The foreheads and necks of the patients were nearly all scarred with
the marks of former cuppings, or were bandaged from the effects of
more recent ones. Many patients were suffering from sore legs, or
from blisters on their backs and legs. Every one looked emaciated
and wretched. Strongly built men were shrunk to skeletons, and poor
idiots were lying on their beds motionless, and as if half dead. Every
patient has his or her head shaved. One miserable court-yard was
the only airing court for the 60 or 70 patients—men or women. The
doctor, in response to my questions, and evident disgust, persisted
that his was the only method of treating lunatics, and boasted that he
employs no restraint , and that his cures are larger than those in
any English or Continental Asylum. I left the place sickened with
disgust, and could hardly sleep at night, as the images of the suffering
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patients kept floating before my mind’s eye in all the horrors of the
revolting scenes I had witnessed.”
Dr. Workman reformed the asylum, and could an unvarnished tale
be told of the condition in which he found and in which he left it, no
better tribute could be paid to his character and work during the
period he superintended it.
Dr. Workman now resides at Toronto, and has attained to nearly
80 years of age. His mind is still extraordinarily active; and his pen
is frequently in his hand engaged in both original writing and in
making translations from foreign Medical Journals. As longevity is
in the family it is no mere form to express the hope that this Nestor
of Canadian specialists may pursue his literary work for many years
to come. In making Dr. Workman an Honorary Member of our Asso¬
ciation at the last annual meeting, the latter honoured itself as well
as him. In conversing with me on the provision required for the
insane in Ontario, he gave it as his decided opinion that there had
been an increase in their number beyond what either the increase of
population or the accumulation of chronic cases could explain.
Although the proportion of ascertained lunatics is about one to 700,
Dr. Workman estimates that there is in reality one to 500. Formerly
there was no general paralysis, now it is common enough; not so
common, however, as in England, for at the Toronto Asylum there
were not, at the time of my visit, more than a dozen cases ; and there
are only three or four deaths from this disease in the course of a
year. Dr. Clark considers it more frequent among the better classes
than the poor.
I visited with much interest the London Asylum , which Dr. Bucke
superintends with great energy and enthusiasm. Not only is the
town itself called after London, but the river upon which it stands is
the Thames; and it boasts of its Westminster Bridge and its
Piccadilly. The resemblance does not end here : for if it be allowed
that there is a good asylum in or near our Metropolis, it will not be
denied by anyone who inspects Dr. Bucke’s institution that its
analogue resembles it in this particular also. It was opened in
1870, and the present superintendent entered on his duties in
1877. The whole establishment, the main building, the separate
one for the refractory patients, the cottages and the farm, convey
the impression of active life, and of the sustained interest of an able
head. Dr. Bucke has resolutely set himself to employ the patients
in some way or other, especially on the farm—with great advantage, it
need scarcely be said, to their mental and bodily health, and with
the result of emptying the wards of those helpless, hopeless cases
whose drear existence in the dead-alive asylums of any country
suggests cut bono to the pessimist, and makes even the optimist
sad at heart. If Dr. Bucke is asked how he employs a man in a state
of acute mania, he replies, “ Oh, I make him break stones.”
Without taking the reply too literally, it may serve to show
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616 Psychological Retrospect. [Jan.,
the exceeding but just importance attached to labour or being out of
doors, as has been so long and frequently maintained in the Mother
Country. I gathered from enquiries that very few cases of mania
with exhaustion are admitted to this asylum, a very important fact in
this connection, which might have been expected as a point of
contrast between the admissions into an asylum in old and new
London. Mania in some form is about four times as frequent as
melancholia. Only one patient was instrumentally fed last year.
The number of patients in this asylum is 888; 438 males and 450
females. It has a capacity for 906. The estate consists of 300
acres, 200 being occupied by the farm, 40 by the gardens, while the
buildings coyer the remainder.
The main building cost a little more than £100 per bed. (Land is
here about £30 an acre.) It accommodates about 500 patients of
both sexes of the quieter class and an assistant medical officer,
Dr. Burgess, resides here. It consists of the usual arrangements
—corridor (12ft. in width), recess, day, and bedrooms. Some of
these are dormitories containing 16 beds. The number of single
rooms in the whole establishment is 250. As I went through the
men’s side as many as 250 patients were at dinner in an associated
dining-room. All had meat, and I found this was usual.
There is a distinct three-storied building for patients of a more
or less excited character, male and female. The first assistant
physician, Dr. Beemer, resides here. There is nothing special in
the arrangement of the wards. There are 184 single bedrooms,
affording 720 cubic feet of breathing space per patient. The windows
were unnecessarily guarded by iron bars and net work. No doubt
these are survivals of the past, and if rooms for the refractory were
now built at this asylum, no trebly guarded window would be in¬
troduced, for it is out of character with the air of freedom which now
everywhere prevails in the institution. More light would be also
admitted into the building. There is a good airing court, shaded by
trees, and provided with a shed and seats. In this asylum, as
in most others on the other side of the Atlantic, the number of
epileptics is small—only about 25. There was no patient in re¬
straint and none in seclusion. Dr. Bucke observed that it was rare to
have black eyes among the patients since he determined not to resort
to mechanical restraint unless absolutely necessary. No patients were
crouching on the floors in strong dresses. I must add that “ chemical
restraint ” is not resorted to in the asylum. Sedatives are rarely given,
even in small doses. In addition to the morning round, I went
through the wards after the patients were in bed, and there was very
little noise indeed. Before quitting this building for the excited
patients I should state that, of 92 men residing in it, from 75 to 80
are on an average employed.
Dr. Bucke observes in his last report: “ The disuse of all forms
of restraint, and the employment of so large a proportion of the
patients in the asylum, has been accompanied by (or has caused)
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617
an unmistakable elevation of the tone of life throughout the whole
institution; and as one evidence of the fact 1 may mention that
the Sunday attendance at chapel has nearly doubled during the
year just closed ; a year ago the average attendance at Divine
service on Sunday morning being about 260, and now over 400. . . .
Along with the disuse of restraint and seclusion, we have almost
entirely ceased using strong dresses, of which, up to within the
last few months, we were in the habit of using a large number, and
although we now use no restraint or seclusion, and hardly any strong
dresses, we have less tearing of clothes and bedding, and breaking of
furniture, etc., and far less striking and fighting on the part of
the patients than when restraint and strong dresses were freely used.
It should also be mentioned that we use absolutely no sedatives
of any kind ; and it is seldom indeed that any patient is held
or restrained, even for a few minutes at a time, by the hands of
attendants. The last fact was a very surprising one to me, for I had
always believed that when mechanical restraint was discontinued
in any asylum, manual restraint had to be substituted for it, and the
chief argument which I have in former times used, and heard
used, against the discontinuance of mechanical restraint, has always
been that it was much preferable to restrain by the hand of an atten¬
dant, always wrongly taking it for granted that where the former was
not used the latter must be.”
In addition to the main building and the north or refractory
branch, there are two excellent but cheaply constructed brick
cottages, containing 60 patients’each. The cost amounted to 32,000
dollars, or about £58 per bed. The patients in these cottages are
either convalescent or able to appreciate the comparative independence
of a separate house, not presenting any appearance of an asylum for
the insane. The rooms were tastefully furnished and very clean.
There is still anothe^r cottage for 60 male patients—those who are
particularly engaged in working on the farm. The cost was 18,000
dollars, being at the rate of a little more than £60 per bed.
As compared with most County Asylums in England, the furnishing
of the main and north building struck me as somewhat scant. I am
told that the patients of the class that go to the London Asylum are
not accustomed to more at home in the way of carpets, &c., than they
find when they come to the asylum. It is true, also, that they are so
much out of doors that they may not care much for somewhat
bare corridors and rooms. The cost per head for maintenance
amounts to 105 dollars 12 cents, or about £21 a year; this includes,
in addition to food, salaries and furniture, but not any considerable
repairs or the additional buildings—certainly a low figure—and it
should be mentioned that about 80 per cent, of the patients are
clothed by the institution. I have already said that the total cost per
annum of patients at the London Asylum amounts to 145 dollars 12
cents, or 2 dollars 79 cents per week. The above charge for
maintenance is no doubt kept down by the large yield from the farm
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Psychological Retrospect. [Jan.,
and garden, although the total cost is greater than in any asylum in
Ontario. I wished to ascertain the exact extent of this, but the
accounts at the Superintendent’s command did not show it, nor
was the Inspector, Dr. O’Keilly, able to put me in the way of
obtaining this information valuable and interesting as he felt it to be.
A clear estimate of the net profit would greatly redound, I doubt not,
to the credit of the institution, and the strenuous endeavour made to
have a profitable farm connected with an asylum for the insane. Dr.
Bncke drove me over the farm. Its produce and that of the gardens
were roughly estimated by him at about £3,000 a year. There were
200 pigs on the day I was there. Over 100 are killed every year.
Some 6,000 bushels of potatoes are raised annually, and as many
quarts of berries from the gardens. Last year the crop of hay
amounted to 140 tons. The asylum has 40 cows.
As none of the patients pay a cent (for it is a genuine pauper
asylum), it is doubtless easier to induce them to work than in mixed
institutions, and also to find men accustomed to farm, and to be handy
at various trades. To compare the amount of work done at such an
institution with one for private or mixed patients would be very un¬
fair. It will not, however, be denied that there are some pauper
institutions in the world in which the patients do little or no work
from year end to year end, and spend a much larger proportion of the
day in the wards of the asylum than out of them. Nor is it altogether
impossible that there are institutions of a mixed class in which the
patients might do a little more work both indoors and out, especially
the latter, than they do already. In this I include the constant
attempt to induce the patients to take exercise in the open air with as
definite an object as possible. This can only be effectually done by a
superintendent who has his heart in the work, and who will insist
upon having a sufficient staff of attendants, even on the score of
economy, should those who hold the purse-strings be deaf to an appeal
to higher motives. But what if there is no breathing space outside
the walls of the asylum ? Then, woe betide the superintendent and
the unhappy patients under his care. Their fate is sealed.
On examining the record of work, and taking a single day, I found
that out of the 438 men no less than 392 were employed ; while out
of 451 women, 404 were occupied in some sort of work. Of 40 that
do not work, 25 are physically incapable, and 15 cannot be induced to
work without more pressure than it is thought right to use. I am well
aware that figures like the above may mean much or little, but I am satis¬
fied from personal observation that in this instance they mean much.
It is especially interesting to observe how a better system of
treatment has become possible by the increased employment of the
patients. With 880 patients the average number at work was, at the
date of Dr. Bucke’s last report, 625. He observes : “ I have always
found that, no odds how violent a patient is, if you can once get
him or her to work, the case will give you very little further trouble
in that way. . . , The male patients have been engaged in all the
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various kinds of farm and garden work ; they work with the carpenter,
mason, painter, tailor, engineer, baker and butcher ; they work in the
horse and cow stables, and do most of the milking ; they assist in
dining-room, kitchen and laundry; they sew, knit, make and mend
shoes, boots, and slippers ; seat chairs with cane and reed; make
mats ; they do tinsmithing, blacksmithing, locksmithing, upholster¬
ing, clerking ; all kinds of work in the halls, as bed-making, sweeping,
scrubbing, sawing and splitting wood, shovelling coal, grading laud,
making roads, feeding and tending two hundred pigs, working in the
store, picking hair for mattresses, and doing all sorts of odd jobs. The
female patients are largely engaged in sewing and knitting; and,
besides, they work in the kitchen, laundry, and dining-rooms ; do all
sorts of work in the halls, as bed-making, sweeping and scrubbing ;
milk, pick hair for matresses, and gather fruit and vegetables in the
gardens.”
The proportion of attendants to patients is certainly not high in
the London Asylum ; in fact, the Province ought not to complain if
the Superintendent should increase the number. For the violent
patients, the proportion was one in nine—considerably less for the
others. It ought, however, to be remembered that the number of
ward attendants does not adequately represent the services rendered
to the patients, inasmuch as those workmen who labour on the grounds
or at any handicraft exercise surveillance over some of the patients at
the same time. Several years ago, Dr. Eames, the President of the
Medico-Psychological Association, urged upon his Committee the
need of more attendants, and he states that while the proportion of
attendants, with the above-mentioned helps, was one to eleven in his
asylum, it averaged about one to eight in the asylums of Ireland
generally. The maximum pay of male attendants at the London
Asylum is about £50 a-year; that of the females is about £30. On
the male side are several female attendants—not the wives of atten¬
dants, as at Brookwood and some other asylums in England, but
respectable widows. Dr. Bucke attaches great importance to this
feature of his management, as ensuring cleanliness, tidiness, and con¬
sideration. He states that he has had no difficulty in finding suitable
persons. He is fortunate, for he requires pleasant manners, in¬
dustrious habits, good feeling, and, above all, good sense, in addition
to widowhood. They must be widows indeed. To do him full justice,
however, I must cite a few passages from his last annual report:—
“ The first was engaged in January, 1883, and became the super¬
visor of the upper storey, and does all the work that a man in that
position would do, and besides that she has a general supervision over
the tidiness and cleanliness of the whole wing ; the other two women
act as her assistants on the other two flats. They look after the
men's clothing, see to the tidiness of the beds, cleanness of the floors,
&c. &c. ; and, especially, they oversee the indoor work of a large
number of male patients, who pick hair, sew, knit, make mats, &c.
But the active duties of these women, though important, are scarcely
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so valuable as is their mere presence in the halls, which has a strong
tendency to check improper and unseemly talk and conduct, so that
these halls are different places now from what they used to be before
these women took service in them. . . . Down to the present time
none of them have been by speech or action either injured or insulted
by any patient. Almost universally the patients like to have them
amongst them, and I find that often the women can get the patients
to work when the male attendants can get them to do nothing.”
In an institution where the gospel of fresh air and employment is
so fully believed in and carried out, one feels especially interested in
the dietary. The meals are taken at 6.30 a.m., 12, and 6 p.m., the
patients going to bed after supper up to 9 o'clock p.m. I append the
dietary in detail, but must premise that work, whether out or indoor,
is not encouraged by the stimulus of beer, for Dr. Bucke is an out-
and-out teetotaler. He has not used alcohol in any form, even as a
medicine, for three years. When he became Superintendent a con¬
siderable sum was expended on beer ; more food is now given, but not
more milk, which is, I think, to be regretted. The attendants never
had any beer, so no money equivalent has been necessary.
The dietary in the main asylum on a particular day which I chose,
viz., June 8th, 1884, was as follows :—
BREAKFAST.
Sunday.—Bread and butter, tea and coffee.
Monday and Wednesday.—Porridge and milk.
Tuesday.—Boiled rice and syrup.
Thursday.—Oatmeal porridge and syrup.*
Friday and Saturday.—Porridge and milk.
DINNER.
Sunday.—Stew, potatoes.
Monday.—Corn-beef, potatoes and beans.
Tuesday.—Roast beef, potatoes, bread pudding.
Wednesday.—Boiled beef, potatoes and peas.
Thursday.—Haricot, potatoes, and bread pudding.
Friday.—Fish, boiled beef, pickles and potatoes.
Saturday.—Roast beef, potatoes, bread pudding.
TEA.
Sunday.—Bread and butter.
Monday and Saturday.—Bread and butter.
Tuesday.—Stewed rhubarb.
Wednesday.—Bread and butter.
Thursday.—Currant rolls.
Friday.—Apple sauce.
With the foregoing may be compared the dietary of an English pauper
asylum, that at Hanwell:—
J 1 BREAKFAST.
For males.—Cocoa, bread and butter.
For females.—Tea, bread and butter.
* Molasses.
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621
DINNER.
Sunday.—Boast pork, beef, or mutton.
Monday.—Soup, thickened with oatmeal, rice, and peas, and con¬
taining 2 oz. of meat for each patient; also 6 oz. currant pudding
or 10 oz. baked rice pudding.
Tuesday.—Meat pies.
Wednesday.—St. Louis corned beef.
Thursday.—Boiled bacon or pickled pork.
Friday.—Fish, fried or boiled, with melted butter.
Saturday.—Irish stew.
SUPPER.
Tea, bread and butter.
For patients who are employed, luncheon, consisting of bread and
cheese and beer (half*pint), is provided in addition ; and for Mon¬
day’s dinner, boiled bacon or pickled pork is given instead of soup.
The following are the principal salaries and wages allowed at the
London Asylum :—
Males. —Medical superintendent, £420 ; first assistant physician,
£210; second ditto, £210; third ditto, £154 ; bursar, £290 ;
steward and storekeeper, £166; engineer, £154; two carpenters,
£220 ; tailor, £94; gardener, £83 ; assistant ditto, £50 ; butcher,
£50 ; baker, £83 ; farmer, £125 ; two ploughmen, £115; cowman,
£45 ; three night-watchmen, £157 ; three chief attendants, £195 ;
twenty-nine ordinary male attendants, £1,389.
Females. — Matron, £105; assistant ditto (refractory ward),
£52 10s.; chief attendant, £52 10s. ; thirty ordinary female attend¬
ants, £990 ; three night attendants, £82 ; five cooks and assistant
cook, £187; five laundresses, £115 ; nine housemaids, £195 ; one
dairymaid, £25; two seamstresses, £50.
With the foregoing may be compared the following salaries, &c.,
at the Han well Asylum (750 men, 1,143 women) :—
Officers. —(a) Kesident medical superintendent (female depart¬
ment), £700 per annum ; (a) resident medical superintendent (male
department), £700; (d) chaplain, £350; (/) clerk to the Committee
of Visitors, £275 ; assistant medical officer, £200; ditto, £200 ; ditto,
£165 ; ditto, £150; (e) apothecary, £120 ; (5) engineer, £450; (a)
storekeeper, £500 ; (e) clerk of the asylum, £325 ; ( e ) first assistant
clerk, £130; (c) second assistant-clerk, £110; («) storekeeper’s
clerk, £110; ditto, £60 ; outdoor inspector, £74 ; ( e ) matron, £345;
assistant matron and organist, £66 ; junior assistant matron, £40;
superintendent of laundry, £55 ; superintendent of workroom, £50 ;
principal female attendant, £36 ; ditto, £34 ; ditto, £30 ; workroom
assistant, £33.
(a) Furnished house, rates and taxes free, coals, gas, milk, and vegetables ;
(b) part ditto, ditto, ditto, washing, milk, and vegetables; (c) furnished apart¬
ments, attendance, coals, gas, washing, milk, and vegetables; the matron boards
two servants; (ci) unfurnished house; (e) dinner daily; (/) neither boarded
nor lodged. The others have board, lodging, and washing*
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622 Psychological Retrospect . [Jan.,
(a) Male Attendants. —(b) Three supervisors, at £80 ; (c) eigh- *
teen charge attendants, £25 to £40 ; forty-four ordinary ditto, £25
to £35 ; hall attendant, £40; ((f) six night ditto, £62 to £72.
(a) One suit of uniform every eight months, and a suit of serge every two
years under certain conditions; (b) do not reside in asylum; (c) have board,
lodging, and washing, except in the case of Borne of the attendants, who are
allowed £1 per month in lieu of their lodging and washing. Three out of the
eighteen receive £47. (d) These attendants are neither boarded nor lodged.
(a) Female Attendants. —Four supervisors, £30 to £39 ; twenty-
five charge attendants, £15 to £29 ; eleven night ditto, £19 to £32 ;
seventy-one ordinary attendants, £15 to £25.
(a) All have board, lodging, and washing; three suits of uniform every eight
months.
(a) Kitchen and Laundry. —One head cook, £46 ; one assistant
ditto, £26, with three suits of uniform every eight months ; one ditto,
£20, with ditto ; two kitchenmaids, £14 to £20, with ditto ; one
head laundress, £20 to £25, with ditto; one assistant ditto, £18 to
£25, with ditto; one officers’ ditto, £18 to £25, with ditto ; eleven'
laundry maids, £15 to £25, with ditto ; seven domestic servants, £14
to £20.
(a) All board, lodging, and washing.
Workmen. —One upholsterer, £1 12s. per week; one ditto, £1 4s. ;
two ditto, £1 and 18s.; two tailors, £1 8s. and £1 4s.; one tailor, £1;
two shoemakers, £1 10s. and £1 3s.; one tinman, £1 9s. ; one
basket-maker, £1 7s.; (a) one butcher, £1 4s. ; (b) two bakers,
£1 6s. and 17s. ; (c) one gardener, £1 16s.; one ditto, £1 4s.;
( d ) one carter and driver, £1; one carter, £1 ; one cowman, £1 Is.;
one ditto, 18s.; one gardener (front grounds), £1 Is.
(a) Breakfast and dinner daily; ( b ) boarded, &c.; (c) allowed vegetables;
( d ) lodged and allowed coals, gas, milk, vegetables, and beer. All have an
allowance of beer.
I next visited the Hamilton Asylum. This institution, opened in
1875, is beautifully situated, overlooking Lake Ontario at the point
of Burlington Bay. The situation, however, is not altogether advan¬
tageous. It is inconveniently near a precipitous descent, and the
approach to the asylum is troublesomely steep. It was originally de¬
signed for an inebriate asylum, but the needs of the insane were justly
deemed more pressing and practical than those of dipsomaniacs.
Dr. Wallace is the medical superintendent. Unfortunately he has
been out of health for some time, for which he has had to travel
abroad, but he is now much stronger.
There are 567 patients in the house, of whom 270 are males and
297 females. About 5 per cent, of the patients pay, but only from
6s. to 10s. a week. The construction of the building is on the ordi¬
nary asylum plan, and is a handsome structure. The superintendent's
house is distinct from, but close to, the institution. When I was
going round a number of patients of both sexes were dining together
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Psychological Retrospect .
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—105 men and 95 women. The dietary was good. The heating and
ventilation of the house, the former by steam and the latter by flues to
the roof, are well secured.
In the refractory galleries the least excited patients are, I was glad
to observe, placed in the upper storey. Frequently in asylums on the
American Continent the most violent are placed at the very top of the
house, a practice very likely to involve neglect and the omission of
proper outdoor exercise. The bringing of this class of patients up and
downstairs is in itself a frequent cause of outbursts of excitement and
struggling.
With regard to restraint, Dr. Wallace informed me that when he
regarded it necessary he employed leather muffs for the men and the
camisole for the women. Were a patient actually suicidal, he would
at night, if not in the day, be placed in restraint, while a more intelli¬
gent patient would be placed in the same room. Some months had
elapsed since a male patient had been restrained. A woman at the
time of my visit was in restraint who persistently mutilated her face.
When the camisole was removed she immediately resumed her inju¬
rious work. Judging from the reports of the Inspector, I should con¬
clude that there has been a remarkable diminution of restraint during
the last few years.
On the female side there is a sewing-room, where many of the
patients work. All the sewing required by the institution is done
here. As I am speaking of employment, I may add that for the male
patients, in addition to other work, it is found convenient to employ
them in winter, when it is more difficult to supply employment, in
breaking stones under a shed.
The following is a statement of the employment of patients during
the quarter ending June 30th, 1884: —
FEMALE PATIENTS.
Nature of Employment.
Number of Patients
Working.
Number of Days
Worked.
Laundry
15
1170
Kitchen
7
546
Sewing-room...
12
936
Dining-room ...
13
1014
Mending
6
468
General Work
5
390
Knitting ...
30
2340
Work in Halls
35
2745
Store-room ...
8
624
Total
131
10233
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624 Psychological Retrospect. [Jan.,
MALE PATIENTS.
Nature of Employment.
Number of Patients
Working.
Number of Days
Worked.
Laundry
5
890
Kitchen
5
466
Tailor’s Shop...
2
147
Dining-rooms
8
728
Carpenters
6
292
Engineers
4
281
Masonry
12
466
Roads
12
822
Coal and Wood
20
849
Bakery
1
78
Dairy
6
646
Butcher
1
91
Piggery
2
182
Painting
2
112
Farm
12
624
Garden
20
746
Grounds
6
211
Stable
1
91
Halls
60
6460
Store-room ...
2
156
General Work
26
1652
Quarry
60
1400
Total
262
16177
In the refractory galleries on the men’s side the number of the
attendants was certainly too few. However, not only was no patient
in restraint, but none were in seclusion or in a strong dress. A separ¬
ate building for a certain number of the refractory class has been
erected, and will be shortly occupied. This is another illustration of
the tendency there is to adopt the plan of separation of classes
of patients which has been carried out for some years in Great
Britain. It is a neat red-brick building, with a limestone basement,
and consists of a centre and two wings, having two storeys. It will
accommodate 60 men. The cost seems high compared with some of
the separate buildings which I have mentioned, viz., £120 a bed, but
this is due to the class of cases for which the building is designed
being acute instead of chronic. There are rooms on both sides of the
corridors. The single rooms are well adapted for their purpose, but
the provision for ventilation appears to be scarcely sufficient. The
construction of the building readily admits of separating the noisiest
from the less noisy patients, and also for placing patients on admis¬
sion under special observation if desirable. When the building is
occupied, an assistant medical officer is to be resident in this building.
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Psychological Retrospect.
625
He has not yet been appointed. Should a false economy prevent his
appointment, the separation of this the most important class of the in¬
sane from the rest of the household, still further removed as they will
be from the superintendent’s quarters, will be an evil instead of a
blessing. That such an evil is not imaginary I can assert from what
I have witnessed in some Continental asylums, where the paramount
idea seems to be to remove violent and dirty patients as far as pos¬
sible from the centre of the asylum, and that without any medical
officer.
There are objections, doubtless, to placing maniacs close to the
central offices, but of the two evils I am sure that for the interests
of the patients, to whom every other consideration ought to be sacri¬
ficed, this arrangement is better than putting them beyond the reach
of sound and sight. 1 was glad to find that at the Hamilton Asylum
an assistant medical officer resides in the main building near the
wards for the refractory male patients. It is to be regretted that this
is not the case in every institution for the insane in which acutely ex¬
cited patients are admitted. He ought to be cognisant of noise if it is
unusual, and to be within easy call. It will be said that the appoint¬
ment of night-watches renders abuses or neglect impossible. This I
entirely deny. No asylum is free from the possible, or rather pro¬
bable, ill-treatment of patients when out of sight of the heads of the
institution, but at no time is this so likely to occur as with the violent
class during the night and early morning, for then it is that the
patients and their attendants are least under observation.
There is another cottage on the ground, which was, I understand,
formerly occupied by the bursar. This is now occupied by 19 female
patients of a harmless kind. It looked home-like and clean, and the
inmates, who were quite of a humble class, seemed very comfortable
and contented. This cheerful cottage might be used for the conva¬
lescent class. It is comparatively inexpensive.
The attention paid to the dirty patients is highly creditable. The
night-watches carry out the system of getting this class up to the
fullest possible extent. 1 looked at the reports handed in to the
superintendent in the morning, and found the number of reported
soiled beds remarkably few. On the day I was at the asylum there
were only two on the female and one on the male side. There are four
night-attendants. I also examined many of the beds when passing
through the dormitories, as also did Dr. Ashe, of the Dundrum
Asylum, who happened to join us in our round, and we were struck
with the cleanliness of the bed-linen in the division where it was most
likely to be foul. I may state that only five men in this asylum were
the subjects of paresis, and two women. Hence, as compared with an
asylum in England of the same size, the number of patients likely to
be dirty would be much smaller.
No alcohol is used at this asylum except medicinally, and that
rarely. Formerly beer was an article of diet. When discontinued
milk was given as a substitute when the patients desire it. No money
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626 Psychological Retrospect. [Jan.,
equivalent was given to the attendants. Their salaries reach £50 for
men and £25 for women per annum.
The last asylum I visited in Ontario was that at Kingston. In the
absence of the superintendent, Dr. Metcalf, his brother-in-law, Dr.
Clarke, the assistant medical officer, obligingly showed me over the
institution. It is situated on the north bank of Lake Ontario. There are
255 male and 250 female patients. These 505 patients are paupers,
with the exception of a very few who pay the cost of maintenance, viz.,
two dollars, or nearly 8s. 6d., a week. The asylum, which is of stone,
was opened in 1859. It is built in the usual corridor style, and has
four storey8 in addition, to the basement, which is not used for the
patients. There are 180 single rooms, 90 of which are for the worst
class. The associated dormitories have not more than 11 beds in any
one of them. The breathing space per patient amounts to 1,034 cubic
feet in the former and 700 in the latter. In this asylum the suicidal
patients are scattered in dormitories with other patients on whom re¬
liance can to a considerable extent be placed. In addition, the atten¬
dants’ door opens into the dormitory, and the night-watch looks in
every hour. There has been no suicide since 1877.
The estate covers 140 acres, 85 being devoted to the farm and
garden, on which patients are employed. Eight look after the
cattle ; 25 work on the roads ; five assist the engineers ; two are car¬
penters, two painters, three tailors, two shoemakers, two bakers ; two
assist in the kitchen; and 160 are employed in the wards. Of the
women, upwards of 150 are employed.
I was glad to see here, as at the other asylums in Ontario, cottages
for certain classes of cases. One cottage was occupied by 37 women
of the quiet and incurable class. An annexe, only opened this year,
for 70 patients of both sexes, aDd built of limestone, cost 30,000
dollars, including warming apparatus and furnishing, or about £100
per bed. There are no single rooms in the house. The centre consists
of four and the wings of three storeys. At the present time it is full.
The general appearance of the patients at this asylum was very
satisfactory. Evidently they are under kind and skilful management.
The asylum is inspected four times a year by Dr. O’Reilly and nomi¬
nally by the Grand Jury at the Assizes.
It is a matter of some interest to be able to compare the salaries
given to the staff in an asylum in Canada with those allowed in Eng¬
land. For this purpose I append the salaries of the officers at the
Kingston Asylum:—
Medical superintendent, £333, with house, rations for himself and
family, &c., &c.; assistant medical officer, £210, with like extras ;
bursar, £240, dinner on the premises; steward, £100, with house,
rations, &c. ; storekeeper, £100, dinner on the premises; engineer,
£155, with house and garden ; assistant-engineer, £83, with meals
and lodging, and stoker, £60, with meals and lodging ; farmer,
£72, with house, garden, and meals; gardener, £83, with house
and garden; ditto vegetable garden, same ; butcher, £50, with house
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and garden and meals; baker, £83, with like extras ; tailor, £83,
with meals; carpenter, £90, with ditto; the night-watch (male
side), £72, with meals ; female night watch, £50, with meals ;
head male attendant, £83; ten attendants, £72 each, and eight
attendants, £50; matron, £83, with rooms, rations, <fcc.; assistant-
matron, £4110s., with like extras ; thirteen female attendants, £25 ;
two night-watches, ditto; laundress, £30, with meals; assistant-
laundress, £25; cook, £30; under-cook, £25; dairymaid, £20;
two domestics, one at £25 and the other at £20.
In no case can a claim be made for a pension, which must be borne
in mind in contrasting these figures with those of English asylums.
For the sake of comparison I add the following table from the
last report of the Portsmouth Borough Asylum (England), where the
patients number 450 :—
Officers.— Medical superintendent, £480 per annum, with* unfur¬
nished residence, light, fire, garden produce, milk and washing; assis¬
tant medical officer, £120 per annum, with board, furnished apartments,
gas, coal and washing; chaplain, £180 per annum, non-resident;
clerk of the asylum and steward, £200 per annum, non-resident.
Attendants (male department).—One head attendant, £40 per
annum, with board, lodging, washing and uniform ; three night atten¬
dants, 18s. 6d. per week, with one meal per night, non-resident; one
charge attendant £30 per annum, one ditto £27, two ditto £26 10s.,
one ditto £25, each with board, lodging, washing and uniform;
one second class attendant £25, two ditto £23 10s., two ditto £23,
each with board, lodging, washing and uniform; one third class
attendant £23, one ditto £22, six ditto £21, each with board, lodg¬
ing, washing, and uniform; one hall porter £27, one ditto £19 5s.,
each with board, lodging, washing and uniform.
Nurses (female department).—One housekeeper and chief nurse,
£55 per annum, with furnished apartments, board, washing, &c. ;
one organist, £30 per annum, with ditto ; one needle mistress, £27
per annum, with board, lodging, washing and uniform , one night
nurse, 14s. per week, with one meal per night, non-resident; one night
nurse £21 per annum, one ditto £21 10s., each with board, lodging,
washing and uniform; one charge nurse £24, four ditto £22, one
ditto £21, one ditto £20, each with board, lodging, washing and uni¬
form ; two second class nurses £24, two ditto £20, one ditto £19 10s.,
one ditto £19, each with board, lodging, washing and uniform; two
third class nurses £17 10s., two ditto £17, one ditto £16 10s., six
ditto £16, each with board, lodging, washing and uniform.
It is stated in the last report of the Kingston Asylum that the
value of the produce of the farm and garden amounted to upwards of
£1,370. Two hundred and twenty three patients performed 57,244
days’ work during the year. When 1 visited this asylum, a circum¬
stance which had just occurred displays in its after-history a curious
condition of Canadian law. A male patient escaped from the asylum
xxx. 42
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628 Psychological Retrospect . [Jan.,
and made a criminal assault, for which he was arrested and tried. In¬
credible as it may seem, the opinion of the medical superintendent of
the asylum was never sought. He was found guilty, and sentenced to
six months’ hard labour in jail without the question of the prisoner's
insanity being gone into. The Judge stated that he must be lenient
under the circumstances, but what these were have not been stated.
Having read the history of his case, I should regard him as a most
dangerous lunatic, and should be surprised if he does not commit
some frightful crime when he regains his liberty. It is difficult to
understand why he was not placed in the criminal asylum, where he
would certainly have been prevented doing any injury to society.
I am informed that in the old Lunacy Act (prior to 1871) there
was a clause which should not have been repealed, viz., the provision
made for the detention of criminal lunatics in the criminal asylum as
soon As their sentences expired. At present the asylum-authorities
are forced to receive all criminal lunatics and insane criminals belong¬
ing to the province of Ontario at the time their sentences have expired.
This state of affairs is, as might be expected, most unfortunate for the
Kingston Asylum, for it is made the repository for all these criminals,
and their influence is anything but salutary.
I append the dietary table at the Kingston Asylum for one week in
July of this year:—
Days of
Week.
Breakfast.
Dinner.
Tea.
Monday
Bice and milk.
Coffee, bread and
butter.
Barley soup.
Beef, potatoes and
bread.
Tea, bread
butter.
and
Tnesday
Porridge and milk.
Coffee, bread and
butter.
Boast beef, pota¬
toes, and bread.
Cheese.
Tea, bread
butter.
and
Wednesday...
Cold meat.
Coffee, bread and
butter.
Barley soup.
Beef, potatoes and
bread.
Bhubarb.
Tea, bread
butter.
and
Thursday ...
Porridge and milk.
Coffee, bread and
butter.
Plum pudding.
Boast beef, pota¬
toes and bread.
Tea, bread
butter.
and
Friday
Porridge and milk.
Coffee, bread and
butter.
Boiled fish.
Beef, potatoes and
bread.
Buns.
Tea, bread
butter.
and
Saturday ...
Porridge and milk.
Coffee, bread and
butter.
Pea soup.
Pork, beef, pota¬
toes and bread.
Tea, bread
butter.
and
Sunday ...
Coffee, bread and
butter.
Beans.
Boast beef and
bread.
Bhubarb.
Tea, bread
butter.
and
Digitized by <^.ooQLe
1885.] Psychological Retrospect . 629
With this dietary may be compared that of the Portsmouth Borough
Asylum (England), which is probably above the average dietary of
County and Borough Asylums :—
breakfast (daily).
Males.~8ozs. bread, ^oz. butter, 1 pint tea, coffee or cocoa.
Females.—6ozs. bread, ^oz. butter, 1 pint tea, coffee or cocoa.
surPER (daily).
Males.—8ozs. bread, 2ozs. cheese or £oz. butter ; 1 pint tea.
Females.—6ozs. bread, 2ozs. cheese or ^oz. butter; 1 pint tea.
DINNER.
Sunday.—16 to 18ozs. suet pudding, with treacle sauce, and the
addition of fruit in the summer and dried fruit in the winter—males
and females. 3ozs. of meat where ordered.
Monday.—5ozs. meat, males and 4ozs., females ; vegetables not less
than lib.
Tuesday.—3ozs. tinned meat, males and females ; vegetables as on
Monday.
Wednesday.—2 pints soup, 2ozs. meat, 5ozs. bread—males. 1£
pint soup, 4ozs. bread—females.
Thursday.—Meat pie, 12ozs.—males; lOozs.—females. £lb. pota¬
toes or ^lb. of other vegetables.
Friday.—Same as Monday.
Saturday.—lib. fish, males and females ; vegetables same as Mon-
day.
Half-pint of ale daily for dinner, except on Wednesday, for both
males and females.
W omen working in laundry have bread and cheese and half-pint of
ale for lunch, with meat and ale for dinner on Wednesday; also extra
tea at 3 p.m.
Women scrubbing in wards have bread and cheese daily for lunch,
with half-pint of ale. Men the same.
Men working in the shops or on the farm have half-pint of ale and
bread and cheese at 10 a.m., and ale at four o’clock.
Meat pie contains 3ozs. of meat without bone for each patient.
Soup is made from liquor of boiled meat, thickened with pearl barley,
&c., to which are added vegetables, herbs, &c.
From the asylum I proceeded to visit the Penitentiary, which is in
the vicinity, accompanied by Dr. Clarke. Mr. Creighton, the warder,
who showed me over, is a very kindly gentleman. The prison appears
to be in excellent order. There is a separate modern building for 43
criminal lunatics. The number on the day of my visit was 37. The
character of the cells is, I am sorry to say, similar to those of a
prison, and, so far as I could judge, the patients are treated with
almost as much rigour as convicts, though not dressed in prison garb.
This is wrong. * Either they are or are not lunatics. If they are, they
ought to be very differently cared for, while every security to prevent
escape is taken. In the basement are “ dungeons,” to which patients
Digitized by <^.ooQLe
630
Psychological Retrospect. [Jan.,
are consigned when they are refractory as a punishment, although the
cells above are in all conscience sufficiently prison-like. The floors of
the cells are of stone, and would be felt to be a punishment by any
patient in the asylums of Ontario.
In a day-room above the ground floor a number of patients were
congregated, moody and apathetic. Some were in mechanical restraint.
Two men in the cells had once been patients in the asylum. One,
with whom we conversed at the iron gate of his dungeon, laboured
under a distinct delusion of there being a conspiracy against him. It
was certainly not very likely to be dispelled by the dismal stone-floor
dungeon in which he was immured without a seat, unless he chose to
use the bucket intended for other purposes, which was the only piece
of furniture in the room. Surely something will be done to terminate
a condition of such unnecessary hardship. For criminals of the worst
class this building is no doubt admirably suited, but it is astonishing
that it should have been constructed for lunatics in recent times. In
these remarks no reflection is for a moment cast on the excellent
Warden of the Penitentiary. As to what the Visiting Medical Officer
does in the medical treatment for these patients, or to secure their
comfort, I shall not attempt to give an opinion.
I hasten to remark that the Penitentiary is not under the control
of the Province, but the Dominion ; otherwise, judging from the
asylums of Ontario, it would, I have no doubt, be in a totally dif¬
ferent condition.
It will thus be seen that the Province of Ontario possesses in its
Asylums excellent institutions, in which modem views and the results
of experience in other countries are vigorously and intelligently ap¬
plied ; in which employment is being carried out more and more to
the extent consistent with the comfort of the patients ; in which
mechanical restraint is not resorted to unless every other means
have failed, and in which a good example of segregation is exhibited,
the usually constructed asylum being supplemented by an annexe or
cottages adapted for particular classes. That such a system as this
works well, no one who has seen it in operation in British or other
asylums will be surprised to hear.
Province of Quebec .
On the 30th of August last I visited the lunatic asylum at Longue
Pointe, seven miles from Montreal, called the Hospice des Alienee de
St. Jean de Dieu. It was built by the Sceurs de Providence, and
opened in 1876. The Province of Quebec contracts with them to
maintain the lunatic poor* in one of the two parts of the Province
* At the rate of 100 dollars or £20 per annum per head at Montreal and 130
dollars at Quebec-—a very insufficient sum, it would seem, for board, lodging
and clothing. I understand that the money originally borrowed of the
Provincial Government by the Montreal Asylum has been refunded, and that
money has been borrowed from private quarters to assist in the erection of the
additional buildings.
Digitized by v^ooQle
1885.] Psychological Retrospect . 631
into which it is divided; the asylum at Beauport, near Quebec,
providing similarly for the other district. Private patients are
admitted. The building—which, surmounted by three cupolas, is a
prominent object from the St. Lawrence in approaching Montreal
from Quebec—is built of red brick, and consists of a centre and wings.
Some of the latter have been added three or four years ago; others
are now in course of erection, and will not be finished till the end of
the year. Dr. Henry Howard, the visiting physician, kindly facilitated
my desire to see the asylum, and escorted a small party, consisting of
Dr. Ross of Montreal, Dr. S. Mackenzie of London, and myself, to
the institution. I must express to Dr. Howard my lasting obligations
for his attention and assistance. We were received by the Mother
Superior, Ste. Th4r&se, who had been apprised of our visit. She
conducted us through the building, and was most courteous in her
manner and in replying to the numerous questions with which I
troubled her. I am glad to have this further opportunity of thanking
her and the nuns for their kindness throughout the visit.
The neatness and cleanliness of the hall, reception-room and office
strike the visitor ver^ favourably on entering the establishment. The
Apothecaire is a model of neatness. The nuns have themselves
published a pharmaceutical and medical work, a large volume, entitled
“ Traits Elementaire de Mature M^dicale et Guide Pratique,” a copy
of which the worthy Mother Superior was good enough to present to
me. I was somewhat disappointed to find, on examining its pages,
that only one was devoted to mental alienation, of which nine lines
suffice for the treatment of the disorder. Among the moral remedies,
I regret to see that “ punitions ” are enumerated ; their nature is not
specified. Two skeletons in the Apothecaire were shown to us by Ste.
Th4r&se, as being much valued subjects of anatomical study for the
nuns, who would, it is not unlikely, consider their knowledge of the
medical art sufficient for the needs of the patients. The law, however,
obliges a medical man to reside in or near the asylum. Dr. Perrault,
whom we did not see, occupies this post. This officer is appointed
and paid by the Sisters; the visiting physician, on the contrary, is
appointed and paid by the Provincial Government. We looked down
upon a very large kitchen, where cooking by steam was going actively
on, and a favourable impression as to the supplies was left upon the
mind by the busy scene which presented itself. The amount of
vegetables (potatoes, turnips, cabbages, &c.) produced on the land,
is very large—more potatoes, I believe, than they consume. Maize,
wheat, oats and buckwheat are raised. The estate consists of 600
acres. There are a large number of cows, and the asylum buys beasts
to fatten and kill, thereby saving a considerable sum. I was informed
that about fifty patients were usually employed out of doors, and more
in harvest time. That such an establishment should be conducted by
nuns must seem remarkable to those who are unacquainted with the
large part taken by Sisters of Charity in the management of hospitals
Digitized by <^.ooQLe
632 Psychological Retrospect . [Jan.,
in countries where the influence of the Roman Catholic Church
extends. Theoretically, it would seem to be an admirable system,
and to afford, in this way, a wide field for the employment of women
in occupations congenial to their nature, and calculated to confer great
advantages upon the sick, whether in mind or body. That women
have an important rSle in this field will not be denied ; but experience
proves only too surely that to entrust those of a religious order with
administrative power is a practical mistake, and leads to abuses which
ultimately necessitate the intervention of civil power.
The asylum consists of a succession of corridors and rooms similarly
arranged, there being dining rooms, recesses, and single and associate
dormitories. There are four stories uniform in construction, exclusive
of the basement and the rooms in the roof, and these four are supplied
with open outer galleries or verandahs, protected by palisades. The
lower stories are clean and well furnished, and the patients appeared
to be comfortable. The apartments of the private patients were, of
course, the best furnished. It was curious to see in the day rooms
on the male side a nun with a female assistant. They are in the
wards all day, and sleep together in another part of the building. In
the refractory ward for men there were two male attendants, and in the
other wards one male attendant, in addition to the two females. In
each ward on the women’s side there were two assistants with the nun
in charge, and in the refractory gallery there were three assistants.
The nuns and female assistants are not paid. The corridors, the
width of which was fair, were carpeted down the centre, and there
were pictures on the walls in considerable number. In the day-rooms,
on the floors of which was oilcloth, the furniture, though simple, was
by no means insufficient. In the recesses of the corridors, as well as
in the corridors themselves, were seats for the patients. Although
there were rooms on both sides of the corridor, the latter was fairly
lighted by the recesses, &c. The dormitories were very clean, and
presented a neat appearance ; the beds were of hair, and a bright-
coloured counterpane had a pleasing effect. Single rooms, used as
bed and sitting room, were very neatly furnished, and had every
appearance of comfort. For paying patients, and for a considerable
number of the poorer class, I have no doubt the accommodation is good,
and as I must shortly speak in terms of strong reprobation, I have
pleasure in testifying to the order, cleanliness, and neatness of those
parts of the building to which I now refer, and which we went over
in the first instance.
It is as we ascend the building that the character of the accommo¬
dation changes for the worse. The higher the ward, the more
unmanageable is the patient supposed to be, the galleries and rooms
become more and more crowded, and they look bare and comfortless.
The patients were for the most part sitting listlessly on forms by the
wall of the corridor, while others were pacing the open gallery, which
must afford an acceptable escape from the dull monotony of the
Digitized by v^ooQle
1885.] Psychological Retrospect . 633
corridor. The outlook is upon similar galleries in the quadrangle
at the back of the building, and to a visitor, the sight of four
tiers of palisaded verandahs, with a number of patients walking up
and down the enclosed spaces, has a strange effect. These outside
galleries are, indeed, the airing courts of the asylum. There are no
others. If the patients are allowed to descend, and to go out on the
estate, they usually do so in regular order for a stated time, in charge of
attendants, like a procession of charity school children. Those who
work on the farm must be the happiest in the establishment.
In the fourth tier were placed the idiots and imbeciles—a
melancholy sight necessarily, even when cared for and trained
in the best possible manner, but especially so when there is no
attempt made, so far as I could learn, to raise them to a higher
level or educate them. If, however, they are kindly treated and kept
clean, I should feel much less regret for educational neglect than I
should feel pained by the state of the patients and their accommoda¬
tion in the parts of the establishment next described. Far be it from
me to attribute to these Sisters of Charity any intentional unkind¬
ness or conscious neglect. I am willing to assume that they are
actuated by good motives in undertaking the charge of the insane,
that they are acute and intelligent, and that their administrative
powers are highly respectable. Their farming capacities are, I have
no doubt, very creditable to them. It is not this form of farming to
which I have any objection or criticism to offer. In the vegetable
kingdom I would allow them undisputed sway. It is the farming out
of human beings by the Province to these or any other proprietors
against which I venture to protest.
It is impossible to convey an adequate idea of the condition of the
patients confined in the gallery in the roof, and in the basement of
this asylum. They constitute the refractory class—acute and chronic
maniacs. They and the accommodation which has so long been pro¬
vided for them must be seen to be fully realized. To anyone accus¬
tomed to a well-ordered institution for the insane, the spectacle is one
of the most painful character. In the course of seven-and^thirty years
I have visited a large number of asylums in Europe, but I have rarely,
if ever, seen anything more depressing than the condition of the
patients in those portions of the asylum at Longue Pointe to which I
now refer. I saw in the highest storey, that in the roof, an ill-lighted
corridor, in which at least forty refractory men were crowded
together ;* some were walking about, but most were sitting on
benches against the wall or in restraint-chairs fixed to the floor, the
occupants being secured to them by straps. Of these seated on the
benches or pacing the gallery, a considerable number were restrained
* I substitute this figure for that originally given, in consequence of the
statement of one of my critics. I conclude that this number sleep in the roof,
and that the others whom I saw ocoupy beds in the storey below. Of course
the number of refractory men patients greatly exceeds 40.
Digitized by <^.ooQLe
634 Psychological Retrospect . [Jan.,
by handcuffs attached to a belt, some of the cuffs being the ordinary
iron ones used for prisoners, the others being leather. Restraint, I
should say in passing, was not confined to the so-called refractory
wards ; for instance, in a lower and quieter ward, a man was tightly
secured by a strait-waistcoat. Dr. Howard had him released, and he
did not evince any indications of violence. It was said he would tear
his clothes—a serious matter in an asylum conducted on the contract
system ! The walls and floor of the corridor in the roof were abso¬
lutely bare. But if the condition of the corridor and the patients pre¬
sented a melancholy sight, what can be said of the adjoining cells in
which they sleep and are secluded by day ? They are situated between
the corridor and a narrow passage lighted by windows in the roof.
Over each door is an opening the same length as the top of the door,
and 3 to 4 inches in height, which can be closed or not as the atten¬
dant wishes. This aperture is, when open, the only means of lighting
the cell. The door is secured by a bolt above and below, and by a
padlock in the middle. In the door itself is a guichet or wicket,
secured, when closed, by a button. When opened, a patient is just able
to protrude the head. There is, as I have intimated, no window in the
room, so that when the aperture over the door is closed, it is abso¬
lutely dark. For ventilation, there is an opening in the wall opposite the
door, which communicates above with the cupola; but whatever the
communication may be with the outer air, the ventilation must be very
imperfect. Indeed, I understood that the ventilation only comes into
operation when the heating apparatus is in action. What the con¬
dition of these cells must be in hot weather, and after being occupied
all night, and, in some instances, day and night, may be easily con¬
ceived. When the bolts of the door of the first cell which I saw
opened were drawn back and the padlock removed, a man was seen
crouching on a straw mattress rolled up in the comer of the room, a
loose cloth at his feet, and he stark naked, rigorously restrained by
handcuffs and belt. On being spoken to he rose up, dazzled with the
light, and looked pale and thin. The reason assigned for his seclusion
and his manacles was the usual one, namely, “ he would tear his
clothes if free. ,, The door being closed upon this unfortunate man,
we heard sounds proceeding from neighbouring cells, and saw some of
their occupants. One, who was deaf and dumb, as well as insane,
and who is designated Vhomme inconnu , was similarly manacled. In
his cell there was not anything whatever for him to lie or sit upon
but the bare floor. He was clothed. Some of the cells in this gallery
were supplied with bedsteads, there being just room to stand between
the wall and the bed. When there is no bedstead a loose palliasse
is laid on the floor, which may be quite proper. In reply to my
enquiry, the Mother Superior informed me that it was frequently
necessary to strap the patients down in their beds at night.
Passing from this gallery, which I can only regard as a (i chamber
of horrors, 1 ” we proceeded to the corresponding portion of the build-
Digitized b v Google
635
1885.] Psychological Retrospect.
ing on the female side. This was to me even more painful, for
when, after seeing the women who were crowded together in the
gallery, on benches, and in fixed chairs, many of whom were re¬
strained by various mechanical appliances, we went into the narrow
passage between the pens and the outer wall, the frantic yells of the
patients and the banging against the doors, constituted a veritable
pandemonium. The effect was heightened when the guichets in the
doors were unbuttoned, and the heads of the inmates were protruded
in a row, like so many beasts, as far as they could reach. Into this
human menagerie, what ray of hope can ever enter ? In one of the
wards of the asylum I observed on the walls a card, on which were
inscribed words to the effect that in Divine Providence alone were
men to place their hopes. The words seemed to me like a cruel irony.
I should, indeed, regard the Angel of Death as the most merciful
visitant these wretched beings could possibly welcome. The bolts and
padlocks were removed in a few instances, and some of the women were
seen to be confined by leathern muffs, solitary confinement not being
sufficient. One of the best arguments in favour of restraint by
camisole or muff is that the patient can walk about and need not be
shut up in a room, but we see here, as is so often seen, that unneces¬
sary mechanical restraint does not prevent recourse being had to
seclusion. A cell, darkness, partial or total, a stifling atmosphere,
utter absence of any humanizing influence, absolute want of treat¬
ment, are but too often the attendants upon camisoles, instead of being
dispensed with by their employment. When such a condition of
things as that now described is witnessed, one cannot help appreciat¬
ing, more than one has ever done before, the blessed reform in the
treatment of the insane which was commenced in England arid France
in 1792, and the subsequent labours of Hill, Charlesworth and
Conolly. But it is amazing to reflect that although the superiority
of the humane mode of treating the insane, inaugurated nearly a
century ago, has been again and again demonstrated, and has been
widely adopted throughout the civilized world, a colony of England,
so remarkable for its progress and intelligence as Canada, can present
such a spectacle as that I have so inadequately described as existing,
in the year of grace 1884, in the Montreal Asylum.
Before leaving the asylum, I visited the basement, and found some
seventy men and as many women in dark, low rooms. Their condi¬
tion was very similar to that already described as existing in the top¬
most ward. A good many were restrained in one way or another, for
what reason it was difficult to understand. Many were weak-minded,
as well as supposed to be excitable. The patients sat on benches by
the wall, the rooms being bare and dismal. A large number of beds
were crowded together in a part of the basement contiguous to the
room in which the patients were congregated, while there were single
cells or pens in which patients were secluded, to whom I spoke
through the door. The herding together of these patients is pitiful
Digitized by <^.ooQLe
636
Psychological Retrospect .
[Jan.,
to behold, and the condition of this nether region in the night mast
he had in the extreme. I need not describe the separate rooms, as
they are similar to those in the roof. The amount of restraint and
seclusion resorted to is, of coarse, large. Yet I was informed that it
was very much less than formerly.
To the statement in regard to the crowding of the patients
in this asylum, it will he objected that I have given a description
of a state of things which will shortly disappear, as additional
wards are being provided for their accommodation. While I
am glad to hear that other rooms will be available before long,
I am not by any means convinced that the lowest and topmost
wards of this asylum will be disused for patients. There are
now, the Mother Superior said, about 1,000 lunatics in the build¬
ing, and when first informed that new wings were being prepared,
I concluded that it was for the purpose of providing increased accom¬
modation for the existing number of inmates only. That hope,
however, was greatly lessened, if not wholly dispelled, when I learnt
from this lady that when these new wards are ready there will be
room in the institution for 1,400 patients. It is 6aid the new rooms
will contain 600 beds, but how many cubic feet are allowed in this
calculation I do not know. I have no hesitation in Raying that when
the patients are removed who now occupy the two portions of the
building I have described, and when the occupants of the other
galleries are reduced to the number the latter ought properly to
accommodate, there would be at least 400 patients who should be
removed from the old to the new building. If I am correct in this
opinion, the present lamentable evils will continue after the opening of
the additional apartments, or if they are mitigated for a time, they
will but too surely be renewed as fresh admissions take place. Assum¬
ing, however, that overcrowding is lessened, and that these dark cells
should cease to be used, what guarantee—what probability—is there,
that the manacles will fall from the wrists of the patients of this
asylum ? I am not now speaking from the standpoint of absolute
non-restraint in every conceivable instance of destructive mania. It
is sufficient to hold that the necessity for mechanical restraint is excep¬
tional, and that in proportion as an asylum is really well managed, the
number whose movements are confined by muffs, strait-waistcoats and
handcuffs will become fewer and fewer. The old system of treating
the insane like felons has been so completely discarded by enlightened
physicians devoted to the treatment of the insane, that it can no longer
be regarded as permissible in a civilized country. The astonishment
which I experienced in witnessing this relic of barbarism in the Province
of Quebec is still further increased when I see such excellent institu¬
tions as the lunatic asylums of the adjoining Province of Ontario. I
am perfectly certain that if it were possible to transfer the worst
patients now in the asylum at Montreal to these institutions, they
would be freed from their galling fetters and restraint-chairs. They
Digitized by <^.ooQLe
Psychological Retrospect .
637
1885 .]
would quit their cells also, and, in many instances, be usefully occupied
where they are now restrained, with the result that in not a few cases
perfect recovery to health would follow. “ Look on this picture and
on this,” were words constantly in my mind after visiting the institu¬
tions of the two Provinces. It can hardly be contended that a system
which succeeds in one Province, and is attended by great success, ought
not to be followed out in the other.
The question arises, why this difference in the condition of the insane
in the asylums of the two Provinces ? Whatever other reasons there
may be for this extraordinary contrast, I have no doubt that the main
cause is to be found in the different systems upon which the financial
management of these institutions is based. It is a radical defect—a
fundamental mistake—for the Province to contract with private parties
or Sisters of Charity for the maintenance of lunatics. This, it cannot
be too often repeated, is the essential root of the evil; and unless it
be removed, the evil, although it may be mitigated, will remain and
will bear bitter fruit. If any steps are to be taken to remove the
present deplorable condition of the insane in the asylum of Montreal,
it must be by the Province taking the actual responsibility of these
institutions into their own hands. Whatever may be the provision
made by private enterprise for patients whose friends can afford to pay
handsomely for them, those who are poor ought to have the buildings
as well as the maintenance provided for them by the Legislature.
They are its wards, and the buildings in which they are placed should
belong, not to private persons, but to the public authorities, with
whom should rest the appointment of a resident medical officer.
The official inspection of this institution must now be referred to.
When I was at the Quebec Asylum (Beauport) I obtained a copy of
the report of that establishment. The names of three inspectors of
the asylums and prisons of the Province are there given, namely, Drs.
L. L. L. Desaulniers, A. de Martigny, and Mr. Walton Smith.
They report to the Provincial Secretary, who resides at Quebec, and is
the Government officer to whose department these institutions pertain.
I was informed that the visits of the inspectors are due three times
in the year. The Grand Jury are empowered, when they meet, to visit
asylums and make a presentment to the Court in regard to their con¬
dition, but I understood that this is generally a very formal proceeding.
With regard to the authority of the visiting physician appointed and
paid by the Government, it has been hitherto, so far as I could ascer¬
tain, almost, if not entirely, nil . His hands have been so tied that he
could not be held responsible for the way in which the asylum has
been managed. The Quebec Legislature passed an Act in June last
which has only just come into force, and which, among other provi¬
sions, extends and enforces the authority of this officer. It remains
to be seen whether this Act invests him with sufficient power to carry
out any system of treatment or classification of the patients which he
may deem requisite.
Digitized by {jOoq le
638 Psychological Retrospect. [Jan.,
There should, however, in any case, be a medical superintendent,
with competent knowledge of the treatment, moral and medical, of the
insane, with undivided authority and responsibility inside the institu¬
tion, although subject to the Government, aided by efficient medical
inspection.
Should the contract system be abolished, should capable medical
men be placed at the head of the institutions of the Quebec Province,
and should inspection made by efficient men be sufficiently frequent
and searching, the asylums for the insane of this Province would be¬
come institutions of which Canadians may be justly proud, instead
of institutions of which they are now, with good reason, heartily
ashamed.
Beauport Asylum, Quebec .
I visited the Beauport Asylum, at Quebec, Aug. 18, 1884. It was
established in 1845; additions were made to the original building in
1865 for the male patients, and in 1875 for the female patients. The
medical superintendents reside in the city, several miles away, and I
had not the pleasure of seeing them. There are two visiting
physicians. The asylum is inspected by Dr. Desaulniers, Dr. A. de
Martigny, and Mr. Walton Smith. Resident on the premises is the
warden, and in the vicinity is an assistant physician. I have to ex¬
press to both these gentlemen my obligations for the kind way in
which they received me, the time they devoted to my visit, and their
readiness to show me the various parts of the building. My thanks
are especially due to Mr. A. Thomson, of Quebec, for the assistance
he rendered and for accompanying me.
The asylum is a striking object to visitors to the Montmorency
Falls as they pass along the road where it is situated. The approach
is pleasant and the entrance attractive, being marked by the taste and
cleanliness which characterise the dwellings of the Canadians gener¬
ally. The warden received us politely, and took us round the
building devoted to female patients. His wife occupies the post of
, matron, and has two assistants under her. The corridors into which
we first went are sufficiently spacious, and serve the purpose of day-
rooms to a large extent, the patients being seated or walking about.
The patients here were well dressed, and appeared to be as comfortable
as their condition would allow. The associated dormitories are large,
cheerful rooms, well ventilated, and the beds neat and clean. I sup¬
posed that the linen had been clean that morning, but was informed
that it was the last day in use, and was changed weekly. Strips of
carpet and mats in the dormitories, as well as in the corridors, relieved
the bareness of the floor.
The position and construction of a series of single bedrooms
attached to the wards are most unfortunate. They are placed back
to back, so that there is no window in them, the narrow passage which
skirts them receiving light from a window at either end. There is an
Digitized by <^.ooQLe
1885.] Psychological Petrosyeci. 63d
aperture over the door, and a small one in the door itself. The
ventilation is most imperfect, and it was not denied that in the morn¬
ing their condition is the reverse of sweet. Some of these cells—for
cells they must be called—were very close when I visited them. How
such rooms came to be built for lunatic patients, for whom good air
and sufficient light are so important, it is difficult to comprehend. I
was informed that they were planned to expedite the escape of the
inmates in case of fire, there having been a conflagration some years
ago in which twenty-six patients perished, but I failed to see the fit¬
ness of such an arrangement. It appeared to me to be due to the
desire to economise room, and I am not surprised to find, from one of
the annual reports given me, that credit is claimed on the ground
that the cost for care and maintenance is less than at ten asylums
with which the Beauport Asylum is compared.
I have 6poken favourably of the associated dormitories opening
into the corridors. Those, however, in the attic were very gloomy
and crowded with beds. I have also referred favourably to the dress
of certain patients. I must add that in some parts of the house
they were barely clad, and presented a very neglected appearance
altogether.
The number of women in restraint was very considerable. Some
wore the manchon or muff, others the close glove ( mitaine ) ; others
were restrained by leather wristbands ( poignet ) fastened to a belt,
while some were secured by the gilet de force , so that movements of
the arms were effectually prevented. Several were secured to the
bench on which they were seated. In one small airing court upon
which I looked down, not a few were restrained ; the whole company
appeared to be unattended, or if there were attendants, the latter did
not consider it a part of their duty to keep their dress in decent
order. In referring to mechanical restraint, I do not judge of
the condition of the patient, from the total non-restraint point of
view. The amount resorted to in this asylum would not be seriously
justified by any physician of the insane with whom I am acquainted,
whatever his views on non-restraint may be.
After leaving the building in which the women are located, we
walked into the grounds over a stream to a steep, grassy, airing
court, which was fortunately shaded from the blazing sun of that day.
Here a number of female patients were congregated, with one or two
attendants. A wooden fence separates this ground from a correspond¬
ing grass plot for the men. From a window in the building for the
latter sex I looked down subsequently, and the sight of the female
patients lying or sitting on the grass in unseemly attitudes, and with
scant and neglected attire, did not commend itself as one altogether
desirable. The number of attendants is quite insufficient, and I
cannot say I was favourably impressed with their appearance. Where
so much importance is attached to economy, this cannot excite
surprise. Their pay is very insufficient, as well as their number.
Digitized by v^ooQle
640 Psychological Retrospect . [Jan.,
Passing to the building for the male patients, over which the
resident physician escorted us and manifested the greatest willingness *
to show every corridor and room, I would observe that there are
certain wards which, like those for the corresponding class of women,
8re both clean and respectably furnished; but when I have done
justice to the accommodation afforded in these galleries, I have said
all that I can say in the way of commendation. The higher one
ascended in the building, the lower the condition of the patient—the
corridors were much crowded, and the amount of mechanical restraint
excessive. In the worst ward, the sight was in the last degree painful
to witness. Here were some thirty patients. Some had leathern
muffs, others the belt and poignet, while several were in cells as dark
as those on the women’s side, and were also restrained. One had his
legs fettered at the ankles. There were also several men in restraint-
chairs, to which they were fastened, and not only so, but they wore
muffs. They were in their shirts, and over their exposed persons flies
were crawling in abundance—a spectacle which it must suffice to
describe without characterizing further. Among patients of the class
now referred to, I counted fourteen restrained, but I do not pretend to
have noted them all. For a man who was given to scratching his face,
it was considered necessary not only to secure his hands by the muff,
but to place him in a crib-bed.
But it is needless to describe in more detail an institution which,
however willingly I may praise where praise is due, is so radically
defective in structure and so fundamentally different from any well-
conducted institution of the present day, in the matter of moral, to say
nothing of medical, treatment, that no tinkering of the present system
will ever meet the requirements of humanity and science. I regret to
write thus. It is a thankless task for a visitor, courteously treated as
I was, to criticise any institution which the officers permit him to
inspect. But I write in the hope of helping, in however humble
a way, to bring about a reform in the injurious practice of the State
contracting with private individuals for the maintenance of its insane
poor. The proprietors receive 11 dollars (45s. lOd.) per head per month
for maintenance and clothing. This system involves the probability of
patients being sacrificed to the interests of the proprietors. It has the
diastrous tendency to keep the dietary as low as possible, to lead to a
deficiency in the supply of clothing, and to a minimum of attendants,
thus inducing a want of proper attention to the patients and an
excessive resort to mechanical restraint, instead of that individual
personal care which is no needful for their happiness and the promo¬
tion of their recovery. I consider that the number of attendants in
such an asylum should not be less than 1 fn 8,* instead of l in 15 ;
and that a higher class should be obtained by giving higher wages.
At present they are as follows : 9 to 10 dollars a month in winter for
♦ So in original MS., bnt in the “ Canada Medical and Surgical Journal ” the
number 7 appears, owing to the writer’s hasty correction of proof in travelling.
Digitized by <^.ooQLe
1885.] Psychological Retrospect . 641
male attendants ; 12 to 14 in summer. Women attendants have 5 to
6 dollars a month, or £12 to £15 a year. With a higher class,
it might no longer be an irony to speak, as the chaplain does in one
of the Reports, of “ the good and virtuous keepers who are selected
with great discernment.”
I venture also to express the hope, in conclusion, that the Province
of Quebec will itself undertake the responsibility of providing the
necessary accommodation for its insane poor and their skilful treat¬
ment, that a resident medical superintendent, with full authority, will
be appointed, and that there will be a Board of Management, as well as
really efficient inspectors.
Since this article was written, the following has appeared in the
“ Canada Medical and Surgical Journal,” November, 1884:—
“ At a largely attended meeting of the Medico-Chirurgical Society
of Montreal, held on Nov. 7, the following resolutions were unani¬
mously passed:—
“ 1. That this Society has every reason to believe that the state¬
ments contained in the Report of Dr. D. Hack Tuke, of London,
England, upon our Provincial Lunatic Asylums, are, in every material
respect, true and well-founded.
“ 2. That these statements show a most lamentable state of things
as regards the general, and especially the medical, management of
these Institutions.
“ 3. That it appears to this Society to be the imperative duty of the
Provincial Government to institute a thorough investigation by com¬
petent persons into the entire system of management of the insane
poor in this Province.
“ 4. That the * farming ’ or 1 contract ’ system, either by private
individuals or by private corporations, has been everywhere practically
abandoned, as being prejudicial to the best interests of the insane, and
producing the minimum of cures.
" 5. That in the opinion of this Society all establishments for the
treatment of the insane should be owned, directed, controlled and
supervised by the Government itself, without the intervention of any
intermediate party.
“ 6. That the degree of restraint known to be employed in our
provincial asylums is, according to the views of the best modem
authorities, excessive. That the ablest European, American, and also
Canadian alienists have almost entirely given up any method of
mechanical restraint. That these facts call urgently, in the name of
humanity, for reform in this direction in our provincial asylums.
“ That this Society concurs fully in the opinion already expressed
by Dr. Tuke in his Report, to the effect that ‘ the authority of the
Visiting Physician (Dr. Henry Howard), appointed and paid by the
Government, has been hitherto almost, if not entirely, nil . His hands
have been so tied that he could not be held responsible for the way in
which the asylum has been managed.’ ”
Digitized by {jOoq le
642
[Jan.,
PART IV.—NOTES AND NEWS.
THE MEDICO-PSYCHOLOGICAL ASSOCIATION.
The usual Quarterly Meeting of the Medico-Psychological Association was
held at Bethlem Hospital on Wednesday, 5th November, 1884, at four o’clock,
Dr. Rayner, President, in the chair.
The following gentlemen were elected members of the Association, viz. :—
Benj. Hall, M.B.Lon., Earlswood Asylum; L. W. Bryant, M.B.Edin., Colney
Hatch Asylum ; D. G. Johnston, M.B., C.M., Glasgow, Moorbroft, Hilling¬
don ; Edward Howard Paddison, M.D.Lond., Asst. Med. Off. County Asylum,
Wandsworth; Edward E. Moore, M.B., Asst. Med. Off. District Asylum,
Downpatrick; John Francis Woods, Med. Supt. Hoxton House Asylum,
Hoxton; F. J. J, Barnes, M.R.C.P.Ed., F.B.C.S., Asst. Med. Off. Camberwell
House, Camberwell.
Dr. W. Julius Mickle exhibited specimens of two hearts and a portion of
brain, upon which he made the following remarks, viz.:—The pathological
specimens shown are mainly from two necropsies made by me last week. One
specimenju3.that of degeneration and moderate aneurysmal dilatations of the
left ventricle of the heart, ending in spontaneous rupture of the wall of the
heart: The patient, aged 50, had been for some years in the asylum, and
recently had become nearly cured of former pulmonary phthisis. But he had
also heart-disease, and this had not undergone cure. Between two and three
weeks before death he was seized with some collapse, from which, however, he
soon rallied. Subsequently it was noted that the praecordial area of dulness
was increased, the apex beat of the heart being scarcely felt, and the cardiac
sounds being feebly heard at the apex. A systolic bruit existed at the apex,
and was slightly propagated towards the left. For a day or two vomiting oc¬
curred at times, and • a burning pain was complained of in the praecordial
region. The patient was kept quiet and in bed, and the above cardiac signs
improved ; but later on he died suddenly in the night, whilst lying quietly in
bed. The heart was ruptured at the apex of the left ventricle, and 22 fluid
ounces of blood and black clot were in the pericardial sac; the way out for the
blood* being (mainly at least) at the ruptured apex. There were some old
pericaraitic adhesions over the left side of the left ventricle, and on separating
these the heart-wall was torn through, and from the adherent infiltrated clot
it was evident that at least a partial prae-mortem tearing of the heart-wall had
occurred here, and perhaps complete perforation at a small rent, permitting of
a slight haemorrhage at the time of the collapse, 17 days before death.
Aneurysmal bulging of the wall existed here, as well as at the apex ; and at
these parts the ventricular parietes were thinned and degenerate; partly
fibroid, partly fatty. There was also some general dilatation of the left
ventricle. In connection with this, is also shown the heart of a former patient,
the subject of cardiac bruit, and aged 44; who, while urinating, suddenly sank
to the floor, breathed heavily, then vomited and defecated; and when seen by
me, immediately afterwards, had turgid, livid face, laboured respiration,
small, feeble, thrilling pulse, profuse perspiration, vomiting and unconsciousness.
Then respiration ceased, was resumed, became stertorous, panting, and up-and-
down in rhythm. Then were noticed:—Right hemiplegia, dilated almost im¬
mobile pupils, continued coma; cessation of respiration, return of it under
artificial respiration and brandy-enema. Then, vomiting, paler lividity, and
finally ceasing respiration. The necropsy showed slight meningeal haemorrhage ;
and 5^ fl. ozs. of blood and clot were in the pericardial sac. From the upper and
right part of the left ventricle passed a sinuous aneurysmal cavern, lined by a
continuation of the endocardium, commencing by an aperture immediately
Digitized by v^ooQle
1885.]
Notes and News -
643
below the aortio semilunar valve, and passing rightwards behind and below the
pulmonary valve, above and in front of the right auricle, thence curving round
the right side of the heart, and terminating in a pouch, on the posterior aspect,
and between the aortio arch and the right auricle, where was a ruptured slit
in the aneurysmal wall and the way out for the blood. The left ventricle was
hypertrophied, and had a second cardiac aneurysm behind and to the left of
the mitral valve. The recognition of like cases is important, as the lives of
the patients may be, possibly, saved or prolonged by securing the avoidance of
any strain or excitement, and even if prevention is not feasible, one may be en¬
abled to anticipate the rapid or sudden death, which in these cases immediately
follows the actual rupture, when the latter is such as to permit of free
haemorrhage into the pericardial cavity. The remaining recent specimen is one
of local acute red softening of grey cerebral cortex. The patient was in
advanced pulmonary phthisis, with ulceration of the bowels. Only the
symptoms connected with the lesion shown at the ^meeting are mentioned. Two
days before death, sudden right brachial monoplegia came on, sensibility not
being abolished. Next day there was also a slight paresis of the right lower
limb, but the face was unaffected. The motor palsy of right upper limb was
absolutely complete. On the day of death there were spasmodic twitchings of
the right hand, and three dextral epileptiform seizures beginning there. On
the last two or three days of life there were a few pneumonia patches; respir¬
ation also was irregular, of up-and-down rhythm; the relation between the
a.m . and p.m. temperature was reversed, the morning temperature being then
the higher; whereas for some months previously (as shown in the charts ex¬
hibited) the evening temperature had usually been in excess, and often from 2° to
4° higher than that of the morning.—At the necropsy, among other conditions,
the one of principal interest was a patch of acute red softening of the grey
cerebral cortex of the upper one inch of the anterior central gyrus, and of the
posterior half of those portions of the superior and middle frontal gyri, which
are adjacent to each other, and markedly in the superior frontal sulcus itself*
This lesion, in the fresh brain, had been very sharply and precisely defined j
and as far as it went the case bore out conclusions that have been drawn, from
a study and comparison of pathological cases, as to the cerebral cortical fields
connected with various departments of the muscular system. For the upper
part of the left anterior central gyrus is one of the parts of the cortex
specially associated with the right upper limb; as is also the posterior part of
the superior and middle frontal convolutions in some, but in far less, degree.
Hence the palsy of right arm and convulsive phenomena. That the right leg
almost escaped palsy was also of interest in relation to other pathological oases.
Had a similar and symmetrical lesion occurred in the right hemisphere, it is
probable that the left leg would have been more affected than was the right in
this particular case, the left cerebral lesion of which is now shown. The case
is mainly of interest from the association of a sharply defined lesion with very
definite localized clinical symptoms j from the limitation of that lesion to the
cerebral cortex; and from the bearings of the case, therefore, on the question
of cortical function and theories of localization.
Dr. Savage submitted a specimen. In the case of a man aged 78, suffering
from senile melancholia, he had found on post-mortem examination very con¬
siderable disease of the aorta, and in the middle third of the first frontal con¬
volution there was an ulcer three-quarters of an inch across, with a sloughy
surface and adhesion of membranes to edges. There were one or two other ap¬
pearances, but that which he specified was the most marked. Just before
death there was a puffing of the side of the face, but in regard to the legs and
arms there was nothing worthy of notice. The patient was insane only three
weeks from the first. He had married late in life, and started with profound
melancholia. It had afterwards been found that there had been a great deal of
domestic trouble, and with his bad arteries he had been unable to stand
domestic strain.
xxx. 43
Digitized by boogie
644
Notes and News.
[Jan.,
The President said that pathological specimens suoh as these were always
of interest to the Association. In the asylum post-mortem room nothing was
more striking than the extent to which heart-disease could go under the
healthy conditions of asylum life. Was Dr. Mickle’s case of brain-disease
associated with syphilis P
Dr. Mickle replied that the patient had suffered from primary syphilis—
primary sores—but there was no proof of secondary syphilis.
Dr. Savage asked Dr. Mickle whether the mental symptoms were in any way
affected by the aneurism. In the only case which he had himself seen of an
insane person suffering from well-marked aneurism, he had found that with
thoraoio pressure there was developed the idea of poisoning; and he had been
interested in seeing that case, as he had so often seen cases of delusion of
poison associated with lung disease.
Dr. Mickle said that in the cases of aneurism of the heart the principal
thing noticed was a tendency to a depression which he associated with the
embarrassed condition of the heart.. In that condition the heart not being up
to its work, the brain was not sufficiently nourished by a good type of blood.
In those cases, too, there were very well marked delusions of bodily injury, one
thinking that darts of fire were coming down upon him, and the other being
troubled by hydraulic pressure. In thoracic aneurism there was frequently
most painful delusion. He had had several cases of cardiac aneurism quite a 1 )
well marked, but he thought that the second case he had quoted was of
extraordinary interest, on account of the curious course which the cavern had
taken, and so forth.
Dr. W. H. O. Sankey said that he had investigated the conditions, according
to statistics, of diseases of the heart in connection with ordinary insanity, and Dr.
Burman’s paper had gone into the subject, but he could not find that there was
anything like unanimity of ideas upon it, although he thought Dr. Burman had
proved his case that in ordinary insanity there was a greater tendency to
disease of the heart than in the population generally. As to aneurism suggest¬
ing the idea of suffocation, he did not remember a case, but he had a very
curious one in which a woman was always saying she had gas inside her, and
after death her gall bladder was found to be distended by gall stones.
The President said he remembered one case of extreme aortic regurgitation,
in which there was a good deal of exaltation. The delusions subsided when
the heart disease had improved.
Dr. Savage said that they used to be told as students that “ mitral meant
melancholia.” He had had cases in which large hearts had been associated
with grand ideas. He had very rarely got anything like aneurism, but had
had many dilated hearts. In his experience melancholia had more frequently
occurred with mitral than with aortic disease.
Dr. B. B. Fox re-introduced the subject of “ Exaltation in Chronic Alcoholism ”
(see Original Articles, page 233, of the July number). In recapitulating the
points upon which he invited discussion, he said that he would remind the
members that he did not propose to discuss alcoholic insanity as a whole, but
merely one group of symptoms—exalted ideas—and the propositions which
he ventured to bring forward were that these exalted ideas were very fre¬
quently associated with chronic alcoholism, but that they had much in common
with the exaltation of other forms of insanity, more particularly of general
paralysis, and that the bodily symptoms which occurred at the same time with
them were so extremely similar that it was almost impossible to differentiate
the two classes of cases, and in some instances this could only be done by-
watching the course of the malady. He had also ventured to lay before the
Association the theory that these delusions of exaltation, which were usually-
fixed, constant, and ineradicable, were due to repeated hyperemia, and there¬
fore owing to organic or structural change, and that little or nothing could bo
done for their removal. He might say. that in looking through the cases of
alcoholic insanity in the asylum he had been struck with the large number of
Digitized by <^.ooQLe
1885.]
Notes and News.
645
cases suffering from delusions of persecution and suspicion, which seemed
to prove that such ideas were nearly always associated with some physical
change in the organism. Then, since he read his paper, he had seen one by a
New Tork physician, in which it was stated that strychnia had been found to
be almost a specific in these cases, given with quinine and a little gentian.
That was, no doubt, a very excellent prescription in cases of chronic dyspepsia,
&o., but he had yet to learn whether strychnia had the effect of being an
antidote for alcohol.
The President said that he quite agreed with Dr. Fox’s suggestion as to
sensory hallucinations being associated with vitiated blood in the system. For
a long time he had regarded the existence of a very active sensory hallucina¬
tion as a proof of there being some disease inducing a vitiated condition of the
blood either by kidney disease or some other cause, and he thought that if
they were to examine all their patients who had very active sensory hallucina¬
tions—for instance, of burning of skin and of the application of heat and cold
—this would prove to be the case.
Dr. Sankey asked how they were to distinguish vitiated conditions of the
blood. There had recently been an interesting paper on that subject by Dr.
Macphail; but he should like to see the same enquiry carried on in regard to
patients not in public asylums, where, of course, patients were sometimes not
too well fed; and it would be very interesting to see whether this deficiency of
the essential elements of the blood were due only to a bad diet or to a morbid
state of the blood connected with insanity.
The President remarked that the only case which he could quote upon this
point was one of general paralysis, in which a chemical examination had been
made for him by Dr. Wynter Blyth, who had described the subject of his
examination as “ a sort of porridge of blood ”—it contained such an exoess of
all kinds of materials.
Dr. Sankey said that Dr. Marcet had had an analysis made, but the chemistry
of that day was not sufficiently advanced. Probably a microscopical examina¬
tion would be more likely to give results than a chemical one.
Dr. Savage said that the question of localization and its effects in producing
symptoms had always seemed to him, next to general paralysis, the most
interesting of subjects; and just as general paralysis proved that almost any
variety of disease might be accounted for by loss of higher. control, so with
alcoholism. They might call to mind the saying of Dr. Wilks, of Guy’s, who
referred to certain festive dinners and said, ** If you watch the men who get
drunk from them, you will be able to judge what the symptoms of general
paralysis are.” He looked upon exaltation of ideas as loss of the highest
control and nothing more. Exaltation of ideas, with chronic alcoholism, was
very hard to cure, and two years ago he might have said it was incurable; but
he had lately found that very active treatment had been attended with benefit.
He had only just discharged an Irish doctor who had had delirium tremens, and
had suffered from the wildest exaltation. He was going to do wonderful things,
cure everybody, take titles, &c.—the ordinary type—boastful and benevolent
—a fine-grown fellow, and with every characteristic of general paralysis.
That gentleman was sent into Bethlem with a very black mark by the persons
who examined him. They both said, “ Probably G. P.” For months he (Dr.
Savage) was in doubt. He blistered his scalp, and did so again and again,
keeping the blister open, with the most satisfactory results. He was conse¬
quently now more hopeful than he used to be as regards curability. He
believed that in most cases persons who had delusions of poisoning and were
thoroughly filled by hallucinations of their senses were sufferers from bodily
disease, but he did not accept that as a general principle. He had another case
of a member of their profession at Bethlem, who was persecuted in the most
terrible way by hallucinations of the senses. He had all kinds of tricks played
upon him, people interfering with him and injuring him, &o. He was perfectly
healthy, but there, perhaps, it was worth saying that it was almost beyond
doubt that, having been sleepless, he had used morphia.
Digitized by <^.ooQLe
646 Notes and News. [Jan.,
Dr. Thomson mentioned a ease of innominate aneurism in a ease of imbecility
where no delusions were present, either of exaltation or depression.
Hr. Hayes Newington said that he should be glad if Dr. Fox would inform
them from what point of view or upon what basis he had decided upon the
cases.
Dr. Bakeb referred to a ease of a patient with very exalted ideas who had
been sent to him as a general paralytic, and concerning whom he was at first
in doubt, but he used the Turkish bath and the patient rapidly recovered. He
had since had a similar case. Both cases recovered in three or four months.
Great care should be exercised in giving opinions in these very doubtful cases,
some of which very rapidly recovered as soon as the alcohol was eliminated
from the system.
Dr. Grieve said that at his asylum at Berbice, British Guiana, about fifty
per cent, of the patients were East Indians, who consumed a large quantity of
opium and were addicted to the use of cannabis indica. As a rule he saw no
cases of general paralysis, and it might be taken as an accepted fact that
among the dark races, general paralysis was unknown; but latterly he had
watched five or six cases of chronic alcoholism which had exhibited exaltation,
followed by physical symptoms resembling general paralysis, and which, after
death, had shown undoubted meningeal cerebritis, and he should much have
liked to have obtained the opinion of the Association as to whether these cases
could be accepted as cases of general paralysis or merely of chronic alcoholism.
With regard to the mental symptoms produced by opium, he could only say that
after many years’ experience he had never been able to connect any case of
insanity with the use of opium, but insanity was very often connected with
cannabis indica.
Mr. C. M. Tuke said he should like to hear more about Dr. Savage’s oase
of the doctor who was cured by having the blister kept open. No
doubt Dr. Savage had some hope from the absence of some symptom which
led him to try that means. As regards the association of delusions of poisoning
and so forth with physical disease, he might say that he knew of four cases,
all of which showed very active delusions of poisoning and burnings, and all
sorts of cruelties, and in all those four cases there was physical disease—one
had phthisis, two heart disease, and one diabetes.
Dr. Savage said that the reasons which made him think that the case was'
not one of general paralysis were, first, the very definite history of drink to
begin with, and acute onset, also the facts that he had been pursuing his
business up to such a point, and that he was under thirty, and single, and an
Irishman, with a neurotic temperament. Whenever he again got such a case
in which alcohol played a part, he should certainly not hesitate to blister, and,
if necessary, to blister freely.
Dr. Clapham said that gentian had been found of service in these cases.
Dr. Fox, in reply, said that he did not wish to state broadly that persons who
suffered from these exalted ideas in chronic alcoholism never recovered 5 but
that they very rarely recovered, and usually did not do so. He suggested that
a great deal depended upon the length of time that the exalted delusions had
appeared and lasted. One of the cases he had referred to had recovered, and
in that case the patient had only been ill a month. His opinion was supported
by Griesinger, who said that when those conditions had lasted six months,
there was very little hope of the patient’s actual recovery. As to what Mr.
Hayes Newington had asked, he might say that he took a great deal of trouble.
He scarcely attached any weight to the ordinary statement; but pursued the
course which he had been taught at Bethlem. He saw the patient’s friends
and submitted to them a list of questions, and although he had been told that
he would have [great difficulty in getting those questions answered, he had
never yet experienced a single refusal, and had got, as he believed, candid and
truthful answers. It was upon those answers that he had based the remarks
he made in his paper. He had found it very difficult to distinguish between
chronic alcoholism and general paralysis.
Digitized by <^.ooQLe
Notes and News.
647
1885.]
In reply to further inquiry by Dr. Fox, Dr. Grieve said that he believed
that oannabis indica produced quite as much chronic insanity as alcohol, but of
a very different type. In the former there was a marked absence of all motor
symptoms—no tremor. Probably the secondary effects of the two poisons
bore the same relations to each other as the primary effects; and as cannabis
indica was, as it were, less degrading than alcohol, so the chronic insanity
arising from Indian hemp was limited much more to the higher centres than
ohronic alcoholism.
Dr. Savage then read a Paper “ On Cases of Delirium Tremens passing into
Mania ” (see Original Articles), and discussion was resumed on the two papers
together.
The President said that they would probably agree with Dr. Savage, that
delirium tremens and all forms of mental disturbance arose in acute febrile
attacks, and were more common in the neurotic than in the non-neurotio
classes. The brain fever which they heard of was very frequently delirium
dependent upon the febrile condition.
Mr. Hates Newington said that Dr. Fox had rather misconceived the object
of his question to him, which was to ascertain if he had been able to get at
any history, not of the amount of drink, but of the nature of the drink.
Much depended upon the material which had upset the patient. He had seen
a great deal of insanity arising from strong liquor, both in England and Scot¬
land, and he could not help being struck by the great difference between the
two in that respect; and in analysing a great number of cases it should be
considered whether the patient, like the London cabman, had being going into
the gin palace and having his three-pennyworth of gin without anything, or
whether he drank as a well-ordered Scotchman, taking a quantity of whiskey
with a large quantity of hot water and drinking it in the evening. Naturally,
if a man drank enough alcohol to poison him right off, his mental symptoms
would differ from the symptoms arising from the long-continued ingestion of
poison in the shape of beer. So also with regard to chloroform and opiates.
As bearing upon Dr. Savage's paper, he quoted a case in which a tendency
either towards drink or opium could be traced through an entire family.
Dr. Fox said that in the majority of his cases the individuals had a very
miscellaneous taste, but preferred to have their poison in the most concen¬
trated form possible, and as a rule drank spirits. There was one who had
very exalted notions, and who stuck to wine. His physical appearance bore
out the idea, for he was fat, and round, and jolly. He came in craving for
sherry, and kept up his craving for it all his life. He (Dr. Fox) was sorry
that he could not state distinctly the definite relation between the form of the
alcohol consumed and the form of the insanity, but, as a general statement,
he might say that most of the cases to which he alluded in his paper were
spirit drinkers to some degree. With respect to Dr. Savage's paper, it was
to be remembered that they saw so many more neurotic oases than other cases,
and it was consequently difficult for them to answer the question involved in
it. For his own part, he thought that drink bred truly, and he could quote
some cases to prove this, but his knowledge of the progeny of drunkards was
too limited for him to answer Dr. Savage’s question. Certainly, as far as his
own experience went, it would be that a neurosis of drink was more fre¬
quently transmitted to successive generations in the same form.
Mr. C. M. Turk mentioned the case of a lady who was taken with very
acute mania after an operation on the breast, treated antiseptically. There
was always great difficulty in keeping the wound properly bandaged. It was
dressed as usual, and the operation evidently terminated favourably. The lady
has been perfectly impervious to narcotics, many having been tried, and it was
almost impossible for her to get any sleep, but when the wound was dressed
she was placed under chloroform, and almost invariably slept four or five hours,
or even longer. He had never heard of any case of acute mania in which
chloroform had been given to procure sleep, but in this case it certainly did
procure sleep, and very materially benefited the patient.
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Dr. Sankey said that the chronic results of alcoholism might take pretty
nearly any form; they might come out in intellectual disturbance, or they
might go into motor disturbances and resemble some of the spinal affections
described in the Pathological Society’s papers. Although he had never yet seen
a case in which there was exaltation resembling that which occurred in general
paralysis, he had seen various other disturbances, particularly with delusions
and symptoms of poisoning and bodily harm, and that not only after drink,
but in the delirium after fever. Dnring the time he was at the Fever Hospital
he had altogether under his care some 8,000 cases of fever of various kinds,
and out of that number there were eight or ten cases of delirium remaining
after fever, and of those two were permanently insane. As regards alcohol,
however, it was generally supposed that when it became—as to its chronic
effects—a foreign body in the blood, it might, according to the area it affected,
produce certain symptoms. Many of those oases, formerly called mania a
potu, certainly closely resembled general paralysis, but to the practised eye
the appearances were different. He certainly did not think that alcoholism
was incurable. He had had a gentleman who drank so hard that his hand got
to shake so that he could no longer carry the glass to his mouth, and his memory
was so bad that he could not tell when he had drunk last. His modicum was
one bottle of brandy per diem. When he came under treatment that was
gradually reduced, and in about three months he got perfectly well. He lived
long afterwards, and became chairman of one of the largest public concerns.
In these cases there is generally a little imbecility left, but this gentleman got
quite well. He had been drinking for many years, and had become quite a
chronic case.
Dr. Savage said he quite agreed with Mr. Hayes Newington, that it
was of the greatest importance to know what kind of drink had upset the man*
As far as he could see, he was inclined to think that a very strong stimulus,
such as gin or whiskey, was much more likely to permanently upset than
a weaker kind. He was afraid he did not make his remarks as to inheritance
sufficiently clear. He rather wanted to trace the effect of the alcohol in cases
which were descended, not from alcoholic parents, but from neurotic parents.
He quite accepted Dr. Fox’s remark upon this point. Seeing neurosis on all
sides they were inclined to forget that there were non-neurotics outside. As
to chloroform, they had seen several cases in which insanity had followed opera¬
tions. He saw a case of ovariotomy at St. George’s Hospital. Within
twenty-four hours after a successful operation, acute mania set in, and the
patient died. The brain showed nothing special, but the acute mania in a
person who had suffered from so severe a shock was enough to kill her. In
some cases of small operations the chloroform might have set up the disturb¬
ance, though, of course, it might be said that the simple shock might have
done it, or that even the idea of being in a hospital might have had some¬
thing to do with it. But as regards the use of chloroform, he could quote a
case of a young Greek girl upon whom, having tried everything else unsuccess¬
fully, they tried chloroform as long as they dared, and he was then astonished
to see her first return of consciousness exhibited by her putting her fingers to
her nose. He was very much interested in Dr. Sankey’s experience as to
-febrile cases. Of course, they only got cases which were insane—some with
the history of fever. He had had a case (the third in a family) where a girl
had had scarlet fever. The delirium passed off, and the most marked eroti¬
cism exhibited itself; and then the patient passed into a condition of profound
depression, from which she had only recently recovered. The oases he had.
referred to in his paper, were distinctly cases of delirium tremens, following
upon a somewhat prolonged course of drunkenness.
A Quarterly Meeting of the Medico-Psychological Association was held in the
rooms of the Literary and Antiquarian Society, Perth, on Friday, 21st Novem¬
ber. Present: Drs. Campbell (Murthly), Clark (Bothwell), Cloueton (Edin-
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burgh), Howden (Montrose), Macphail (Garlands), Rorie (Dundee), Rutherford
(Dumfries), Turnbull (Cupar), Urquhart (Perth), Xellowlees (Glasgow). Dr.
Urquhart in the chair.
William R. Watson, L.R.C.P., and S.Edin., Medical Superintendent, Govan
Parochial Asylum, was elected a member of the Association.
Dr. Howden (Montrose) showed a fire escape which was exhibited in the
Health Exhibition by H. T. Bailey, Blackheath, and which seemed well adapted
for use in asylums and hospitals. It consists of a long canvas tube or shute, two
feet in diameter, suspended from an iron cage framework, which is fixed and
folds up under an ordinary dressing table at the window. When the lower sash
of the window is opened, the shute can at once be thrown out, and persons can
descend with great rapidity and safety.
Case of Compensatory Hypertrophy of the Calvarium, covering an Atrophied,
Hemisphere of the Brain. —Dr. Clouston showed the brain and calvarium of
a case of “Infantile Paralysis,” who since birth had had the left side paralysed,
and in whom the limbs on that side remained stunted and contracted. The
patient had also been idiotic and epileptic. He had died of catarrhal pneumonia
at the age of twenty. The skull was asymmetrical, and the right sides of the
frontal, sphenoid, parietal, and occipital bones had been found to be greatly
thickened in comparison with the left halves of these bones, while the whole of
the bones of the skull were more or less hypertrophied. The frontal sinuses of
both sides were enormously enlarged, running backwards over the whole of the
orbital plate on the right side. The os frontis was inch thick on the right
side, this being £ inch thicker than on the left. The sphenoid was much
thickened on its cranial surface, presenting a rough, irregular surface, as if large
nodules of solid osseous substance had been deposited on its surface. The crista
galli was large, irregular, thick and solid, and the right middle fossa was
considerably smaller than the left, being filled up, as it were, by a thickened
inner table of the skull. The brain generally was much atrophied, and the
convolutions poorly developed, but the right hemisphere of the cerebrum much
more markedly so than the left. The former weighed 10 ozs., the latter 17 ozs.
The atrophy, while general in the whole of the right hemisphere, assumed a
markedly localised form in the frontal region. The ascending parietal, ascend*
ing frontal, and posterior portions of the middle and inferior frontal convolu¬
tions had almost disappeared, only little fibrous tissue being left over these
wasted convolutions; there was a greatly hypertrophied pia-mater and arachnoid.
The membranes generally were thickened, and there was, of course, much cere-
bro-spinal fluid. The ventricular surface of the right corpus striatum was ridgy
from atrophic depressions. Altogether the pathological appearances of the surface
of the brain resembled some cases of syphilitic arteritis of slow progression.
Dr. Howden referred to a case of atrophy of the right hemisphere of the
cerebrum and left side of the cerebellum, with atrophy of left side of the body,
which he published in the “Journal of Anatomy and Physiology” for May,
1875. The case was that of a woman who died at the age of 34. She was
epileptic, weak-minded, and irritable; there was muscular atrophy and
contraction of the left side of the body. Occasionally after the fits she
became excited, but at other times showed no symptoms of insanity. The
right cerebral hemisphere and the right half of the pons were atrophied,
as also the anterior pyramid and restiform body of the medulla, while the
left cerebellar lobe, the sub-peduncular lobe, and the amygdala were atrophied on
the left side. There were two remarkable pear-shaped bodies, each 15 mm. in
their greatest diameter, depending from the anterior and inferior surface of the
corpus callosum. The right lateral ventricle was greatly distended with fluid, and
a gritty deposit, the size of a pea, was found in the substance of the corpus
callosum. The brain measurements were as follow :—
Cerberum.
Length of hemisphere .
Ditto of ant. lobe to fiss. of sylvius.
Ditto of post, lobe to ant. extremity of middle lobe
Right Left.
144 mm. 166 mm,
35 „ 53* „
112 „ 125 „
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£ J &&• y
Cebeeblluh. Bight. Left.
Transverse diam. from margin of medulla to outer edge of
hemisphere.45 mm. 87J mm.
MEDULLA.
Breadth of anterior pyramid. 5 „ 7 „
The brain is preserved in the Anatomical Museum of the Edinburgh University.
Dr. Rutherford Macphail read a paper on A Case of Insanity Associated
with Addison*s Disease (Original Articles, page 488).
The Chairman complimented Dr. Macphail on his very interesting paper,
which illustrated the importance of bearing in mind that asylum-physicians
should not lose sight of the importance of the careful study of general
diseases.
Dr. Campbell mentioned a case of Addison’s Disease occurring sixteen years
after what seemed to be hip-joint disease of two years’ standing.
Dr. Yellowlees said that the last clause of Dr. Macphail’s highly interest¬
ing paper was to his mind the most practical. The Addison’s Disease may have
been a mere coincidence. There is a tendency to associate coincident diseases as
cause and effect, while it should be borne in mind that the insane are liable, like
other people, to nearly all the diseases that afflict humanity.
Handbook for the Use of Attendants on the Insane. —The meeting then pro¬
ceeded to revise the proof of the 11 Handbook for the Use of Attendants on the
Insane,” prepared by the sub-committee appointed at the Quarterly Meeting of
the Association, held in Glasgow on 21st February last, which occupied the
remaining time at the disposal of the members.
Special Subjects for Discussion. —Dr. Howden suggested that when any
subject is specially brought up for discussion stylographic copies of the paper
introducing the subject should be circulated among the members with the
notices calling the meeting.
BRITISH MEDICAL ASSOCIATION, BELFAST, 1884.
(Discussion on Dr. D. H. Tuke’s Paper.*)
Dr, Norman Kerr said they must all welcome the extraordinary reduction
in the amount of intoxicating liquor consumed in asylums throughout the
kingdom. Dr. Lindsay, to whom Dr. Tuke had referred, had conducted a
very satisfactory experiment in the Derby County Asylum, extending now over
a year and a half, during which period no beer, no wine or spirits had been
given to the staff or to patients, except as a medicinal remedy. Dr. Lindsay
reported that neither he, nor the Committee of Management, nor the Visiting
Justices, had anything to regret in the change, and they had no desire to
return to the old regime. After deducting the liberal allowance to the
attendants and officers, instead of beer, and the extras to patients, there had
been a saving during the twelve months of £410. In the treatment of the
sick, the cost for alcohol had greatly decreased, while there had been an in¬
creased expenditure on milk, beef-tea, and eggs. The average cost for alcohol
had been reduced from 2d. per patient per week to £d. The health neither of
the well nor of the sick had suffered, the death-rate, in fact, having been
slightly less than during the period of freer alcoholic consumption. In
the West Biding Asylum, Dr. Major found no injurious result from the
withdrawal of alcohol. The meat allowance had been increased, and there
had been an extra supply of bread and cheese. Dr. Kerr thought the
data at present available did not warrant any positive conclusion as to
the lowering or raising of the mortality among the insane by the exclu¬
sion of intoxicating drink, though there was a reasonable presumption of
the former; but there could be no doubt that no bad effects would ensue.
This being so, it was very desirable to reduce to the lowest possible extent the
* See “ On Alcohol in Asylums, chiefly as a Beverage.” See Original Articles, p. 535.
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amount of alcohol, for several reasons. Many patients were improved in
health, while none suffered, and all became much more amenable to treatment.
There was thus increased comfort and happiness to the patients, which greatly
lightened the labour and anxieties of the attendants and officers; there was
also improved discipline, and very much more reliable service. On the whole,
it could be said with truth, that the marked diminution in the consumption of
intoxicants in asylums had been attended by most satisfactory benefits, a
diminution which Dr. Eerr trusted would go on till all such dangerous and
disturbing agents were practically banished from establishments for the care
and cure of the insane, except for strictly medical purposes.
Dr. Yellowlees (Glasgow) did not think beer at all necessary as a habitual
article of diet for the insane, and had never given it, but insisted strongly on a
very liberal dietary in all other respects. Private patients who have used stimu¬
lants all their lives, and deem it a comfort and a luxury, certainly ought not to
be deprived of their wine simply because they have become insane. He did
not deem it wise to give beer to the working patients only as a reward for work,
for thus the weakly patients, who need beer far more and yet cannot earn it, are
apt to be overlooked. Of course, as to the use and value of alcoholic stimulants
as medicines there is no question.
Dr. Bruce Ronaldson stated that he had withdrawn beer from all workers
as well as others at the Haddington Asylum, the result being most satisfactory.
Previously he had found a female patient in a state of intoxication, she having
contrived to get the allowance of other patients. Another consideration was,
that working patients who were thus supplied with beer during their asylum
residence, were not nearly as hard-worked as when they were at their usual
occupation, before admission and after discharge.
Dr. Rees Philipps (Virginia Water) said that he noticed that the Superinten¬
dent of one large County Asylum gave it, as his principal reason for discontinu¬
ing patients* beer rations, that the beer was always poured out before the patients
sat down to dinner; and being drunk before the meat was served, this, in some
cases directly injured the digestion. It would have been best, perhaps, to order
the beer to be served in a civilized manner, namely, with the meat, before
resorting to such a radical cure as cutting off the supply. But the dis¬
cussion would be of value if it led Asylum Superintendents to give a little more
attention to patients* food service. How seldom, even in asylums for the
middle-classes, was the meat really well-cooked; how often was a delicate
feeder disgusted by the sight of a plate loaded with food ; how rarely was any
serious attempt made to prevent patients from contracting vulgar table manners 1
And yet, by attention to these small matters, the patients’ comfort and recovery-
prospects were increased, while there was an actual saving in expenditure.
Dr. Lyle said that from the opening of Rubery Hill Asylum he had given no
beer as an article of ordinary diet, and patients submitted to the new system
without a grumble; at the same time, he increased the diet by giving an extra
amount of butcher’s meat, and a liberal supply of milk, tea or coffee ; many of
the patients had increased in weight, and were better physically. Where cases
have a strong tendency to take too much stimulant, the only chance of a per¬
manent cure is to cut off every kind of stimulant, so that the patient may lose
any taste he had acquired for alcohol.
Dr. Stewart (Clifton) had had experience of the use of beer of very different
alcoholic strength in two English County Asylums. One was the Dorset
Asylum, from which Dr. Tuke received such a pathetic appeal in reply to his
circular. In the other, the Barming Heath Asylum, the quality of beer was
much stronger than could be borne with impunity by any neurotic case, but
especially by such as could be traced to alcoholic excess. In the former of
these two, the beer contained such a small percentage of alcohol that it could
do no harm, even if it did no good. In a third asylum with which he was
connected (Belfast), not only alcohol, but also tobacco was excluded from the
dietary. In it the proportion of recoveries was rather above the average. The
disappointment experienced by the patient at not getting his accustomed pipe
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[Jan.,
was made up for by many other indulgences. We must not allow our judg¬
ment as to treatment to be influenced too much by the feelings of a few patients.
We have to ask ourselves the question, Will the cure of the disease be retarded
by the patient ceasing to mix alcohol with his food 1 He believed the experience
of the largest number of alienists would say that it would not.
Dr. Ruthebfobd said that, after lengthened and varied experience, he had
come to the conclusion that the indiscriminate use of beer as an article of diet
was unnecessary and injurious. Many years ago, when assistant physician at the
Birmingham Asylum, a change was made in the distribution of beer ; it was
stopped to epileptics and to many chronic patients. He could not help thinking
at the time that it was only a half measure, and that it would have been better
to have stopped it altogether and improved the dietary. As Superintendent of
the Argyll District and of the Barony Parochial Asylums, he did not use beer as
ordinary diet, and within the last year, at the Dumfries Royal Institution, he
had greatly modified the practice in regard to the distribution of stimulants by
entirely abolishing wine and beer as an article of diet and making it extra or
medical diet. At the same time, however, he improved the dietary by securing
the services of a first-class hotel cook. The change had, he thought, had a
beneficial effect on the patients, on the discipline of the staff, and on the whole
tone of the establishment.
Dr. Savage said he could not order persons to be abstinent and not abstain
himself; he did not think pleasures ought to be removed from insane patients
without replacing them ; he did not mind if the patients were sleepy after
dinner; he thought the danger greatest in the case of male attendants—the
women having little tendency to drink. Men who have become charge-atten¬
dants run risk from opportunity and lack of active work. Alcohol, whether in
the form of beer or wine, was good in some cases. He believed more, however,
in good diet, and would be glad to sacrifice the beer for really good dinners. He
believed also that the lads who came to their asylums would be much better
without any beer.
INTERNATIONAL HEALTH EXHIBITION, Aug. 2, 1884.
Among the lectures delivered under the auspices of this Exhibition, was one
of much interest by Dr. Shuttle worth, of the Royal Albert Asylum. A more
appropriate opportunity could not have been chosen for introducing the very
important subject of “The Health and Physical Development of Idiots as
Compared with Mentally Sound Children of the Same Age/’ After describing
certain well-known types of idiocy, he unhesitatingly asserts that the most fre¬
quent physical disorder amongst idiots is scrofula. Full 75 per cent, of the
deaths in the Royal Albert Asylum have been due to scrofulous or tubercular
diseases. As the object of the lectures at the Health Exhibition is to deduce
lessons regarding the prevention of disease, Dr. Shuttleworth seized the occasion
to insist upon the fact that scrofula is “ essentially a disease of darkness and
dirt,” and that light and cleanliness, temperance, and avoiding imprudent
marriages, are necessary conditions in the prevention of scrofula aud idiocy.
Referring to the large proportion of epileptics among idiots, there being at the
Darenth Schools 153 out of 496 patients, and at Earlswood one-fourth of the
inmates, Dr. Shuttleworth speaks of the inherited predisposition to nervous
instability, for the origin of which we must look back to the circumstances of
bygone generations. In England, unhappily, intemperance is too likely to
figure in a certain number of cases as an ancestral cause.
That idiot children are more liable to sickness than ordinary children is
amply proved ; the exact ratio in this respect between the two classes is difficult
to show by statistics, but the death-rate at institutions for idiots, compared
with that of the general population at the same ages, guides us to their com¬
parative vitality. Taking the figures in the reports of Earlswood and the Royal
Digitized by v^ooQle
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653
1885.]
Albert Asylum from 1879 to 1883, the following are the death-rates (calculated
upon an average number under treatment at these ages) of 775
Ages.
Deaths per 1,000 resident at each age.
Male.
Female.
Total.
From 5 to 10
52-9
44*6
50*1
From 10 to 15 .
31*6
38-8
33-9
From 15 to 20 .
460
43-2
45-1
From the Registrai>General'8 Reports the following is deduced as the
mortality in 1,000 persons living at certain ages from 1878 to 1882:—
Ages. Males. Females.
From 5 to 10 . 6*3 . 5*9
From 10 to 15 . 3*3 . 3*4
From 15 to 20 ... ... 4*6 ... ... 4*9
Contrasting these figures and those above given, we may say that the
approximate ratio between idiot and ordinary mortality at the various ages is as
follows:—
From 5 to 10, as 8 to 1 ;
From 10 to 15, as 10 to 1;
From 15 to 20, as 9 to 1;
the conclusion to be drawn from these limited data being that the death-rate of
idiots between the ages of 5 and 20 is at least nine times as great as that of
sound-minded children at the same period of life.
We have not space for two interesting tables showing the relative weight and
stature of the general population and of idiots and imbeciles, but of course the
comparison shows that the latter weigh less, and are shorter than the former.
Adult idiots are 23 lbs. below the average in weight, and their stature is 3
inches below the average.
Dr. Shuttleworth concludes his paper with enforcing the moral that, in con¬
sequence of the tendency to disease and death among idiots, a medical man
should be in charge of all institutions for their education and care. Further, that
their surroundings should be salubrious and spacious, that the buildings them¬
selves should be situated in accordance with hygienic principles, and that the
dietary should be liberal, and contain the heat-forming constituents of food in
abundance. Of course Dr. Shuttleworth does not omit the education of idiots
on physiological principles, but this aspect of the question was specially treated
of in a subsequent address.* The impression left on the auditors would no doubt
be as encouraging as the state of the case allows, for it is probable that many would
fail to catch the little but significant word, “ perhaps,” which precedes the
closing sentence, in which an observer of the education of idiots is represented,
in the words of Prospero, as seeing the cloud of idiocy lifting, and the rising
senses chasing away “ the fumes that mantle their clearer reason.” This lecture
will, we hope, be published in the “ Transactions of the Health Exhibition.”
* This, with a demonstration, was given in the Division of the Exhibition in connection
with the exhibit, by the Boyal Albert Asylum, of educational appliances and products, for
which we are glad to see that Institut ion was awarded a Diploma of Honour.
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Notes and Nem.
[Jan.,
THE BOYAL ALBERT AND EASTERN COUNTIES ASYLUMS.
As a fitting pendant to the foregoing, we would briefly refer to two institutions
the Royal Albert Asylum, Lancaster, and the Eastern Counties Asylum. The
annual meeting of the former was held in October last at Manchester, and refer¬
ence was made to proposed changes in the Lunacy Laws,as bearing upon Institu¬
tions for Idiots. The Committee of the Asylum will press upon the attention of
the Government the necessity for some alteration in the present law. It is held
that, in the interest of the education of imbeciles, modifications are needed. As
idiots, including imbeciles and feeble-minded, are comprised under “ Lunatics ”
in the Act 8 A 9 Vic., c. 100, children cannot be received into idiot asylums
without the certificates, Ac., required for lunatics. It is no doubt true that
this Act is a bar with many parents to sending their children to educational
institutions. We wish every success to this attempt to alter the present Lunacy
Act.
In reference to the Eastern Counties Asylum, Colchester, we regret that the
long and valued services of the superintendent, Mr. Millard, have now been
brought to a close in consequence of failing health. This gentleman’s un¬
wearied interest in the work, and the conscientious discharge of his duties for
so many years, are well known to our readers, and his name will always be
associated with the reforms in the condition of idiots and their education. We
rejoice to know that Mr. Millard will, as a member of the Board and House
Committee, be able to assist in the management of an institution, the future
progress of which he has so much at heart. The Directors have appointed Mr.
and Mrs. Williams, of Birmingham, to be Superintendent and Matron, while
Dr. W. G. Coombs has been appointed Resident Medical Attendant. Dr.
Coombs brings from Peokham House, where he was Assistant Medical Officer,
the highest testimonials to his character and fitness for his new post.
RETIREMENT OF DR. MAJOR FROM THE WEST RIDING ASYLUM.
With profound regref the medical profession must witness from time to time
the falling out from the ranks of those whose unselfish devotion to duty necessitates
a rest from the heat and the toil of the day. The resignation by Dr. Herbert C.
Major of the Directorship of the West Riding Asylum is another instance of
what so frequently occurs when unswerving integrity conjoined to thorough
conscientiousness leads to exertions which overleap themselves and compels
the spirit to recognize the laws of flesh. Dr. Major had no light task to
accomplish when he accepted the Directorship of an institution which had taken
so prominent a position amongst British Asylums. How Dr. Major has fulfilled
the task assigned to him, the warm and unanimous verdict of his fellow-workers
will sufficiently attest
Embued with that spirit which best characterises the progressive age in which
we live, and which alone can save our asylums from degenerating into huge work-
houses, Dr. Major has persistently endeavoured to organize a band of scientific
workers, and has by his individual efforts in varied histological research advanced
science pari passu with the fulfilment of the routine duties of administration,
although unfortunately at the sacrifice of bis health.
.Dr. Major has contributed several memoirs of great value to Neurological
Science. We sincerely hope that his retirement from office will leave him
leisure for further work in this ever-widening field.
We are glad to see that so excellent a choice of a successor to Dr. Major has
been made as that of Dr. Bevan Lewis. We sincerely hope that he may be able
to pursue, in no inconsiderable degree, his excellent scientific work, do his duty
to the patients, and retain his health and strength.
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1885.]
Notes and News .
655
Obituary .
M. DUMESNIL.
We record with regret the death of Dr. Dumesnil, for many years one of the
principal editors of the “ Annales Medico-Psychologiques/’ and devoted chiefly
to the department of the English literature of our subject.
Dr. Edouard J. B. Dumesnil was born at Constance on December 1,1812, and
was therefore just completing his 72nd year. After distinguishing himself at the
Lyc6e of his native city, he proceeded to Paris for his medical studies. He
passed with success the Concours for the position of “ Internet des Hospitaux,”
and remained a long time as an interne attached to the service of Orfila,
Lisfranc, Martin-Solon, &c., in which position he carried off several medals in
various Concours, and particularly one from the Society de Medicine of Bordeaux
in 1839. .. , ,
Having married, he gave up a career which seemed opening for him in Pans,
and sought a position in the provinces. The question of the Treatment of the
Insane in France was at this period just becoming mooted, and competent per¬
sons were required for the reorganization of the Asylums and other Establish¬
ments for the Insane. Dr. Dumesnil was selected as one eminently qualified to
fulfil the duties of reorganization, and in 1847 he was appointed Medical
Superintendent (Directeur Mfcdicin en Chef) of the Asylum of St. Dizier (Haute
Marne). Among those chosen on the same occasion were men whose names are
very familiar to the whole of our specialty, Foville (p&re), Parchappe, Ferrus,
Marcde, Morel, Renaudin, and others.
In 1852 he was removed to Dijon, in which appointment he had for assistant
(interne) Dr. Legrand-du-Saulle, with whom he maintained a close intimacy
and friendship ever after.
Lastly, in 1858 he was called upon to preside over the foundation of a new
asylum for the very important Department of Seine Inferieure, at Quatres Mares,
near Rouen, of which asylum he continued to be Medical Superintendent for the
following 14 years. In this post he was, unlike many holding the office of
physician to asylums in France, the administrator as well as Chief Medical
Officer of the establishment. He conducted the duties of his office with great
zeal and solicitude—taking equal interest in every department, being, in fact, at
the same time its physician, financier, architect, and agriculturist, &c. Every
detail, in fact, came immediately under his personal attention. The asylum at
Quatres Mares, besides resembling our English County Asylums in being devoted
to the poor, has besides a separate wing for private patients, and the manage¬
ment of this department added considerable complication to the general duties
of the establishment. ^ , A .
Having acquired a well-merited reputation in these various duties, profes¬
sional and social, he became entrusted with other official matters of civil char¬
acter which added considerably to his social position as well to his labours. He
was elected President of the Academy of Rouen, and appointed a Chevalier de
la Ldgion d’Honneur.
On his retirement from his office of Physician in Chief at Quatres Mares in
1872, he was made Inspecteur-G4n4ral of Asylums and Prisons. He continued
to occupy this office during eight years, when he was compelled to resign, having
attained, according to the rules of the French laws, the limit of age for public
employment. On his resignation of his official connection, he took up his resi¬
dence in Paris. He was promoted about this time to be Officier de la Legion
d’Honneur. He was also elected President of the Soci^td Medico-Psychologique,
and he took much interest in every question connected with lunacy. He con¬
tinued to be one of the principal collaborators of the “ Annales Psycho¬
logies ; ” the section of the review of the English journals and literature being
his chosen department, and he was occupied in this duty the day previous to his
Digitized by v^ooQle
656 Notes and News .
fatal attack. He had been ailing a few days only, when he was seized with
the symptoms of embolism.
Dr. fiamesnil was well acquainted with English, and took much interest in
English views on insanity. He visited the chief English Asylums in 1860, and
thus became known to many members of the Association. He was extremely
well read on all subjects. He was the author of several original articles. His
inaugural thesis on affections of the bladder has been often referred to. He
wrote also a memoir, entitled “ Sur les Alidnta Alcooliques.” He was one of
the authors of the official report of 1877 upon the state of asylums in France.
He was always courteous, kind, hospitable, and a warm-hearted friend.
W. H. 0. S.
Appointments .
Braine, G. M. P., M.R.C.S., L.R.C.P.Lond., appointed Second Assistant
Medical Officer to the Worcester County and City Asylum.
Coombs, W. Godwin., M.D., appointed Resident Medical Superintendent of
the Eastern Counties' Asylum for Idiots, Colchester.
Denning, C. Ernest, L.K.Q.C.P.L, L.R.C.S.I., appointed Senior Assistant
Medical Officer to the Salop and Montgomery County Asylum, Shrewsbury.
Dodds, W. J., M.D., D.Sc., appointed Assistant Medical Superintendent of
the Montrose Royal Asylum.
Douty, J. H., M.R.C.S., L.S.A.Lond., appointed Senior Assistant Medical
Officer, and Deputy Superintendent of the Worcester County and City Asylum.
Dunn, Thos., M.B., appointed Assistant Medical Officer of the Woodilee
Asylum, Lenzie.
Fielden, W. E., M.D.Lond., appointed Assistant Medical Officer of the
Asylum for Idiots, Earlswood, Redhill.
Hale, Chas. J., L.R.C.P., M.R.C S.Lond., appointed Junior Assistant Medical
Officer of the Salop and Montgomery County Asylum.
Hall, B., M.B.Lond., M.R.C.S., appointed Second Assistant Medical Officer
of the Middlesex County Asylum, Banstead.
Jelly, F. Adolphus, M.B., C.M.Ed., appointed Assistant Medical Officer of
the Wonford House Asylum, Exeter.
Lewis, W. Bevan, L.R.C.P., M.R.C.S., appointed Medical Superintendent of
the West Riding Asylum, Wakefield, vice Dr. Major, resigned.
Martin, Jas. P., M.R.C.S., appointed Junior Assistant Medical Officer Wilts
County Asylum, Devizes.
McWilliam, Alex., M.B., C.M.Aberd., appointed Senior Assistant Medical
Officer Somerset and Bath Asylum, Wells.
Murchison, Fin. Fin., M.B., M.A., appointed Medical Superintendent of
the Peckham House Asylum. Peckham, S.E.
Stewart, Rothsay C., M.R.C.S.,L.S.A., appointed Assistant Medical Officer
of the Peckham House Asylum, Peckham, S.E.
Suffern, A. C., M.D., M.Ch., appointed Assistant Medical Officer of the
Borough Asylum, Winson Green, Birmingham.
Taylor, A. Everley, L.R.C.P. and S.Ed., appointed Second Assistant
Medical Officer of the County Asylum, Stafiord.
Tomkins, Harding H., M.R.C.S., appointed Assistant Medical Officer
Gloucester County Asylum.
Tuke, J. Batty, appointed Deputy Medical Superintendent of the Saughton
Hall Institution.
Williams, P. Watson, L.R.C.P., appointed Clinical Assistant in the Bir-
mingham Borough Asylum.
Digitized by <^.ooQLe
INDEX TO YOL. XXX.
Acute mania exhibiting a quasi-aphasic speech affection, 84
„ „ treated by breaking stones, 615
Adam, Dr. James, on pathological research in asylums for insane, 359
Addison’s disease associated with insanity, 556
Agricultural colonies for insane, 149
Alcoholic beverages in asylums 336, 351, 535, 650
„ delirium, acute, 135
„ insanity, 135
Acoholism, chronic, exaltation in, 233, 331, 644, 645
“ After Oare,” extract from sermon of Rev. H. Hawkins, 164
„ „ association, anniversary meeting, 477
Alienism, the data of, 7, 369
American retrospect, 129, 303
Amusements for patients, evening, 306
Amyl Nitrite, hypodermic injection of, followed by epileptic convulsions, 252
Aneurisms of aorta in insane, 643
Annuity to an attendant for injury, 120
Aphasia with dementia, case of, 64
Aphasia quasi—in case of acute mania, 84
Apoplectiform cerebral congestion, 551
Appointments, 178, 336, 482, 656
Archives de neurologie, 152
Art, works of, illustrating postures indicative of state of mind, 30
Assault by a patient on a superintendent, 574
Asylum attendants, digest of essays on hallucination by, 78
i, „ difficulty of getting, 128
„ „ special training for, 160
„ „ views of Dr. Kirkbride on, 310
„ „ manual for, 312
i f „ training and instruction of, 352
„ „ female in male wards, 619
„ clinical instruction in, 121
„ dietetics, 349
„ Isle of Man, and Dr. Outterson Wood, 92
„ Ontario, 609
„ private, abolition of, 339
„ Quebec, 630
„ reports for a 1882,118, 295, 452
„ Toronto, 614
„ Trinidad, 141
„ unlicensed, prosecution for having, 101
Auditory hallucination, insanity from, 443
Axenfeld, Prof., Traits des Ndvroses. (Rev.), 115
Bain, Dr. Alexander, practical essays. (Rev.), 434
Beer in asylums, 336, 351, 535, 650
Behandlung der Psychosen mit Elektricitat, von Dr Tigges. (Rev.), 285
Blood of the insane, observations on, 378, 488
Body and will, by Dr. Maudsley. (Rev.), 280, 697
Brain disease, mental symptoms of, 74,156
Digitized by <^.ooQLe
658
INDEX,
British Medical Association) Belfast meeting, 475, 650
Bulletin de la Society de Medicine Mentale de Belgique. (Rev.), 153
Canada, the insane in, 609
“ Called back,” a novel. (Rev.), 428
Campbell, Dr., on escapes, liberty, happiness and “ unlocked doors ” as they
affect patients in asylums, 197
Causation of insanity, results of collective record, 1, 157
„ „ „ remarks of Dr. Clouston, 126
Causation of insanity, remarks of Dr. Rayner, 345
Cerebellar haemorrhage, case of, 253
Certification, evils of delaying, 341
11 Certificates of emergency,” 585 .
Chapman, Dr., value of recovery rates of different asylums as tests of efficiency,
210
Charcot’s, lectures on localisation of cerebral and spinal diseases. (Rev.), 287
Circular insanity, case of, 62 ^
Clark, Dr. Campbell, digest of essays on hallucinations by asylum attendants, 7o
Clinical instruction in asylum, 121
„ lectures on mental disease, by Dr. Clouston. (Rev.), Ill, 273
„ observations on the blood of the insane, 378, 488
„ Notes and Cases—
Acute mania exhibiting a quasi-aphasic speech affection, 84
„ „ in a boy of thirteen years, 251
Addison’s disease associated with insanity, 556
Apoplectiform cerebral congestion or serous apoplexy, 651
Cerebellar haemorrhage, 253
Circular insanity (folie circulaire), 62
' Congenital mental defect in twins, 262
Dementia with aphasia ; atrophy of left cerebral hemisphere, 64
Digests of essays on hallucination by asylum attendants, 78
Endothelial tumour of dura mater; general paralysis, 87
Four cases of melancholia in one family, 553
General paralysis with lateral sclerosis of spinal cord, 57
„ „ » pachymeningitis, 261
Hypodermic injection of nitrite of amyl, followed by epileptiform con¬
vulsions, 252
Insanity of seven years’ duration treated by electricity, 54
„ of twins suffering from melancholia, 67
„ after head injury, 393
Post-hemiplegic hemi-chorea associated with insanity, 256
Sexual perversion in a man, 390
Some mental symptoms of ordinary brain disease, 74
Supposed case of acute mania; death after a succession of epileptiform
attacks, 391
Unexpected recoveries, 247
Clouston, Dr., lectures on mental disease, 111, 273
„ „ remarks on causation of insanity, 126
Colonial retrospect, 137, 609
Compulsory feeding, 150
Congenital mental defect with delusions of suspicion in twins, 262
Consciousness, physical conditions of, by Prof. Herzen, 41,179
Constant watching of suicidal cases, 17,154
Correspondence—
Dr. Mercier on Dr. Cleland and Dr. Huggard, 170, 333
Dr. Huggard on Dr. Mercier, 171
Cortical centres for touch, sensibility and muscular sense, 439
CysticercuB in the brain, 145
Digitized by <^.ooQLe
INDEX.
659
Data of alienism, 7, 369
Deception in treating insane, avoidance of, 308
Delirium tremens, some relations of, to insanity, 531, 647
Dementia with aphasia, atrophy of brain, 64
Despine, Dr., “ Science du cceur humain,” &c. (Rev.), 292
Development of nerve fibres in gyri of brain, 437
Dietary in Canadian asylums, 620, 628
Digest of essays on hallucinations by attendants, 78
Dipsomania, 135, 233, 645
Diseases of brain and spinal cord, by Dr. D. Drummond. (Rev.), 108
Dramatic copyright, 270
Dumesnil, M., obituary, 655
Ear symptoms in the diagnosis of nervous disease, 133
„ sound in, causing melancholia, 147
Electricity, insanity of seven years’ duration treated by, 54
„ medical, by Dr. de Watteville. (Rev.), 117
„ in the treatment of insanity, 354
„ „ mental disease, 483
Elektricitat, Behandlung der Psychosen mit. (Rev.), 285
Employment of patients, importance of, 304, 615
Endothelial tumour of dura mater ; general paralysis, 87
Epilepsy, researches on. (Rev.), 443
Epileptics in the Rhine provinces, 149
„ supervision of, at night, 122
Escapes, liberty, happiness and unlocked doors, as they affect patients in
asylums, 197
Exaltation in chronic alcoholism, 233, 645
Fattening up as a method of curing insanity, 127
Fatty granules and cells, 440
Fire, means of extinguishing, 38
„ at Haydock Lodge, Ashton, 165
„ suggestions as to precautions against, 582
Folie circulaire, 62
Forcible feeding of lunatics, 120, 150
Foreign lunatics, repatriation of, 478
Fox, Dr/B. B., exaltation in chronic alcoholism, 233, 331 644, 645
Gasquet, Dr., some mental symptoms of ordinary brain disease, 74, 155
Galton, Francis, Mr., record of family faculties. (Rev.), 115
General paralysis, with lateral sclerosis of spinal cord, 57
„ „ endothelial tumour of dura mater, 87
„ „ in an imbecile, 151
„ „ recovery? 151
„ „ views of MM. Ball and R5gis on, 152
„ „ with pachymeningitis, 261
„ „ disturbance of vision in, 448
„ „ tendon reflex and tache meningitique in, 450
German retrospect, 144, 437
“ Gesetze des periodischen Irreseins und Verwandter Nervenzustande,” von Dr.
Koster. (Rev.), 113
Green, Mr., prolegomena^and ethics. (Rev.), 280, 597
Hallucinations in an old blind man twice operated on for cataract, 151
„ essays on by attendants, 78
Handbuch der Gerichtlichen medicin, etc. (Rev.), 294
Hawkins, Rev. H., sermon on “ after care,” 164
Hearts, specimens of diseased, 642
Digitized by boogie
660
INDEX.
Heredity, 152.
Herzen, Prof., physical conditions of consciousness, 41,179
Hewson, Dr. J. D., death of, 166
Histogenesis of the human brain, 438
Homicidal impulse, 162
Homicide and intemperance, 122
„ by a mother, 451
Howden, Dr. J. C., precautions against fire in asylums, 38
Hutchinson’s pedigree of disease. (Rev.), 288, 419
HyoBcyamine in insanity, 149
Hypertrophy of calvarium covering an atrophied hemisphere, 649
„ and sclerosis of brain in idiots, 144
Hypnotism in hysteria, 152
Idiots, health and physical development of, compared with sound children, 652
„ hypertrophy and sclerosis of brain in, 144
Imbecile, general paralysis in an, 151
„ lunatics better in their own parishes, 347
Index medico-psychologicus, 171, 479
Inquiry into value of recovery rates at different asylums as tests of efficiency, 210
Insane, can they be treated in private dwellings ? 588
„ in Ontario, 609
„ mother kills her five children, 451
Insanity, causation of, 1 ,
„ of seven years’ duration treated by electricity, 64
„ circular (folie circulaire), 62
„ of twins, with melancholia, 67
„ its classification, diagnosis and treatment. (Rev.), lw
„ considered in its medico-legal relations, 109
„ moral, or hysterical, 131
,, after head injury, 393
„ following exposure to a high temperature, 441
„ from auditory hallucinations, 443
„ treatment of, 348
„ increase of, 345, 347
„ and uterine disease, 609
„ some relations of delirium tremens to, 531
„ with Addison’s disease, 556
Intetnational Health Exhibition, 652
Ireland, Dr., German retrospect, 144, 437
Isle of Man asylum and Dr. Outterson Wood, 92
Kerr, Dr., on reduction of alcohol in asylums, 650
Kirkbride, Dr. Thomas S., memoir of, 167, 304
Law of sex, by Mr. G. Starkweather. (Rev.), 424
Lecons sur les maladies mentales. (Rev.), 116
Lectures on mental disease, by Dr. Sankey. (Rev.), 604
Lewis, Dr. W. Bevan, post-hemiplegic hemi-chorea associated with insanity,
(illustrated), 256
Localisation of cerebral and spinal diseases, by Prof. Charcot, 287
Lunaoy Laws, 394
Macphail, Dr. S. R., clinical observations on the blood of the insane, 878, 488
„ case of Addison’s disease associated with insanity, 556
Maior, Dr, H. C., results of the collective record of the causation of insanity,
1,157
, retirement from West Riding Asylum, 654
Digitized by
Google
INDEX.
661
Mania, acute, exhibiting a quasi-aphasic speech affection, 84
„ „ in a boy of thirteen years, 251
„ „ death after a succession of epileptiform attacks, 891
„ „ treated by breaking stones, 615
Manual of psychological medicine and allied nervous diseases, by Dr. E. C.
Mann, (Rev.), 109
Maudsley, Dr. H., body and will. (Rev.), 280,597
MacDowall, Dr. T. W., translated by, the physical conditions of consciousness,
by Dr. Herzen, 41, 179
„ „ endothelial tumour of dura mater in general paralysis,
(illustrated), 87
„ it French retrospect, 150
„ „ congenital mental defect with delusions of suspicion in
twins, (illustrated), 262
Medical journalism, 163
Medico-psychological Association—
Quarterly meeting on Feb. 5th, 1884, at Bethlem Hospital, 153
„ „ „ Nov. 16th, 1883, at Royal College of . Physicians,
Edinburgh, 160
„ „ „ May 6th, 1884, at Bethlem Hospital, 327
Annual general meeting, July 23rd, 1884, at Royal College of Fhysioians,
London, 460
Presidential address, 337
Quarterly meeting at Bethlem Hospital on 5th Nov., 1884, 642
„ „ on Nov, 2l8t, 1884, in Perth, 648
Melancholia, case of twins suffering from, 67
„ four cases in one family, 553
„ induced by a sound in the ear, 147
Mental disease, clinical lectures on. (Rev.), Ill
„ symptoms of ordinary brain-disease, 74,155
Mercier, Dr. C., the data of alienism, 7, 369
Mickle, Dr. A. F., insanity of twins—twins suffering from melancholia, 67
„ Dr. W. J., rectal feeding and medication, 20
„ „ pathological specimens of hearts and brains, 642
Mitchell, Dr. R. B., case of acute mania, exhibiting a quasi-aphasic speech
affection, 84
Moli&re’s works psychologically studied, 292
Moral insanity, 131
Murder during homicidal impulse, 162
Needham, Dr. F., colonial retrospect, 187
Newington, Dr. H. H.J unverified prognosis, 223, 828
Newth, Dr. A. H., the valtie of electricity in the treatment of insanity, 354
Obituary notices—
Dumesnil, M., 655 Hewson, Dr. J. D., 166
Kirkbride, Dr. T. S., 167, 803 Parsey, Dr. W. H., 166
Ontario, insane in, 609
“ Open-door ” system, 197, 296, 300, 302
Original articles—
Clinical observations on the blood of the insane, 878, 488
Constant watching of suicidal cases, 17
Exaltation in chronic alcoholism, 233
Inquiry into the value of the recovery rates of different asylums as tests of
efficiency, 210
On alcohol in asylums chiefly as a beverage, 535
On escapes, liberty, happiness and “ unlocked doors,” as they affect patients
in asylums, 197
Digitized by
Google
662
INDEX.
Original Articles— , . ,, .
On pathological research in asylums for the insane, 359
Physical conditions of consciousness, 41, 179
Precautions against fire in lunatic asylums, 38
Practical remarks on the use of electricity m mental disease, 483
Presidential address, 337
KOTiMtroDthewLultiof lb* collective record of the ceuaatko of ioeamty, 1
Sjsj y;a" „ a**. ■.
works of art, 30
The data of alienism, 7, 369
Unverified prognosis, 223
Uterine disease and insanity, 509
Value of electricity in the treatment of insanity, 854
Outline of psychology, with special reference to the theory of education. By
James Tully, M.A. (Rev.), 415
Ovaries, removal of, for hysterical mania, 133
Over-crowding asylums, 119, 295
Over-pressure in schools, 561
Pachymeningitis, case of, 261
Packer, Dr. W. H., case of circular insanity, 62
Paralysis, general, see general paralysis
Paralysie, generate, theorie de la, par le Dr. Baillarger. (Rev.), 428
Parsey, Dr. W. H., death of, 166
Pathological research in asylums for insane, 359
Pedigree of disease. By Jonathan Hutchinson, F.R.S. (Rev.), .288,419
Pennsylvania hospital for insane, 303
Periodicity in insanity, 113
Pharmacopoeia of unofficial drugs, etc. (Rev.), 112
Physical condition of consciousness, 41,179
Post-hemiplegic, hemi-chorea with insanity, 256
Postures indicative of mind, as illustrated in works of art, 30
Practical essays, by Alexander Bain, LL.D., 434
Precautions against fire in lunatic asylums, 38, 582
Predisposition to insanity, 126
Presidential address, by Dr. Rayner, 337, 466
Private dwellings, insane in, 588
Probation, discharge of patients’on, 124
Progressive hemiatrophy of the body, 446
Prolegomena and ethics, 280, 597
Prussia, census of insane in, 148
Quasi-aphasic speech affection’in acute mania, 84
Quebec, province of, lunatic asylum in, 630
Rabies canine, lesions in, 441
Rannie, Dr. A., case of dementia with aphasia; atrophy (sclerosis 7) of left
cerebral hemisphere (illustrated), 64
Rapport sur les projets de reforme relatifs h la legislation sur les alienes, etc.
(Rev.), 153
Rayner, Dr., presidential address, July 23rd, 1884, 337
„ „ case of insanity after head injury, 393
Reception house for the insane, Darlinghurst, 140
Recoveries, unexpected, 247
Recovery rates of different asylums as tests of efficiency, 210
Record of family faculties (Galton’s). (Rev.) 115
Digitized by boogie
INDEX.
663
Rectal feeding and medication, 20
„ medication, 27 ,
Recurring degenerations from lesions to the cortical motor centres and motor
columns of cord, 440
Reg. v. Strong, 101
Relations of mind and brain, by H. Calderwood. (Rev.}, 114: .
• „ between speech-disturbance and the tendon reflex in paretic de¬
mentia, 134 .
Remarks on the results of the collective record of the causation of insanity, 1
Repatriation of foreign lunatics, 478
Report (38th) of the Commissioners in Lunacy, 1884, 575
n f9 tJ „ for Scotland, 585
” „ Inspectors of Irish Asylums, 592
Restraint, disuse of, 616
„ Dr. Kirkbride’s views on, 309
„ use of, 633,639 , J x . A , A ,
Robertson, Dr. Alex., case of insanity of seven years duration: treatment by
electricity, 54
Royal Albert and Eastern Counties Asylums, 654
Sankey, Dr. W. H. O., lectures on mental disease. (Rev.), 604
Savage, Dr. G. H., constant watching of suicidal cases, 17, 154
f> ff on cases of general paralysis, with lateral sclerosis of spinal
cord, 57
t9 w case of general paralysis with pachymeningitis, 261
case of sexual perversion in a man, 390
f> M some relations of delirium tremens to insanity, 531,647
v specimen of diseased heart, 643
Science du cceur humain ou la psychologie des passions d’apres les oeuvres de
Moli&re. (Rev.), 292
Sclerosis of the spinal cord with general paralysis, 57
Scott, Gilbert, case of, 266
Sexual perversion in a man, 390 ,
Shaw, Dr. J., case of cerebellar haemorrhage; abnormalities of cerebral arteries, 253
Shuttle worth, Dr., the health and physical development of idiots as compared
with mentally sound children of the same age, 662
Spitzka, Dr., on insanity. (Rev.), 103
Strahan, Dr. S. A. K., cases contributed by, 251
Strong, W., charged with receiving lunatics into his house without license, 101
Studies of postures indicative of condition of mind as illustrated in works of
art, 30
Stuttering and stammering, 447
Suicidal cases, constant watching of, 17, 154
Sully, Dr., outline of psychology, with special reference to education, 415
Supporting tissue of the central nervous system, 437
Tendon reflex and tache meningitique in general paralysis, 450
Toronto, asylums in, 614
Treatment of insanity, progress in, 348
Traits des ndvroses. (Rev.), 115
Tuke, Dr. D. Hack, American retrospect, 129, 303
t9 „ the insane in Canada, 609
99 9f on alcohol in asylums chiefly as a beverage, 535
Tumour, endothelial, of dura mater, 87
Twins, insanity of, 67
„ congenital mental defect with delusions of suspicion, 262
Unexpected recoveries, 247
Digitized by {jOoq le
664
INDEX,
e
Unlicensed asylum, prosecution for, 101 if 4
Unlocked doors, 197 _ 1
Unverified prognosis, 228, 828
Uterine disease and insanity, 609
Vision in general paralysis, disturbances of, 448
Warner, Dr. F., studies of postures indicative of the condition of mind, as
illustrated in works of art (with woodcuts), 80
Watteville, Dr. A. de, practical remarks on the use of eleotrioity in mental dis¬
ease, 483
Weldon v. Semple, 411
„ v. Winslow, 672
Wiglesworth, Dr. J., uterine disease and insanity, 609
„ „ clinical cases, 651
Wilbur, Dr., tribute to memory of, 134
Willett, Dr., unexpected recoveries, 247
Wood, Dr. O., and the Isle of Man asylum, 92
,, Dr. W. E. B., supposed case of acute mania terminating in death after a
succession of epileptiform attacks, 391
Workhouses not suitable places for insane, 125
ILLUSTRATIONS.
Woodcuts illustrating Dr. Warner’s paper, 30—
Venus de Medici, 31
Nervous hand, 32
Festival in honour of Bacchus, 32
Diana, 33
Energetio hand, 34
Cain, 34
Hand in fright, 35
Dying gladiator, 35
Hercules at rest, 36
Lithographic plate of brain, illustrating Dr. Rannie’s case, 64
Lithographic plate of brain and microscopical section of brain, to illustrate
Dr. McDowall’s case, 87
Woodcuts of upper surface of brain and pre-frontal section, to illustrate Dr.
Be van Lewis’s case, 256
Coloured lithograph, to illustrate Dr. Savage’s case, 261 £
Lithographic plate, to illustrate Dr. McDowall’s case, 262 '
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