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I
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THE JOURNAL
OF
MENTAL SCIENCE
(Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland ).
EDITED BT
D. HACK TUKE, M.D.,
GEO. H. SAVAGE, M.D.
“ No* vero intellectual longius a rebus non abet rah imas qu&m ut rerum imagines et
radii <ut in sensu fit) coire poeaint.”
Francis Bacon, Proltg. hutaurat. Mag,
VOL. XXXIII.
LONDON:
J. ahd A. CHURCHILL,
NEW BURLINGTON STREET.
MDCCCLXXXTIU.
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“ 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 pathdlogy, 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.”—*/. C. BuchniU , M.I)., F.It.S.
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THE JOURNAL OF MENTAL SCIENCE.
[Published by Authority of the Medico-Psychological Association]
No. 141. HB ^ 0 ?!ok IBS ’ APRIL, 1887. Vol. XXXIII.
PART 1.—ORIGINAL ARTICLES.
On the Treatment of the Insane sixty years ago as illustrated
by the Earlier Records of the Dundee Royal Asylum . By
James Rorie, M.D., Physician and Superintendent of
the Dundee Royal Asylum.
Having been invited by our indefatigable Secretary to
give a contribution to the present meeting, and having been
recently engaged in looking over the earlier records of the
Old Asylum of Dundee, it occurred to me that a few remarks
on the early history of this institution and the means then in
use in the treatment of the patients might not prove unin¬
teresting, as the Asylum was erected at a very important period
in the history of psychological medicine, namely, that period
when it had dawned on the public mind that harshness and
chains were not the proper remedies for the insane, but that
much might be done in the treatment of this affliction by kind¬
ness, gentleness, and especially by healthy occupation. The
circumstances, then, which led to the erection of the Dundee
Asylum, as described in a report published in 1815, were as
follows:—
Dundee, which, as to population, ranks the third in Scot¬
land, had no public institution for furnishing medical and
surgical aid to the poor till 1782, when two gentlemen, a
clergyman and a surgeon, commenced a subscription for the
establishment of a dispensary. Their laudable zeal was liberally
supported by an annual contribution and by the gratuitous
assistance of the medical gentlemen in town, who, having
divided the town into districts, not only prescribed to such as
called upon them, but visited the poor at their own houses.
The good effects of this infant dispensary was very sensibly
felt by the poor; but it was limited in its means, and the want
of a house for the reception of patients greatly diminished its
usefulness. Under these circumstances the contributors re¬
solved to make an effort to procure the means for building an
aV,.-
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2 On the Treatment of the Insane Sixty Years Ago , [April,
infirmary. It was in attending to the affairs of the infirmary
that the managing committee had to witness several cases of
mental derangement, and to regret that the institution did not
enable them to afford any relief to the unhappy persons. The
subject was not only impressed upon the attention of the infir¬
mary directors, but also excited much interest in other parts of
the country, with the result that a liberal support was given to
the movement by public bodies and inhabitants both in town
and country. A committee of contributors being appointed,
about three and a quarter acres of ground were purchased about
half a mile north of the town in an elevated situation, sloping
to the south, with a dry soil and the air free and unconfined.
As the plan then furnished “ had the unqualified approba¬
tion of the best judges,” the following outline, as representing
the views then entertained on this subject, may not be unin¬
teresting. This plan possessed in a high degree the following
advantages :—It admits of a very minute classification of
S atients according to their different ranks, characters, and
egrees of disease. It secures to every room the freest ventila¬
tion, and provides for the diffusion of heat through the building.
Under one general management it separates the different
classes of inhabitants from one another as completely as if they
lived at the greatest distance; and it enables that system to be
executed which every asylum ought especially to keep in view,
that of great gentleness and considerable liberty and comfort,
combined with the fullest security. The plan which I now
show you, and which is one of the original plans, exhibits a
building, consisting of a central building and four wings—the
letter H plan. At each end of the building was a room for the
superintendents, having on one side a day-room for the patients
which communicated with the adjoining wings and with the
airing-grounds, of which there were two at each end of the
building. At each of the eastern and western extremities of
the airing-courts the plans showed wards for ten patients, with
attendant’s room and two day-rooms, and two airing-courts, all
separately enclosed, but communicating with the main house
by a covered passage. This portion was intended for violent
and epileptic patients, but was never erected. It is of interest,
however, as indicating the separate block system with com¬
municating covered ways, but in a somewhat rudimentary stage
of development. The front court was occupied by the entry to
the house, and on each side by a walk and shrubbery. The
back court, embracing kitchen and laundry, were laid out in a
similar manner. Such were the general arrangements of the
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1887.] by James Robie, M.D. 8
building, whose foundation stone was laid in 1812. This cere¬
mony attracted much attention at the time, the whole town
being en fete. The stone was laid by the Right Hon. Lord
Viscount Duncan, and with usual Masonic honours and accom¬
paniments. The object of the institution, as inscribed on the
parchment roll, was “ to restore the use of reason, to alleviate
suffering, and lessen peril where reason cannot be restored.”
Next in importance to the stone and lime arrangements of a
charitable and public institution is the constitution of its direc¬
torate, which, in the present instance, was as follows :—Under
a Royal Charter in 1819, all contributors over certain sums to
the infirmary or asylum funds were incorporated into one body,
“ the Dundee Infirmary and Asylum,” but providing that this
corporation should consist of two separate establishments, with
distinct and separate estates and funds, the Infirmary and the
Asylum; and in order to secure a thoroughly public and repre¬
sentative direction of the affairs of the asylum, the following
directorate was established:—The Lord Lieutenant of the
County, the representative in Parliament for the county, the
Sheriff Depute of the county, the representative in Parliament
of the burgh, the Moderator of the Synod of Angus and
Mearns, five life directors appointed by the contributors, the
Provost Eldest Bailie and Dean of Guild for the time being,
three persons chosen by the nine incorporated trades, one by
the three united trades, four by the Guildry, one by the
fraternity of seamen, one by the chairmen of contributing
lodges or societies, two by the Kirk Session, two by the Presby¬
tery of Dud dee, four by the freeholders and commissioners of
supply, and eight by the governors of the infirmary. It would
have been difficult to have selected a more judicious and repre¬
sentative directorate, and the harmony which has always pre¬
vailed in the administration of the affairs of the institution is
the best proof of the sagacity and wisdom then displayed in
their choice.
Accustomed to hear so much of the great improvements
which have of late years been effected in the amelioration and
treatment of the insane, one turns with a feeling of something
more than ordinary curiosity to the earlier reports of such
venerable institutions as the Scotch Chartered Asylums to
ascertain the views then entertained as to the nature of insanity
and its means of cure; but it is to be feared few nowadays
realize the advance that had then been made. The earlier
reports of the Dundee Asylum are full of interest in this re¬
spect, showing, as they do, that at the date of erection and
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4 On the Treatment of the Insane Sixty Years Ago , [April,
opening of the institution for the admission of patients in 1820,
the idea that the insane belonged only to the dangerous classes
of society, and required nothing but safe custody for the benefit
and safety of the public, had already given way to more
humane, benevolent, and enlightened views. The fact that
insanity was after all a disease, and capable of medical treat¬
ment like other diseases, was now admitted, and the great
benefit of kindness, gentleness, and careful attention fully
recognized; but few will be prepared to hear of the extent to
which amusements, occupation, and recreation were regarded
already as indispensable to the successful treatment of the
insane. Nevertheless, in the first report of the asylum, pub¬
lished 1st April, 1820, we find this subject treated of as
follows :— u The means of cure, though resting mainly on the
moral regimen and general management of the house, have a
constant reference to the medical art, as the functions of mind
are immediately dependent on bodily organization, and insanity
is thus often found intimately connected with, or the obvious
result of> disease in the general system, which at all times
sympathizes deeply with mental distress. Hence the applica¬
tion of medicine has been of decided and effectual service in
many instances in the experience of this institution.” But not
only the value of medicinal, but also the importance of the
moral agents was fully recognized. Thus we find the enclosing
of the ground referred to not only as of consequence in respect
to economy, but also “to the enlarged field of amusement
which this would open up to many of the patients. Manual
labour and innocent amusements form an agreeable recreation
to those in a certain state of convalescence, and by abstracting
the mind from the subject of erroneous thought, and improving
the general health, have been always found a powerful means
of remedy, while they add so much to the comfort and enjoy¬
ment necessarily abridged by this sad calamity. Many of the
patients fill up a tedious hour by reading on various subjects,
books, newspapers, &c.” The views held in regard to such
matters as the use of restraint would also seem to have made
considerable advance, for although at this date regarded as abso¬
lutely necessary, mechanical restraint was employed with much
caution and reserve. Thus it is said—“ In cases of violence,
restraint is necessarily had recourse to; but this is done as
seldom and with as little severity as possible; and when the
paroxysm that has rendered restraint necessary subsides, it is
immediately withdrawn. Indeed, restraint even in cases of
violent paroxysm is often superseded by those personal atten-
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1887.]
5
by James Kobie, M.D.
tions on the part of the keepers, who, with a quick discernment
—the fruit of experience—can often anticipate outrage, and
counteract its force, before it is thoroughly evolved. Certain
discipline, indeed, without harshness, is, in general, sufficient
to overawe the more violent; and habit confirms the fortunate
association which produces tranquillity, and this, aided by the
powers of nature and other subsidiary means, often leads to a
happy issue.” No regular attending physician would appear
to have been at first appointed, the only officers being a trea¬
surer, secretary, lay superintendent, and his wife acting as
matron. In the second report, however, we have the visiting
physician recognized as one of the regular officers of the
institution.
In this second year’s report for 1821 we have evidence of
the recognition of the importance of the removal of the patient
from old habits and associations, and especially the advantages
presented by a public asylum for the treatment of the poor, and
those of limited means and unable to pay for special attend¬
ance.
“ One of the first steps,” writes the reporter for the year
ending May 31st, 1822, “ towards the successful treatment of
the insane was the establishment of Lunatic Asylums. In few
private familes can a course of judicious treatment ever be suc¬
cessfully followed out. Many conveniences must always be
wanting in them, which are to be found in every well regulated
public establishment, while change of scene, and of those asso¬
ciations by which alienation of mind is often aggravated and
confirmed, besides other things of very powerful influence on
the health, comfort, and recovery of insane persons—all unite in
recommending the removal of persons labouring under insanity
from home, and a temporary separation of them from their
relations. The time is happily gone by when it was thought
enough to prevent the patient from doing violence to himself
or to those around him. To security are added comfort and
the means of cure. No longer condemned to drag out a miserable
existence in filth and wretchedness, in solitude and nakedness,
perhaps in darkness and in chains, the spirit of the times respects
the feelings of the unhappy sufferer, fans the latent spark of
reason in his mind, soothes him under his strongest excitements,
and by means the most gentle and humane, either restores him
to himself and to the world, or at least renders his situation
infinitely more comfortable than was formerly attempted or
even contemplated.”
“ If these observations,” continues this reporter, “ will apply
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6 On the Treatment of the Insane Sixty Years Ago , [April,
to the treatment of the more affluent, they are still more applic¬
able to that of the insane poor. The rich may contrive to sur¬
round their suffering relatives with many sources of comfort,
and to provide for them the means of recovery in private,
although seldom, if ever, with that success which attends an
institution conducted by those who are familiar with the appli¬
cation of the proper means of soothing and restoring the insane.
But the poor have no resources: their friends have not the
means of providing for them what is necessary for their security
and still less for their recovery. An attempt to do so, indeed,
continued for any length of time, is often fatal to the very
object they have in view, as it confirms the false impressions
indulged by the patient, and renders recovery more precarious.
Nor will asylums conducted for private advantage, however
skilfully and successfully managed, meet the exigencies of the
poor. To the poor an institution conducted on public principles,
and with a view eminently to the accommodation of a class of
persons whose circumstances, and those of their friends, render
the lowest possible terms of board indispensably necessary, is
the only refuge. Such an institution is the Dundee Lunatic
Asylum/’
These views, so well expressed, may well commend them¬
selves to the careful consideration of practical philanthropists
of the present day. That the humane treatment was now
thoroughly understood is also seen from the medical report of
this year, 1821-22. After remarking that “ it is almost need¬
less to repeat what is so obvious and so well confirmed by
universal experience, that the numbers of cures, other circum¬
stances being equal, holds a direct ratio to the recency of the
attack,” an axiom which has been well quoted since, the report
goes on to say “ that severity and corporal punishment are
here unknown, and it is surely very satisfactory to announce
that not a single patient has yet been confined during the day
to restrain fury or prevent mischief above an hour or two, and
that very rarely during the past 12 months.” And as showing
how close we are here to a very different state of things, it is
added : “ Several who had known only chains and solitary con¬
finement for many years experienced immunity from all re¬
straints,” and one case illustrative of this is given of an elderly
man who had been confined for 15 years in the prison of one of
the northern counties (being a criminal maniac), and whom, to
use the language of the report, “ continued violence and furious
outrage had condemned to perpetual chains, but who, in
a very short time, recovered the use of his senses in a very con-
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1887.]
by James Rorie, M.D.
7
siderable degree, and was enabled to join in the amusements and
recreations that belong only to those advanced in convalescence,
or of a milder class.” In this report a strange intimation is
made, namely, that “ the whirling chair has only once been
employed, but without decided benefit. Further trials war¬
ranted by the experience of other institutions are yet awanting
here to determine its value.” This is the only notice of this
curious instrument which I have found in connection with the
Dundee Asylum, and, indeed, we rarely find it referred to even
in the literature of that age, far less at any subsequent time,
and the only description of one I have been able to discover is
that of Sir Alexander Morison in his book of cases published
in 1828. Its action is thus described: "The excitement of
certain emotions or passions is sometimes of use in mental treat¬
ment, in particular the agreeable emotions of hope and of
religious consolation, and the disagreeable ones of shame and
fear. To excite the latter, in a moderate degree, certain
mechanical means have been employed, as the rotatory
machine and the douche of cold water.” These whirling
chairs would seem, therefore, to have belonged to the same
category as the bath of surprise, an arrangement whereby a
patient walking along a corridor suddenly found the floor give
way and himself tilted into a cold bath. They would seem to
have been variously constructed. In some by mechanical
arrangements the top of a low table, on which a chair could
be placed or where the patient could be laid on his back, was
made to revolve with greater or less speed. In others, as in the
one described by Sir A. Morison, an ordinary arm-chair is made
to turn by ropes and pulleys moved by a small wheel. The
chair, with straps to secure the patient, was then suspended
from a cross-beam, and by lowering or raising the different
ropes the patient could be placed at any inclination or position
desired. The only effect that I ever heard to result from whirl¬
ing chairs was in some cases to produce severe diarrhoea. The
following account, extracted from the Report of 1824, gives a
very good idea of the extent to which occupation and amuse¬
ment were employed and valued as curative agents:—“ Seventy-
four patients,” says the reporter, “ still remain in the house,
and though no general description can apply to cases that must
be almost infinitely diversified, yet, at this moment, it can be
stated that none of the patients are confined to their apart¬
ments, that in fine weather they are generally found in the
airing-grounds ” (indeed, it was a standing order about this date
that the doors leading into the airing-courts should stand open
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8 On the Treatment of the Insane Sixty Years Ago , [April,
from morning to night, so that the patients might go in and out
when they liked), “ pursuing those avocations or amusements
to which they are directed by their former habits or tastes. Some
are engaged in reading, some in playing on musical instru¬
ments, some in drawing; some are employed in manual labour
in the garden—here a party is seen at cards, there a couple are
intent at backgammon. Some females are sewing, some knit¬
ting or spinning, some voluntarily engaged in the work of
the house, while it must be added, with regret, that there are
others from whom the eye of the keeper must not wander.”
Indeed, from this time constant attention seems to have been
given to the occupation and employment of the patients, although
it was not till several years afterwards, 1837, that the develop¬
ment reached its fullest extent. By this time weaving and
other workshops had been erected aDd fitted up, and yards for
stone-breaking, &c., specially set apart for industrious patients,
and the general result is thus referred to by the Directors
in their Keport :—“ The spade, the hammer, the hoe, the
loom, the spinning-wheel, the needle, have been found most
efficient expedients for dispelling the gloom of the melancholy,
and of diffusing serenity and contentment throughout the
different departments of the establishment.” “ The cheerful¬
ness and alacrity with which the patients engage in their labours
is a proof of their anxiety to obtain relief from the burden of
inactivity. The pleasure with which they regard the fruits of
their labours, and the attachment they gradually form to their
various kinds of occupation, prove the value of manual labour
to be a remedial measure of the greatest importance.” As great
misunderstanding now exists in the minds of many as to the ex¬
tent to which the patients were then employed, it may not be out
of place to give the following facts :—In 1835 the daily average
of pauper patients resident in the Dundee Asylum was 96, and
of these 92 were constantly employed, principally as follows :
14 men and 6 women were engaged teazing hemp and oakum;
10 men and 2 women weaving sheeting; 14 men gardening;
14 women spinning, and the rest were occupied in shoemaking,
tailoring, mat-making, cutting firewood, mangling, pumping
water, shoebinding, dressmaking, shirtmaking, knitting, quilt¬
ing, upholstery, staymaking, flowering, fringe-making, re¬
pairing clothes, and assisting in laundry, scullery, kitchen, and
general housework, the annual outcome presenting such results
of work done as 642 webs of sheeting and 23 of bagging
woven, 400 spindles of hemp spun, 211 cubic yards of metal
broken, &c. About the same period 100 out of 130 patients
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1887.]
by James Rorie, M.D.
9
are referred to as attending chapel. Now I think it must be
frankly admitted that these are not the ideas we are apt to
form of the state of the Scotch asylums during what are now
regarded as the dark ages of these institutions, that is before
the abolition of restraint.
Now let us look for a little at the position of the officers,
and especially the medical staff. At first, when the asylum
was opened in 1820, no regular physician would seem to have
been appointed, the only officers being a treasurer, secretary,
superintendent, and matron ; but in the report published in
1822 we find Dr. Ramsay occupied the position of visiting
physician, and continued so till his death in 1835. The resident
officers were a lay superintendent, with his wife acting as matron,
the visiting physician being the principal responsible officer,
and visiting the institution several times a week as required.
Indeed, it was not till 1829 that the Act of Parliament was
passed rendering it imperative that a medical officer should be
resident in Asylums, and that only when the patients exceeded
100 in number. In accordance with this arrangement, it will
readily be understood that the superintendent was merely a
house steward, carrying out the instructions of the physician
as principal officer. Accordingly, in the rules then in force,
the physician kept the register of admissions ; no patient was
allowed to leave the precincts of the house without particular
permission and instructions given to the superintendent by the
physician. The physician had to keep the case-books, and
so on.
The superintendent superintended the whole establishment,
had authority over and power to dismiss the male servants,
kept accounts of all provisions received and of moneys ex¬
pended. The matron had similar authority over the female
servants and female side of the house.
In addition, however, we find rules drawn up for an apothe¬
cary, who was never appointed, but whose duties were to be
discharged ad interim by the lay superintendent. His duties
were to get full information in regard to patients’ histories for
the physician’s information, entering into case-books reports
and physician’s prescriptions, to faithfully administer every
medicine ordered by the physician, but except in cases of
sudden emergency to prescribe nothing.
Indeed, the efficiency of a lay superintendent' was so
thoroughly believed in, and the management seems to have
been so satisfactory, that when the Act was passed in 1828,
enacting that “ Wherever there are 100 patients or upwards in
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10 On the Treatment of the Insane Sixty Tears Ago , [April,
any asylum there shall be a medical gentleman resident in the
house/ 5 the directors resolved, “ That as the house cannot, in
its present state, afford comfortable accommodation for more
than 100 patients, this number should not be exceeded in the
meantime, the directors being fully satisfied that the appoint¬
ment of a resident medical gentleman, while it brought ad¬
ditional expense to the establishment, would not contribute to
the real welfare and comfort of the patient.” The necessity of
appointing a “ resident physician and surgeon 55 was thus for
the time got over, but only by adopting a policy which, had it
been persisted in, would have certainly brought disaster on the
asylum, and which was several times afterwards temporarily
adopted, but never without serious consequences. Indeed, no
policy can ever be so hurtful to any institution, situated as
the asylum then was, as that of restricting the number of
patients to be admitted to the available accommodation, instead
of extending the buildings.
A consideration of the position of the medical officers naturally
leads us to examine the medical treatment then in vogue, and at
the present time, when the question of adopting the best means
for keeping alive the true spirit of the medical profession in
asylums is under review, we turn to our early records with
feelings of more than ordinary curiosity, and we find there that
the direct influence of medicinal treatment would seem to have
been much more believed in than even at the present day. In
the report for the year 1824 it is said : il Within the last twelve
months there have been examples of the successful application
of medicine in dispelling some of the most unhappy illusions of
the senses and perversion of the natural feelings. One man
having the idea of a consuming fire in his vitals, was rendered
miserable beyond conception by this notion, which perpetually
haunted his imagination, and had rendered him obstinate in
refusing food and drink, as, in his estimation, adding only fuel
to the flame within him. After the use of appropriate medicine
in correcting great and manifest disorder of the stomach and
bowels, this idea gave way to more correct thought. He is now
convalescent and happy. 55 Again, the experience of the year
following is thus recorded :— u Some of the worst varieties of
madness, with all its revolting accompaniments, have given
way to the use of active remedies—but experience justifies the
remark that it is neither by an exclusive moral treatment nor
the use of remedies alone drawn from the medical art, that the
cure of lunacy is to be effected. It is best accomplished by a
happy combination of both, and the discriminate application of
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by James Korie, M.D.
11
their principles to the specialities of every individual case.”
And in another report (1837) we have the remedies specified
thus :—“ As a general rule, every individual case requires a
different plan of treatment; various remedies are employed,
but we find that there is no specific for the cure of insanity.
Topical blood-letting is of the greatest service. So is dry
cupping. Blisters, and a liniment composed of the tincture of
cantharides, the spirit of hartshorn, and croton oil, applied
twice or thrice to the shaven scalp, have also proved beneficial.
General blood-letting is very rarely resorted to. Baths of all
kinds and cold lotions are in constant requisition, and are used
with great advantage. Calomel, jalap, salts, rhubarb, tartar
emetic, colocynth, croton, and castor oil are in general use.”
Although we find the bleedings referred to as topical, still, from
the extent to which they were carried, they must have had a
pretty general effect, as 20 leeches to the head, and cupping
from the neck to the extent of 12 and 14 ounces, and this often
repeated, was very generally practised. The following cases,
which I have extracted from the 1st Case Book—indeed, they
are the cases of the 121st and 272nd patients admitted—will
give a much better idea than can otherwise be done of the
practice and pathology of these days and as they are cases of
intrinsic value, I have the less hesitation in inflicting them on
your attention at present.
Cases .—Case No. 12. A. B., admitted 22nd June, 1820, ast. 40 ;
manufacturer ; sanguine temperament, fair complexion, blue eyes,
married ; with usual signs of furious mania, requiring very close re¬
straint to prevent injury to himself and others; face flushed, eyes very
wild and staring, p. 100, rather full. Copious perspiration,
apparently from his struggles and incessant motion. B. costive.
Tongue white and foul. Temporal artery beating full. Takes his
food tolerably well, and sleeps none.
Complaints began about a fortnight before his admission,
apparently from having taken more spirituous and fermented liquor
than usual. He was bled, his head was shaved and bathed fre¬
quently with cold water and vinegar. Strong cathartics were given,
and his diet regulated accordingly. For a few days he seemed to
recover, but again relapsed, and had his head blistered without
apparent benefit. Spare diet enjoined, and the antiphlogistic
regimen in general, with occasional purgatives.
July 20th.—Has now gradually become more calm, and less subject
to fits of ungovernable fury, less loud talking and quarrelling with
ideal objects. Countenance evidently indicates the approach of con¬
valescence. Walks out regularly to the airing-ground, and joins in
the society of the day-room ; middle diet.
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12 On the Treatment of the Insane Sixty Years Ago , [April,
December 22nd.—Little improvement in bis mental faculties,
though he is more tranquil and much less subject for these last two
months to any fits of irritation. Pulse calm, countenance cheerful,
t. clean, appetite good, belly natural. Sometimes he becomes
affected with severe diarrhoea, which has occasionally been relieved
by magnesia and rhubarb. From 1 to 2 grains of tartrate of
antimony dissolved in %\. to ^ii. of water has done much on several
occasions to tranquillize his mind and relieve those fits of irritation
to which he has been subject ever since his admission.
January 6th, 1821.—Continues to improve.
January 31st.—Is still subject to occasional fits of irritation and
violence, particularly in tearing or otherwise injuring his clothes or
person, but keeps free from febrile symptoms; P. calm, countenance
generally composed, health greatly improved.
February 28th.—Is greatly improved in all respects, but given to
sallies of mischief in tearing his clothes, or throwing stones, or tear¬
ing up the plants in the airing-ground, but seems otherwise of placid
temper, and conscious of everything about his person.
June 15th.—For the last three months his state has been some¬
what more variable than before, and after some brighter periods he
seems to relapse into greater derangement of his ideas, with less
command over them, and without any obvious connection with the
state of bodily health, which, on the whole, has continued good,
the bowels, however, often requiring medicine. On the I6th May
he was seized suddenly, in the morning, with epilepsy, which recurred
several times during the day, and left him in the evening under coma
resembling apoplexy. P. slow, and neither hard nor full, face rather
pale, pupils contracted, bowels easy. Temporal arteriotomy was
performed to 8oz., head shaved and blistered, sinapisms to his feet,
01. Ricini and several enemata of senna immediately exhibited. A
quantity of roots of grass and much fceculent matter were discharged.
The coma was evidently relieved by the remedies employed, and
gradually gave way to the entire restoration of his consciousness,
and of as much reason as he has of late enjoyed. In the two
successive days he has had a slight return, but without coma, and
he is now, without any particular remedy (though with a restricted
diet and constant attention to his bowels), in a convalescent state.
July 10th.—Has had no return of fit, but is equally mischievous
and destructive of his clothes, &c., as ever, but attends to his natural
wants. There is some degree of weakness, resembling paralysis, in his
left leg and arm, but to no severe degree.
August 10th.—Ceases to attend to his natural wants, and seems
not to regain any portion of his mental faculties. He is silent and
stupid. Health good. No return of fits.
September 12th.—No return of fits, and his paralytic affection is
much gone, but he remains insensible to the calls of nature, and has
become extremely dirty. In a few days after last report he had
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1887.] by James Robie, M.l). 1&
another lucid interval, and was left free of restraint, but he soon re-*
lapsed into his present state. Appetite good. Sleeps ill. Some
sores about the genitals threatening gangrene from the irritation of
the urine healed up under the linseed meal poultices.
September 25th.—Was attacked with epileptic fits at 8 p.m. Hab.
dos. Cal. et Jalap cum 01. Ricini, &c. Opus sit et enemata.
September 26th.—Free of fits. Medicines operated freely.
October 3rd.—Is now convalescent. No further occasion for
medicine.
October 12th.—More stupid than ordinary, and has that ex¬
pression of countenance indicating the approach of a fit. B. costive.
T. whitish. Appetite good, P. calm, sleep variable. Hab. dos. Cal.
and Jalap.
October 13th.—Medicine operated powerfully, and with evident
good effect.
November 10th.—Particularly noisy during the night.
November 14th.—Still continues in the same way.
November 24th.—Again attacked with fits about 7 p.m., which
continued with little intermission until next evening, when he died
quite comatose. Body not opened.
Here we have a very well reported case of general paralysis
running its usual course.
The following shows also how a case of organic brain disease
was then described and treated.
No. 27. Mr. M.P., from Edinburgh, set. 42. Spare habit, dark
complexion. Inukeeper. Some of his relatives are known to have
been affected with derangement.
Admitted on the 6th January, 1821, with symptoms of very mani¬
fest derangement of intellect, occasioned by a long course of hard
drinking, particularly of spirituous liquors. Quick and lively in his
expressions, but free of violence. His mind is naturally turned
towards the objects of his usual pursuits, but perfectly confused and
extravagant on this or any other topic that engages his attention.
Pulse calm, T. clean. Appetite bad, B. irregular.
General health indifferent for some time past owing to frequent
excesses. Has been formerly subject ^about seven years ago) to
epileptic fits from the same cause, but of short duration, and no great
violence. The dyspeptic symptoms resulting from continued intoxica¬
tion had been so violent as to give rise to the suspicion of schirrus of
pylorus. Purgatives and laudanum ether and assafcetida were said to
have been useful in his former attacks of what 1 apprehend to have
been more allied to the delirium tremens than any settled attack of
the maniacal kind. Hab. Pulv. Rhei c. Magnes.
January 7th.—A very violent diarrhoea came on prior to the use of
the powder, accompanied by retching and vomiring. P. very calm.
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14 On the Treatment of the Insane Sixty Years Ago, [April,
Mind more serene and collected, but still very manifest incoherency
of thought and unnatural elevation of spirits.
January 17th.—Had remained in a state of convalescence in all
respects until within these two days, when he became irascible and
quarrelled with his keeper on the slightest occasions. At 2 or 3 a.m.
he was seized with a very violent fit of mania after a restless and
sleepless night, requiring the strait waistcoat and very strict con¬
finement. During the whole day the fit raged with unabated fury,
when he again became calm and was released from strict confine¬
ment. P. a little quickened, eyes bright and sparkling, countenance
flushed, T. whitish, spits often, attempted to burst from confinement
with most violent and unceasing exertions towards morning, and re¬
fused for some time to take food. Thirst urgent.
19th.— Violent and tranquil by turns, but has been out to the open
air in the course of this day. Low diet. Hal. Sol. Tart. Emetic £i.
January 20th.—This operated violently, and occasioned severe
diarrhoea.
January 31st.—Is still under confinement from the frequent recur¬
rence of violent agitation and fury ; P. on the whole calm ; heat of skin
varies ; eye bright and unsettled ; pupil much contracted; headache;
B. again costive ; appetite indifferent; much thirst; T. clean.
February 1st.—Abrad. Capillitium et appr. Capiti raso Emplast.
vesecator am plum. Capiat dos. in Mag. c Rheo.
February 2nd.—Blister has risen well. Is more tranquil ; P. and
heat of skin natural. Is still under the restraint of the jacket.
March 1st.—Continues nearly as in last report. The paroxysms
have been equally frequent and violent, dependent on no perceptible
cause, and very uncontroulable by any means employed to abate them.
A second blister seemed rather to do harm. The pulse generally small
and natural in frequency ; the pupil of the eyes still remarkably con¬
tracted ; appetite good ; B. regular, and at all times very sensible
(sensitive) to the operation of purgative medicine.
Requires constraint almost constantly from his disposition to injure
himself and destroy his clothing, as well as the furniture of the room.
Cont. Sol. Tart. Antim. vel Pulv. Rhei c. Magnesia, pro re nata.
June 12th.—Within the last three months his case has been nearly
uniform in many respects. In consequence of the command of his
relatives, his board was reduced, with—patient put into another ward—
the manifest effect of inducing a change for the better in the violence
of his paroxysms, probably from his attention being strongly
abstracted from his own feelings and erroneous ideas, and fixed on
those more striking objects with which he was now surrounded, and
from the effect of sympathy and imitation. But at no time was it
ever for a moment safe to leave him free of restraint, from certain
danger to himself and those around him. His mind never regained
tranquillity, nor became subject to reason. It dwelt on the business
of his former life with an imagination full of caprice, varying every
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15
1887.] by James Rorie, M.D.
hour, and quite beyond the power of volition. He was always iras¬
cible and prone to mischief, artful and exceedingly expert. Was
restless, and slept ill during the night, which was often spent in
talking loud or singing, or raving with passion and resentment against
imaginary enemies. P. seldom or never quick, or full or hard,
even under severe paroxysms, though his face then was red and
swollen, his eyes staring wildly, gnashing with his teeth, and equal
desire to bite and tear his clothes, &c. Heat of skin only on such
occasions increased, seldom with perspiration. Bowels unequal, but
easily moved by any medicine, even the gentlest, as rhubarb and
magnesia, &c., T. always clean. No headache or throbbing at
temples ; no affection of vision, eyes always animated ; pupils closely
contracted at all times. Within these six weeks his appetite, which
was always keen, became voracious, while he became more emaciated
and pale, and apparently under the power of some visceral disease,
though nothing perceptible was to be discovered either about the
thorax or abdomen. He became covered with patechia?, many of which
about the back and lower extremities went into sloughs, leaving small
foul sores. He passed dark-coloured offensive stools. (Edema about
the limbs succeeded to an attack of erysipelas in both, and afterwards
more generally over the body.
These symptoms had just begun to leave him entirely when he was
seized, without obvious cause, with epileptic fits on the morning of
the 12th. They proved severe, and returned at short intervals during
the day (about five in number), the last at half-past four p.m., when
he fell into a comatose state, and expired about three a.m. on Thurs¬
day. No practice was or could possibly avail in a case so utterly
hopeless. About seven years ago, prior to marked insanity, he had
been affected with convulsions, and afterwards with delirium tremens
of drunkards.
On opening the head, there was found unusual turgescence of the
veins and sinuses, with considerable effusion of serum on the surface
of the brain everywhere. The four sinuses were distended with
water—the left containing more than an ounce, the others rather less.
The choroid plexus very vascular, and thicker than common. Veins
running over the surface of the lateral ventricles uncommonly turgid
and beautifully ramified. On the right side of the crista Galli a very
evident disorganization had taken place in a portion of the anterior
lobe of the cerebrum, adhering to the bone, and of a soft pultaceous
consistence and yellowish colour, lying over and evidently in contact
with the right optic nerve. The origin of the nerve seemed sound, as
well as the nerves themselves. Cerebellum entire. A large quantity
of water issued from’The spine, and the medulla spinalis seemed re¬
markably small. The brain was undoubtedly extremely firm two days
after dissolution.
In abdomen, liver sound; stomach diseased about pylorus, thickened
and firmer than natural ; colon large, and distended with flatus;
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16 On the Treatment of the Insane Sixty Years Ago , [April,
omentum absorbed ; much bile effused; intestines seemed vascular. *
No other signs of disease.
Remarks on this case .—From the history and appearances after
death, it is obvious his disease must have been incurable by any means
of art.
Now, when we consider that these were the ideas then enter¬
tained before it was considered necessary that there should he
a resident medical officer in asylums, it must be admitted that
insanity was even then fully recognized to be a disease—indeed,
the frequent use of the term Hospital instead of Asylum in
these early reports fully bears this out.
And now the question naturally presents itself to us : Has
there been any great change in the views of asylum physicians
since those days; and, if so, to what are they to be ascribed ?
and secondly, Is the present system of asylum adminis¬
tration the best that can be adopted ? The first part of
this query must, I think, be admitted, and answered in
the affirmative. We do not bleed, and blister, and cup
our patients so vigorously as in the days of old; leeches
have almost disappeared, and setons seem a thing of the
past. And what are the reasons ? Partly, no doubt, this
is due to increased knowledge and more enlightened views, but
in a great measure, I am convinced, to other causes which have
not been sufficiently recognized. Shortly after the days to
which I have referred, the great discussion arose as to the
abolition of restraints, and raged through the profession with
a force and fury of which we have now little conception. This
naturally diverted men's minds from attending to the purely
medical or medicinal elements of treatment at that time. Again,
the physician of the asylum had to become resident, and, from
motives of economy, had added to his medical functions certain
duties in no ways connected with the medical profession, such
as general supervision of the institution, government of
servants, attendants, regulation of stores, &c., which could
have been equally well, if not better, discharged by a lay
superintendent. These all tended to kill the physician's
medical interest in his patients; and of late years we have had
added the introduction of what may be termed the gregarious
mode of treatment so strongly advocated by a late Commis¬
sioner in Lunacy, and which seems to have been developed
from an idea that the insane, with few exceptions, require
no further treatment than good food, good clothing, good
lodging, and suitable mild occupation and recreation. Now, I
humbly think such ideas may be carried too far. By all means
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1887.]
17
by James Rorie, M.D.
let ns have these general principles carried out so far as they
can be done, bnt not to the exclusion of the individual treat¬
ment ; and year by year I am becoming more and more con¬
vinced of the correctness of what we have seen so strongly
advocated in these early reports, that there is no panacea for
insanity, bnt that every individual case ought to be judged of,
mid treated in all its individual bearings. And this brings me
to query number two : Can this be done in asylums as at
present officered ? Judging from my own experience,
namely, of an asylum with about 300 patients annually resi¬
dent, and a general movement represented by about 150 annual
admissions, and the same number leaving the institution, I
believe that a principal resident medical officer and an assistant
are insufficient, especially when, in addition, they are hampered
with the discharge of duties which could be equally well, if
not better, performed by a lay general superintendent. For a
population such as the above, and one so constantly changing,
I am becoming more and more convinced that the medical
staff ought to be relieved of many fiscal duties, and materially
increased, say by the addition of clinical clerks, before proper
justice can be done to the patients.
Since writing the above, I have had my attention directed
to a paper which exactly embodies many of my views of the
subject, and consequently leaves me little to do but endorse
them. I refer to l)r. Strahan’s paper read before the Psycho¬
logical Section of the British Medical Association, at Brighton,
and an abstract of which is published in the Journal of 25th
September, 1886.
Referring to the necessity for more medical officers in asylums,
Dr. S. writes as follows :—“With asylum medical staffs at
their present strength, little more can be done than we are
doing for the insane. Our asylums are splendid places for the
care of the incurable insane; and so long as they are looked
upon as mere retreats, the present staffs will suffice: but the
moment we attempt to change them into hospitals, where every
case is to be studied, we must augment these staffs, and so
make the change a possibility. At present an asylum with 700
inmates has generally but two medical officers. The superin¬
tendent must* give the greater part of his time and thought to
fiscal duties. There is a fast-increasing custom of abolishing
the office of steward in asylums. This makes the superinten¬
dent the universal provider and adds to his fiscal duties, and it
must directly tend to the extinction of the medical spirit/’
Now, this has been precisely my experience. When ap-
xxxiii. 2
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18 On the Treatment of the Insane Sixty Years Ago, [April,
pointed to the Dundee Asylum, in 1860, there had been for
many years about 200 patients resident, with an annual admis¬
sion and discharge of about 40 to 50 patients; but when the
lunatic wards of poorhouses were opened in 1864, the number
resident fell to 153, and the admissions suddenly rose to 101.
Then ensued violent fluctuations, the resident population rising
rapidly to 350, and the annual admission in one year reaching
150 cases.
Now, although in the old asylum I had neither steward,
medical assistant, nor head-attendant, and consequently the
greater part of these duties devolved upon myself, so long as the
resident number kept about 200 and the admissions under 50,
I had no difficulty whatever in keeping myself thoroughly
acquainted with the individual histories of all the patients, and
so doing them full justice; but when the admissions rose to
100, 120, and 150, I felt myself no longer able to individualize
the cases as I could have desired, and had to be content with a
more general acquaintance with the patients' varying peculiari¬
ties. Now, how is this to be remedied ? and it is on this point
that I am specially desirous of eliciting the opinion of this
meeting. Dr. Strahan suggests the separation of the curable
from the chronic, but in our case this has already, to a great
extent, been done; at least, the useful and harmless have been
pretty thoroughly separated from the recent, violent and de¬
graded. Since 1864 no fewer than 521 cases have been trans¬
ferred from the asylum to the lunatic wards of the Dundee
poorhouses; during 1884-5-6 no fewer than 156 have been
disposed of in this manner. Now, in the first place, it will be
seen from the above that the functions of the chartered asylums,
at least in Scotland, have of late been very materially changed
from what used to be the case; and it seems extremely desir¬
able that what is to be expected of them in future should be
clearly defined. When the Dundee Asylum was opened in 1820,
its duties were defined to be “ to restore the use of reason, and
to alleviate suffering where reason could not be restored.” It
was, therefore, a curative hospital for the curable, a place of
detention for the dangerous, and a place of residence for the
incurable; and it is of importance to bear in mind that these
were the views held by the Commissioners in Lunacy at the
time of the appointment of the Lunacy Board, and for several
years subsequently. But now these views have materially
changed. It has now been considered that suitable accom¬
modation for a large number of the incurable patients can be
found in poorhouse wards, and the functions of the asylums
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1887.]
19
by Jambs RofciE, M.D.
have altered accordingly. These institutions are now looked
upon as hospitals for the curable, places of detention for the
dangerous, and places of residence for the rest of the incurable
only who are degraded and dirty in their habits, and neither
curable nor dangerous, but simply expensive to look after. I
have never, however, seen any reason why the last class should
not be as easily provided for in the lunatic wards of poor-
houses as the incurable of more cleanly habits. It seems to
me that if this succursal arrangement for disposing of the
harmless insane in poorhouses is to be acknowledged as satis¬
factory, then all incurable, not dangerous, should be admissible
into these wards; and, if so, there seems to me to be no reason
why similar wards, on equally good grounds, should not be estab¬
lished in connection with our local prisons, similar to the wards
in connection with the General Prison, Perth, for the incurably
insane who are dangerous, and the asylums would then be
left free to discharge what, I think, everyone will admit is
their proper function—the treatment and cure of insanity and
allied diseases. From an instructive table given in the last
Report of the Commissioners in Lunacy for Scotland it will be
seen that few patients would require to remain over five years
in the Asylum; for of 1,319 new cases admitted into estab¬
lishments, it was found that while 305 were discharged re¬
covered within the next twelve months and 209 the following
year, 51 recovered the 3rd year, 38 the 4th, and only 26
the 5th.
But to carry out the idea of a curative hospital thoroughly,
the medical staff would require to be increased in number,
and relieved of all mere fiscal duties; and if in addition to the
treatment of the insane in the asylum a certain control of the
district, by appointing them also local inspectors, were con¬
ferred on the asylum officers, patients suitable for being boarded-
out, and for being sent to lunatic wards, &c., would be much
more satisfactorily selected than at present, and also the
anomaly of asylums being converted for convenience into recep¬
tacles tor degraded cases requiring only careful, though it
may be expensive, supervision as to cleanliness and ordinary
comforts, would be prevented.
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20
[April,
Illustrations of normal and defective development of the multi¬
polar cells of the cerebral cortex ; of their degeneration in
senile insanity, and of certain albuminoid or protoplasmic
exudations commonly found in the neighbourhood of the
junction of the white and grey matters of the convolutions
in cases of general paralysis and ordinary mania , in which
the symptoms have been more or less acute. By Edward
Palmer, M.D., Medical Superintendent, County Asylum,
Lincoln.
(Concluded from p. 471.)
9* Acute Mania.
Case. —J. P., a travelling hawker, aged 53, of whose history
previous to his insanity nothing could be ascertained. His
mental condition was one of almost continuous wild and
incoherent excitement from the commencement of the attack
to the day before his death, when he suddenly collapsed and
became unconscious, and so remained to the last. The whole
duration of the attack was just eleven weeks.
Post-mortem examination. —Body much emaciated; rigor
mortis strongly marked ; calvarium thin, in some places almost
transparent; dura mater firmly adherent to the calvarium
along the longitudinal sinus; considerable effusion into the
sub-arachnoid tissue; the membrane itself very opaque,
especially over the frontal lobes; the brain generally much
congested ; kidneys large, the left nodulated; both, under the
microscope, showed lardaceous infiltration of the Malpighian
bodies, hypertrophy of the muscular coats of the arteries, and
commencing cirrhosis; spleen also lardaceous, nearly all the
blood-vessels being imbedded in the filtrate. Bight lung :—
old pleuritic adhesions; nodules of cheesy tubercle and a
large cavity in the middle lobe. Left lung emphysematous.
Other organs apparently healthy.
Fig. 9.—Protoplasmic exudations from the arterioles in the
outer portion of the white matter of the left middle frontal
convolution.
a. Distorted arteriole.
b . Nuclei of the nervous tissue.
c. Exudations attached to arteriole.
d. The same detached and enveloping the nuclei.
* These numbers refer, as in the previous article, to tho Figs, on the litho -
graphic plates accompanying the paper.
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1887.]
Cerebral Multipolar Cells .
21
From the comparatively great bulk of the exudations (see
also Figs. 10 and 12), and the large size of the detached
portions and of the nuclei contained within them, they can
scarcely be regarded as ordinary leucocytes, although they are
most probably protoplasmic in character. They appear to
have issued almost in streams from the arterioles, and then,
following the tracts of least resistance—the lymphatic channels
—to have invaded the lymph-spaces around the nerve-nuclei.
As far as my observations have extended they have only been
found in cases where the symptoms had been actively progres¬
sive and accompanied with delirium, and there can, 1 think, be
no doubt that they form part of the phenomena of inflamma¬
tion. It is remarkable, however, that they are generally
limited to the innermost layer of the cortex and the imme¬
diately subjacent portion of the white matter, occurring only
in a modified form in the external layer, and but rarely in any
intermediate part.
10 and 11 .—Recurrent Mania .
Case. —J. G., a fisherman, aged 41, of dissolute habits;
had been three times under treatment in the asylum for mania,
and twice discharged apparently recovered, but on each occa¬
sion relapsed in two or three months after his return home.
His attacks were all characterized by noisy, incoherent raving,
extreme restlessness, turbulence, destructiveness of clothing
and furniture, and disposition to personal violence; and in his
last, which ran its course in three months, he also displayed
some of the grandiose notions of a general paralytic, but had
no paretic symptoms beyond slight tremor and jerkiness of the
tongue when protruded. His pupils were always abnormally
large, and frequently unequal in size, though not persistently
so. Latterly he had albuminuria, with oedema of the face,
hands, and legs. He became emaciated, and his physical
powers steadily declined ; but he was still noisy and boisterous,
and so continued up to within a few hours of his death, which
was preceded by coma.
On post-mortem examination the brain was found to be firm
in substance and much congested, the arachnoid opaque and
adherent over the frontal and middles lobes on each side, and
there was an excess of fluid in the arachnoid sac. Both
kidneys were fibrous, and all the other abdominal organs in a
'more or less pathological condition. The lungs and heart were
healthy.
Fig . 10.—Protoplasmic exudations from the arterioles in the
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outer portion of the white matter of the left ascending frontal
convolution.
a. Arterioles.
b. Nuclei of the nervous tissue.
c. Exudations attached to arteriole.
d. The same detached and enveloping the nuclei.
Fig . 11.—From the third layer of the same convolution.
a. Molecular degeneration of multipolar cells.
b . Blood-stasis and nuclear proliferation of arterioles.
c. Nuclei of the nervous tissue.
It is to be observed that there is an entire absence of
protoplasmic exudation in any form.
12, 13 and 14 .—General Paralysis {acute.)
Case. —6. H., a coal-higgler, aged 38, stated to have been
insane for one month only before his admission; no further
particulars respecting him were furnished. He was a stout,
well-nourished man; his features heavy and void of expres¬
sion ; right pupil permanently larger than the left; conjunctivas
congested; tongue and lips tremulous; deglutition impaired;
gait staggering, and pulse thready and feeble.
Mentally, he was at first dull, confused, timid, and suspicious,
and had auditory hallucinations, often fancying that “ he heard
someone tell him that he was going to be snot.” This con¬
dition subsequently alternated with one of restless, noisy
excitement, during which he considered himself to be quite
well and strong, but he never manifested any delusions of
grandeur. All his symptoms became rapidly worse; he fell
into a state of dementia, had convulsive twitchings of the left
arm and leg, and died comatose six months from the com¬
mencement of his insanity.
Post-mortem:—Calvarium very thin; arachnoid milky and
infiltrated with serum; brain congested, somewhat shrunken
over the lateral ventricles, which were distended with fluid.
Patches of recent lymph on the peritoneal surface of the small
intestines. Other organs apparently normal.
Fig. 12.—Protoplasmic exudations from the arterioles in the
outer portion of the white matter of the left superior frontal
convolution, showing the various stages in their transit from
the blood-vessels to the nerve-nuclei.
a. Protoplasmic masses within the vessel, in one place
bulging out its coats.
b. Large protrusions of them beyond the walls.
c. Their first contact with the nuclei.
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Journal of Mental Science
Aeri l. 188 r/
23
1887.] by Edward Palmer, M.D.
d. The nuclei surrounded.
6. The drawing out and final separation of the exudate from
the vessel.
/. Nuclei of the nervous tissue.
Fig . 13.—Molecular degeneration of multipolar cells and
nuclear proliferation of arterioles in the third layer of the grey
matter of the same convolution. No trace of exudation.
а. Degenerated multipolar cells.
б. Arterioles.
c. Nuclei of the nervous tissue.
Fig . 14.—Coarse neuroglia and protoplasmic exudation, in
the form of Deiters 5 cells, from the external layer of the same
convolution. The membranes, containing large nuclear bodies,
were tom and partially detached in making the section.
a. Arterioles.
b. Protoplasmic exudations attached to arterioles.
c. The same detached.
15 and 16.— General Paralysis (chronic ).
Case. —(This case so well illustrates the progress of chronic
general paralysis, without the intervention of acute symptoms,
that it may be considered worth recording somewhat in extenso ,
and this I am enabled to do through the kindness of Dr.
Bussell, who has favoured me with an abstract from the case¬
book of the Lincoln Lunatic Hospital, where it was under
treatment in the earlier stage.)
E. G., a farmer’s wife, aged 45, was admitted into the hospital
in May, 1876; she had been under treatment at home for an
attack of insanity during pregnancy five years before, and had
recovered in three months after a premature confinement. The
certificate in her admission paper speaks of her dislike to her
husband and familiarity with strangers ; also of her talking of
buying property and building houses for herself and son (aged
14) to live in; of her volubility, incoherence, and disregard of
truth; and of her threatening to poison herself and child. She
showed no sign of organic disease, except feeble heart-sounds.
She talked in a flighty, boastful manner; her memory seemed
good, and she manifested no delusions. In October she was
childish and weak-minded. In December she continued childish,
and was constantly grumbling at her detention, and her hus¬
band removed her. Her friends were able to take care of her
from this time to October, 1879, when she was admitted into
the Lincoln County Asylum. She was then a stout, pallid
woman, with iron-grey hair, hazel eyes, small and equally con-
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24
Cerebral Multipolar Cells,
[April,
tracted pupils, and extremely thready pulse. Her gait was
tottering; she was unable to walk without assistance; her
tongue was tremulous and her speech mumbling; deglutition
impaired; hands very unsteady; and habits wet and dirty. She
talked almost incessantly, frequently repeating her name in
answer to a question; was elated with the fancied possession
of fine silk dresses and other expensive articles, also of an
abundance of money. Her conversation was simple and ramb¬
ling, and her words were uttered in a very imperfect and
hesitating manner. In November she is noted as being rest¬
less at night, and often also during the day, requiring constant
watching to prevent her from falling. Her mind was entirely
absorbed with her delusions. In December the restless¬
ness had quite passed off; she was cheerful and tractable, but
had become very imbecile. Her paralysis had increased, and
she could not stand without support. In May she was cheer¬
ful, childish, and delusional, chiefly with regard to her imagi¬
nary fine clothes. Her paralysis was advancing; she could
# only swallow with difficulty, and was losing flesh. In August
she had an attack of right hemiplegia (transient), followed by
further impairment of speech. In November she was nearly
speechless, and could only swallow liquids carefully administered.
In December she had a second right hemiplegic attack, which
left her bedridden and helpless, with barely sufficient mental
power to enable her to recognize those in attendance on her.
Her inability to swallow steadily increased, bed-sores made
their appearance, and she gradually sank, dying, comatose, in
February , 1881, rather more than five years from the onset
of her special symptoms.
Post-mortem :—Calvarium thick and heavy; the diploe
obliterated ; dura mater firmly adherent over the anterior part
of the cerebrum; a large quantity of serum in the arachnoid
cavity; semi-gelatinous infiltration of the sub-arachnoid tissue;
the membrane opaque and almost as thick as the normal dura
mater; the whole brain much atrophied, especially anteriorly
and in the left hemisphere; the left lateral ventricle very full
of fluid.
Fig. 15.—From the posterior part of the left inferior frontal
(Broca’s) convolution.
a. Arterioles, of which one is atheromatous.
b . Degenerated and wasted multipolar cells.
c. Amyloid destruction of multipolar cells, a very small
remnant of the nucleus being all that is left of the
normal structure.
d. Nuclei of the nervous tissue.
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1887.] by Edwabd Palmes, M.D. 25
Fig. 16.—From the lower part of the left ascending frontal
convolution.
a. Arterioles.
b. Molecular decay of multipolar cells.
c. Progressive amyloid degeneration of ditto.
d . Nuclei of the nervous tissue.
In this case, corresponding with its slow progress and the
mildness and short duration of the mental excitement, no
protoplasmic exudation was found in any part of the cortex,
or in the underlying white matter. The amyloid degeneration,
however, was present in other convolutions in each hemisphere.
It has not been sought in this paper to enter minutely into
the development and pathology of the brain-cell, but simply
to illustrate with accuracy some salient points of interest
connected therewith, and to describe with sufficient detail a
mode of preparing sections which materially facilitates their
study under the higher powers of the microscope.
Remarks on Evolution cmd Dissolution of the Nervous System .
By J. Huohlings Jackson, M.D., F.R.C.P., F.R.S.,
Physician to the London Hospital and to the National
Hospital for the Epileptic and Paralysed.
(1) The Universal Symptomatology of an Epileptic Fit owing
to discharge beginning in some part of the highest cerebral
centres .—There is but little doubt that in a severe epileptic
paroxysm (“ genuine epilepsy ”) there are effects, although
very crude ones, produced in, or referred to, all parts of the
body, animal and organic. Speaking figuratively, there is
an endeavour to develop activity of all parts of the body
excessively, and of all of them at once,* and as rapidly as
possible.
Consciousness begins to cease, that is to say mind begins
to cease, at or soon after the onset of the paroxysm; equiva¬
lently there is no warning, or a transitory one. I take this
as proof that the correlative physical event, the sudden and
excessive discharge which produces universal effects, begins
in some part of the “ organ of mind ” or physical basis of
consciousness—that is to say, in some part of the highest
centres of the cerebral system. It is well to give other
* I have gone into this matter at length in the Bowman Lecture, delivered
Nov., 1885, and published in *• Ophthalmological Society’s Transactions,” Vol.
▼i. I do not mean that there is demonstration that literally all parts are
involved.
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26 Evolution and Dissolution of the Nervous System , [April,
synonyms, so we add that the discharge begins in some part
of the latest evolved (the continually evolving) centres—
highest level of evolution of the cerebral system.
The severe epileptic fit is dissolution, universal or nearly
so, being effected. The post-paroxysmal condition, post¬
epileptic coma, is such dissolution effected. There is not
total dissolution unless the patient dies. The patient
universally convulsed in the paroxysm is after it universally,
not totally, paralysed, and is insane, viz., demented. Per¬
fect dementia, or, I suppose I should say, amentia, is, to my
thinking, synonymous with absence of all consciousness and
with total mindlessness (Section 14). Dementia is chronic
persisting coma; coma is acute transitory dementia.* Re¬
covery from post-epileptic coma is re-evolution from universal
and almost total dissolution (from what is often nearly, if
not quite, psychical death, and from what is nearly physical
death).
(2) Different Epilepsies (The Scale of Fits ; “Discharging
Lesions”). —Before going further I would remark that,
although I shall continue to speak for the most part of
epilepsy as if there were one such clinical entity, there are
really many different epilepsies (I mean what would be called
“ varieties ” of “ genuine ” epilepsy), each dependent on a
“ discharging lesion ” of some part of the highest centres.
Epilepsies are only one class of fits (Highest Level Fits). To
prevent confusion, I must mention the other classes, and thus
complete what I call the Scale of Fits. There are, as every¬
body admits, different epileptiform seizures from “ dis¬
charging lesions” of different parts of the middle motor
centres (Middle Level Fits). There are, I think, different
fits (bulbar fits, laryngismus stridulus for one example) de¬
pendent on discharges beginning in different parts of the
lowest level of central evolution (Lowest Level Fits).
I use here the most general term I can find, “ fits,” ad¬
visedly, because I do not, as I should when working clinically,
care, as an evolutionist, to know whether any paroxysm is
or is not “ a case of epilepsy,” nor how near it approaches
* Certain qualifications will be given to these statements later on. M Coma
is a fulminant form of insanity; insanity is a lingering form of coma. Patho¬
logically, coma is loss of function of the nervous centres, beginning in the
highest centres of all ; in those centres, which are the substrata of conscious¬
ness which effect the adjustment of the organism as a whole to its environ¬
ment, which represent, first and most, tho most precise and elaborate bodily
movements, and which represent in some degree every part of the organism.”
— Dr. Merrier , Brain, January , 1887, p. 483.
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27
1887.] by J. Hughlings Jackson, M.D.
the clinical type of “ genuine ” epilepsy. As an evolutionist,
I wish to learn how cases shew departures from normal states ,
and how the three classes of fits resemble and differ as results
of discharges beginning on three different evolutionary levels.
Whether consciousness is lost or not is not the matter of
first moment; it is lost in severe fits of each class. Obviously
the comparative study indicated is involved. For in a severe
epileptic fit, to take that as an example, the discharge be¬
ginning in some part of the highest level will discharge
parts on the middle and next parts, on the lowest level, and
finally the muscles will be discharged. So that such a
paroxysm is triply compound, or quadruply, if we take
into account the discharge of the muscular periphery, the
real lowest level. The paralysis after such a fit will be very
compound.
Certainly there are as many epilepsies (Highest Level Fits)
as there are paroxysms setting in with different “ warnings.”
The “ warning ” is a sign of the locality of the " discharging
lesion ” ( a physiological fulminate ”); it is the first event in
the paroxysm occurring from, or during, the incipient dis¬
charge. The “ discharging lesion ” I hold to be a persistent
local change of some nervous arrangements; the few cells
making it up varying in their degree of tension from that
of very high instability, permitting sudden and excessive dis¬
charge, to that, after their discharge, of stability far below
normal. In all cases of epileptiform and epileptic seizures
the “discharging lesion” is supposed to be of some small part
of one half of the brain, and is thus, so to speak, doubly local.
A very small local “fulminate” in but one half of the
brain, when suddenly and rapidly discharged, can, by over¬
coming the resistances of healthy nervous arrangements, set
up discharges of so many of these healthy nervous arrange¬
ments, associated collaterally and downwardly with those
altered into the fulminate, that severe universal convulsion
results.
(3) Different Insanities ; Local Dissolutions of the Highest
Centres. — Similarly we should, in strictness, speak not of
varieties of insanity, but of insanities; for obviously there
are different kinds as well as degrees of insanity—that is,
there are dissolutions beginning in different divisions of the
highest centres. Melancholia (posterior lobes?) and general
paralysis (anterior lobes ?) signify different local dissolutions
of the highest centres as certainly as brachioplegia and cruro-
plegia signify different local dissolutions of the middle motor
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28 Evolution and Dissolution of the Nervous System , [April,
centres, or as ophthalmoplegia externa and ordinary pro¬
gressive muscular atrophy signify different local dissolutions
of the lowest motor centres. Here is hinted at a “ scale of
paralyses,” on which we speak later. (Sections 10 and 18).
(4) Evolution and Dissolution always coexist or occur m
alternation ; Different Levels of Evolution left in different Dis¬
solutions of the Highest Centres. —I particularly wish to urge
that in post-epileptic insanities the dissolution is local in the
sense that it preponderates i»n the highest centres of one
half of the brain. If so, it follows that the level of evolution
remaining is a lower one in one half of the brain, and a very
high collateral one in the other. This is important with re¬
gard to post-epileptic cases in which the dissolution is not so
deep as in coma, cases of post-epileptic unconsciousness with
mania for example ; the mania is the outcome of activities on
the levels of evolution remaining. And I submit that the
seeming exceptions to the law of dissolution which some of
these cases present (the coexistence of great negative affection
of consciousness with highly special actions) is accounted for
by the hypothesis of there being deep dissolution in one hemi¬
sphere, and a high level of evolution in the other. If general
paralysis be a dissolution beginning in the highest motor
centres, ultimately on both halves of the brain, the positive
mental symptoms arise during activities of the intact posterior
lobes, posterior level of evolution, and of what is left intact
of the anterior. It is only in such dissolutions as that pro¬
duced by alcohol that we can expect anything like a uniform
dissolution, and simply a lower level of evolution. But even
here no doubt some divisions of the highest centres will
begin to “ give out ” before others, and thus, early in the
poisoning by alcohol, there will not be an uniform dissolution,
and thus not an even lower level of evolution remaining.
We have instanced—it may be taken hypothetically—four
local dissolutions and one uniform dissolution of the highest
centres. We have implicitly urged that, in each case of
insanity, indeed in all nervous diseases, we have a problem
in evolution as well as in dissolution. The levels of evolution
vary in the different kinds of insanity. Indeed, in healthy
states there is a rhythm of evolution and dissolution. But
keeping to cases of insanity, I would remark that disease, in
the strict sense of pathological process, produces the negative
physical change dissolution only, answering to negative
affection of consciousness; disease is not the cause of
positive mental symptoms. He who is studying the physical
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1887.] by J. Hughlings Jackson, M.D. 2d
conditions of positive mental symptoms in any case of in¬
sanity is dealing with evolution. The physical process during
an illusion is as certainly an evolutionary process as that
during normal perception is; the illusion is the insane man’s
perception, and is part of the mentation going on on the
lower levels of evolution remaining (his then highest levels),
of a nervous system mutilated by disease. The qualifications
stated in this section are to be borne in mind when the term
insanity is used.
(5) The Hierarchy of Nervous * Centres .—I am supposing the
nervous system to be a sensori-motor mechanism, from
bottom to top; that every part of the nervous system repre¬
sents impressions or movements, or both. (Under the head
of movements we place effects produced through motor
nerves to glands, and through inhibitory nerves.) The
further hypotheses are that the highest divisions of this
sensori-motor mechanism, “ organ of mind” (1) represent
impressions and movements of all 'parts of the body; (2) in
most complex, &c., combinations; and (3) triply indirectly.
We must now say something of lower centres in order to see
how the constitution of the highest centres is, so to speak,
achieved.
It is not possible at this stage to do more than state, in
incomplete outline, the evolutionary hierarchy of the
nervous centres. Qualifications will be given and additions
made later. The periphery is the real lowest level; but we
shall speak of three levels of central evolution. (1) The
lowest level consists of anterior and posterior horns of the
spinal cord, and of Clarke’s (visceral) column, and Stillings
nucleus and of the homologues of these parts higher up. It
represents all parts of the body most nearly directly. (It is
at once the lowest cerebral and the lowest cerebellar level of
central evolution; the periphery being also cerebro-cerebellar,
and the lowest level of the whole organism). (2) The middle
level consists of Ferrier’s motor region, with the ganglia of
the corpus striatum, and also of his sensory region. It re¬
presents all parts of the body doubly indirectly. (3) The
highest level consists of highest motor centres (prse-frontal
lobes), and of highest sensory centres (occipital lobes). They
represent all parts of the body triply indirectly* These
highest sensori-motor centres make up the “ organ of mind ”
or physical basis of consciousness; they are evolved out of
* My hypothesis is that the middle and highest motor centres are only chiefly
motor, and that the middle and highest sensory are only chiefly sensory.
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SO Evolution and Dissolution of the, Nervous System , [April,
the middle, as the middle are out of the lowest, and as the
lowest are out of the periphery; thus the highest centres re-
re-represent the body—that is, represent it triply indirectly.
I wish to bring prominently into notice objections to the view
here taken as to the highest sensory and motor centres.
(6) The Highest Motor and Highest Sensory Centres .—I have
long held the hypothesis that the whole of the anterior lobe
is (chiefly) motor. But that the pim-frontal lobes are motor
is a doctrine held by few. Ferrier and Gerald Yeo (“ Proc.
Royal Soc.,” January 24th, 1884) have concluded, from ex¬
periments on monkeys, that the prae-frontal lobes represent
some movements, and significantly these are lateral move¬
ments of the eyes and head—the most representative of* all
movements. But I have now to say that whilst Ferrier
agrees with me in thinking that the whole anterior part of
the brain is motor, and that, to use his words, u mental
operations, in the last analysis, must be merely the subjective
side of sensory and motor substrata ” (“ Functions of the
Brain”), as I have long earnestly contended, he does not
agree with me in thinking there to be a division into middle
and highest cerebral motor centres ; and he thinks that what
I call the highest motor centres represent only movements
of the eyes and head, and not movements of all parts of the
body, as I do.
Ferrier combats the view I take in the second edition of
his “ Functions of the Brain,” p. 460 and seq. For the con¬
trary opinions of such a man I have a most profound re¬
spect. I do not suppose that there is such a decided division
between middle and highest centres as there is between
lowest and middle. Indeed, Ferrier has found that there is
some wasting after ablation of the pras-frontal regions in
monkeys descending to the medulla oblongata, but no further.
This may tell in favour of his opinion that there is no division
into middle and highest motor centres, or may show only
that the division is not absolute. It may shew that some
direct connexions exist between the highest centres and
some of the lowest centres, without the intermediation of
the middle.*
I have long held that the posterior part of the brain is
(chiefly) sensory, and have for some years called the occipital
lobes the highest sensory centres. But now I have mis-
* Some time ago (“ Med. Times and Gazette,’* March 1,1879) I suggested
that “ there are movements, organic and animal, concerned during emotional
states, which will have an exceedingly wide representation in the cerebrum,
and probably more directly in the highest centres than any other class of move -
i nents."
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31
1887.] by J. Hughlings Jackson, M.D.
givings as to the occipital lobes being the highest sensory
centres, consequent on reading Gowers* masterly work,
“ Diseases of the Brain/* especially pp. 22 and 174. How¬
ever, I shall have little, if anything, directly to say of the
cerebral sensory centres. The morphological position of
these centres is a very important matter, but does not con¬
cern us much for the things to be discussed in this paper.
(7) The Process of Evolution .—Each of the levels is univer¬
sally representing, and thus we have yet to state the evolu¬
tionary differences between them beyond that of degrees of
indirectness of representation. I do little more than give the
formula of process of evolution. “ Following out hints fur¬
nished by Linnaeus, K. F. Wolff, Goethe, and Schelling, this
great embryologist [Yon Baer] announced in 1829 his great
discovery, that the progressive change from homogeneity to
heterogeneity is the change in which organic evolution
essentially consists ” (“ Fiske’s Cosmic Philosophy/* Vol. I.,
p. 342). The modern doctrine of evolution goes further
than this. There are, according to Spencer, other factors in
evolution. I state four factors. Illustrating by movements
and with reference to the three ranks of motor centres, we
say that there is from lowest to highest centres, (1) increas¬
ing complexity (differentiation), representation of a greater
number of different movements; (2) increasing definiteness
(specialization), representation of movements for more par¬
ticular duties; (3) increasing integration, representation of
movements of wider ranges of the body in each part of the
centres*; (4) the higher the centres the more numerous
the interconnexions of their units (co-operation).f
* The formula of evolution states a doctrine of localization, and one very differ¬
ent from the current one. Integration, a very important factor, is ignored by the
current doctrine. It is an exceedingly important factor. It is admirably and
very simply stated by Dr. Mercier, who, in an article to be referred to again
presently, p. 480, writes: * Such centres [lowest centres] represent a limited
part of the body very strongly; they represent little else, and that little but
feebly. But in the highest regions each centre represents a large part of the
organism preponderatingly, a still larger part in less degree, and the whole of
the organism in some degree. And in the intermediate centres the representa¬
tion is intermediate in character, a larger or smaller area being preponderatingly
represented, and the halo of partial representation being larger or smaller,
while the intensity of representation is less or more, according as the centre is
more or less elevated in the hierarchy of the nervous system.”
t I have used terms more familiar to medical men than those Spencer uses.
For this change, of course, Spencer is not answerable, nor must he be held
responsible for the correctness of my statements and applications of his
formula of evolution. I should consider it a great calamity, were any crudities
of mine imputed to a man to whom I feel profoundly indebted. It is for this
reason that I do not quote Spencer in other parts of this article, although I
believe it to be pervaded by Spencerian ideas.
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82 Evolution and Dissolution of the Nervous System , [April,
Thus, to recapitulate, the highest centres are the most (1)
complex, (2) most special, (3) most integrated sensori-motor
centres, with (4) most numerous interconnexions. They
represent all parts of the body in the ways mentioned, and
represent them triply indirectly. They are the anatomical
substrata of consciousness. I say anatomical . The anatomy
of nervous centres is not to be confounded with their mor¬
phology. Indeed some parts of the cord, and of the bulb
too, do not belong to the lowest level of evolution. The
patient who has “ idiopathic ” lateral sclerosis has “ disease
of the cord,” but not of the lowest level of evolution,
although of part of a plexus or strand of fibres between
motor centres on the lowest and on the middle level.
It will have been noticed that the evolutionary scheme of
centres ignores morphological divisions. Any centre, bulbar
or spinal, which represents a part of the body most nearly
directly and in simplest ways is a lowest centre. Lowest
centre is a proper name, and hence we may speak of two
lowest centres. As said, Section 3, ophthalmoplegia externa
(wasting of cells of some lowest centres in the floor of the
aqueduct of Sylvius) is a lowest level paralysis as much as
the ordinary type of progressive muscular atrophy is.
To give an account of the anatomy of any centre is to give
an account of the parts of the body it represents, and of the
ways and of the degree of indirectness in which it represents
them. The anatomy of the highest centres or “ organ of
mind ” is given, although most generally, in the recapitu¬
latory statements just made.
(8) The Dynamics of the Chain of Centres .—A way of speak¬
ing of degrees of indirectness of representation (Section 5)
more fully, is to say that nervous evolution does not imply
insensible gradations, but occasional stoppages, which are
re-beginnings. For example, the lowest motor centres
are connected by a plexus or strand of fibres, pyramidal
tract, with the middle centres, which are the lowest centres,
suddenly “raised to a much higher power.” Hence centres
are not only “ reservoirs of energy,” but also “ resisting posi¬
tions.” Ignoring the resisting side of the function of centres
prevents our seeing clearly the differences between the
physical processes during faint and during vivid states of
consciousness in health and in disease. The highest sensory
centres are triply detached from (protected from) the sensory
periphery. The muscular periphery is triply detached from
(protected from) the highest motor centres. Were it not for
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1887.]
by J. Hughlings Jackson, M.D.
33
these “ protections ” there would be no physical basis corres¬
ponding to the differences between faint and vivid states of
consciousness. Thanks to the u protection,” activities of
the highest centres can go on uninterfered with by the
environment, and without producing reactions upon it;
psychically there can arise trains of thought, faint states
of consciousness, independent of present experiences. There
is internal evolution. For these and other purposes we
should note that the evolutionary ascent, from lowest to
highest sensory centres, is a passage, not only from the simple,
&c., to the complex, &c., but from the most towards the least
organized—from centres easily transmitting accustomed
stimuli and resisting novel stimuli, up to centres which
have to be forced into activity. The peripheral impact being
strong enough, all sensory centres are overcome in order,
there is a multiplication of energy liberations upwards, and
finally great irradiation in the highest sensory centres and
ci survival of the fittest” states. Thus from a very local
peripheral change we have ultimately changes induced in
many nerve units of the highest centres, each of which repre¬
sents the whole organism, although they represent by far
the most the part of the periphery engaged. Consequent on
the strong discharges of the highest sensory centres the
connected highest motor centres are next put in great activity.
The passage next is not only from the most complex motor
nervous arrangements to the most simple, but from the
least organized to the most organized, from centres capable
of being forced into new kinds of activity to centres acting
in ways they have been trained to act in, and resisting new
ways of acting; the stage of “effecting of the possible.’ 5
Here is a narrowing of energy liberations downwards, so that
from energizing of motor nervous arrangements of the highest
centres representing the whole organism, there results move¬
ment of but the part most specially represented in those
motor nervous arrangements.
The resistance offered by middle to highest centres is
important with regard to the differences between les petits
maux and les grands maux , and with regard to differences in
degrees of post-epileptic states. Above all, it is important
with regard to differences in the physical conditions during
faint and vivid states of (object) consciousness, ideation and
perception for example. In speaking of resistances by
centres we suppose there to be degrees of resistance, the
smaller cells of the centres resisting least.
xxxm. 3
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34 Evolution and Dissolution of the Nervous System, [April,
(9) Recapitulation and Recommencement .—The highest
centres are, we repeat, nothing else than centres of universal
and most complex, &c., representation, or what is equivalent
of universal and most complex, &c., co-ordination. There is
nothing else for them to represent than impressions and
movements. Using old-fashioned language they are poten¬
tially the whole organism; the whole organism is “ poten¬
tially present ” in them. They are the unifying centres of
the whole organism, and thus the centres whereby the
organism as a whole is adjusted to the environment. Antici¬
pating, they are, although the most complex, &c., the least
organized, the ever organizing, and thus the centres whereby
new adjustments of the organism, as a whole, to the environ¬
ment are possible, that is, the centres in which evolution is
most actively going on. Correspondingly they are the least
automatic, or most imperfectly reflex, centres.
I have long since come to the conclusion above stated,
that the cerebrum (I now say highest centres of the cerebral
system) is universally representing. Nearly eighteen years
ago I wrote : “ We have now, then, to add to the constitu¬
tion of the units of the cerebrum nerve fibres to the heart
vessels and viscera, or rather possibly to regions, of the
sympathetic system from which these parts are supplied.
The inference we have now arrived at is that the units of the
cerebral hemisphere (in the region of the corpus striatum, at
least) represent potentially the whole processes of the
body” (“Medical Mirror,” Oct., 1869). Some years ago I
asked the question, “ Of what ‘ substance 5 can the organ of
mind be composed unless of processes representing move¬
ments and impressions P And how can the convolutions
differ from the inferior centres except as parts representing
more intricate co-ordinations of impressions and movements
in time and space than they do ? Are we to believe that the
hemisphere is built on a plan fundamentally different from
that of the motor [and sensory] tract?” (“St. Andrew’s
Med. Grad. Reports,” 1870). These are crude statements,
but I have since given, I hope, clearer accounts of the hypo¬
thesis.
In “Brain,” January, 1887, there appears an article by
Dr. Mercier on “ Coma,” already quoted from, which deals
with insanity realistically and in a very masterly manner. It
is a great satisfaction to me to find that Dr. Mercier agrees
with me in many of the opinions I have formed on insanity,
considered as dissolution beginning in the highest centres
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35
1887.] by J. Hughlings Jackson, M.D.
of the cerebral system. These centres he agrees with me in
thinking to be sensori-motor, universally representing and
most complex. When dealing with the physical condition
in coma, Dr. Mercier writes, “ Thus we arrive at this most
important conclusion: that the highest nervous processes,
which form the substrata of the most elaborate mental
operations, represent at the same time not only the most
elaborate forms of conduct and muscular movements, but
also every part of the organism (italics in orig.) in some
degree.” Ribot, in his remarkable and most valuable work
on “ Personality,” writes, “ Nous pourrons dire quelaconche
corticale represente toutes les formes de l*activit£ nerveuse;
visc6rale, musculaire, tactile, visuelle, significatrice.” In
another part of his book Ribot writes, “Le moi est une
co-ordination.” The assertion I make is that the physical
basis of the Ego represents—that is, that the highest centres
represent—or co-ordinates the whole organism in most
complex, &c., ways. Just as the consciousness of the
moment is, or stands for, the whole person psychical, so the
correlative activities are of nervous arrangements, represent¬
ing the whole person physical.* In this connexion I would
refer to a very able paper (“ On the Pathology of Mania ”) by
Dr. Wiglesworth, “ Journ. Mental Science,” January, 1884.
(10) Representation and Co-ordination—Disorders of Co¬
ordination with Negative Lesions. —A statement made (Section
9) that representation and co-ordination are the same thing,
is contrary to. current opinion. Although co-ordination or
representation is always sensori-motor, I shall arbitrarily
limit present illustration to motor centres. I should say
that the highest motor centres (prse-frontal lobes) co¬
ordinate movements represented in the middle centres
(Rolandic region) only in the sense that the former repre¬
sent over again in more complex, &c., ways, the movements
represented by the latter; just as the latter represent over
again and in more complex, &c., ways, what the lowest
motor centres have represented in less complex ways, and
just as these lowest centres represent the muscles in least
complex ways. In short, all centres of all ranks are at once
co-ordinating and representing. I have a particular reason
for this recapitulation. I assert that negative lesion of
* This sentence implies more than has been expressly stated, viz., that each
unit of the highest centres is a miniature highest centre, that is, represents in
some degree the whole organism (Factor Integration), no two units representing
it in just the same way (Factor Differentiation).
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36 Evolution and Dissolution of the Nervous System , [April,
any centre never produces “ disorder of co-ordination; 55 it
produces paralysis, sensory or motory, or both, and nothing
more. The doctrine of nervous evolution will not be under¬
stood unless it be seen clearly that centres do not represent
muscles but movements of muscles. Thus, referring to the
illustration given (Section 3), there is in progressive muscular
atrophy loss of simplest movements (in this case, it is true,
nearly approaching loss of muscles), in cortical monoplegias
there is loss of more complex movements, and in cases of
general paralysis there is loss of most complex movements.
Motor paralysis from negative lesion of any motor centre is
always loss of movements.
There is something more than paralysis in inco-ordination
from negative lesions, but this something more is not pro¬
duced by the negative lesion, not by disease in the proper
sense of pathological change. When we speak of evolution
it is understood (Section 4) that there is evolution with
dissolution. Dealing only with dissolution from disease,
we say that in the cases of inco-ordination from negative
lesion of lowest motor centres, for example “ professional
cramps,” there is loss of some most special movements
(dissolution) of certain muscles, and from over-activity of
levels of evolution left, there is forcing of other more general
movements of those muscles. There is on a small scale what
there is on a large scale in insanity (Section 4). In fact,
the formula of all inco-ordinations due to negative lesions,
from the duplex symptomatology of cases of paralysis of
ocular muscles up to the duplex symptomatology of cases of
post-epileptic unconsciousness with mania (the physical con¬
dition), is that there is loss of some (most special) movements
with forcing of other (more general) movements. This is
assuming that there is paralysis from the negative state of the
highest centres which is implied by the negative affection of
consciousness.
(11) Consciousness and the Physiology of the Highest Centres.
—So far we have said nothing, except incidentally, of con¬
sciousness. To the assertion that the highest centres are
only the latest developed and most elaborate part of a sensori¬
motor mechanism, it may be rejoined that “they are for
mind/ 5 So we have taken them to be in the sense that they are
the physical basis of mind . But they are “ for body 55 too;
strictly they are for nothing else—for nothing else than for
co-ordinating or representing the different parts of the body
in relation to the whole in most complex, &c., ways.
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37
1887.] by J. Hfghlings Jackson, M.D.
It may be said that “ consciousness is a function of the
brain” (highest cerebral centres). This I deny. Function
is a physiological term; it has to do with the dynamics of
the nervous system, with things physical only. It has to do
with storage of energy (the taking in of materials having
potential energy),* with nervous discharges (or liberations
of energy) by nerve cells ; with the rates of the liberations,
the resistances encountered, and the degrees of those resist¬
ances. The “ organ of mind” is only the most complex,
&c., part of what is anatomically a sensori-motor machine,
and there is nothing going on in it, other than nervous dis¬
charges, overcoming lines of resistance in order, from least
towards most; there is no interference by volition, emotion,
&c. We cannot take a too brutally materialistic view of the
" organ of mind,” but in order to do so we must not take a
materialistic view of mind.
(12) Several Doctrines as to the Relation of Consciousness
to Activities of the Highest Centres .—I am not competent to
discuss the metaphysical question of the nature of the rela¬
tion of mind to nervous activities. There are three doctrines
(1) That mind acts through # the nervous system (through
highest centres first) ; here an immaterial agency is supposed
to produce physical effects ; (2) that activities of the highest
centres and mental states are one and the same thing, or
are different sides of one thing. A third doctrine, (3) one I
have adopted, is that (a) states of consciousness (or synony¬
mously states of mind) are utterly different from nervous
states of the highest centres; (b) the two things occur to¬
gether, for every mental state there being a correlative ner¬
vous state ; (c) although the two things occur in parallelism,
there is no interference of one with the other. Hence we
do not say that psychical states are functions of the brain
(highest centres), but simply that they occur during the
functioning of the brain. Thus in the case of visual percep¬
tion, arbitrarily simplifying the process, there is an un¬
broken physical circuit, complete reflex action, from sensory
periphery ultimately through highest centres, back to
muscular periphery. The visual image, a purely mental
state, occurs in parallelism with— arises during (not from )—
the activities of the two highest links of this purely physical
chain (sensori-motor elements of highest centres)—so to
speak, it “ stands outside ” these links.
(13) The Doctrine of Concomitance .—It seems to me that
* Perhaps this storage is better described as being part of the nutritive
process.
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38 Evolution and Dissolution of the Nervous System, [April,
the third doctrine, that of concomitance, is at any rate
convenient in the study of nervous diseases. A critic of
my Croonian Lectures, who in all other respects dealt with
my opinions very good-naturedly, says that I state this
doctrine in order to evade the charge of materialism. It, or
an essentially similar doctrine is held, so far as I can make
out, by Hamilton, J. S. Mill, Clifford, Spencer, Max Muller,
Bain, Huxley, Du Bois Raymond, Laycock, Tyndall and
Herman. The critic referred to says that the doctrine of
concomitance is Leibniz’s “two clock theory/’ It may be;
it matters nothing for medical purposes whether it is or is
not. The evolutionist does not, however, invoke super¬
natural agency. As Fiske says, “The assertion of the
evolutionist is purely historical in its import, and includes
no hypothesis whatever as to the ultimate origin of con¬
sciousness; least of all is it intended to imply that con¬
sciousness was evolved from matter.” (“Darwinism and
other Essays,” p. 67.)
The doctrine of concomitance will seem unsatisfactory to
those who seek an explanation of mental states. But no
explanation is intended in any part of this paper. Sup¬
posing the account given of the constitution of the “organ
of mind ” to be more thorough and quite accurate, it would
be no explanation of the mental states correlative with its
activity. The second doctrine seems to give an explanation,
or rather complacently assumes that there is nothing to ex¬
plain. It, like the two others, is a metaphysical doctrine,
although I imagine some holders of it would consider it a
very realistic and most practical statement of the facts. To
merely solidify the mind into a brain, is to make short work
of a difficult question. And if we go on talking of the “ brain
mind ” essentially in the same way as the popular psycholo¬
gist does of the mind—“ emotional centres,” “ volition pro¬
ducing movements,” &c.—we help nothing in a scientific
study. Further, supposing the doctrine of crude materialism
be true, it does not go far enough. For to give a correct
materialistic account of mind—I mean, granting for the
moment that such an account can be given—is not to give an
anatomical account of brain, which (Section 7) is to show
what parts of the body it represents, and the ways in which
it represents them.* The first doctrine seems to me to be the
least worthy of attention.
* For many medical purposes I could adopt the seoond doctrine if it were
formulated that the brain had two functions—one mental, and the other that
of co-ordinating parts of the body.
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1887.]
by J. Hughlings Jackson, M.D.
39
To put the matter in another way, let it be granted for
the sake of argument that the separation into states of the
highest centres, and what we called the utterly different and
yet concomitant states of consciousness, is known to be erro¬
neous, and that the doctrine (2) is ascertained to be the true
one. I then ask that the doctrine of concomitance be pro¬
visionally accepted as an artifice, in order that we may study
the most complex diseases of the nervous system more easily.
There can be no difficulty in understanding the statement . It
is as easy to understand the statement that states of con¬
sciousness simply occur during activities of the highest parts
of the nervous system, as it is to understand the statement
that states of consciousness occur from such activities. It
makes it neither more nor less difficult that the activities are
of centres which represent or co-ordinate impressions and
movements in the ways several times mentioned.
Our concern as medical men is with the body. If there
be such a thing as disease of the mind, we can do nothing for
it. Negative and positive mental symptoms are for us only
signs of what is not going on, or of what is going on wrong,
in the highest sensori-motor centres.
(14) The Range of Concomitance .—What is the range of
concomitance ? For my part I think the whole body is “ the
organ of mind,” as I have in effect asserted (Section 8) when
speaking of the dynamics of the chain of centres. I shall,
however, continue to speak of the highest centres as being
the “ organ of mind.” Here the question recurs : “ How far
down” in the highest centres is there consciousness attend¬
ing nervous activities ?
A distinction is made by many between mind and con¬
sciousness.* I suppose they would say that consciousness
shows activities of the highest and mind activities of the
lower nervous arrangements of the highest centres. I take
consciousness and mind to be synonymous terms (Section 1);
if all consciousness is lost all mind is lost (Section 2). Un¬
conscious states of mind are sometimes spoken of, which
seems to me to involve a contradiction. That there may be
activities of lower nervous arrangements of the highest
centres, which have no attendant psychical states, and which
yet lead to next activities of the very highest nervous
arrangements of those centres whose activities have at¬
tendant psychical states, I can easily understand. But
* I admit the distinction into Subject and Objeot consciousness, and also that
into faint and vivid states of consciousness.
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40 Evolution and Dissolution of the Nervous System, [April,
these prior activities are states of the nervous system, not
any sort of states of mind.
There is one way in which this question directly con¬
cerns us. After some epileptic fits the patient is “ uncon¬
scious ,^ 93 and acts elaborately. Is he really void of all
consciousness ? Some might say that the fact of his
remembering nothing of his actions on recovery (this is
the rule) is proof of entire absence of consciousness ; others
would say that the elaborateness and the purposive
seemingness of the patient’s actions show that he had
some consciousness remaining. Each opinion has con¬
sequences, as we shall see. To say that the patient had
unconscious or latent states of mind does not, I think help
us. As evolution progresses, consciousness is, so to speak,
“ raised higher; ” it may be that in dissolution the activities
on the lower level of evolution have attendant states of con¬
sciousness which in normal conditions they had not, or that
their normal slight states of consciousness become more vivid.
(15) Consequences of Accepting the Doctrine of Concomitance .
—Those who accept the doctrine of concomitance do not
believe that sensations, volitions, ideas, and emotions pro¬
duce movements or any other physical states. These ex¬
pressions imply disbelief in the doctrine of conservation of
energy*; movements always arise from liberations of energy
in the outer world, and it would be marvellous if there were
an exception in our brains, marvellous if, for example, The
Will, an immaterial agency, interfered in the activities of
nervous arrangements of the highest centres.f They would
not say that an hysterical woman did not do this or that be-
* It may, however, be said that it has not been, shown that the principle of
conservation of energy does apply in physiology. On this matter I quote from
Daniel’s “ Principles of Physics,” p. 45 : “There is one case in which the prin¬
ciple of the conservation of energy is not as yet definitely established. This is
in the domain of Physiology, but the words of Clark Maxwell may, in this con¬
nection, be quoted : * It would be rash to assert that any experiments on living
beings have, as yet, been conducted with such precision as to account for every
foot pound of work done by an animal in terras of the diminution of the intrinsic
energy of the body and its contents; but the principle of Conservation of Energy
has acquired so much scientific weight during the last twenty years, that no
physiologist would feel any confidence in an experiment which showed a con¬
siderable difference between the work done by an animal and the balance of
the amount of Energy recovered and spent.’ ”—“.Nature,” Vol. xix., p. 142.
f I mean that they would not in scientific exposition. I no more object to the
statement that “ fright makes the heart beat,” or that “ mind influences the
body ” at a clinical conference, than I do to the statement that the “ sun rises
in the east” in ordinary talk. But the mind does not influence the body,
although the highest centres affect the rest of the body, and the sun does not
rise in the east.
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1887.]
41
by J. Hughlings Jackson, M.D.
cause she lacked will; that an aphasic did not speak because
he had lost the memory of words; and that a comatose patient
did not move because he was unconscious. On the con¬
trary, they would give, or try to find, materialistic explana¬
tions of physical inabilities. They would not use the term
sensation convertibly with active states of any sensory ele¬
ments. They would avoid such expressions as “ Physiology
of the Mind/’ “ Psychology of the Nervous System,” and
“ Dissolution of the Mind.” They would not use such com¬
pounds of (l) psychological, and (2) anatomico-phvsio-
logical terms, as (l) “ideo- (2) motor,” (1) “ voluntary
(2) movement ” “(1) ideas of (2) movements,” (1) “psycho-
(2) motor,” &c. They would not speak of “ (1) voluntary
(2) centres,” (1) “ emotional (2) centres.” They would not use
“ most voluntary ” as the proper opposite of “ most auto¬
matic.” Automatism is a purely physical thing. There are
degrees from most automatic, not up to the most voluntary or
to volition, but to least automatic. During activities of the
least automatic centres (highest centres), Will and other ele¬
ments or states of (object) consciousness arise. They would
not in scientific exposition make piebald classifications of
symptoms, e.g. 9 sensory , motor , emotional, and intellectual.
The two words italicised are names of physical states; the
other two of psychical states. Such classifications, perhaps
allowable clinically, are, for scientific purposes, as unjustifi¬
able as a classification of plants into endogens, graminacese,
kitchen herbs, ornamental shrubs and potatoes, would be.
They would not compare, nor even contrast, loss of conscious¬
ness in cases of disease of the highest centres with paralysis
from disease of any lower centres.
The term subjective is used in different senses in medical
writings. It is sometimes used for psychical states in con¬
trast to the correlative nervous states, which latter are then
called objective; sometimes for faint states of consciousness,
as in ideation, in contrast to vivid states of consciousness, as
in perception, which are then called objective; sometimes
very crudely, for mind and brain together in contrast to
“real things,” that is, objects in themselves coloured,
shaped, &c., which are then called objective.
(16) Recapitulation .—I speak now in recapitulation both
of the sensori-motor mechanism and of states of conscious¬
ness. The assertion is not simply that states of conscious¬
ness attend activities of nervous arrangements. Nor is it
enough to say that they attend activities of highest nervous
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42 Evolution and Dissolution of the Nervous System, [April,
arrangements of the highest centres unless it be understood
that these nervous arrangements represent, or co-ordinate,
parts of the body in most complex, &c., ways. A morpho¬
logical account of the physical bases of psychical states does
not suffice; we must give an anatomical account. Whilst a
man is thinking, or even dreaming, of a brick, he is having
a purely psychical state; the correlative physical state is
slight discharge of some complex, &c., nervous arrangements
of his highest centres. So far, the statement as to the
physical process is only morphologico-physiological. But
we go on to add representing parts of his body —certain retinal
impressions and particular ocular movements—that is, an
anatomico-physiological account of the physical process. So
far for the faint state of consciousness, thinking of the brick
(ideation); the physical process is confined to the highest
centres. In perception, seeing the brick vivid state of con¬
sciousness (see Section 8), the highest centres are acted on
from the periphery, and react upon it; here at any rate is
sensori-motor action, exceedingly compound reflex action.*
Similarly, mutatis mutandis , for vivid and faint mental states
of other kinds and for the anatomy of their physical bases.
Repeating, in effect, a former statement (Section 1), the
epileptic convulsion is nothing other than a sudden, exces¬
sive and nearly simultaneous development of the motor ele¬
ment in the anatomical substrata of crowds of psychical states
(in their totality, states of consciousness), with next develop¬
ment of less evolved motor elements of the middle and lowest
centres.
I will now try to show the bearing of the remarks in Sec¬
tions 14, 15 and 16 by a particular case.
(17) Analysis of the Symptomatology of Slight Fits of Epi¬
lepsy .—A slight fit (le petit mat) of epilepsy proper is owing
to a slighter discharge beginning in some part of the highest
centres than that which produces the severe fit (Section 1).
The discharge being resisted by the middle motor centres,
produces slight peripheral effects, but irradiating widely in
the highest centres, there may be seemingly absolute loss of
consciousness. Apart from the particulars of this speculation,
let us consider the differences in what we put together
clinically “as symptoms of epilepsy.” We shall take symp-
* The illustrations are arbitrarily simplified. The nervous arrangements dis¬
charged during any mental process no doubt represent the whole body (Inte¬
gration), although some part of it most (specialization) ; during visual percep¬
tion those discharged represent most especially the retinal and ocular parts of
the body.
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1887.]
by J. Hughlings Jackson, M.D.
43
toms of slight fits from cases of several patients. I wish to
suggest that the proper analysis of this complex symptoma¬
tology is impossible unless, among other things, we distin¬
guish between the psychical and the physical. We have also
to note degrees of positive and superpositive states of con¬
sciousness in these cases from the crudest to the most
elaborate, and to consider the physical conditions of them.
We have also to consider separately negative affections of
consciousness and degrees of them. We have also to dis¬
tinguish between physical conditions, especially between
convulsions and movements ordinarily so-called. In things so
complex as epilepsy and insanity, generalizations are worth¬
less without prior analysis. As was shown, Section 1, the
epileptic paroxysm is an exceedingly complex thing.
(1) There is sometimes a “ warning” of crude sensation,
e,g. 9 a stench comes into the nose. As the term sensation
tells us, this is a mental state, it is superpositive. It is a
very crude and excessive state, and implies the correlative
physical condition of sudden, &c., discharge of many central
olfactory elements at once, and is our clue to the seat of the
“ discharging lesion.” (2) There is the emotion of fear.
(I do not mean a fear of the fit, but “fear which comes by
itself.”) This is a very complex psychical state, and, I sub¬
mit, does not occur during sudden, &c., discharges, but arises
during slight discharges of very complex nervous arrange¬
ments representing parts of the body, especially organic parts,
concerned in the manifestations of fear.* (3) There is some¬
times the “ dreamy state,” so-called “ intellectual aura ; ” for
example, there rises a feeling “ of being somewhere else.”
This is an exceedingly complex mental state, and cannot, I
submit, arise during discharges at all comparable in
degree with those which produce convulsions. Consider
how vastly it differs in degree of elaborateness from a crude
sensation, the physical condition for which crude sensation
is comparable to the sudden, &c., discharge of motor elements
from which convulsion results. So far we have spoken of
positive and superpositive states of consciousness, urging
that there are great differences in their degrees of elaborate¬
ness, and alluding to their physical correlatives. There are
negative states of consciousness.
There is very often a stage of (4) defect of consciousness
* My belief is that what are called the manifestations of fear are really
after-effects of a discharge. Fear is anger broken down, and is antithetical to
anger in that sense.
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44 Evolution and Dissolution of the Nervous System , [April,
before what we call (5) loss of consciousness. These nega¬
tive affections of consciousness occur during the sudden,
&c., discharge; for whilst consciousness arises during slight
sequent discharges, it ceases during sudden, &c., discharges
of many nervous arrangements at once.*
We have (6) convulsions of the eyes, face, hands, and
other parts ; these do arise from sudden excessive discharges
developing many movements of the several parts simul¬
taneously. I submit that they occur especially from dis¬
charges beginning in motor elements entering into the
anatomical substrata of visual ideas, of words, of tactual
ideas, and of other psychical states (Section 16), and from
next discharges of connected motor elements of middle and
lowest centres. (7) Pallor of the face, arrest of heart, flow
of saliva, passage of faeces and urine, are results of sudden,
&c., discharges beginning in motor elements entering into
the anatomical substrata of emotions and other psychical
states. Some of these, however— e.g., the passage of faeces
—are the indirect results of such discharges—are owing to
permitted over-activity after exhaustion of inhibitory nervous
arrangements by the epileptic discharge.
Convulsion is the u running up” of very many move¬
ments into a fight. But (8) there are sometimes in the
slight epileptic paroxysm movements properly so-called, e.g. 9
clutching at the throat, rubbing one hand with the other,
chewing and tasting movements. These arise, I submit, as
an indirect result of comparatively slight epileptic discharges
of sensory elements. Thus the chewing movement (so often
associated with the “dreamy state ”) is, I submit, the indirect
result of an epileptic discharge of gustatory elements (Ferrier
finds that faradising a monkey’s gustatory centre produces
such movements). Now for the post-paroxysmal state.
After a slight paroxysm of le petit mat , in many cases the
patient may be (9) simply confused for a short time, that is
defectively conscious; physically there is exhaustion of very
few elements of his highest centres, and correspondingly, I
submit, he is slightly paralysed consequent on this exhaus¬
tion. For it is of the motor and sensory elements in the
physical bases of mental states, and of connected elements
of lower centres. The condition is, however, described
* When there is the u dreamy state v there is doable consciousness (“ mental
diplopia n ), there being remains of consciousness as to present surroundings
(remains of object consciousness), and increase of consciousness as to some
former surroundings (increase of subject consciousness).
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1887.] by J. Hughlings Jackson, M.D. 45
popularly as “ prostration,” &c. After a severer attack
of le petit mat there (10) remains what is called (Section
14) “loss” of consciousness, implying, it is suggested, still
deeper exhaustion, and, correspondingly, more paralysis. But
often there is (11) with the “unconsciousness” a concerted
series of elaborate movements of all parts of the body (mania
for one example) which are the physical counterparts of
what are psychically actions or conduct. Now, contrary to
some physicians, I submit that these are not the result of
anything like an epileptic discharge, but that they arise
during activities on the lower level of evolution remaining
(Section 4). The prior epileptic discharge has left exhaus¬
tion of, say, the highest “ layer ” of the highest centres
(dissolution); the series of movements result from activity
but super-normal of the second, the no longer controlled
layer. Here is a phenomenon of the same order as increased
rate of cardiac action after section of the vagus.
(18) Suggested Scheme of Work .—Before going further I
make the following statements, partly in recapitulation and
partly to give an outline of future exposition. We have to
show how the following superficially different sets of phe¬
nomena occur from disease of the “ organ of mind,” and how
they are explicable on the principle of dissolution.
(I) From sudden, rapid, and excessive discharges beginning
in some part of the “ organ of mind ” we have universal or
widespread convulsion or its equivalents. Although con¬
sciousness arises during slight sequent discharges of nervous
arrangements of the highest centres, it ceases during the
sudden, &c., discharges thereof.
(II) After the fit there is often insanity. We make three
degrees of post-epileptic insanity. There are correspond¬
ingly three depths of exhaustion (dissolution) effected by the
discharge in the prior paroxysm, each depth being propor¬
tionate to the severity of the prior discharge. To these
negative physical states the negative mental symptoms,
defects of consciousness, marked (a) correspond. There are
correspondingly three shallows of evolution ; the positive
mental symptoms, the patient’s mentation, marked (b) corres¬
pond to what are physically activities on these lower levels.
(1) After, or in, a slight fit, there is (a) defect of conscious¬
ness as to present surroundings with ( b ) increase of con¬
sciousness (“ dreamy state ”) as to some former surroundings.
(See Section 17.) These are selected cases of le petit mal, and
the nature of the physical condition for the symptoms is dis-
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46 Evolution and Dissolution of the Nervous System , [April,
puted, it being held by some that the two opposite mental
states occur during a slight epileptic paroxysm. Hence,
beyond now stating (1) as provisionally a first depth of dis¬
solution, I shall say no more of it. (2) After a severer fit, or on
partial recovery or re-evolution from the effects of a severest
one, there is (a) so-called (Section 14) “ loss ” of conscious¬
ness with (6) actions (post-epileptic “ unconsciousness 99 with
mania for one example). Here is a second depth of dissolu¬
tion with a less high level of evolution remaining. (There
are sub-degrees of this degree. There are, speaking only of
the positive element, degrees from most elaborate and highly
special actions to the simple and very general actions of
sprawling on the floor.) (3) After a severest fit there is (a)
coma. Here there is no positive mental state according to
current opinion ; there is acute dementia. There is a lower
level of evolution; there are, as outcomes of its activity, of
course, certain “vital” movements (circulatory and respira¬
tory), or the patient’s dissolution would be total. But these
“ vital 99 movements being physical things are not comparable
and contrastable with ( b ) in (1) and (2). Here is a third
depth of dissolution with a very shallow level of evolution
remaining.
Everybody regards No . 2 as insanity (middle depth of
dissolution with middle level of evolution remaining), but
scarcely anyone takes No. 1 and No. 3 to be insanity. Some¬
times (2) occurs on partial recovery from (3) ; even then,
although 2 is called insanity, 3 is not. My contention is that
from a scientific, I do not say from a clinical standpoint, 1,
2, and 3 are insanities ; 3 is temporary acute dementia. That
each is a departure from the patient’s normal mental state is
enough for us as evolutionists to whom all three are insani¬
ties ; for us as clinicians, 1 and 2 do not approach standard
clinical types of insanity, and are thus, for the clinician, not
insanities.
(Ill) These degrees of insanity have to be compared and
contrasted with three degrees of the physiological insanity
of sleep: —(1) Sleep with dreams; (2) Deeper sleep with
actions (somnambulism); (3) Deep so-called dreamless sleep.
Also with three degrees of drunkenness (Mercier makes
four). They have to be compared and contrasted with
degrees of insanity in acute non-cerebral disease (pneumonia
for example); with degrees of insanity from poisoning with
belladonna, cannabis indica, Ac. Finally, they have to be
compared and contrasted with degrees of chronic cases of
insanity ordinarily so-called. (As before said, there are
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47
1887.] by J. Hughlings Jackson, M.t).
different kinds of insanities, physically dissolutions of dif¬
ferent parts of the highest centres.) Besides this kind of
comparative study, there is another far more important to
the evolutionist.
(IV) Insanities* considered as diseases of the highest
centres have to be compared and contrasted with diseases of
middle and lowest centres. To this end we have to find the
physical condition correlative with the insanities.
(1) The assertion is that negative affection of conscious¬
ness, both in the acute transitory insanities spoken of in
[II) and the acute and the persisting insanities spoken of
m (III), implies paralysis, the paralysis being proportionate
to the degree of negative affection of consciousness. On
this basis we may compare and contrast not negative affec¬
tion of consciousness, but paralysis from negative lesions of
the highest centres, which the negative affection of conscious¬
ness implies , with paralysis from negative lesions of middle
and lowest centres. To give an illustration, some of the
statements being hypothetical: progressive muscular atrophy,
paralysis agitans, and general paralysis of the insane are
alike in being owing to wasting of cells in the order of their
size from smallest towards largest; they are different in that
the wasting occurs respectively on the lowest, middle, and
highest levels of motor evolution ; there is loss of simplest,
of complex, and of most complex movements.
(2) Now for positive mental symptoms. These make up,
or are to us the present signs of, the patient's mentation
or consciousness, and are the lower homologues of his
normal mentation or consciousness. We have to try to show
how sensori-motor activities—activities of most complex, &c.,
sensori-motor nervous arrangements, those of the highest
centres—are correlative with states of consciousness. To do
this we shall accept the artificial analysis of (object) conscious¬
ness (we neglect for the moment subject consciousness),
into Will, Memory, Reason, and Emotion, and then try to
show the anatomy of the physical bases of each—that is,
what parts of the body the physical bases (sensori-motor
nervous arrangements) of each represent most specially.
In this attempt we must have constant reference to lower
centres out of which the highest are evolved. The following
is an imperfect sketch, among other things, ignoring In-
* As remarked when speaking of different varieties of epilepsies, of epileti-
form seizures, and of bnlbar, &c., fits, there are fits from discharges of different
levels of evolution. These have to be compared and contrasted, and also the
paralyses after fits of each kind.
Digitized by L^ooQle
48 'Evolution and Dissolution of the Nervous System. [April,
tegration: What on the lowest level are (1) centres for
simplest movements of the limbs become evolved in the
highest centres into the physical bases of volition; what
on the lowest level (2) are centres for simple reflex actions
of eyes and hands are evolved in the highest centres into the
physical bases of visual and tactual ideas; what on the
lowest level are (3) centres for movements of the tongue,
palate, lips, &c., as concerned in eating, swallowing, &c., are
in the highest centres evolved into the physical bases of words,
symbols serving us during abstract reasoning. (4) What
on the lowest level are centres representing the circulatory,
respiratory and digestive movements are evolved in the
highest centres into the physical bases of emotions. So to
speak, the lowest level does menial work; the highest level,
evolved out of it, becomes in great degree independent of
it and is the anatomical basis of mind.
Negative affections of consciousness are supposed to imply
paralysis consequent on loss of the motor (or sensory) ele¬
ments in the most complex of all sensori-motor nervous
arrangements, those entering into the physical bases of the
four “ faculties 99 (really four different aspects of object-con¬
sciousness) (dissolution). The positive mental symptoms are
supposed to be the lower homologues of the patient’s normal
Will, Memory, Reason, and Emotion (object-consciousness).
They are the mentation going on on the lower, but then
highest, level of evolution, &c., and imply slight sequent
activities of less complex, &c., sensori-motor nervous arrange¬
ments representing parts of the body, than those lost.
East Riding Asylum , Beverley. Plans and Description of a
Detached Hospital for Cases of Infectious Disease. By
M. D. Macleod, M.B. Edin., Medical Superintendent.
Among the descriptions which have appeared from time to
time in the “ Journal of Mental Science ” of buildings
arranged for the treatment of the insane, I have not observed
any which show details of a building, in connection with an
asylum, set apart for cases of infectious disease.
The plans of the building here shown were drawn by
Messrs. Smith and Brodrick, of Hull, architects, under whose
supervision it has been erected. The plans have received
the official sanction also of the Secretary of State through
the Commissioners in Lunacy.
Digitized by {jOoq le
JOURNAL OF MENTAL SCIENCE.
APRIL 1887.
East Ripinq Asylum Yorks .
New Detached Hospital.
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Digitized by
1887.]
49
East Itiding Asylum, Beverley .
This hospital is situated at a distance of 180 yards to the
south-east of the asylum, that site being for local reasons the
best available on the estate.
The building will accommodate seven male and seven
female patients, or about five per cent, of the average
inmates in the asylum. There are rooms for two nurses, and
the hospital is complete with stores, kitchen, scullery, wash¬
house, and laundry. Over the kitchen and scullery are two
bedrooms for servants. Attached to the laundry is a stove
for disinfection of clothing and bedding by heat.
The hospital proper is a single-story building, having at
each end a dormitory for five beds. These dormitories are
separated from each other by a spacious entrance hall and
two short corridors. The nurses’ rooms and store-rooms are
placed in these corridors, so that separation of the sexes is
amply provided for in the event of there being patients of
each sex in the hospital at the same time. The dormitories
are fourteen feet high, well lighted on each side, and warmed
by open fire-places, having thus good provision for natural
ventilation. Ventilation is also further provided for by
means of Boyle’s ventilators in the roof to exhaust foul, and
wall-tubes to admit fresh, air from outside.
At the farthest end of each ward is a passage, into which
open two single rooms. These single rooms are warmed by
a stove placed at the end of the partition-wall between
them, and separated from the rooms by perforated terra cotta
bricks.
Behind each dormitory and attached to it is a small
annexe in which the closets, baths, and sinks are placed.
These are divided from the wards by a passage having
windows on each side, obviating the entrance of emanations
into the wards from the closets. The closets are on the dry-
earth system, but the arrangement is equally suitable for
water-closets. The hot water for the baths is provided for
by a boiler connected with the kitchen range.
The building is constructed of red bricks, and has hollow
walls. Ornamental effects are got by lines and arches of
white bricks, and the cornices and eaves gutters are moulded
to suit the general effect of the main building.
The roof of the hospital is boarded and felted under the
slates, which will make it a warmer building in winter and
a cooler one in summer.
The cost of construction will amount to £1,600, or about
£114 a bed.
xxxin. 4
Digitized by Google
50
East Riding Asylum , Beverley. [April,
The building looks well, and has all the requirements of
an hospital arranged in a simple and efficient manner.
The wards on this plan can be made larger, and the whole
building made to accommodate more patients by adding
additional wards to each end, the offices being arranged in
suitable proportion in their present position.
Concerning a new form of Mental Disturbance , having well-
defined characters both clinically and pathogenetically* By
Dr. Meschede, of Konigsberg.
In the classification of the different forms of insanity, it has
been agreed to distinguish two chief groups—the first includ¬
ing those recent and curable psychoses, to which the term
diseased process is of a truth applicable—the second including
those incurable cases which have run their course, and which,
indeed, scarcely merit the term diseased process , representing
rather, as they do, permanent vices, the results of past disease.
Since, in the first group, the psychoses affect principally the
emotional and psycho-motor elements of the nervous system,
the diseases belonging to this category have been described as
of the character or temper (in its older sense) as against diseases
of the intellect, which constitute the second category—these
latter being marked chiefly by failure of the intellectual powers.
In consequence of this somewhat schematic arrangement, the
conception has gained footing that the disturbances of the in¬
tellect are to be considered as for the most part consequential, ex¬
cepting those forms of so-called primary dementia* which result
from direct damage to the brain, excepting also idiocy, which
depends on arrest of development. Hence, one has become
accustomed to regard all cases of recent and curable psychic
affections as a species of character—or emotional—insanity, and
to look upon this, the emotional element, as the essential and
determining one; whilst in cases of intellectual insanity one
lays less stress on this form of unsoundness, and, as a rule,
treats of it as a secondary phenomenon.
This conception I cannot admit as adequate in all cases, for
not in all cases of recent and curable insanity does the character
or emotional element play the chief part; indeed, in not a few
is it just precisely the intellectual upset which is chief, and to
be considered as protopathic, i.e. y independent of any emotional
* In England, Dr. Meschede’s cases would be grouped under primary de¬
mentia, or mental stupor.—[E ds.]
Digitized by L^ooQle
1887.] A Hew Form of Mental Disorder , 51
t upset which may be also present . In cases of this kind, indeed,
we find that symptoms belonging to the will, or generally to the
character, if present, are so feebly marked, and of such variable
form, that it is difficult to determine whether to refer them to
either type—of depression or exaltation. On the other hand,
the intellectual disturbance is from the first well-defined, and
in the further course of the disease maintains its independence
of the ever-varying emotional phenomena. From this we per¬
ceive how greatly we should err did we attempt to deduce the
graver from the lighter disturbance—the more constant from
the varying.
From among the comparatively large number of yearly ad¬
missions into the Town Asylum of Konigsberg, I have observed
cases of recent insanity of the above-described kind—cases
which, as well in their clinical features as also in their etiology,
present so much in common, and so much that is characteristic,
that I consider they must form one group. This group is
characterized principally as follows :— That primarily and in¬
dependently of any emotional disturbance , whether simulta¬
neous or preceding, there occurs a grave disturbance of the powers
of presentation, and generally of the intellect, consisting
especially in the sudden disappearance, as it were at one stroke ,
of whole tracts of memory, also of current and therefore familiar
mental processes. Hence it results that the patient, so to speak,
loses his bearings to the outer world, and gazes around him
amazed and confounded as if he had opened his eyes for the first
time. The condition is analogous to that recently described as
psychic blindness.
This state of mental loss of vision—otherwise to be described
as memory-failure—is—note the second characteristic— curable;
it is therefore not a blindness in the sense of an irreparable
defect such as one meets with in certain forms of dementia and
of grave brain disorder.
Thirdly, characteristic of this form, is the fact that anomalies
of the will or emotions are either completely wanting, or so
slight and untypical that they cannot be admitted as determin¬
ing pathological factors; such emotional disturbances as may
be present, or even prominent, are mostly very changeable, and
appear to be reactionary processes ; not infrequently they fall
within the limits of the normal.
A fourth criterion is furnished by the etiology of the affec¬
tion, as also by the suddenness of the onset. In all cases
observed by me, a sudden fright or analogous psychic impres¬
sion brought about the disturbance. It is this very agreement
Digitized by Google
[April,
52 A New Form of Mental Disorder,
in relation to the nature of the cause, and to the immediate
effect of this cause, which, together with the similarity in the
characters of the psychosis, justify the separation of these cases
into a special group. The powerful effect that fright is capable
of producing is sufficiently well known, more especially also
the fact that even paralytic states may be induced thereby.
A fundamental characteristic of the disturbances which fright
is capable of effecting is inhibition of vital motor processes,
showing itself in spasm or paralysis; affer an analogous manner
its effect on the psychic organ (Seelenorgan) is to be con¬
ceived. However, this is not the place in which to treat of the
theoretic side of the question, since the present contribution has
in view only the establishment of the etiological and clinical
unity of a series of cases observed by me; as an example and
type, I beg leave to bring forward in brief one of these same
cases:—
A servant maid, having previously enjoyed mental and bodily
health, falls without warning into a deep pit. She is drawn
out without having sustained bodily hurt, but mentally there is
a disturbance, characterized chiefly by loss of the recollection
of former perceptions. Being sent into the town on errands,
she is unable to remember her commissions, and she appears
unable to find her way in streets familiar to her for many
years. She is equally incapable in her housework, seem¬
ing not to understand the use of the various utensils. For
this reason she is brought to the Konigsberg Asylum, and
amongst other symptoms presents the following :—The patient
behaves like one who has come into new and unfamiliar
surroundings , the significance of which she is unable at once
to fathom; she looks at things around her with a partly
astonished, partly meaningless gaze. In taking off her clothes
she is at fault, and in the process makes all sorts of blundering
movements, just as though she understood not the meaning or
the fashion of the garments, and could not recollect how they
were fastened. When taken to the bed assigned to her, and
told to lie down, she obeys truly, but lays herself across the
bed. It was clear that this and other failures resulted solely
from want of intellect , and did not follow on any instinctive
initiative. The emotional sphere showed neither marked ex¬
altation nor depression; on the contrary, there was in general
a condition of quiet indifference, though now and again emotional
excitement cropped up. Thus, on immersing the patient in a
bath, there was some vigorous shouting and groaning, much as
happens with children not accustomed to bathing. The patient
answered questions seldom, those concerning her health she did
Digitized by Google
1887.]
53
by Dr. Meschede.
for the most part, whilst those relating to objects held before
her, she mostly left unanswered, or replied only by a shake of
the head or a smile.
She repeatedly complained of pains in the back. In addition,
the following points were determined: hyperalgesia along the
spine, sensitiveness of the limbs to touch, acceleration of the
pulse without febrile exacerbation, halitus ex ore , neuropara¬
lytic erythema of the skin.
For some three days the condition persisted unchanged, thence
onwards a rapid improvement set in, so that by the end of nine
days the patient had completely regained her sanity ; at the end
of three more weeks she was dismissed quite cured.
If I have sketched thus shortly the history of a case,
typical of a group of mental affections, this has not been done
under the impression that something absolutely new has been
brought forward, for I take for granted that similar cases have
come under observation more or less frequently, and are probably
not wanting in medical literature. However, to my knowledge,
such have not been regarded from the point of view of a definite
clinical entity, and been raised to the dignity of a special group,
rather have they been described in part along with the group
of melancholia attonita or stupida , in part have they been in¬
cluded in the category of primary or so-called acute dementia ;
perhaps also they have been referred to other forms.
Such an apportioning seems to me to be rather perplexing,
and at any rate not likely to promote a proper valuing of the
facts. From the history of the case above given, it is evident
that it does not fit in with the group of the melancholiacs, or in
that of dementia, for the conception which the term dementia
carries with it is, according to present usage, that the defective
state is permanent; it is hence not applicable to any temporary
upset of the intellectual faculties.
In conclusion, to restate precisely my position, it is, that, on
the ground of personal observations I have endeavoured to
establish the occurrence amongst the recent curable psychoses of
cases in which a primary disturbance of the intellectual faculties
plays the chief part (in contradistinction to the majority of
curable psychoses in which an emotional disturbance is the
feature), then further to state my conviction that certain of such
cases may be grouped together by reason of a common patho¬
genesis (fright), as also by reason of the special features of the
psychosis (wholesale vanishing of familiar mental processes,
psychic blindness, etc.), and that such is more conformable to
reason than the reference of these same cases to the groups of
either dementia or melancholia.
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Google
54
[April,
Suggestions on the Construction and Organization of Hospitals
for the Insane . By Sanger Brown, M.D. (Late Assistant
Physician to the Bloomingdale Asylum, New York.)
It is not my purpose to discuss in detail hospital organiza¬
tion and construction, but simply to call attention to some
defects in both, which, I think, ought to be carefully
pondered by those who have an interest in the care and
treatment of the insane. My observations are intended to
apply, for the most part, to those hospitals mainly devoted
to the treatment of recent cases of insanity, and where no
considerable number of incurable cases is allowed to accumu¬
late. But with some slight modifications they apply with
equal force to all hospitals and asylums for the insane.
Within the past ten or fifteen years there has been through¬
out this country (America) almost a revolution in regard to
the care and treatment of the insane ; and while, as happens
always in revolutions, some doctrines may have been advo¬
cated, and some practices adopted, which are unsound, yet
it will be generally conceded that much actual improvement
has taken place.
When patients are properly classified and subclassified,
and kept constantly under the supervision of well-trained
and competent attendants, it is found that they do not often
develop into “ unmanageable” cases; and that after a few
weeks of judicious management, they become able to conform
to routine hospital requirements with more or less facility.
But while constant and careful supervision by competent
attendants is of the greatest importance in the treatment of
the insane, it is most difficult of accomplishment.
Various demoralizing influences are more rife, and acci¬
dents happen to patients much more frequently, while the
house work is being done than at other times; and, indeed,
under the present system patients must obviously suffer more
or less from neglect while the attendants’ time and attention
are occupied with housekeeping. Manifestations of disease
will not conform to the regulations of house-keeping, and
regulations are almost indispensable to proper house-keeping.
Both house-keeping and the care of patients are constant
and fairly invariable factors in hospital organization and
work. House work can be efficiently performed by people of
comparatively inferior moral and mental cultivation; while
the proper duties of an attendant demand a person of very
Digitized by
Google
55
1887.] Construction and Organization of Hospitals.
superior moral and mental qualities, who has been long and
carefully trained for his work. Under the present system of
organization the two duties are performed by the same
person—a person who feels above doing house work, but is
forced to do it, and who is too often, both in mind and
morals, far below what an attendant ought to be. By
separating the two lines of work, both might be more
efficiently and more economically performed. A better class
of attendants would be developed, and only enough of them
would have to be employed to give proper and constant
attention to patients; while the house work might be effec¬
tively done by ordinary servants, though this latter class
should not come into general contact with patients.
With some unimportant architectural modifications, the
typical hospital of to-day is constructed according to a plan
devised and adopted about thirty years ago, when views and
methods of treatment and management were very different
from those now in vogue; and, while the present edifices
certainly reflect credit upon the men who contrived them,
and upon the various legislative bodies who have in many
instances made such liberal appropriations for their erection,
they fail certainly in some ways to meet more modem
demands of treatment.
As to organization, the only change which I wish now to
suggest, consists in the employment of a superior class of
specially trained people to perform the duties of attendants
proper, and an inferior and cheaper class of people to do the
ordinary house work. And in order that this may be
properly accomplished, suitable day-rooms ought to be pro¬
vided for the patients while the house work in the sleeping
rooms and corridors is being done. I need hardly to call
attention to the fact that this provision of day-rooms is also
in accordance with the most approved hygienic conditions.
The next alteration I would suggest consists in the provision
of associated dining-rooms contiguous to the kitchen. By
this plan, food might be served in a more palatable form,
the amount wasted might be reduced to a minimum,
patients might receive better attention while eating, and
reparation to the dining hall thrice daily would afford some
additional relief to the monotony of hospital residence. As
many of the necessities of classification are as actively
in operation while patients are eating as at other times, I
cannot approve of a single large common dining hall, but
rather an aggregation of a sufficient number of rooms to
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56 Construction and Organization of Hospitals , [April,
permit of much the same classification as is carried out in
the wards. To those few patients who from various reasons
might be unable to go to the dining-rooms, and who would
be entirely confined to the infirmary and refractory wards,
food might be conveyed by a subway directly from the
kitchen, this same subway being used as a passage for
patients to and from the dining-rooms in very inclement
weather.
Lastly, there is needed in those wards set apart for the
treatment of noisy and refractory patients, some more
efficient provision than now generally exists, for the tem¬
porary isolation of such cases as may be, for the time being,
much more highly excited than their fellows. It is from
these noisy and refractory wards that most recoveries are
drawn, and therefore, in them, patients should be relieved as
far as possible from all influences which might seriously
interfere with recovery. It often happens, in these wards,
that a majority of the patients is disturbed by day and kept
awake at night by, perhaps, one or two who are, for the time
being, noisy. Unless suitable provision is made for isola¬
tion of such noisy patients, the question has often to be
decided, whether it will do less harm to allow the more quiet
patients to be disturbed or kept awake than to administer
so much of some potent sedative to the noisy patients as
shall render them noiseless. The consideration of such
a question must always be most painful to a conscientious
medical officer, but on the principle of the greatest good to
the greatest number, if such provision is not made as I have
referred to, he may feel it his duty to prescribe what he feels
may prove positively injurious to one patient, for the benefit
of others.
The appended diagram is intended as a mere sugges¬
tion as to how these alterations might be effected. Neither
the dimensions of the sleeping-rooms nor, indeed, the exact
accommodation of the different wards, have been carefully
considered, as that did not seem necessary to my present
purpose. It will be found, however, that about eight
hundred cubic feet have been allowed for each patient, both
in the day-rooms and sleeping-rooms,
It might be objected that the original cost of such a
hospital would be greater than that of one constructed
according to the plan now generally adopted. To this I
would reply, that the difference in the original outlay need
not be great, and might be more than counterbalanced by
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paper.
JOURNAL OF MENTAL
APRI L (887.
56
Construction and Organization of Hospitals , [April,
permit of much the same classification as is carried out in
the wards. To those few patients who from various reasons
might be unable to go to the dining-rooms, and who would
be entirely confined to the infirmary and refractory wards,
food might be conveyed by a subway directly from the
kitchen, this same subway being used as a passage for
patients to and from the dining-rooms in very inclement
weather.
Lastly, there is needed in those wards set apart for the
treatment of noisy and refractory patients, some more
efficient provision than now generally exists, for the tem¬
porary isolation of such cases as may be, for the time being,
much more highly excited than their fellows. It is from
these noisy and refractory wards that most recoveries are
drawn, and therefore, in them, patients should be relieved as
far as possible from all influences which might seriously
interfere with recovery. It often happens, in these wards,
that a majority of the patients is disturbed by day and kept
awake at night by, perhaps, one or two who are, for the time
being, noisy. Unless suitable provision is made for isola-
tion of such noisy patients, the question has often to be
decided, whether it will do less harm to allow the more quiet
patients to be disturbed or kept awake than to administer
so much of some potent sedative to the noisy patients as
shall render them noiseless. The consideration of such
a question must always be most painful to a conscientious
medical officer, but on the principle of the greatest good to
the greatest number, if such provision is not made as I have
referred to, he may feel it his duty to prescribe what he feels
may prove positively injurious to one patient, for the benefit
of others.
The appended diagram is intended as a mere sugges¬
tion as to how these alterations might be effected. Neither
the dimensions of the sleeping-rooms nor, indeed, the exact
accommodation of the different wards, have been carefully
considered, as that did not seem necessary to my present
purpose. It will be found, however, that about eight
hundred cubic feet have been allowed for each patient, both
in the day-rooms and sleeping-rooms,
It might be objected that the original cost of such a
hospital would be greater than that of one constructed
according to the plan now generally adopted. To this I
would reply, that the difference in the original outlay need
not be great, and might be more than counterbalanced by
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by Sanger Brown, M.D.
57
the current economy of administration. Indeed, the aboli¬
tion of ward dining-rooms would effect a considerable saving
in plumbing, lifts or dumb-waiters, pantries, etc., as well as
a saving of labour and food. If the advantage to patients
should prove as great as I have anticipated, the number of
recoveries would be increased and the number of violent and
refractory patients diminished, a consummation devoutly to
be wished for, both from a humanitarian and economic point
of view.
CLINICAL NOTES AND CASES.
Cases of Masturbation (Masturbatic Insanity ). By E. C.
Spitzka, M.D., of New York.
With few exceptions,* the classical writers on insanity
regarded masturbation as an important and frequent factor
in its aetiology. Ellinger.f after a careful study of the
patients at Winnenthal, concluded that twenty-five per cent,
of them owed their condition to this cause. More modern
writers, while admitting it to be an element in the production
of mental disease, do not assign anything like so high a pro¬
portion, and it is probable that the distinguished alienist
cited, must have failed to discriminate between those cases
in which masturbation precedes and provokes insanity and
those in which it accompanies, follows, and results therefrom.
Bucknill and Tuke place insanity from masturbation, or
masturbatic insanity, under their Somato-iEtiological classi¬
fication of mental disorders .t The latter (Hack Tuke) says
“ Reliable facts are of course most difficult to obtain, and
such figures reveal little of the real truth, the extensive
mischief done [by masturbation] of which there can be no
doubt whatever.§ Savage|| states that masturbation may
occur as a cause in either sex, but that it is far less fre¬
quently a cause than a symptom of mental derangement.
Folsom^l regards it as an exciting and predisposing factor,
creating a morbid psychical state by exalting the sensibility
* Parchappe and Gaialain.
f “ Allgemeine Zeitschrift fur Psychiatric,” ii., p. 22.
1 “ Manual of Psychological Medicine,” 4th Edit., p. 346.
§ Op. cit., p. 98.
0 “ Insanity and Allied Neuroses,” p. 64.
“ Pepper’s System of Medicine by American Authors/’ Vol. v., p. 119.
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58
Clinical Notes and Cases.
[April,
of the youthful nervous system; but adds that it does not
often do so. The views of both these, the most recent
writers of systematic treatises in the English language, are
in accord with some of the leading German authorities. The
latter do not recognize a special form of masturbatic in¬
sanity in their tables. Schule* * * § speaks of onanistic insanity
in the same sense in which Maudsley uses that term, but
gives it no place in his classification, disposing of it in a few
fines of the text. Krafft-Ebingf recognizes the vice to be
an eetiological factor, and speaks of such-and-such forms of
insanity as being developed on a masturbatic basis. He,
as well as Schule, with the majority of recent German writers,
follows Ellinger in attributing to the masturbatic neurosis
a relation to the causation of insanity, analogous to heredity
and the great neuroses, such as hysteria, epilepsy, and
alcoholism. I am unable to find any dissent among the
Germans from the statement approvingly cited by Emming-
hausj from Krafft-Ebing, that the clinical forms growing
out of this neurosis are too numerous and widely different
to permit the erection of a special form of insanity, such as
that which the renowned somato-aBtiologist Skae § attributed
to, and named after, the vice in question. This criticism
appears to acquire some support from the lack of unanimity
among those writers who have defined and attempted to
demarcate such a type. While Skae speaks of a peculiar
imbecility and shy habits as characterizing the disorder
among the youthful, and suspicion, fear, scared looks, cardiac
palpitations, the delusion of having committed the un¬
pardonable sin, and feeble bodies, as fouud in older victims
of this habit, his most distinguished follower|| attributes to
it exaggerated self-feeling, conceited, shallow introspection,
frothy emotional religious notions, and a restless, unsettled
state, with foolish hatchings of philanthropic schemes.
Luther Bell,If who, with Isaac Ray, was among the first
to direct special attention to insanity caused by masturba¬
tion, furnishes a very faithful picture of certain cases, whose
particular features he states to be a tendency to dementia,
loss of self-respect, a mischievous, dangerous disposition, and
* Handbnch der Geisteskrankheiten ” in “ Ziemssen’s Cyclopaedia,” p. 308.
t “ Lehrbuch der Psychiatric,” Vol. ii., p. 182.
X “ Allgemeine Psychopathologie,” p. 377.
§ Morisonian Lectures, “Journal of Mental Science,” October, 1873.
|| Clouston, “ Mental Diseases,” p. 484.
IT Annual Report of the McLean Asylum, 1844, cited in “ Bucknill and Tuke’s
Manual of Psychological Medicine,” 4th Edit., p. 346.
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Clinical Notes and Cases •
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an irritable, depressed state of mind. Griesinger* states
that the majority of cases are marked by a profound dulness
of sentiment and mental exhaustion, by religious delusions,
and hallucinations of hearing, and a rapid transition to
dementia in the event of incurability; which latter is the
usual destiny. Schiile recognizes two phases of onanistic
insanity, in the brief paragraph alluded to. The first con¬
sists in a persecutory delusional insanity, usually with an
erotic or lascivious tinge; the second is a moral insanity,
marked by a mean hypochondriacal egotism and a loss of the
normal emotions. Savagef speaks of sexual hypochondriasis
as one form of insanity due to masturbation, but also
attributes this disorder to marital excesses and unsuccessful
marital performances. Elsewhere he refers to a form of
adolescent insanity due to “ masturbation and the onset of
sexuality.”J Folsom§ asserts that most of the primary
dementia in asylums is classed in some institutions as in¬
sanity of masturbation (“ masturbatic insanity ”).
In writing on this subject some years ago, I stated|| that
stuporous insanity, the so-called “ primary dementia ” of some
asylum tables, is attributable to masturbation as a direct
cause in some cases, adding that under these circumstances
the prognosis is much worse than in the average of this
ordinarfly favourable group. Regarding the association of
masturbation with insanity of pubescence, I suggested that
the vice, while a frequent accompaniment, and perhaps a
result of insanity of pubescence,H is not its cause, however
much this habit may ultimately modify the character of that
psychosis.* * § At the time of making these statements I
regarded the followingf as expressing the general opinion
among alienists
“ While there is no special form of insanity attributable to mastur¬
bation, yet those psychoses accompanied and modified by this vice seem
to have certain characters in common. Melancholia, stuporous in¬
sanity, katatonia, and insanity of pubescence, are the forms most
frequently found in masturbators, and the essential characters of these
* “ Mental Pathology and Therapeutics .’ 1 Wood’s republication of the “ Syd.
800 . Translation,” p. 122.
f Op. cit., p. 64.
X Ibidem , p. 11.
§ Op. cit., p. 164.
0 ** Insanity, its Classification, Diagnosis, and Treatment,” pp. 159-160.
f Hebephrenia.”
* Op. cit., p. 177.
t Op. cit., p. 379.
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60 Clinical Notes and Cases . [April,
psychoses are always recognizable under these circumstances. The
ordinary characteristics of the masturbator are, however, found in
addition. Thus such lunatics are usually retired, shy, suspicious,
hypochondriacal, mean, and cowardly. ... A variety of primary
deterioration, marked by moral perversion, is observed in young
victims of the habit, which yields to treatment if it be discontinued.
If unchecked, the disorder culminates in complete fatuity; this has
been observed by the writer in subjects between the eleventh and
twenty-third year, and is one of the numerous conditions which passes
under the designation of 4 primary dementia ; * * * § it is the only one to
which the term insanity of masturbation can be properly applied.”
Of those who have furnished figures indicating the
frequency of insanity from self-abuse, Clouston* observed
it in 46 cases, during nine years’ experience with the large
insane population of Morningside. Burr,f of Pontiac, bases
his monograph on cases selected from 158 whose disease was
attributed to masturbation, in a total population of 1,4744
Bucknill and Tuke state that out of 603 male admissions into
the York Asylum, the cause was attributed to masturbation
in 15 instances. In my private practice, I find that in 362
case-records of insane males, accumulated since I dis¬
criminated regarding this astiological factor, the psychosis re¬
garded as masturbatic by the English and American writers
cited, occurred in 41 cases. Of 401 lemales, it occurred in
eight. Seven years ago, through the kindness of James G.
Kiernan, lately of the Cork County Asylum [U.S.], I made a
statistical study at the large pauper asylum for insane males
on Ward’s Island.§ At that time I was compelled to apolo¬
gize for assigning to one common, or rather mixed group,
the forms known as insanity of pubescence or adolescence
and insanity of masturbation. This was partly due to the
fact, that not all of the cases were under repeated or con¬
tinuous observation by myself, partly to the imperfect
nature of the records, and above all, to my inability to
distinguish between them in their various phases. The
occurrence of both forms at nearly the same period of life,
the frequent co-existence of self-abuse and pubescent in¬
sanity, and the modifying effects of the former on the latter,
all contributed to this uncertainty. It is these confusing
* Op. cit. y p. 491; the total nnmber does not appear to be given.
f The Insanity of Masturbation, reprinted from the “ Physician and
Surgeon/’ Ann-Arbor, Michigan, 1885.
• :r Biennial Report of the Pontiac Asylum, for the term ending September
30th, 1884.
§ Race and Insanity, “ Journal of Nervous and Mental Diseases/* 1879.
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features that cause me to institute further inquiries, with
the object of determining the precise merits of this clinical
form, its limitations and its differential characters.
The effect of masturbation on the nervous system varies
according to the age at which the habit is commenced. Like
other agents which are injurious to the developing brain,
such as epilepsy, alcohol, and syphilis, its effect is most
rapid and serious in younger children,* less so in adolescents,
and least so in adults. To produce anything like the
ravages in the adult brain which it effects in immaturity, it
must be greatly protracted. In very young infants it causes
a profound deterioration, manifesting itself in convulsive or
choreic disorder and imbecility. In those who masturbate
between the fifth and tenth years, the effects seem to be
chiefly manifested in arrested brain nutrition. Spontaneity
of thought and action is rare in such children; they do not
play as their comrades do. Here a noteworthy difference is
observed between the two sexes. The boy masturbator
usually becomes shy, and above all when in presence of
female company. The girl masturbator, while shy in general
society, seeks out persons of the opposite sex, makes \
advances to boys, and may even seduce them. To some 1
extent this difference between the two sexes is maintained \
throughout later life. The adolescent and adult male mas- «
turbator, with a few exceptions later alluded to, has in )
the earlier period of his vice a shyness before, and in later f
ones an aversion to women. The adolescent and adult l
female onanist usually entertains ideas of an erotic character, J
develops foolish marriage notions, and may throw away all ^
reserve before males. It is a singular feature of these cases |
that there should exist a very great difference between these
females as regards the fruition of their expectations.
Lombrosof relates the case of one who began masturbating
at ten, continued the habit excessively up to her marriage,
and at her fourteenth year indulged in the reading of
lascivious literature. She intended to become the
* The statement of A. Jacobi, ** American Journal of Obstetrics,” Feb. and
June, 1876, that masturbation is practised by very young children, was, I
think, a surprise to many physicians. I am, however, not only able to confirm
it, but to add a more remarkable observation than any I havo yet found re¬
corded. I was consulted regarding peculiar grimaces and movements in a
male infant eight months old. I witnessed a so-called “ seizure,” and found that
it was nothing but an act of self-abuse, performed by femoral friction, and ac¬
companied by passionate facial distortion. Scarcely a waking hour passed
without an attempt. A cure was easily effected.
t “ Archivio di Psyohiatria e di malatie nervosi,’’ Anno vi., Fascicolo 4.
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62 Clinical Notes and Cases . [April,
“ Messalina ” of her husband, had countless privileged
lovers, but found no gratification, and becoming disap¬
pointed in her anticipations, developed into a quarrelsome,
irritable, and cruel vixen. A similar experience is recorded
in the histories of two of my married female patients, one
of them continuing her unnatural practices till she de¬
veloped a melancholia, from which she recovered.*
The older the victim of self-abuse, the more likely is he to
develop an unpleasant irritability or hypochondriacal
egotism. In those rare cases where the habit is continued
into or commenced late in life, organic brain-disease is a
possible sequence. Whether this be a sole result, or merely a
consequence of a precipitation of existing pathological
changes, or of premature senility, I am unable to say. It is
recognized by a number of writers that masturbation may
be—like natural sexual excess—a contributory cause of
paretic dementia. There is another form of brain-trouble
found as a result of self-abuse when continued through a
lifetime, to which reference will be made.
Among the factors modifying the clinical picture of
masturbatic insanity is the original disposition of the
patient. If this were sanguine or choleric, we find conceit,
project-building, and aggressive meddlesome behaviour; if
the opposite temperaments exist, we find timidity, anxiety,
melancholic and hypochondriacal tendencies. Commonly
there is some dovetailing of these different states. Not in¬
frequently is it found that they alternate somewhat like the
phases of an irregular cyclothymia. Thus, a patient on his
reception in the asylum is found depressed, afraid of others,
suspecting that they can read his crime in his face, or is
filled with an unaccountable dread of death. After a few
weeks or months, however, he who sat motionless in one
corner, with cold hands, a pale, careworn, anxious counte¬
nance and crouched body, who could scarcely be induced to
open his mouth when visited by his relatives, meets the
latter with a firm or even swaggering demeanour, shakes
hands energetically, his eye is brighter, and his expressions
positive and loud, f The relatives are gratified at the
change, even physicians have been, to my knowledge,
* I have also observed one marked exception to the above. A girl of
seventeen, who was brought to me suffering from this same psychosis, was
married before her entire recovery. The orgasm recurred from six to ten
timeB during coitus, and she again sought medical advice in consequence of the
weakening effect of this.
f This is frequently found in cases of mingled masturbatic and pubescent
insanity.
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188?.]
deceived by it. But in the course of an otherwise connected
and able conversation, he drops an expression whose abrupt
silliness betrays the abyss of developing dementia, in which
he is about to sink. The patient who demonstratively
asserts what “ a good boy ” he always has been, who never
“ broke his word,” nor “ did a dirty thing,” is found to
possess the credulity of a child, and attempts to impose
assertions on others which imply the same infantile credulity
on their part.
Another important modifying factor is of a more strictly
psychical nature than the elements just alluded to. The age
between twenty and thirty-five is pre-eminently the period
of somatic introspection. It is at this period, if at any, that
the average man begins to think of his bodily condition.
At this age men weigh themselves, discover—or think they
do—that they have too much or too little flesh, develop
slight gastric disorders, reflex nervous symptoms, indulge in
excesses in tobacco, in baccho , and in venere. They are con¬
sequently on the watch for cardiac, renal, or venereal disease,
or of sexual disability. At this period, too, the remote con¬
sequences of masturbation are felt by the victim of that
habit. The prevalent tendency of his age, and his associates
of the same age, tinctures hi3 depression with a veritable
nosomania. Possibly, under the advice of physicians or
laymen, he attempts coitus, and fails. Body and mind react
on each other in a vicious circle; spinal irritation in the
domain of the former, and hypochondriacal insanity in that
of the latter, being a frequent result. Of 88 tabulated
cases of insanity among military men at Allenberg,* eight
were assigned to masturbation, five of these being classified
as hypochondriacal paranoia, one as hallucinatory paranoia,
one as melancholia with imbecility, and one as mania, f
This illustrates the preponderance of hypochondriacal states
among those who develop masturbatic insanity at the age
mentioned. I believe similar proportions obtain in all
asylums where the clinical principles of classification are
adopted. In the following table I have attempted to give a
brief outline of the history of 28 of my own cases, whose
ultimate termination could be learned, or who were at the
time of writing this paper under observation. J
* Sommer: Beitrage zur Kenntniss der Militarpsychosen, “Allgemeine
Zeitschrift fur Psychiatries 1886, p. 32.
t This was the only case terminating in recovery.
X Borderland cases, and snch with obscure antecedents, or seen but once, are
excluded from this table. The female cases are discussed elsewhere.
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64 Clinical Notes and Cases . [April,
While the above table demonstrates the preponderance of
hypochondriacal insanity in middle life, as a result of mastur¬
bation, as well as of other influences adverted to, it may be
desirable to pourtray in more detail the various forms repre¬
sented in it. The following is a pure and typical case of
insanity in a youth, resulting. from self-abuse practised in
early years, and without any complicating factors, such as
heredity, hebephrenia, or over-work. It has been selected from
among the others, because I am able to submit the patient’s
own writings, than which a better means of exposing the
mental state is not at my disposal.
I.— Self-abuse practised at puberty , increasing at the 17 th year; re -
tired disposition , then silly conduct; vague delusions of persecution ;
indecency; remarkable relationship between exacerbations of mental
disorder and recurrence of habit , or of seminal losses ; tendency to
dementia ; the latter being varied by an attack of stupor, and sub¬
sequently by impulsive acts. No heredity or complications .
George F—, no regular occupation, single, now aged twenty-three
years. Seven years ago he developed a marked change of character.
Previously of a quiet disposition, he was noted to ask questions in the
midst of conversation with which they had no possible relation. He
also showed a habit of laughing in a peculiarly silly manner for con¬
siderable spells of time, and without any discoverable cause. This
continued for nearly three years, when he developed vague delusions
of persecution, claiming that people were about to kill him. He was
removed to a Western asylum, where it was found necessary to place
his hands in muffles to prevent his practising self-abuse. His history
at the institution was that he was depressed, silent, inactive, irreso¬
lute, indolent, indifferent, and showed very little anxiety to return
home. At times he was very capricious. This condition continued
some weeks. At home he would sit brooding for hours in one place.
At table he would demonstratively decline wine, but after dinner
would attempt to obtain some in secret. He positively refused to
enter society, inclined to think the worst of other people, and sus¬
pected that he was despised or mocked at by the rest of the com¬
munity. Within six weeks after his return home, while under the
treatment of a general practitioner, he improved very much, both
physically and mentally. He answered questions rationally, and for
some time nothing abnormal could be detected in his conversation or
acts. But when in the street he began picking up worthless objects,
such as stones, tin-foil, scraps of paper, and even horse-dung. These
he would carefully wrap up, and Ins pockets at home were found filled
with parcels of this kind. On one occasion he offered some horse-
dung, broken pieces of tobacco-pipe, and coal to his favourite canary,
all the while exhibiting a vacant expression, and giggling, while tho
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saliva ran out of his month. As his health improved, an unpleasant
disposition became manifest. He would suddenly break out in a fit
of scolding, and severely abuse his mother, with foul epithets, when
he suspected or saw that she was watching him. His mental state in
his 19 th year may be gleaned from a letter addressed to his cousin,
in which he complains that he has been scolded for not drawing water
at the well as ordered, and intimates that he may require a squad of
police to protect him. In another he says :
We are having splendid weather here now, for the last week, we have had
a moderate temperature and the sun which makes Spring with its mild and
refreshing winds, seem so celestial, has been regular in its appearance every
morn. I like to get up early in Spring and enjoy the effects of the climate.
Over this letter is the superscription, “ Burn this when you have
read it; ” but unless it were the above-cited passage, there is nothing
in it to justify that injunction. As the period of his asylum sojourn
approached, his spelling, handwriting, and syntax deteriorated rapidly.
In one letter written from the asylum, and covering four pages of
letter paper, the sentence “ let me hear from you ” recurs on almost
every line of the first page. Ho asks how the “ flowers on his grave
are growing,” and then argues that he is not insane because he is a
good shot at quail. He desires to go home, not because he is dis¬
satisfied with the asylum, but because the duck-shooting season is
about to open. This letter is written in German, but the English
term “ concubines ” is used to designate the persons responsible for
his asylum incarceration. He speaks in almost the same breath of
“ rock-candy,” asks for “ licorice,” then adds that he does not know
who is more beautiful, Louis T— or Louisa S—, crossing the letter S
so as to resemble the symbol of the United States dollar, and accuses
Cousin Emma of lying in his body. It appears from the same note
that his delusion about concubines is based on his having heard their
old gardener speaking of them while attending to the flowers, and it
is probable that he misinterpreted the word “columbines.” In
another letter, English words, in almost microscopical characters, are
written over the German ones of the letter proper. Thus, over the
German, “ I am sorry that I stand thus in the world ” is written
“ ink,” and over “ I am very much afraid, but trust soon to return,”
is written “ Photograph.” Subsequent letters, dated after his re¬
moval from the asylum, show considerable variation from meaningless
scribbling, without cohesion for a single line, to such as are fairly
well written and coherent throughout. A number begin well and
wind up badly, of which the following is a specimen :—
Please write me a few words of your kindness goodness and your friendship,
and let me know how you are getting on a few days ago I had some, and said
that the impossibilty to go to E— was a lie. having been made redreamed. I
atmired the building and the Grain work and believed it consciencously your
humble servant considering the weather was 1 ink was made very oh: by
Atmosphere and was
After his relapse at home, I placed him on restorative and tonic
mill. 5
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Clinical Notes and Cases.
[April,
treatment, directing special attention to calming sexual excitement,
and for a time he improved considerably. His conversation became
perfectly rational, and some of his letters of this period are the best
he ever wrote in his life. But again he relapsed, became impertinent
to his mother, and unpleasantly disposed as indicated in the follow¬
ing :—
We have a nice honey-snckle growing on the side of the house, we had some
nice cherries on one of our trees, Z— picked, them, all, off, and ate them with
Louisa. Hogish as hxll, then all at once he went off again like a Blunder Bus:
with his head tossing about with his old black cane with a big white fad on it,
as he went strutting up and down the side walk, thinking of a-[chamber-
utensil], as he thought of a white button, it made me think he was God
almighty, he : thought, himself Big, cause, he got the permits from my father
to take me walking But I didn’t care for any body but himself they all feel, so
d—d big to come over me, but, that will stop anyway he comes here to eat Ice¬
cream and Strawberries. I think the Gooseberrys Give him the Stomack acke.
I close signing my name.
Two months later, in a relapse brought on by a recurrence of his
habits, he portrayed the confused state characteristic of such patients
in the following letter addressed to the same person :—
Seeing that good news from me pleases you I will take pains to give you a
deliberate and pleasant view of all my case, doings, and pastimes, you know
that I am always happy to hear from, you and unwilling to answer letters of
that kind letters of pleasant and modest declines are always welcome, and
virtue is the mother of the world. Glad to hear good news always sorry for
news of Illmeaning sure to answer all letters of any kind for that is my char¬
acter in life or death: see myself amiably seated at O— with Father and
Mother at Home, for O— is our home you know in Reality, furthermore I
would like you to know that letters of that kind are always unwelcome and
troublesome to defray seeing that you would like to know further and closer
particulars. ***♦**♦♦
A part of a daily record kept of his condition at this time may serve
to illustrate the routine variation of such cases :—
Date.
Forenoon.
Afternoon.
June 3rd.
Saucy, obstinate, capricious.
Good-natured; speaks in a
silly, babyish way.
„ 4th.
Insolent and capricious.
Quiet and dull.
„ 5th.
In excellent spirits; worked
about the house.
Quiet and depressed.
„ 6th.
Quiet and depressed.
Quiet and depressed.
„ 7th.
Quiet and depressed.
Quiet and depressed.
„ 8th.
Obstinate and depressed.
Muie, apparently introspec¬
tive*
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At the time of his discharge from the asylum he confounded persons
with whom he had been familiar. Under the treament instituted, he
discontinued the habit of picking up worthless objects, no longer con¬
founded persons, and during July and August again improved, being
strictly watched day and night. On one occasion he left the bed to
lie on the floor, evidently to elude observation; but obeyed on being
ordered back. He began to take interest in his father’s business, and
the variations in his condition alluded to ceased. Supervision then
became less rigid. September 12th, he was noticed on arising to have
a very imbecile expression, and began to indiscriminately collect fruit,
vegetables, and other edibles, saying that he must have something
more piquante than the prescribed diet. With this the silly laughter,
which his parents had already learned to regard as an ominous sign,
recurred. In the afternoon he exposed his person before his mother,
and, when remonstrated with, explained it away. On the whole, how¬
ever, he continued to improve, and as the symptoms marking his
relapses were usually noticed to be most marked in the morning, I
had his bedding examined, and it was found, on every subsequent
occasion, when his expression on rising was vacant, listless, and silly,
or when causeless laughter occurred, that it presented the evidences
of seminal emissions. Careful watching was resumed, and revealed
that the patient still masturbated. Confronted with the evidences of
his misdemeanour, he defiantly replied to the question why he per¬
sisted in so damaging a vice, “ because I want to ; ” and when his
mother, with tears in her eyes, implored him, if he cared naught for
himself, at least to think of the misery caused his parents, he said, “ I
don’t care a- ” A jacket with endless sleeves had meanwhile
been made. The first time it was applied, he manifested a child-like
willingness to have it. He recognized its purpose; but indulged in
laughter and bravado in speaking of it, a fact which filled me with
serious apprehensions. For two months this device fulfilled all ex¬
pectations ; neither voluntary nor involuntary seminal discharges
occurred. He continued improving, and during this entire period there
is no record of a single foolish act or word. He voluntarily worked as
a type-setter in his father’s printing establishment, where a small
paper, of which the latter was editor, was published. After this
period, it began to be noticed that he would frequently stand in one
spot gazing at vacancy. Examination showed that he had succeeded
in provoking the orgasm by femoral friction. The knee-pieces which
1 had originally suggested, but which the local physician had delayed
obtaining, were now applied. Unfortunately, they failed; the patient
had become able to effect his purpose without any friction whatever.
1 then had him taken—he was at this time not under my direct
observation—to the nearest large city (St. Louis), where Dr. Bauer
performed an operation on the prepuce, calculated to interfere with or
to stop his vice. For four months thereafter the latter was not re¬
sumed, but the mental state did not improve as before. On his re-
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68 Clinical Notes and Oases . [April,
turn, tjie patient manifested great bitterness of temper, complained
that he was looked down upon, that everyone took him for a fool, and
if he met bis former companions would reply to their questions by
mere monosyllables. He also complained that he had never been like
other children in his infancy, and in the midst of conversation relat¬
ing to other subjects would break in with questions about that period
of his life. Shortly after, he manifested a little more ambition, entered
society, and for a few days again encouraged the hopes of his friends,
but soon he became petulant and taciturn, refused to join the family
at table because “ strangers ” were present—these being invited neigh¬
bours—and again manifested the silly laughter alluded to. On one
occasion, while engaged in cracking open 6ome nuts, a task he had
volunteered to assume for a relative, he suddenly became motionless
and mute; in the midst of this frozen attitude he smiled yacantly,
and repeatedly laughed out loud. After each such fit of laughter, a
look of terror stole over his face. He showed some indications of cata¬
lepsy that evening, which deepened until complete flexibility oerea
was established. At times he subsequently emerged from this condi¬
tion, manifesting the same childish manner as before, and having to
be fed and put to bed like an infant. When he was allowed to leave
the house, he would run around in the garden or street filling his
pockets with trash, as after his return from the asylum. On repeated
occasions he would suddenly open a button of his coat or trousers
with lightning-like rapidity, and when asked his reason, replied,
“ Don't know.” His month became filled with saliva, distending his
cheeks, and continuing to accumulate until he was ordered to void it,
when he let it run out slowly, complaining the while that it ‘‘drew
his mouth together.” He rapidly lost flesh, and his hands became
blue and moist. During the past three years his physical condition,
after a slight improvement, remained stationary. He has frequent
spells of moodiness and obstinacy, on each of which occasions signs of
a seminal emission during the night previous were found. It was
definitely ascertained that most of these were involuntary, occurring
thus about twice a week, or less frequently. On one occasion he
escaped from home on a bitterly cold night, broke through the ice in
crossing a ditch, and returned covered with ice from head to foot.
Apparently his bodily health did not suffer from this, remaining fair
up to date, and his only somatic complaint has been constipation.
At times his conversation was rational, to become by abrupt transi¬
tions irrelevant or absurd. He would repeat the question, “ What
time is it ? ” over a hundred times on certain days. He retains such
musical acquirements as he had—limited to singing, whistling, and
performances on the jew's-harp—and is, as a rule, docile. When
ordered to do a thing, he either does it immediately, or, apparently for¬
getting the order, complies after a repetition. In the course of work
requiring protracted efforts, he has to be repeatedly urged to continue,
otherwise ceasing in the midst of it, and remaining in whatever posi-
Digitized by t^ooQle
1887.] Clinical Notes and Cases . 69
tion—however uncomfortable—he may happen to be at the-moment.
On one occasion his father—who had abandoned medical advice after
a bad prognosis had been given—administered corporeal chastisement
during an outbreak of angry excitement on the patient’s part. This
seems to have had the effect of restraining him, but he has become
more timorous. Occasionally he has spells of craving for tobacco,
and when he is smoking his pipe throws it away violently, so that
it breaks into numberless fragments. Apparently this act is involun¬
tary or impulsive ; when remonstrated with, he appears to have U6
knowledge of the circumstance. He has no other destructive
tendencies.
An almost exact counterpart of this history was found in
the earlier accounts of three patients who had passed into
terminal dementia. All of them exhibited considerable
salivation 5 their demeanour is marked by silly laughter and
confusion, alternating with spells of atony. Occasionally
they appear to recognize their own condition, and as weak
as their memory is for most matters of importance, some of
their recollections are quite vivid. A remarkable feature
of these cases is the occurrence of rational and continuous
conversation for brief periods in the midst of the dementia 5
indeed, rapid and abrupt transition from one mental state to
another is characteristic. It is only where the mental dis¬
order ensues very early that passive and uniform dementia
results. When it begins in the adolescent period, it seems
as if the conservative forces more frequently made head,
however ineffectually, against the overwhelming onset of
mental exhaustion resulting from the vice. The greater
irritability shown in dementia from masturbation as com¬
pared with ordinary forms of terminal dementia, is probably
a result of the same conflict between the productive ten¬
dencies of youth and the destructive ones of the disease.
One of the exploded superstitions of a past era is that the
simple and radical remedy for nervous and mental disorders
resulting from masturbation is the resorting to natural
gratification of desire. How utterly erroneous this is, th6
following case shows:—
H. — Self-abuse at puberty ; later , natural indulgence , imperative im¬
pulses, tetTors , melancholia followed by maniacal excitement, fol¬
lowed by apathy and fading hallucinations .
P. L., aged 19 ; no heredity, but has a very foolish mother; did
not learn to 6peak before his fourth year ; he is a shipping clerk in
his father’s business. Self-abuse commenced at the fifteenth year, and
was carried out both by manipulation and by rubbing against wooden
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70
Clinical Notes and. Cases.
[April,
pillars, lamp-posts, &c. During the past few months has, on the
advice of a friend who discovered his habit, indulged in coition re¬
peatedly, and claims since then to have ceased masturbating. This
was, however, found not to be true. On March 19th, 1885, the
history was given that he had appeared normal, until about two
months ago, when he had spells of terror accompanied by heart¬
beating. He had a fear that God was going to punish him for having
cut someone with a knife. It was subsequently learned that he had
had the morbid impulse in the street to cut passers-by, and had at
times to struggle with such an impulse for a year past. On one
occasion, after an attack of terror, he obtained a “ century almanac ”
to find what day of the week he had been born on. He found it was
a Tuesday—the following day, and the nineteenth of the month, which
also happened to be the case on that day. Hereupon he remained in
bed, saying that he was to die that day. When he hoard the house-
bell ring, he said u The people are calling to see if P. is alive yet.”
He seemed to take leave of the world with regret, and his eyes were
noticed to wander sadly from one to another of a series of engravings
on the wall representing distinguished rabbis. When convinced that
midnight of the error of his apprehension, he said, “ It is the next
nineteenth that I shall die on ; all our family die on the nineteenth.”
This latter statement had some basis, for all deaths that had taken
place in the patient’s recollection were on the nineteenth of the month,
and the fact had been commented on by others.
A week ago his father purchased so-called “ fire-extinguishers,”
glass bombs intended to be thrown into the flames of a beginning
fire. Two of these were placed in each room of the house, but they
had to be removed, as the patient became greatly agitated, and enter¬
tained the fear that he would have to be burned up if they remained.
He answered in a low voice to questions, his answers were respon¬
sive, though reluctant; he had an abstracted look, and at times
smiled vacantly. Thoughts of death were continually passing through
his mind, and he was very apprehensive that I would perform some
serious surgical operation on him.
My advice, confirmatory of that of the family physician, Doctor
Isaac Oppenheimer, was to place him in a large asylum where proper
supervision and classification of such cases were carried Out, but it did
not satisfy the mother, and the patient was for six weeks treated by
another physician. The patient finally reached the lowest rounds of
the ladder to melancholia anxiosa , and was sent to one of the number¬
less “ homes or halls for the insane,” which, under more or less
specious titles, are, in the majority of cases, but country boarding¬
houses, with a little extra gloom and a little worse fare than the
ordinary resorts of that name. As the patient’s father learned that
no attention had been paid to the question of self-abuse and seminal
emissions, he again brought him to me, and transferred him to the
Bloomingdale Asylum. On this occasion he was in a complaining
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Clinical Notes and Cases .
71
1887.]
mood, asserting that his relatives did not care for him, that they had
not visited him often enough, and spoke in an exaggerated and rather
maniacal way. He was going to travel around the United States, had
eaten three lobster salads, &c. The expression of his eye, which pre¬
viously was one of terror, now was piercing and glaring. His pupils
reacted well, but there was great tremor of the hands. During his
sojourn at the u hall” he had been permitted to indulge inordinately
in tobacco. He was covered with acne rosacea. At the Blooming-
dale Asylum he steadily improved, with the exception of slight re¬
lapses, which I found to be connected either with seminal losses or
repetitions of self-abuse. He developed auditory hallucinations,
hearing his father’s and brother’s voices ; but latterly these “ voices ”
had become less distinct. The patient exhibited a marked variation
in his state during the day, being entirely normal in the forenoon, and
becoming monosyllabic towards evening. At this latter period his
eyes resumed the expression alluded to, and the brows became corru¬
gated. He then slowly improved, the sole discouraging feature being
a pronounced apathy. On removal from the asylum to test the effect
of borne and business life, he rapidly improved. For a time he mani¬
fested a boyish dislike towards lii6 parents for placing him in the
asylum ; but bis hallucinations disappeared, and he is now as well as he
ever has been, with the exception of occasional spells of “ the blues.”
He has bad natural (illicit) connection since his return without the
depressing results previously complained of.
In a second patient a more rapidly favourable result was
obtained, the case dififering mainly in the earlier and more
extensive addiction to indulgence with the opposite sex.
III.— Doubtful heredity , early masturbation , subsequent liaison , con¬
fusion of ideas , silly conduct , profound moral deterioration , partial
recovery .
P. S., aged 17 years ; good business and musical education; at the
time employed in the wholesale department of his father’s business.
He was strongly suspected of having practised masturbation, and ad¬
mitted having done so extensively in earlier years. His mother is
neurotic, and a brother of hers is at present in an asylum in France
suffering from a form of insanity which, according to the physicians,
had also been brought on by self-abuse.
Since his fifteenth year the patient has been considered a little
peculiar. He made grimaces occasionally, which at first were re¬
garded as childish attempts to make fun ; but occasionally a remark
would escape him that startled the family, and when in addition to
this he refused to leave his bed, ceased to attend to his business duties,
and displayed a state of mind inimical to his parents, they consulted
me. I at first observed the patient in his business, and the following
evening examined him at his residence. He had a most intensified
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72
Clinical Notes and Cases.
[April,
expression of diabolical meanness. His brows were strongly Corru¬
gated, and his eyes sharp and piercing; but he rarely looked at his
interlocutor directly, and then seemed unable to do so for more than
a moment. As he refused to follow out the treatment recommended,
and the family were loth to send him to an asylum, a nurse was em¬
ployed. To this nurse he took the greatest dislike, not allowing him
to approach, kicking, struggling, and screeching at the top of his
voice when he came near. My arrival only made matters worse. I
found him sitting on the middle of the stairs holding on by the sup¬
ports of the banisters, and resuming his cries as I entered. He
called on a chambermaid by name, and I suggested she be sent for.
She came, and the patient followed her as quietly as a lamb, and con¬
sented to take the medicine at her hands. This seemed, at least,
singular to me, and the apparent mutual understanding between them
led me to cross-examine the girl as to her acquaintance and relations
with P. She exhibited such innocence and naivity that I did not
feel justified in making any pointed inquiries, and informed the family
that my misgivings had been removed. As it turned out, however, I
had been egregiously duped. The mother of the patient searched the
girl’s rooms, and a number of presents and letters from the patient
were found in her trunks. A confession was then extorted. Her
mistress then purchased a ticket for her, and herself saw her on board
the steamer which took her to Germany. Unfortunately the exact
nature of the sexual relations between the two was not ascertained.
The patient remained mute on this subject. A written confession of
the girl states that she had been guilty of seducing P. to the commit¬
ment of natural and unnatural sexual acts. My impression is that
the liaison resulted from her discovery of his solitary crimes. He
was taken to a private asylum, and there enjoyed the character of
being the most troublesome patient they had had in many years. He
was equally mean, insulting, and selfish. He would write letters to
his parents brimming over with filial loyalty, and in the same hour
indite another to his uncle accusing them in the vilest terms of having
placed him at the asylum in order to appropriate the piano which he
had purchased from his own money, as well as his money at the bank,
all of which had been given him by his father in the first place. He
also called his family u a pack of liars and swindlers.” He improved,
however, in other respects, and, being taken out on parole , behaved
himself so well that he was not returned to the asylum, and has ever
since—that is, nearly three years—conducted himself so well that a
recommitment has not been found necessary. On a former occasion,
when he had been paroled for a day, he walked from his residence to
the asylum, through the central park, and destroyed as many flowers
as he could reach, replying to his companion, who endeavoured to pre¬
vent him, “ They can’t do anything to me as long as I am in the
asylum.” On being taken from home, when committed, he gave the
girl in question his keys to keep for him, and told her that in three
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Clinical Notes and Cases .
73
1887.]
years he would take her and his piano to their own house. On his
return from the asylum he regularly went to business, and sent letters
to the girl, which were intercepted. He became much depressed on
getting no answer, and ate no dinner nor breakfast on one day, stating
that he could not afford it. It was ascertained that some vague notion
of saving money for the girl was the motive for this statement. The
next moment he said he would like to have a dog-cart and carriages.
That evening he began to conjugate “Ate, hcec } hoc ” very loud, on
which his sister said, “ Shut my door, P.,” and he ceased. At pre¬
sent he has spells of indolence, in which he is moody and makes
singular or irrelevant remarks. But such spells are less frequent and
less protracted than formerly. His facial expression is greatly im¬
proved.
(To be continued.)
Supplementary Note on a Case of Mental Stupor . By the
late Dr. Geoghegan. Case reported in the “ Journal of
Mental Science,” April, 1881. (Under the care of Dr.
Bland, Medical Superintendent of the Borough Asylum,
Portsmouth.)
The Editors are indebted to Dr. J. D. Mortimer, Assistant
Medical Officer of the Borough Asylum, Portsmouth, for the
following brief notes made by the late Dr. Geoghegan, sub¬
sequent to the report of the case made by him in the Journal of
the above date :—
May 28, 1881.—Perpetually “ on the go.” Walks and
waltzes about ward when he has nothing to do. Can make
mattresses, set up a tennis-court, do fretwork, &c., &c. Always
good tempered. Speaks only when spoken to. Will acknow¬
ledge to no English port, but if any foreign port is mentioned
where he has been he can tell the name of some well-known
person there.
Aug. 28.—Has steadily improved. Acts and talks with
much fewer mannerisms. Up to yesterday week he spoke a
nigger gibberish, or answered questions by signs or writing.
This morning, on being told that champagne would be given
the attendants of his ward if he spoke normally, he spoke per¬
fectly rational English. Is still reserved on his past career.
Sept. 28.—Has steadily improved. Cannot remember (or
will not tell?) anything of the period since he was admitted here
as a patient. Appears quite convalescent. Still works indus¬
triously.
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74 Clinical Notes and Cases. [April,
Oct. 10.—Discharged recovered, and engaged as assistant
upholsterer.
When so engaged we had an opportunity of examining him,
and found him apparently well in mind. He was reticent as to
his mental state when silent.
Dr. Mortimer informs us that the patient has had no
relapse, and for some two years or more he has satisfactorily
filled the post of storekeeper in the asylum. The patient
evades any questioning in regard to his condition when he was
in a state of stupor, or in respect to his former life. He is of
an excited temperament, and rather egotistic. He is very
steady in his habits.
A Case of Moral Insanity. By Colin M. Campbell, M.A.,
M.D., Medical Superintendent, Perth District Asylum.
M. E., 49, single, formerly a merchant, was admitted into the
Perth District Asylum on May 19, 1885. He was stated to have
been insane for some weeks ; not epileptic nor suicidal, but
dangerous to others.
The medical certificates stated that “He spends most of his
time in a dark outhouse, smoking, and in a melancholy condition,
refusing to work, and bursting out at times in uncontrollable
passion, complaining of his sisters* ill-usage, which was untrue,
and of his own condition being unbearable, whereas he was most
comfortable. He was shaky, nervous, and partially incoherent in
speech. That he had threatened his sisters’ lives, had actually
laid hands on them, and had said that he would do for them, and
take seven years for it.”
Along with him were brought some letters, recently written by
him to his sisters, of a threatening character and insane expres¬
sion ; and the Inspector of Poor stated that he had been directed
by the Procurator Fiscal to remove him to the asylum as
dangerous.
Previous History .—His father and mother were in comfortable
circumstances, and he received a good education. No history of
positive neuroses in his family has been ascertained, but his
father seems to have been a somewhat peculiar, though ingenious
and successful man; and his sisters, both of whom are older than
himself, are of an emotional, fussy, and suspicious temperament.
His mother is said to have died of “decline.” His parents and
sisters spoiled him as a boy, and he was of a timid, sulky, and
suspicious disposition, and very lazy, though with fair natural
abilities and some mechanical turn. At an early age his father
started him in a good business of his own as a grocer, and in this
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Clinical Notes and Cases .
75
1887.]
he did fairly well for a year or two, guided by bis father and
living at home. But his moroseness grew upon him; he smoked
heavily, avoided society, was found afterwards to have been given
to quiet tippling, and is supposed to have been addicted to self¬
abuse. After a year or two of this life, he suddenly disappeared
with a company of strolling players. This took all who knew
him by surprise, as he had always been reserved and self-righteous,
and his joining them turned out to be against the players’ wishes,
as he had no aptitude for the stage. He had taken all the money
with him he could scrape together, and as long as it lasted he
was allowed to travel with the company. The manager had,
finally, to negotiate with his father to take him home, as he would
not leave them of his own accord. After this he led an unsettled
life for many years, at home and in America, sometimes with em¬
ployment for a short time, oftener depending for support on con¬
tributions from his parents. Of this period of his life particulars
are not known, and he himself is extremely reticent about it.
His last occupation was as an electrical mechanician in London.
This situation he lost through unsteadiness and some quarrel, six
years before admission; and he then returned to his native village,
to his sisters’ house, his parents having died a year or two before.
His share of their property had, evidently with good reason on their
part, been left to trustees for his benefit. He had attended his
father’s funeral, and, on hearing the first clauses of the will, ap¬
pointing trustees for him, read, he left the room in indignation,
and could never be induced to listen to or recognize the will there¬
after.
For nearly six years previous to admission, then, he lived with
his sisters, alleging ill-health—which was not very serious, al¬
though it is probable that at this period some lung mischief was
active—as disabling him from earning his own living, and per¬
suading them that it was their duty to support him. At first he
did a little work, assisting them in a shop they kept; but he
gradually became more and more lazy, ill-tempered, and tyran¬
nical, lying in bed, exacting great attention, and becoming very
angry and abusive when not supplied with all the tobacco and
money he desired. When supplied with money, he used to consort
with low characters, and spend it on drink in a secret manner.
He abused his sisters for cruelty, and for appropriating his money,
to all he could get to listen, although they appear to have treated
him with even foolish indulgence, and to have been not a little
afraid of him.
His share—one-third—of his parents’ legacies was paid by his
trustees to his sisters for his support during this period, the
expenses of w'hich it by no means covered. Latterly, he demanded to
be supplied with money to live in Edinburgh, away from his sisters’
cruelty; and this they, with great misgivings, finally consented to
do, about six months prior to his admission. He had declared he
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76
Clinical Notes and Cases .
[April,
could easily get work at Edinburgh, and for a time he did act as a
commission agent for several small ventures, but did hardly any
business, and quarrelled with his various employers. He seems
to have spent most of his allowance in Edinburgh on drink, and
to have suffered some real privations in consequence. His drinking
habits throughout were quiet, and he was hardly ever incapably
drunk. After a few months of this life, and on his sisters re¬
fusing to increase his allowance, he wrote the threatening letters
already referred to. Failing thus to gain his point, he ventured
to his native village, billeted himself again upon his sisters, whom
he greatly alarmed by the violence of his language and his threats
to “do for” them and for himself also. They were, therefore,
obliged, after a few days, to take the steps resulting in his com¬
mittal to the asylum.
The threatening letters referred to are nine in number,. and
cover a period of three weeks prior to his leaving Edinburgh.
They are written in a large and shaky hand, and are all in the
same strain. One, dated May 1st, is a fair sample. It runs as
follows :—
Mi Dear Sister, —I wrote you on Saturday last, and have waited till to¬
day expecting a reply—as none has come to hand I see you intend to carry
out your line of action to the bitter end — well and good.
I make this last appeal and 1 do so in the hope of thus saving you as well as
myself from utter ruin. Mark well what I now write. If you persist in the
course you have adopted in regard to me I tell you again as I told you before
and as I also told your friend , Mr. S— the last time you kindly sent me to him,
I had already done three years of solitary confinement, and if I am compelled
again to return to 11— I am quite prepared and will do 5 or 7 years more in a
different manner— but remember this, and I earnestly pray of you— Beware !
this is now a case of Life or Death with me ; I am quite regardless which;
but if 1 have to die, remember we Perish together. I know you have the Law
on your side, but all I demand is Justice. This I will have or perish in the
attempt of obtaining it.
I can live here no longer than to-morrow or Friday. Mr. P. has now left
his work, and is almost gone in consumption. They have a child who is daily
expected to die with Dropsy in the head, a most pitiable case indeed ; if yon
have no pity for me, let me beg of you to consider others—you have never had
to go hungry—I do so now every day of my life; this I care not for, I have
been long inured to it in former years, but even with the greatest economy I
can exercise it is impossible to live on the wind. I can get no steady work,
and you are well aware I am not able to do labouring work now as I did
formerly, and even if I could it cannot be got here at present. I have worked
very hard for a week past and as I told you in my last letter have made
little or nothing of it. I have not been able to go out yesterday nor to-day ;
we have had rain all day so I was compelled to remain indoors. My situation
is to me a very horrible one, and I could not wish the greatest enemy I ever
had to undergo a similar fate. Alas! Alas! well may poor Burns exclaim —
'* Man’s inhumanity to man
Makes countless thousands mourn/’
I have never disgraced myBelf nor you so much as your wicked and cruel
father has done me. 1 pray the Lord to forgive him.
If you see your way to reply to this appeal which is my last one from here ,
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Clinical Notes and Cases.
77
1887.]
<Jo bo at once on receipt —should I not hear from yon by Friday night—yon
may expect to see me on Saturday. I will require to leave everything behind
me as I cannot pay this week’s bill.
My brain seems on fire. I can write no more. You little know, and I do
sincerely trust never may experience the torture and suspense I have lately
endured.
If I have written anything to give offence, all I can do is to ask your
pardon, my language may be strong, but dire necessity alone compels me to
use it.
Trusting you are still in moderate health, and keeping well, I remain, ever,
Your affect, but disconsolate Brother,
M. E.
I am far from being well, but this of course is of little moment. M.E.
Condition on admission .—On admission, M. E. was found to be a
tall, well-built man, somewhat emaciated, with bright brown eyes,
very sallow complexion, well-developed cranium, good upper
features, and iron-grey hair, a full beard of which concealed a weak
mouth and chin.
His teeth were greatly discoloured by smoking,his digestive func¬
tions were somewhat feeble, his heart sounds weak and occasionally
irregular, and the breath sounds over the left apex harsh, but he
had no cough, and the lung mischief was evidently quiescent.
His expression was exceedingly sulky and morose; he appeared
depressed, and kept his eyes down while speaking. He did not
converse freely at first, but answered all ordinary questions in
coherent language, and in a rational manner. His memory was
fairly good. He became somewhat agitated as he spoke of being
put into the asylum, maintaining his sanity, and, when his sisters
were referred to, he became much excited ; his lips turned blue and
trembled, his palpebral muscles twitched, and his fists were
clenched, as he worked himself up, inveighing, with strong lan¬
guage, against what he called their cruel and unnatural treatment
of him. His abuse was in very general terms, though his expres¬
sions were very strong, and he evidenced considerable command of
language. He shifted his ground adroitly when pressed to bring
definite serious accusations against them, and all that could be
clearly made out amid his flood of invective was that they had
treated him with less respect and indulgence, and had given him
less money than he desired. His peculiar appearance, and the un¬
controllable passion and agitation he worked himself into while
speaking of them, gave one the impression that he concealed some
definite delusions of suspicion regarding them.
He was extraordinarily unreasonable in discussing this subject:
He indulged in fierce invective, in high-flow r n language—the de¬
livery of long sentences appearing to give him some satisfaction—
but he could not be brought to the point, nor induced to state defi¬
nitely in what way his sisters were cruel, why he had lived with
them if he did not like them, why he had threatened them, what
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Clinical Notes and Cases.
18
[April,
he thought of his present position, or what he would do if and
when discharged. The following is an example of this
One day, when he had been abusing his sisters for defrauding
him of his share of his parents’ property, I succeeded at length
in nailing him down to the admission that he had not seen the will,
but had gone out of the room when he heard its first clauses read
appointing trustees for himself. He immediately seized on the fact
that he had not seen the will, and made this the basis of a fresh
complaint of injustice, and the subject of a long tirade against his
family and their business men: I then suggested that I would try
to get a copy of the will for him to read. This proposition appeared
rather to disconcert him, and he became sulky and said it was no
use. A few days afterwards I brought him a copy of the will,
obtained from one of his trustees. He utterly refused to read it,
or even to touch it! After some floundering, apparently in search
of some excuse for this refusal, he triumphantly stated that he
would read it if he were out of the asylum, but that it was useless
for him to read it while an inmate, as a patient could not take action
in a court of law, adding, with a sniff, “ and you know, or ought
to know, that yourself.” Having thus furnished himself with a
fresh text, he proceeded to enlarge on the injustice of his detention
in the asylum, &c., &c., and, as usual, adroitly evaded the subject
on hand. He gave one the impression that he was unwilling
to read the will, for fear its provisions took from beneath his feet
the ground on which he had based his accusations of injustice.
His language and conduct in this instance were very charac¬
teristic of his mental state for the first twelve months of his resi¬
dence in the asylum: This extraordinary perversion of reasoning
power, simulating the exaggerated wilfulness of a spoilt child,
characterized all his sayings and doings with reference to his
treatment by his family. It was an interesting leading symptom,
and added seriously to the gravity of his threatening language and
behaviour in the same connection prior to admission, and to the
dangers of farther developments and serious results following pre¬
mature discharge, while he continued to manifest a vindictive
sense of injustice and cruelty, and displayed such agitation when
the subject was mentioned.
For long it was thought that some positive delusion must underlie
such marked symptoms of uncontrollable agitation, but, during
numerous prolonged and exhaustive interviews, none such could
be discovered to exist.
He was a quiet and orderly patient, but sulky and disdainful to
those around him. He expressed great contempt for the asylum,
its inmates, and management, and used to incite other patients to
complain and to little acts of rebellion. He himself complained
of his food, clothing,- bedding, want of tobacco, disturbance by
other patients, &c ., constantly. He would not work outside, though
pressed to do so, but did some ward work, and occasionally paraded
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1687 .]
little acts of attention to the sick and feeble. He always spoke of
his own health as very delicate, and made a great fuss over
one or two very trifling attacks of indisposition. He smoked as
hard as he could with the limited supply of tobacco. He was not
observed to masturbate. He displayed no active religious senti¬
ment. He ate and slept well as a rule.
With tonics and fresh air his general health improved, and, as
regards his mental condition, by July, 1886, he had become some¬
what milder in temper and more reasonable. Taking advantage
of this improved state, and anxious to discharge him if possible, I
pointed out to him his position, and when, as usual, he violently
maintained his sanity past and present, I told him that though I
believed him insane, I would if he liked treat him for a time as if
he were sane, and that, in the first place if his conduct towards his
sisters did not indicate insanity, it did indicate a very selfish, lazy,
and cowardly disposition ; in the second place, that his threats and
violence were inconsistent with personal liberty, and must be re¬
garded as either insane or criminal; that his apparently uncon¬
trollable hatred of his sisters, and his impaired reasoning power
with reference to his family relationships, prevented his discharge,
but that if he showed that he possessed what he claimed to possess,
a sane power of self-control and reasoning, for a short definite
period, I should feel justified in trusting him again outside. I
also pointed out to him that if he acted again when he got out as
he had done before admission, he would almost surely be sent back
to the asylum. I also told him a few unpalatable truths regard¬
ing his natural disposition, which he relished very little.
I deliberately adopted this tone with this patient, and maintained
it for some time. In no other case I have treated, have I employed,
or been tempted to expect benefit from the employment of, moral
suasion with such decided plain speaking.
For about a fortnight after this. M. E. was decidedly more
reasonable, and I was congratulating myself on this result, when
he rather discouraged me by effecting his escape.
In view of his extraordinary perverse clinging to false grounds
in his accusations, I venture to suggest the conclusion I felt al¬
most compelled to come to, that he planned this escape in order to
evade the appearance of acquiescence in past proceedings, and the
implied promise as to future good behaviour, which waiting for,
and as it were accepting, his promised discharge might predicate.
He was absent for a fortnight, and made his w r ay to Edinburgh,
where he succeeded in interesting a lawyer in his case, with whom
he planned taking legal proceedings against his sisters. He ad¬
mitted this when brought back, but he could not be got to allow
that the will, such as it was, was binding, or that he acted un¬
reasonably in trying to institute legal proceedings regarding it
when he was not only ignorant of its contents, but actually refused
to acquaint himself with them. As was his habit, he evaded these
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ao
Clinical Notes and Cases.
[April,
questions, and worked himself into a state of insane agitation over
his hard fate, and the injustice with which he had been treated, just
as before. This escape, and apparent sympathy he obtained from
the lawyer in Edinburgh, and his recapture, acted prejudicially
apparently at first, and for a time he was additionally moody and
reserved. By degrees, however, he became more communicative,
and as he did so it became apparent that his condition, while similar
in character, had become decidedly modified in degree. Agitation
and invective diminished greatly, and, while he maintained their
injustice, he could speak of his sisters quietly.
I continued to treat him as we had arranged, on the hypothesis
of his sanity, and by consequently uttering unpalatable truths;
and this mode of treatment, 1 believe, along with the moral effect
of the failure of his escape and plans for litigation, aided him in
regaining the self-control which began to be apparent. He got
out, too, a good deal in the fresh air during this summer season,
and his general health and spirits showed some improvement also.
This was in August, 1886.
This improvement continued for several months. In November
he was still morose, but much less markedly so. He*adhered to
his accusations of unnatural illtreatment by his sisters, but he did
not enlarge thereon, and was almost quite free from agitation when
discussing them. He said all he wished was never to see or hear
of them again, and he agreed that he would not return to his native
village nor hold any communication with them. An interview
with one of his sisters, both of whom he had violently refused to
see before, was arranged for, to test his power of self-control. The
lady was unfeignedly alarmed at the prospect of his possible dis¬
charge, and afraid to see him, but was at length prevailed on to do
so. He received her in sulky silence, but without any sign of
agitation. He said, in a dignified manner, “ I wish to have nothing
to do with you again,” and refused to converse further. His ap¬
pearance indicated comparative indifference.
The gain in self-control evidenced at this interview, together
with his general improvement, were judged sufficient to justify his
discharge. Arrangements were made for him to go to Edinburgh,
and there, and there only, receive a weekly allowance through the
inspector of poor, and he was accordingly discharged as technically
“ recovered ” on Nov. 15, 1886, after eighteen months’ residence in
the asylum.
Since discharge he has lived in Edinburgh, receiving his allow¬
ance, and occasionally getting light work, which he throws up in
a few days as too trying for his health. He has held no commu¬
nication of any kind with his sisters. I believe he makes frequent
attempts to interest the lawyers again in his case, but with no
result as yet that I have heard of.
To recapitulate briefly: among the salient points of this
interesting case there stand out:—
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Clinical Notes and Cases .
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1887.]
1. Eccentricity of father, death from “ decline ” of mother,
and parallel eccentricity of sisters.
2. Indulgence as youngest child and only son. Reserved
and timid boyhood. Premature establishment in business.
Drinking habits. Self-abuse (?) Sudden outburst in running
off with acting company. Erratic, lonely, and semi-depen¬
dent subsequent life. Disappointment about father’s will.
Probable onset at this time of phthisis. Lazy, self-indulgent
life, with sisters themselves eccentric. Over-smoking, idle¬
ness, and further drinking. Exacerbation of symptoms; in¬
sane unreasonableness, egotism, and hypochondria. Struggle
for living in Edinburgh. More drink and subsequent priva¬
tion. Threats of murder and suicide. Violent language
and conduct. Action of Procurator Fiscal. Committal to
asylum.
3. On admission, moroseness, egotism, hypochondria,
violent language regarding sisters, agitation and loss of
control, aggravated by extraordinary perversion of his rea¬
soning powers on this and allied subjects, and peculiar half¬
conscious self-deception, amounting to quasi delusions of
suspicion, illustrated by his conduct and language about the
will. Absence of any definite delusion. Delicate general
health.
4. Slight improvement, mental and physical, after con¬
siderable time, from discipline, air, exercise, tonics, reduced
tobacco, and enforced alcoholic abstinence. Effect of un¬
usual treatment by moral suasion. Escape. Attempt to
start a lawsuit. Moral effect of failure of escape and collapse
of legal proceedings. Progressive gain in self-control, di¬
minished violence of hatred, less perversion of his reasoning
powers, and general health and spirits, test interview with
sister, discharge, and subsequent behaviour indicative of
improvement.
I have called this a case of “ Moral Insanity,” following
Prichard and subsequent legal authorities. There was of
course in this case no special defect of “ moral sense,” and
the term, “ Affective Insanity ” would perhaps more cor¬
rectly indicate the morbid condition.
6
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XXXITI.
Clinical Notes a/nd Cases.
[April,
82 .
Ataxo-Spasmodic Tabes (Ataxic Paraplegia), occurring in a
case of Primary Dementia .* By R. S. Stewart, M.D.,
Senior Assistant Medical Officer, Glamorgan County
Asylum.
It is only within comparatively recent times, especially in
England, that a distinct place in the nosological classifica¬
tion of diseases of the spinal cord has been granted to ataxic
paraplegia, and that it has been separated, on the one hand,
from spastic paraplegia, and on the other from ataxic tabes.
Rossf classifies it as a compound form of lateral sclerosis,
and BramwellJ mentions it as owing its origin to an
occasional extension of the lesion from the postero-extemal
columns in locomotor ataxia, while Erb (Ziemssen’s
“ Cyclopaedia ”) regards it as tabes complicated by lesion of
the lateral columns, or lateral sclerosis complicated by lesion
of the posterior columns, according to the preponderance of
the symptoms of one or other disease. On the other hand, the
most recent English work on diseases of the spinal cord,
that of Gowers,§ devotes a separate section to the considera¬
tion of the affection, while on the Continent, especially in
Germany and France, it has attracted considerable atten¬
tion. In the “Archives de Neurologie ” for March, May, and
July of last year, a detailed description of the symptoma-
tology, pathology, diagnosis, and treatment, with a tabulated
resume of 33 cases followed by autopsy, described by various
French and German authors, is given by Grasset.
The following case, both from a clinical and pathological
point of view, presents many of the features of this form of
disease of the spinal cord.
Summary :—History of intemperance in the father . Commence¬
ment by speech-embarrassment a/nd mental enfeeblement. Ataxic gait.
Absence of knee-jerk. Retention of superficial reflexes. Partial
a/ncesthesia. Absence of lightning pains. Gradually advancing motor
failure. Rigidity of limbs. Fibrillary tremors. Emaciation.
Muscular atrophy. Bedsores. Diarrhoea. Increasing loss of con-
* It may be questioned whether these terms, the introduction of which into
our nosology is of dubious wisdom, are justified by the case here reported. It
is not yet, we think, sufficiently recognised, how frequent is the combination
of lateral and posterior column changes in General Paralysis. [Eds.]
f “ Treatise on the Diseases of the Nervous System,” 2nd Edit., Vol. ii.,
p. 80.
} •« Diseases of the Spinal Cord,” 2nd Edit., p. 224.
} “ Diseases of the Nervous System/* Vol. i., p. 341.
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Clinical Notes and Cases .
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18870
sciousness. Temporary improvement. Affection of taste and smell.
Auditory hallucinations . Returning loss of consciousness; coma;
death 16 months from commencement. Degeneration and atrophy of
nerve-cells of cerebral cortex and spinal cord. Primary lateral and
posterior spinal sclerosis.
James B., aged 24, a smith’s striker, native of Cardiff, was
admitted on Nov. 26th, 1886. Up to within 12 months of his
admission, according to information given by his wife, he had
been an active, steady man, kindly-dispositioned, of temperate
habits, and of uniformly good health. At that date he had been
unable for some time to obtain employment, and it was observed
that he was becoming dull and reserved, that his speech became
slow and hesitating, his movements uncertain, and that his
memory began to fail. During the 12 months prior to his ad¬
mission these symptoms became gradually more and more marked.
Very little information could be obtained as regards family ante¬
cedents, beyond the fact that his father was an habitually intem¬
perate man. Patient himself had been married two years, and
there was one child.
His condition on admission was as follows:—
He is a poorly-nourished man, pale and sallow, and of medium
height; height 6ft. 4^ in., weight 9st. 41bs.; features emaciated,
head well formed and amply developed anteriorly; hair dark;
irides light blue. The pupils are much dilated, but equal and
responsive to light. The tongue is pale, flabby, indented at the
edges, and slightly coated, and voluntary attempts to protrude it
take place in a highly tremulous and uncertain fashion. Speech
is also very hesitating and drawling, amounting to little more
than mere mumbling. There is nothing noteworthy as regards
the heart, lungs, or abdominal viscera; urine, specific gravity
1011, acid reaction, straw colour, mucous sediment, no albumen.
The mental condition is one mainly of stupor; his expression is
vacant and unintelligent; to many commonplace questions he is
unable to give a rational reply, though he responds to such simple
requests as asking him to put out his tongue, to walk a certain
distance, &c.; memory both for remote and recent events is very
much impaired, and his habits are defective.
His gait, though by no means characteristic, approximates to
that of locomotor ataxia rather than that of spastic paralysis.
The knee-jerk is completely absent on both sides; the plantar and
other superficial reflexes are normally active. Sensation as re¬
gards painful impressions is very much blunted, and the same
applies to the localization of touch, and the discrimination by
touch of different objects or parts of objects—such as the head
from the point of a pin. There is considerable diminution of
voluntary motor power, and some ataxia, both of the lower and
upper limbs, manifested in the walk and such actions as touching
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84
Clinical Notes and Cases.
[April,
the tip of the nose with the fore-finger. There is likewise sway¬
ing of the body when the eyes are closed and the feet approxi¬
mated. In both upper and lower extremities there is considerable
rigidity, and resistance to passive movement. As he lies in bed
the legs are strongly flexed and adducted, and the arms flexed and
closely applied to the chest wall. Fibrillary tremors very
generally distributed, and affecting the superficially placed
muscles, are noted.
Three weeks after admission, owing to increasing helplessness
and stupidity, he had to be confined to bed. Consciousness. be¬
came more and more involved, until he became almost comatose.
He lay on his back all day unless moved, the saliva dribbling
from his open mouth. He paid no attention to remarks addressed
to him, nor could he be roused by vigorous slapping of the face.
Evacuations were passed in bed, and there was considerable
paralysis of deglutition.
On January 12th it is noted as follows :—There has been a con¬
siderable change for the worse. He is still very confused and
stupid; he has become very emaciated, the muscular masses are
much atrophied, and bedsores, dry, super6cial, and leathery in
character, have formed over the sacrum and left trochanter (a
water bed has been in use all along). The knee-jerk is still
absent; the plantar reflex active. He suffers from an intractable
form of diarrhoea, not yielding to large doses of bismuth, but con¬
trolled to some extent by a combination of tincture of opium and
aromatic sulphuric acid.
February 2nd. A considerable improvement is indicated by the
note made at this date. He has become bright and observant,
noting what is going on around him. On testing the special
senses, it is found that hearing is normally acute, but that
taste and smell are both affected, more so the latter. For
example, quassia tastes “ sour,” acid “ sweet,” sugar “ sweet,”
and salt “ salty ; ” oil of cloves smells “ like gin,” turpentine
“ like rum,” and assafoetida “ like cocoa-nut.” Auditory hallucina¬
tions have lately developed; he hears his father and mother out¬
side, and he often holds conversations with them. Although he
has begun to gain both flesh and strength, a loss of 31 lbs. has
taken place since his admission (three months). The eschars ex¬
hibit healing action and are improving rapidly. The appetite
improves, and he takes large quantities of food without any
apparent difficulty as regards swallowing, while the diarrhoea has
quite disappeared. This improvement has taken place during the
administration of the opium and sulphuric acid, and to these are
added cod-liver oil and Parrish’s syrup.
In the early part of March he was able to be up part of each
day, but by the middle of the month he was again confined to bed.
There he remained, and the further progress of the case was
steadily and progressively downward. Emaciation and muscular
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1887.]
Clinical Notes and Cases .
85
wasting became extreme ; bis face became haggard and ghastly,
and for two days prior to his death, which occurred on March
31st, 1886, a little over four months after his admission, he gave
little sign of life beyond slow regular breathing and a feeble
pulse.
The autopsy was performed 40 hours after death, and the
following notes were taken.
The spinal cord weighs 17 drams, and its measurements are as
follows :— #
Transverse.
Sagittal.
Cervical ...
. 13
10
Dorsal
. 10
8
Lumbar ...
. 10
9 mm.
The cerebro-spinal fluid is in considerable excess. The cord
itself is firm throughout, but more especially so in the lumbar en¬
largement. The dura is normal. The soft membranes are con¬
gested, particularly over the posterior aspect of the lumbar en¬
largement, where, in addition, they present a grayish appearance.
On section, the central gray matter appears slightly congested.
In the lumbar region a grayish patch is apparent in each postero¬
external column, while the postero-internal division is also grayer
than normal, and somewhat pink. No other change is apparent to
the naked eye.
The skull-cap weighs lOJozs., and is thin generally. The dura
mater is normal. The encephalon weighs 53^ozs.; the right
hemisphere, 22£; the left, 22 ; the cerebellum, pons, and medulla, 7.
The soft membranes are gelatinous, opaque, and tough; but they
are nowhere adherent, being separated from the underlying con¬
volutions by a considerable quantity of subpial fluid. The brain
tissue'is cedematous and soft; the cortex is congested in a some¬
what patchy manner, but not apparently atrophied. The ven¬
tricular fluid is slightly increased, but the walls are perfectly
smooth. The central medullary substance is of a pure white
colour.
The heart weighs 7ozs.; its cavities are contracted; its tissue
pale and firm, and its orifices normal. There is rather extensive
atheroma of the ascending aorta. The left lung weighs lOJozs.,
the right 24ozs.; in the latter there is basal congestion; other¬
wise both are normal. Spleen 2ozs.; left kidney 3£ozs., right 3ozs.
* The average weight of the spinal cord in 73 male insane persona dying
under the age of 30 is given by Boyd (“ Table of Average Weights of the Body
and Brain ”) as 1*1 oz. The weight of the cord varies, according to Quain
(“ Anatomy,*’ 8th Edit.), from 16 to 28 drams. The measurements of the
normal cord are:—
Transverse. Sagittal.
Cervical . 13 or 14 10
Dorsal . 10 8
Lumbar . 1& 9 mm.
— Erb in Ziemssen’s 41 Cyclopaedia,” Yol. xiii., p. 11.
Digitized by L^ooQle
86 Clinical Notes and Cases • [April,
Liver, 55ozs., is slightly fatty. Intestines normal. Enlargement
and caseation of mesenteric glands.
Microscopic examination. — Brain. In sections taken from the
upper end of the central convolutions, and stained with carmine,
the large pyramidal nerve-cells of the third layer of the cortex
present evidences of a considerable degree of atrophy and
degeneration. They are smaller than normal, and they have
indefinite outlines and withered-looking processes; they have a
generalized yellow-granular appearance, and in many instances
the nucleus is completely obscured. In sections stained with
osmic acid (£ per cent, sol.) the degenerated nerve-cells take on a
dark stain, varying from a deep brown to almost complete black.
The vascular walls are nowhere thickened, but the perivascular
sheaths in many of the smaller arteries is occupied by hssmatoidin
particles, lying free or enclosed in granular cells.
Crura cerebri .—The nerve-cells of the locus niger are filled with
brown and often quite black pigmentary particles, so that the
nucleus is only exceptionally to be detected. Hsematoidin par¬
ticles occur in the perivascular sheaths, but as regards the
medullary substance no material alteration is to be noted, and in
particular no sclerotic process either in the region of the pyra¬
midal tract or elsewhere.
Cervical cord .—The microscopic appearances indicate a degree
of generalized sclerosis, with specialized areas of degeneration of
greater intensity. The supporting connective tissue over the
whole section is coarser than normal; the neuroglia-cells are
large and prominent; the vascular walls are considerably
thickened, and heamatoidin particles occur occasionally in the
walls and perivascular spaces. In carmine-stained sections, the
areas of more advanced sclerosis are indicated by a deeper stain¬
ing. These areas (Fig. 1) affect the lateral and posterior columns.
That in the lateral columns assumes a triangular form; it has badly-
defined outlines ; it is separated externally from the periphery by
a narrow zone of more healthy tissue; posteriorly it touches the
posterior cornu, and anteriorly it reaches as far forward as the
level of the central canal, shading off gradually into the more
normal tissue of the anterior root-zone. In this area the nerve-
fibres are diminished in number, but many of those remaining are
of normally large size. This description applies to both lateral
columns, the degeneration being strictly symmetrical. In the
posterior columns the degeneration is less intense; it affects the
whole extent of the internal divisions, but only a small portion of
the external divisions, forming a wedge-shaped area which reaches
quite to the periphery, but is separated from the posterior cornua
and central parts of the gray substance by a zone of more healthy
tissue.
The smaller nerve-cells of the anterior cornua of the gray sub¬
stance seem fewer in number than normal. The large multipolar
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Glimcal Notes and Cases .
87
1887.]
oorpuscles are extensively degenerated and slightly atrophied;
their outlines are wanting in definition; their processes are
shrunken-looking, and their interior is occupied in varying pro¬
portion by brownish granules, collected sometimes in one or other
of the polar recesses, or distributed more generally through the
cell-substance, more or less completely obscuring the nucleus. In
carmine-tinted sections these degenerated parts of the nerve-cells
do not take on the staining, but appear as brownish-yellow areas,
and in sections stained with osmic acid they assume a tint varying
from deep brown to black. The vessels are numerous and dilated,
and the central canal is obliterated and replaced by a mass of
round cells.
Lumbar cord .—In this region there are also evidences of a
generalized slight sclerosis, and localized areas of more advanced
degeneration. The area (Fig. 2) of lateral sclerosis is here much
diminished, and it is confined to the posterior extremity of the
column, reaching quite up to the periphery, but separated from
the central gray substance by a zone of comparatively healthy
tissue. The posterior sclerosis does not affect the deeper parts of
the columns, nor, except at the extreme outer part of the external
divisions, the parts lying towards the periphery. It extends
transversely over the whole extent of the columns in their middle
three-fifths, and it varies somewhat in intensity. Here also
the nerve-cells of the central gray substance are extensively
degenerated, and it is noticeable that the smaller bipolar cells of
the posterior cornua share in some degree in the degeneration.
The central canal is normal.
In several of its features, e.g., the tremor of the lingual
muscles and the speech-embarrassment, this case resembles
one of general paralysis, but never, during the whole course
of the affection, either before admission, so far as could be
gathered from the history, or during his residence in the
asylum, did he manifest any symptoms of that mental exal¬
tation which is so common a characteristic of the early
stage of confirmed general paralysis. On the other hand,
the prevailing mental condition was one of more or less
progressively advancing enfeeblement, pointing rather to
primary dementia.
The physical signs indicate a widespread affection of the
whole cerebro-Bpinal nervous centre, but from the point of
view of the affection of the spinal cord, the case presents
the features mainly of ataxic paraplegia. The gradual
failure of motor power, the rigidity of the limbs, and resist¬
ance to passive movement, indicate an affection of the
lateral columns, while the absence of the knee-jerk, the
ataxia, the diminished sensibility, and the deficient equilibru-
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Clinical Notes and Cases .
[April,
tion on closure of the eyes, constitute the symptoms of
posterior sclerosis. It must be remarked, however, that the
case involves more than the question merely of sclerosis of
the posterior and lateral columns. Symptoms indicating
extension of the morbid affection to the gray substance are
not awanting. The gradual wasting of the muscles, and the
fibrillary tremors, indicate a tropho-irritative affection of the
nerve-cells of the anterior cornua, and the dermic necroses
an irritative affection of the posterior parts of the central
gray substance.
There is on some points a discrepancy of opinion between
the two most recent writers on this subject—Grasset and
Gowers. From a perusal of the section devoted to the
description of this affection, I should say that probably the
latter had not, at the date of publication of his work on
“ Diseases of the Nervous System,” seen Grasset’s article in
the “ Archives de Neurologie.” While Grasset’s article
comprises three cases observed by himself, and a tabulated
summary of 33 other cases, in all of which autopsies had
been performed, Gowers says “ a few pathological observa¬
tions have been published.” According to Gowers, the knee-
jerk- is in the majority of cases quick and extensive; in
Grasset’s 33 tabulated cases explicit reference is made to the
condition of the patellar tendon-reflex in 19 instances, and of
these abolition is noted in 12, exaggeration in 7. In the
case here described, in a case of melancholia which I have
elsewhere* described, and in a case of general paralysis whose
cord I have recently examined, in all of which there was
found, post-mortem , sclerosis, both of the lateral and posterior
columns, the knee-jerk was abolished, so that I am rather
inclined to adopt the view of Grasset, viz., that “ abolition
is much more frequent than exaggeration.”
The facts of this case, so far, at least, as regards the lower
extremities, are not altogether in accordance with the view
expressed by Westphal and Zacher, viz., that in a combined
lesion of the pyramidal and posterior columns the spastic
phenomena are not developed in the superior or inferior
members when the lesion of the posterior columns affects the
posterior radicular zones in the corresponding sections of the
cord.
Grasset, who proposes for this form of disease the name .
Combined Takes , classifies it as one of the Mixed Myelitis 9 in-
* “ Glasgow Medical Journal,” October, 1886, p. 250.
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Clinical Notes and Cases .
89
1887 .]
cloding under that term those myelites which are at once
diffused and systematic —the posterior sclerosis being syste¬
matic, the lateral diffuse. The lateral sclerosis I look upon
as primary , as contradistinguished from secondary descend¬
ing degeneration, the anatomical features approximating
more to those of the former than the latter.
Cervical (J. Bradley).
Fio. I.—Spinal cord; cervical region ; from a case of ataxio paraplegia;
degeneration of lateral and posterior columns.
Lumbar (J. Bradley).
SPINAL CORD.
Fig. 2. —Spinal cord; lumbar region; from a case of ataxio paraplegia;
degeneration of lateral and posterior columns.
Note. —The writer may here mention that Grasset considers that the
description of the cases collected in his tables affords a reply to the question
raised by Dr. Pram well in the foot-note of page 224 of the second edition of
his work on “ Diseases of the Spinal Cord ” as to the condition of the knee-
jerk in cases of locomotor ataxia which have become complicated with lateral
sclerosis.
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90
Clinical Notes and Cases.
[April,
Cases of Typhoid Fever in the Insane .* By R. Percy Smith,
M.D., M.R.C.P., Assistant Medical Officer, Bethlem
Hospital.
The following cases of typhoid fever have occurred recently
in Bethlem Hospital. The first was an isolated case, occur¬
ring in the summer of 1885, in a female patient who had been
eleven weeks in the hospital, the source of infection not being
clear, although at that time drainage-defects undoubtedly
existed. The other cases occurred in the autumn of 1886;
they all arose within a few days of one another; the patients
were all females, and at the time of attack were in the same
ward on the ground floor. All apparently originated from a
local drainage-defect, and one attendant suffered at the same
time. The origin of the disease in food or water-supply
would appear to be negatived by its limitation to one ward,
in which there was undoubtedly an escape of sewer gas,
possibly emanating from an old cesspit infected by the
evacuations from the first case, although there was an
interval of more than a year between that case and the
next. The epidemic has led to a thorough overhaul of the
drainage of the hospital, and practically the relaying of a
great part of it.
I shall give a brief summary of each case, and then
append a few remarks.
Case 1.—F. W. B., set. 28, single, governess ; admitted into
Bethlem Hospital June 1st, 1885, suffering from an attack of
acute mania of three weeks’ duration.
She had had two previons attacks of insanity, in each of which
she was depressed, but she had never been under certificates
before. She was at first playful, excited, and restless, singing,
dancing about, and decorating herself with flowers and leaves; but
about the beginning of August became noisy, violent, and using
foul language. On August 15th she menstruated for the first time
since admission, and then complained of great headache, and
became much quieter. The bowels were confined. Four days
later she was sick in the morning, and had general abdominal pain
and tenderness. The temperature was found to he 102° F. She
also had epistaxis, and was slightly deaf, and had some diarrhoea.
She passed through a mild attack of typhoid fever, the tempera¬
ture reaching 104° F. during the second week of the disease, and
becoming normal both morning and evening by September 12th,
* Bead at the Quarterly Meeting of the Medico-Psychological Association,
held at Bethlem Hospital, February 23rd, 1887.
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the duration of the attack being between three and four weeks,
and there being no complications.
With regard to the mental condition of the patient, with the onset
of the fever the excitability and violence disappeared almost sud¬
denly ; there was no delirium associated with the attack, but she
became sleepy and quiet, and was perfectly tractable and manage¬
able. The excitement did not return with the abatement of the fever,
and she was soon sent to the Convalescent Hospital. She subse¬
quently passed through a rather prolonged period of dulness and
apathy, from which, however, she eventually recovered.
Case 2.—M. A. S», widow, ®t. 41; admitted December 7th, 1885,
Buffering from acute mania, following the death of her husband
and of a favourite child. She had had a previous attack at the age
of 20. She was extremely violent, noisy, and destructive on
admission, and although her general condition improved somewhat,
as a result of plenty of food, she remained for eleven months one
of the most troublesome cases in the hospital, her excitement
not yielding to hyoscyamine, bromide of potassium, or chloral
hydrate.
On November 19th, 1886, nearly twelve months from her ad¬
mission, she complained of some pain in her left side, and it was
remarked that she had looked rather ill for two or three days.
She had become much more manageable, although still incoherent
and deluded. Her temperature was found to be 103° F., and she
had some crepitation at the base of the left lung. At first the
case was regarded as one of commencing pneumonia, but the
persistence of high temperature, with a morning fall and evening
rise, and the non-development of any further lung-signs, except
slight general rhonchi and crepitation, led one to suspect typhoid
fever. There was now no difficulty whatever in keeping her in
bed, and she had quite ceased to be destructive or dirty. During
the first week her temperature reached 104° nearly every evening,
and the maniacal excitement had been replaced by a drowsy con¬
dition, with periods of restless, quietly talkative delirium.
Spots appeared at the end of the first week.
During the second week there was a great deal of abdominal
pain, tenderness, and distension, with some retching, associated
with small, feeble pulse and a rather rapid fall of temperature,
but no diarrhoea. Her condition gave considerable anxiety as to
the onset of peritonitis, but she was kept under the influence of
morphia, and the serious symptoms disappeared. Her temperature
finally became normal, both morning and evening, early in the
third week after she was first noticed to be ill, except for a rise a
week later, lasting two days, and associated with pains in the
elbows and knees. The bowels were confined throughout, and had
to be moved by enemata every three days. For the first week
after the abatement of the fever she was quiet, talked fairly
rationally about her illness, and attributed it to the death of her
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Clinical Notes and Cases.
[April,
husband and child; the improvement, however, only lasted a few
days, and she again became noisy, destructive, and sleepless, and
by the end of December had become as bad as ever.
She was finally discharged uncured, and went to a County
Asylum.
Case 3.—B. A., set. 20, single, no occupation; admitted October
21st, 1886, with a first attack of acute mania, lasting ten weeks
before admission, and attributed to a sudden cessation of the
catamenia from bathing in the sea. She was slightly deaf as the
result of an attack of scarlet fever in 1880, during which she
was very delirious and excited. On admission she was very excited,
incoherent, violent, and destructive. She remained in this con¬
dition for a month, and on November 20th she was noticed to be
quiet and rather out of sorts. Her tongue was furred, and she
complained of some giddiness, and was more deaf than on ad¬
mission. She had some discharge from the left ear.
Her temperature was found to be elevated, and slight general
rhonchi were heard over both lungs. She became quiet and
rational from the first onset of the fever, and gave no trouble at
all. Spots appeared at the end of the first week. The bowels
were slightly relaxed, and the only cause for anxiety in her attack
was the very abundant crepitation which existed all over both
lungs for about a fortnight. The temperature during the first
two weeks ranged between 102° and 104° F., and during the suc¬
ceeding week came down in the typical manner. In a month from
the onset of the attack she was convalescent.
During the period of high temperature she wandered somewhat
at night, but she passed the greater part of the twenty-fours in
sleep, and had no manical excitement, and after the abatement of
the fever she remained well mentally.
She menstruated on January 3rd for the first time since, ad¬
mission. She has been to our convalescent home, and has
to-day been discharged “recovered,” looking fat and perfectly
well.
Case 4.—S. B., set. 37, deaconess; admitted January 28, 1886,
with an attack of melancholia lasting fourteen days, characterized
by great restlessness and agitation, religious doubts, self-accusa¬
tion, and refusal of food. She improved very little, and by the
middle of November the only change was that she was taking
food fairly well, was fatter than on admission, and not quite so
restless, occupying herself with needlework, &c.
Two or three days after the commencement of the attacks of
typhoid fever in the cases just narrated, it was noticed that her
appetite had failed, and that she was much less agitated, and
talked less about her delusions. She complained of feeling ill,
and her temperature was found to be elevated. She passed
through a mild attack of typhoid, not attended by diarrhoea or
lung complication, but associated with considerable abdominal
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Clinical Notes and Cases .
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1887.]
pain and tenderness. In a fortnight her temperature was normal
both morning and evening.
During the attack she was perfectly quiet, had no agitation, and
recognized that she had had delusions, and seemed to remain
fairly well mentally till the end of the year, one month from the
onset of the febrile symptoms.
Early in January, however, she became restless and miserable
again, and finally relapsed into her old condition, and was even¬
tually discharged uncured.
Case 5.—M. A. F., aet. 47; single, no occupation; admitted
January 26, 1886, with a first attack of melancholia, with delu¬
sions of being watched by policemen and others, and hallucina¬
tions of hearing, suicidal attempts, and refusal of food. The
attack followed the death of her mother.
By the middle of November she was practically unchanged. On
December 4th she had slight sore throat and abdominal pain, w r as
sick, and had some diarrhoea. At the end of the second week of
the fever the temperature became normal for two days, and then
a relapse followed lasting three weeks. There was some diarrhoea,
principally towards the end of the relapse, but this w r as easily
controlled by starch and opium enemata. Persistent vomiting
about the same period gave considerable anxiety. With regard to
the mental condition it may simply be remarked that there was no
improvement whatever. During the whole attack she was obsti¬
nately resistive to everything that was done for her, was constantly
trying to get out of bed, and even when the temperature was at
its highest utterly failed to realize that she was at all ill. This
condition of course gave us considerable anxiety, as the quiet so
essential in the treatment of typhoid fever was absolutely un¬
attainable in her case, even in spite of the administration of
sedatives and narcotics, and the relapse was probably due to this
constant restlessness, for no solid food had been given before its
occurrence. However, she became convalescent at the end of five
weeks from the onset of the fever, as far as that was concerned,
but remained mentally in the same condition as on admission.
She has since been discharged uncured. I think her recovery
from typhoid fever may be fairly attributed to the very great care
displayed by those who nursed her, for she certainly was a most
unfavourable subject for an attack of a disease beset with so many
dangers.
Case 6.—E. J. P., set. 27, single, dressmaker; admitted
July 20th, 1886, with a second attack of melancholia lasting ten
days. She had practically been unstable from October, 1885, and
had been in Bethlem Hospital from then till June, 1886. The
existing attack had followed her sudden discharge from employ¬
ment, and she was restless, suspicious, depressed, and had been
wandering about Highgate Ponds with suicidal intent. She
passed into an almost stuporous condition, refusing food, and
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94 Clinical Notes and Cases. [April,
being always wet and dirty in habits, and frequently grovelled on
the floor, never speaking or taking interest in surroundings.
In. the middle of November her head was shaved for the pur¬
pose of blistering the scalp, but she improved slightly after the
shaving, so the application of any blistering material was deferred.
In ten days she was much better, and was taking food well, and
gaining flesh and looking brighter.
On December 2nd she was sick, and complained of pain in the
right iliac fossa. Her temperature was elevated for only a few days,
but the chart was characteristic of the end of a mild attack of
typhoid fever, and she was treated for that disease. Had it not been
for the other cases occurring in the same ward, the possibility of her
having a mild attack of typhoid might have escaped recognition.
She had no diarrhoea, but her tongue resembled that common in
typhoid fever, and she had abdominal pain lasting some days.
The mental improvement which had begun before the febrile
process was discovered progressed, and seemed intensified by it,
and she is now at our convalescent home remaining perfectly well.
Remarks .—In reviewing these cases one may first note the
difficulty sometimes experienced in detecting diseases of this
nature in the insane, the patient frequently making little or
no complaint until noticed to be looking ill or to be losing
appetite or to be manifestly feverish.
Secondly, with regard to the alteration in the mental
condition with the onset of a fever the matter is referred to
in the works of Griesinger, Ball, and Bucknill and Tuke, and
Dr. Campbell, now superintendent of the Murthly Asylum,
reported twenty-two cases occurring at the Durham County
Asylum in the “Journal of Mental Science ” for July,
1882.
It may be summarized briefly that in two cases (No. 1
and No. 8) a definite, sudden abatement of maniacal
symptoms appeared concurrently with the onset of the fever,
and the mania did not recur. In Case 1 the attack was
followed by a certain amount of temporary depression, but
this was in all probability due to the patient’s unstable
nervous system, and was not quite the same as the
alteration of mental condition sometimes seen in the sane
after an attack of typhoid. This is rendered the more
probable as she had had two previous atacks of insanity.
In Case 3 it is interesting to note that the patient had
previously had an almost maniacal delirium during an attack
of scarlet fever.
In one other case (No. 6) the patient had entered upon
mental convalescence before the discovery of any febrile
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Clinical Notes and Cases .
1887.]
95
process, but the mental improvement progressed con¬
currently with the latter and was certainly not delayed by it.
In the remaining three cases (Nos. 2, 4, and 5) there was
no permanent benefit.
In Case 2, however, the maniacal excitement, which
would have been a source of real danger to the patient,
happily abated during the fever, thus rendering her treat¬
ment comparatively easy ; and in this case it was interesting
to notice the quieter delirium of typhoid fever replacing
the intense excitement she laboured under before.
In Case 4 there was merely a temporary remission of
the depression the patient suffered from, and there was no
delirium during the fever.
Case 5 was the most anxious one in consequence of the
extreme restlessness and obstinate resistance of the patient
during the whole of the attack, and, as remarked before, there
was no mental improvement whatever. Why this occurred in
this case only is not very apparent. It may, perhaps, be
looked upon as unnecessary to report these cases, as the fact
of remission or cure of mental disease is such a common
occurrence in association with the development of physical
disease; but I am not aware that any good explanation has
yet been given of the reason of this, although the fact is
referred to in nearly all works on Insanity, and, therefore, it
can hardly be superfluous to report cases where a common
cause acts upon patients mentally diseased. It may be
remarked that two of the patients (Nos. 2 and 4) had pre¬
viously during their stay in the hospital suffered from local
inflammations, the one an abscess in the temporal region and
the other suppuration of some severity about one finger,
but with no mental improvement.
At present typhoid fever is too dangerous a disease to the
patient to suggest that it should be administered medicinally.
Perhaps at some future date, when the specific fevers have
been rendered manageable, acute attacks of insanity may be
cured by inoculation. All that can be said at present is that
in some cases of insanity an attack of typhoid fever appears
to cut short the mental disease.
It may be remarked finally that only those cases which
one would have expected to get well under any circumstances
actually did recover; the others were looked upon as in all
probability cases which would be of very long duration even
if eventually recovering.
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96
[April,
OCCASIONAL NOTES OF THE QUARTER.
Superannuation-Pensions of Medical Officers of County
Asylums.
Recent discussions at Quarter Sessions have brought the
important question of superannuation prominently before
the notice of asylum medical officers. Anyone who has
read reports of the proceedings of Dorset, Norfolk, and
Berkshire Quarter Sessions in January cannot fail to be
impressed with the very unsatisfactory state of matters as
regards the superannuation of asylum medical officers, and
the uncertainty of their position in this respect, for the
agitation against pensions appears to be chiefly directed
towards obtaining a reduction in the amount proposed to
be granted to the medical superintendent, some even going
the length of advocating the total abolition of pensions.
Let us briefly state a few facts in proof of this assertion.
1. The Dorset Asylum Committee recommended a pension
of £600 a year, being two-thirds of total estimated value
of office, to their able superintendent, who has served 32
years. The various Boards of Guardians organized an
agitation against the pension as excessive in amount,
which was so successful that the Magistrates at Quarter
Sessions rejected the Committee’s recommendation by the
large majority of 39 to 13, suggestions being thrown out
that a reduced amount should be asked for at the April
Sessions.
The Earl of Eldon remarked, “ he did not like to give his
consent to the doctrine that when a man had served a
certain time, he was entitled to a pension as a matter of
course. He must protest against Mr. Glyn*s argument that
they must give Dr. Symes something for his 30 years*
service.**
Lord E. Cecil remarked, “ I am not hostile to the pension,
but I plead for the sake of the ratepayers.**
Mr. Montagu Guest said, “ it seemed to him the public
feeling was against this pension being granted. He thought
it was an excessive proposal to make under the circum¬
stances.*’
Major Groves said, “he much regretted that he felt
bound to oppose the granting of the pension of £600, not
upon the ground that Mr. Symes had not done his duty, but
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97
1887,] Occasional Notes of the Quarter . *
because he objected to the argument which was so rnudh
spoken of, that because a man had done his duty he was to
receive a very large pension. He had heard not only the
opinions of the ratepayers, but those of almost all other *
classes in the county, and they were all decidedly against
the pension.”
If Mr. Symes, with such efficient and lengthened service
of 32 years, is not worthy of and entitled to the maximum
two-thirds pension, it is hard to tell who is. Such observa¬
tions and decision, emphatically expressed at the Dorset
Quarter Sessions, tend to discourage asylum officers, and are
calculated to shake their confidence in the sympathy and
generous dealing of the County Magistrates towards them
in the matter of a retiring allowance.
Surely a medical superintendent, who has to combat the
risks, worries, and anxieties of asylum life, is worthy of and
entitled to at least as much consideration as officers in Her
Majesty’s service and Civil servants, who are free from the
uncertainties and anomalies of our permissive system of
superannuation, and are not subjected to suspense or the
indignity of begging for their recognized pension.
The question may be asked, when, and for what length and
quality of service, may a medical superintendent reasonably
expect the maximum two-thirds on retirement under our
present system ? And what amount may he reasonably ex¬
pect for any period after 15 years’ service?
2. The Committee of the Norfolk Asylum recommended a
pension of £600 a year, being rather less than two-thirds of
total estimated value of office to their superintendent after a
meritorious service of 25 years, which was confirmed at the
January Quarter Sessions, although not without a grumble
and an attempt to obtain a reduction in the amount.
“Lord Wodehouse thought that £600 was an enormous
sum to give. He thought that £500 a year would be amply
sufficient, and he moved accordingly,” but this amendment
he subsequently withdrew.
The Earl of Kimberley said, “ it was open to remark that
Dr. Hills was 59, whereas with other services a man must
be 60 years of age before he was pensioned. Nothing was
so burdensome as pensions, and nothing required such careful
consideration as the amount of a pension which was given.”*
• Ever since the Norfolk pension has been granted, Boards of Guardians in
that county continue to agitate and protest against what they consider an
excessive pension, as the following resolutions will show:—
xxxiii. 7
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98
Occasional Notes of the Quarter, [April,
3. The Committee of the Asylum for the County of
Berks, Borough of Reading, and Borough of Newbury,
recommended a pension of £400 a year, being one-half of
the total estimated value of office to their medical superin¬
tendent, who resigned on account of ill-health after a service
of nearly 17 years. This amount has been confirmed by the
Berkshire Quarter Sessions, and the two boroughs named, the
Chairman at the Berkshire Sessions, however, remarking that
“ the whole of the superannuation allowance was £400, un¬
doubtedly a large sum/’
The foregoing facts are significant, and seem to indicate
that the time has arrived when a combined, earnest, and
practical attempt should be made to alter or modify the
permissive system, and to get the superannuation of asylum
officers and servants placed upon a more satisfactory basis,
according to some fixed scale and period of service, on the
lines of the Medico-Psychological Association Resolutions of
August, 1879, or otherwise, as may be thought best.
In connection with this subject, the Suggestive Report of
the Parliamentary and Pensions Committee of the Medico-
Psychological Association, dated December, 1882, and signed
by the Chairman, Dr. Lockhart Robertson, is well worthy of
serious consideration. It suggests a scheme of readjustment
of the 4s. grant, which, instead of going to the Unions,
should be paid to County Financial Boards towards County
Asylum expenditure, including salaries, wages, pensions,
repairs and enlargement of the fabric.
As Editors of the Association Journal we wish to help
forward this good and just cause, and we naturally look to
Erpingham.—Protest against Dr. Hills’ Pension. —At a meeting of
Guardians of this Union at Beckham, on Monday, February 14th, it was unani¬
mously resolved : “ That this Board, having heard that a retiring pension of
£600 per annum was recently granted at the Norfolk magistrates’ meeting to
Dr. Hills, lately Medical Superintendent to the County Asylum, desire to ex¬
press their opinion that such a sum is excessive, and they desire to protest
against such large sums of the ratepayers’ money being voted away for that
and similar purposes.”
The Aylshah Guardians* and the late Medical Superintendent of
Thorpe Asylum. —At the usual fortnightly meeting of the Guardians of this
Union, held on Tuesday, February 15th, Mr. J. S. Hickling presided. The
usual business having been disposed of, the following resolution was carried:
“ Besolved unanimously that the superannuation allowance of £600 a year
recently granted by the Court of Quarter Sessions to Dr. Hills on his retire¬
ment from the post of medical superintendent of Thorpe Asylum, is, in the
opinion of this Board, excessive, having regard to the present depression of the
agricultural interest, and the heavy burden now imposed on the ratepayers by
the county rates, and thiB Board desires to protest against such large pensions
being granted by the county magistrates in future.”
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1887.] Occasional Notes of the Quarter . 99
the Lunacy Commissioners to show their sympathy with
asylum officers in a practical way by bringing the question of
pensions under the notice of the Government, either in con¬
nection with the proposed County Boards Bill or the Lunacy
Bill now under discussion in the House of Lords. It is to
be hoped that the large-hearted sympathy of the late Lord
Shaftesbury with the staff of asylums still permeates the
Lunacy Board. Perhaps the Commissioners would be dis¬
posed to receive a deputation on the subject.
As is well known, medical officers in the prison depart¬
ments have seven years added to service. Further, the
Treasury would allow “ an injury allowance ” in addition
to this, should a medical officer be obliged to retire in con¬
sequence of receiving an injury whilst in the performance of
his duty.
Lord MonkswelPs amendment to the Lunacy Bill now
before Parliament, and adopted by the Lord Chancellor, will,
if the Bill become law, allow superintendents to reckon their
service in more than one asylum in the same county, a prin¬
ciple adopted in the Police Superannuation Bill of the late
Government. Dr. Murray Lindsay, who has done more than
anyone in advocating the claims of superintendents, has for
years maintained the justice of counting service in different
asylums towards a pension, whether in the same county or
not.
Dr. Rutherford and his Assistant Medical Officer .
We have deferred commenting on the unhappy incident
which has occurred at the Institution at Dumfries, of which
Dr. Rutherford is the esteemed Superintendent, until in
possession of the official Report upon the charges made
against the management of one of the houses of the asylum
by the Junior Medical Assistant, Dr. David Lennox. It
may be briefly stated that on June 11th, 1886, this officer
resigned after seven months’ service. When Dr. Rutherford
became aware, a week afterwards, of this fact, he at once
suspended him, a proceeding which was confirmed by the
Board of Direction. The result was an official inquiry into
the above charges by the Scotch Lunacy Board. The follow¬
ing is the memorandum made by this Board for the Trustees
and Directors of the Crichton Royal Institution as to the
inquiry by the Board, under section 11 of 20 and 21 Vic.,
Cap. 71, into the charges brought against the management
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100
Occasional Notes of the Quarter . [April,
of the second house of the institution by the late Junior
Medical Assistant in a letter to Sir Alexander Jardine,
Bart., dated 11 th June, 1886 , a copy of which letter was on
the same day transmitted by the said Junior Medical Assis¬
tant to the Board:—
I. On the 21st day of July, 1886, the Board met in Edinburgh
—all the members and the Secretary being present—and the
following persons, who had been duly cited to appear, were
examined on oath :—
1. The Junior Medical Assistant who had made the charges
leading to the Inquiry.
2. The Secretary and Treasurer of the Institution.
3. The Medical Superintendent.
II. On the 22nd day of July, 1886, the Board again met in Edin¬
burgh—all the members and the Secretary being present—and the
following persons, who had been duly cited to appear, were
examined on oath:—
4. The Senior Medical Assistant.
5. The Matron of the Second House.
6. The Matron of the First House.
7. The Head Male Attendant of the Second House.
8. The Head Male Attendant of the First House.
9. The Steward.
10. The Housekeeper.
III. On the 29th day of July, 1886, the Board met at Dumfries.
Present—Sir John Don Wauchope, Bart, (chairman), Sheriff
Guthrie Smith, Dr. Arthur Mitchell, and Mr. T. W. L. Spence for
the Secretary. The following persons were examined, and, with
the exception of the two patients, they had been duly cited to
appear and were examined on oath:—
11. Nine Female Attendants or Servants.
12. Five Male Attendants.
13. Three men formerly in service as Attendants in the Second
House.
14. Two patients.
IV. Altogether 29 persons were examined at the three special
meetings of the Board. The persons examined included all whom
it seemed to the Board necessary to examine, and also, with the
exception of three patients, all whom the late Junior Medical
Assistant, who made the charges under investigation, desired to
have examined, as persons whose testimony w'ould support the
charges. Of the five patients he had named, the three who were
not examined w r ere considered by the Board unfit for examination,
partly on evidence given orally by tho Senior Medical Assistant,
and partly on evidence given in the Case Books by the late Junior
Medical Assistant. There was besides, in the opinion of the Board,
a sufficiency of evidence from sane persons.
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1887.]
Occasional Notes of the Quarter.
101
V. Though the inquiry was not made at the instance of any
parties, the Board sanctioned the presence during it of agents and
counsel, representing (1) the Trustees and Directors; (2) the
Medical Superintendent; and (3) the late Junior Medical Assis¬
tant. At the two meetings in Edinburgh all the three were
represented; and at the meeting in Dumfries the Trustees and
Directors were represented. The gentlemen who attended as
representatives were informed that, while the Board could not
allow them a general right of cross-examination as in a contested
case, they would be permitted to suggest or put questions as
through the Board, and they freely availed themselves of this
privilege by questioning the persons under examination.
VI. At the meeting in Dumfries the Board closed the inquiry,
and gave instructions that the two Medical Commissioners should
visit the Second House, and report as to its management at the
time of their visit, with special reference to the discipline of the
House, and the feeding of the patients and attendants.
VII. The conclusions which the Board have come to as the
result of the inquiry into the charges brought against the manage¬
ment of the Second House of the Crichton Royal Institution by
the Junior Medical Assistant, in his letter to Sir Alexander Jar-
dine, Bart., of 11th June, 1886, are as follows :—
(a) That the charge of want of discipline in the Second House
of the Crichton Royal Institution has been proved to their
satisfaction to be unfounded. The conduct, however, of
the late Junior Medical Assistant during the time he held
that position was shown to have been subversive of disci¬
pline.
(b) That as regards the quantity of food supplied to the
patients in the Second House, many of the figures in the
letter referred to are shown to be erroneous ; and that the
statements in it generally in reference to the quantity of
food and the condition of the patients are undeserving of
confidence.
(c) That both as regards patients, attendants, and house ser¬
vants, the food supplies of the Second House have been of
good quality, but that the cooking of the food appears to
have been on a considerable number of occasions unsatis¬
factory.
(d) That the estimate of the cost of the food of the patients in
the Second House, given in the letter referred to, is unsup¬
ported by facts, and shows an ignorance of the cost of the
food of patients in other asylums.
(e) That the charges in the letter referred to against the
management of the Second House have been prepared,
and have been brought forward, in a way which deserves
strong censure.
VIII. The following is a copy of the Report by Commissioners
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102 Occasional Notes of the Quarter . [April,
Mitchell and Sibbald after the visit which they were instructed to
make :—
“ 1 6th September , 1886.—According to instructions from the
Board, we visited the Second House of the Crichton Royal
Institution to-day for the purpose of inquiring into, and
reporting on, its management at the time of our visit with
special reference to the charges lately brought against the
management by the Junior Medical Assistant. We have
now to report as follows :—
u (1) We looked carefully into the question of discipline,
and nothing came under our observation to show that it was
in any respect defective. On the contrary, the management
and discipline appeared to us to show ability, in view of the
difficulties arising out of the extensive structural changes at
present in progress, which have made it necessary to remove
all patients from more than the half of the female side, and
to use the kitchen as an ordinary passage, and which have
necessitated for the time being many make-shift arrange¬
ments. There seems at present to be no failure on the part
of the staff to co-operate loyally with the Superintendent in
overcoming these unavoidable difficulties.
“ (2) We also made careful inquiries as to the quality,
quantity, cooking, and serving of the food of the patients
and attendants, and we came to the conclusion that they are
all satisfactory. No complaints were made to us regard¬
ing the food, either by patients or attendants. The dinner
served during our visit was, in our opinion, excellent in
quality, abundant in quantity, and well cooked, and it was
served in an orderly manner.
“ (Signed) W. FORBES, Secretary
General Board of Lunacy,
Edinburgh, 3rd November , 1886.
We sincerely congratulate the able Superintendent of the
Dumfries Asylum on the result of the investigation into the
charges preferred against his administration, and sympathize
with him in the unjustifiable annoyance which he has been
made to suffer. It need hardly be said that if the manage¬
ment of an asylum were justly open to grave censure, it
might become the duty of even a Junior Medical Officer to
bring under the notice of the Board the abuse which he
considered existed, and, if he thought proper, to resign his
post. But nothing can justify the course which Dr. Lennox
pursued in the present instance, wanting as it was in open¬
ness with the Superintendent, and loyalty to him as his Chief,
who, moreover, had treated him with singular kindness and
Digitized by AjOOQle
1887.] Occasional Notes of the Quarter. 103
consideration. The publication of private letters without
permission also deserves the severest censure.
The one point in the official report which at all favours Dr.
Lennox’s charges has reference to the cooking of the food,
which “ appears to have been on a considerable number of
occasions unsatisfactory.” Doubtless, had this defect been
brought under Dr. Rutherford’s notice by the assistant, he
would have been thankful for the information and acted
upon it. Unfortunately, however, the Lunacy Commissioners
report that the conduct of Dr. Lennox during the time that
he held office “ was shown to have been subversive of dis¬
cipline/’ and his statements in reference to the quantity of
the food and the condition of the patients “ undeserving of
confidence,” while his estimate of the cost of food in the
institution “ shows an ignorance of such cost in other
asylums.”
We hope that it will be long, indeed, before Dr. Rutherford
is subjected to similar annoyances, which must for the time
being seriously interfere with the proper work of a medical
superintendent, and add very unnecessarily to the already
sufficiently heavy strain under which he has to perform his
daily duties.
Idiots Act, 1886.
The above is the name of an important Act which passed
through Parliament last year, simplifying the certificates
and removing restrictions affecting the admission of idiots
and imbeciles into Training Institutions, and which we have
not found room to notice before. Previously, Training In¬
stitutions for Idiots and Imbeciles were regarded, in the eye
of the law, either as licensed houses or registered hospitals
for lunatics. Before a patient could be received into them
it was necessary for the parent or guardian to fill up an order,
stating that the child was a lunatic, an idiot, or a person of
unsound mind, and to reply to a series of questions totally
unsuited to the case. In addition to the order and state¬
ment, two medical certificates, the same as were necessary
for the admission of insane persons into lunatic asylums, and
quite inappropriate for idiots and imbeciles, were required
from independent practitioners.
Now, since all training institutions for idiots and im¬
beciles are really schools , in which the patients are educated
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104 Occasional Notes of the Quarter. [April,
and trained for the duties of life, and so prevented from be¬
coming useless members of the community, it is clear that
difficulties should not be thrown in the way of parents seek¬
ing education for their feeble-minded children. Again,
many parents object to having their children called idiots;
in some cases because the children are of a much higher
mental standing, in others from sentimental reasons. The
writer of these remarks has for some time past advocated
the removal of the word idiot, and the substitution of the
word imbecile in its place. The term imbecile can then
include all cases of mental defect, whether congenital or
acquired, and avoids difficulties of classification, such as
sometimes occur when the words idiot and imbecile are
used, it being at times difficult to say under which heading
a patient should be placed, especially when demonstrating
cases to persons unacquainted with the subject. By this
Act the word imbecile becomes a legal term, and therefore
there is no legal objection to its use.
The first step in drawing attention to the restrictions
affecting the admission of idiots and imbeciles into training
institutions under the Lunacy Law, was the issue by the
Central Committee of the Royal Albert Asylum, of a
€t Memorandum of Suggestions for the Modification of the
Lunacy Acts as they affect Institutions for the Training of
Imbeciles ” to all who were interested in the subject.
Meetings were called to discuss the question at Lord Win-
marleigh’s house ; certain decisions were arrived at, and the
Lord Chancellor eventually decided to bring forward a Bill
bearing the above name.
The chief alterations of those previously in force are
The registration of all hospitals, institutions, or licensed
houses in which only idiots and imbeciles have been or are
intended to be received; the requirement of one medical
certificate instead of two, such certificate stating that the
patient (an infant or of full age) is an idiot (or has been
imbecile from birth, or for some years past, or from an early
age), and is capable of receiving benefit from the institution;
a simpler statement by the parent or guardian of the patient;
the non-application of certain provisions of the Lunacy Acts
to the Idiots Act; and the power given to committees to
grant superannuation allowances to officers or servants
employed in hospitals, institutions, or licensed houses
registered under this Act.
The Act itself is appended.
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Occasional Notes of the Quarter ,
105
49 & 50 YICT., CHAP. 25.
A.D. 1886.
An Act for giving facilities for the care, education, and
training of Idiots and Imbeciles. [25th June, 1886.]
Whereas it is expedient to make provision for the admission into
hospitals, institutions, and licensed houses of idiots and imbeciles, and
for their care, education, and training therein :
Be it therefore enacted by the Queen’s most Excellent Majesty, by
and with the advice and consent of the Lords Spiritual and Temporal,
and Commons, in this present Parliament assembled, and by the
authority of the same, as follows :
1. This Act may be cited as the Idiots Act, 1886.
2. This Act shall not extend to Scotland or Ireland.
Short
title.
Extent of
Act.
3. This Act shall commence from and immediately after the Oommenoe-
thirty-first day of December, one thousand eight hundred and eighty- menfc *
six.
4. An idiot or imbecile from birth or from an early age may, if Hoepitai*,
under age, be placed by his parents or guardians or by any person tions^and
undertaking and performing towards him the duty of a parent or
guardian, and may lawfully be received into, and until of full age de- idiot* and
tained in, any hospital, institution, or licensed house, registered under lmbecilea ‘
this Act for the care, education, and training of idiots or imbeciles
upon the certificate in writing of a duly qualified medical practitioner
in the Form One in the Schedule that the person to whom such
certificate relates is an idiot or imbecile, capable of receiving benefit
from such hospital, institution, or licensed house, accompanied by a
statement in the Form Two in the Schedule signed by the parent or
guardian of the idiot or imbecile, or the person undertaking or per¬
forming towards him the duty of a parent or guardian.
5. Any idiot or imbecile who has while under age been received
under this Act into any hospital, institution, or licensed house, mission of
registered under this Act may, with the consent in writing of the d
Commissioners in Lunacy, be retained therein after he is of full age, fuI1
and an idiot or imbecile from birth or from an early age may be ^ ’
received into any hospital, institution, or licensed house, registered
under this Act after he is of full age upon the certificate in writing of ■>
a duly qualified medical practitioner in the Form One in the Schedule,
accompanied by a statement in the Form Two in the Schedule signed
by the parent or guardian of the idiot or imbecile, or the person
undertaking or performing towards him the duty of a parent or
guardian.
6. The Commissioners may at any time, by order, direct any order of
person of full age retained in any hospital, institution, or licensed
house, registered under this Act to be discharged therefrom, and such *foner* in
order shall specify the reason or reasons for such discharge and the Lun *°y*
date thereof.
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106
Occasional Notes of the Quarter.
[April,
Registra¬
tion of hos¬
pitals, in¬
stitutions,
and
licensed
houses
under this
Act.
Provision
for existing
hospitals,
institu¬
tions, and
licensed
houses for
idiots or
imbeciles.
Notice of
reoeption
to be sent
to Com¬
missioners
in Lunacy.
Notioe of
death or
discharge.
Certain
provisions
of Lunacy
Acts not
to apply to
this Act.
Inspection
by Com¬
missioners.
Medioal
journal to
be kept.
7. The managing committee or the principal officer of every
hospital, institution, or licensed house, in which idiots or imbeciles are
intended to be received under this Act, shall apply to the Commis¬
sioners to have the hospital, institution, or licensed house registered
in the office of the Commissioners, and the Commissioners, if satisfied
upon inquiry that the hospital, institution, or licensed house, is a
proper one to be registered, shall issue a certificate of registration
accordingly ; and no idiot or imbecile shall be received into any
hospital, institution, or licensed house, under this Act, until the same
hospital, institution, or licensed house has been duly registered.
8. Any hospital, institution, or licensed house, which at the
passing of this Act is devoted exclusively to the care, education, and
training of idiots or imbeciles, may be registered under this Act,
and all idiots and imbeciles lawfully retained therein at the passing
of this Act may continue to be so retained without further certifica¬
tion.
9. When any idiot or imbecile is first received into a hospital, in¬
stitution, or licensed house, registered under this Act, the superinten¬
dent or principal officer thereof shall, within fourteen days, certify in
writing under his hand to the Commissioners in the Form Three in the
Schedule the fact and time of his reception, specifying his name and
age and the names and addresses of the persons placing him in such
hospital, institution, or licensed house, and that he is alleged to be
capable of deriving benefit from the treatment to be received therein.
10. When any idiot or imbecile dies in any hospital, institution, or
licensed house, registered under this Act, or is discharged there¬
from, the superintendent or principal officer thereof shall forthwith
notify in writing such death or discharge to the Commissioners.
11. The provisions of any Act relating to the registration and
regulation of hospitals, asylums, and licensed houses for the reception
of lunatics, to the orders, certificates, or reports necessary for the re¬
ception, detention, or treatment of lunatics, and to the care, treat¬
ment, and visitation of lunatics, and the books to be kept and the re¬
ports to be made concerning lunatics respectively, shall not apply to
any hospital, institution, or licensed house, registered under this Act,
or to any idiot or imbecile received or to be received therein under the
provisions of this Act.
12. The Commissioners shall at least once in every twelve months
visit and inspect every hospital, institution, and licensed house,
registered under this Act, and all the children and other persons
under treatment therein.
13. A medical journal shall be kept in every hospital, institution,
and licensed house, registered under this Act, in such form as the
Commissioners may from time to time direct.
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1887.]
Occasional Notes of the Quarter.
107
14. In the case of any hospital, institution, or licensed house, 5?med?cal
registered under this Act, the Commissioners may by order in writing prao-
direct that a duly qualified medical practitioner shall reside therein. fc tkmm*
15. Nothing in this Act shall operate to deprive the guardians of money to
the poor of any union of the power of sending pauper idiots or guardians
imbeciles to hospitals, institutions, and licensed houses, registered 0 fche poor '
under this Act, or from receiving in respect of such idiots or
imbeciles such sums of money as shall from time to time be granted
by Parliament towards the maintenance and care of pauper lunatics
as if the same idiots and imbeciles were pauper lunatics.
16. The committee of management of any hospital, institution, or
licensed house, registered under this Act, may grant to any officer or
servant who is incapacitated by confirmed illness, age, or infirmity, or
who has been an officer or servant in the hospital, institution, or
house, for not less than fifteen years and is not less than fifty years
old, such superannuation allowance, not exceeding two-thirds of the
salary, with the value of the lodgings, rations, or other allowances
enjoyed by the superannuated person, as the committee think proper.
Power to
grant super¬
annuation
allowance.
17. In this Act, if not consistent with the context,—
“ Commissioners means the Commissioners in Lunacy for the time
being.
u Idiots 99 or “ imbeciles ” do not include lunatics.
“ Lunatic ” does not mean or include idiot or imbecile.
Definition.
Commis¬
sioners.
Idiota or
Imbeciles.
Lunatic.
“ Hospital ” and " institution ” mean any hospital or institution an 5 < infSta-
or part of a hospital or institution (not being an asylum for tion.
lunatics) wherein idiots and imbeciles are received and supported
wholly or partly by voluntary contributions, or by any charitable
bequest or gift, or by applying the excess of payments of some
patients for or towards the support, provision, or benefit of other
patients.
“ Licensed house ” means any house licensed by the Commissioners in
Lunacy, or by the justices of any county or borough, for the recep¬
tion, care, education, and training of idiots and imbeciles.
THE SCHEDULE.
A.D. 1686.
Form 1.
Form of Medical Certificate,
I, the undersigned A.B ., a person registered under the Medical Act,
1858, and in the actual practice of the medical profession, certify that
I have carefully examined C,D, } an infant [or of full age], now
residing at , and that I am of opinion that the said
CJ). is an idiot [or has been imbecile from birth, or for
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108
Occasional Notes of the Quarter. [April,
years past, or from an early age], and is capable of receiving benefit
from [the institution (describing it)], registered under the Idiots Act,
1886.
Dated
( Signed)
(full postal address).
Form 2.
Form of Statement to accompany Medical Certificate.
[If any particulars in this statement be not known, the fact to be so
stated.]
Name of patient, with Christian name at length.
Sex and age.
When and where previously under care and treatment.
In any asylum or institution.
Whether subject to epilepsy.
Whether dangerous to others.
I certify that to the best of my knowledge the above particulars
are correctly stated.
(Signed) Name and full postal address.
[To be signed by the parent or guardian of the idiot or imbecile
or the person undertaking and performing towards him the
duty of a parent or guardian.]
Form 3.
Form of Certificate of Reception.
I hereby certify that aged was admitted
into on the day of , 18 , on the
request of of and
of and that he [or she] is alleged to be capable of
deriving benefit from the treatment he [or she] will receive herein.
A.B.
Superintendent or
Principal Officer.
Dated this day of 18.
To the Commissioners in Lunacy.
Honours Examination in Psychological Medicine.
The Gaskell Prize.
As will be seen from the advertisement, an examination
for Honours in Psychological Medicine will take place in
London next July. It was a fortunate circumstance that
shortly after the establishment of the Pass Examination for
the Certificate of Efficiency in Psychological Medicine, under¬
taken by our Association, a fund was placed at its disposal.
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1887.]
Occasional Notes of the Quarter.
109
through the generosity of Mrs. Holland, the sister of the late
Mr. Gaskell, in whose memory she desired to hand over to
the Association the sum of £1,000. When Mr. Wilkes, one
of the executors of the former Commissioner of Lunacy,
communicated to a member of the Council, Mrs. Holland's
wish, it was at once felt that no better appropriation of the
fund or one more in accordance with the wishes of Mr. Gaskell
could be devised, than the encouragement of the practical
knowledge of mental disorders on the part of medical men
entering upon this special department. For this end it was
made a primary condition of candidature that there should
have been a residence for at least two years in an asylum for
the insane in the character of a qualified medical officer.
Another condition was that the candidate should have
attained the age of twenty-three.
It is essential that a candidate for Honours should have
passed the Examination for the Certificate of Efficiency.
Money and a medal, gold or silver (total value about £30),
will be awarded to the successful candidate, the Council being
left free under certain circumstances to confer prizes on
one or more candidates in addition. The examination, it
is stipulated, shall be always held in London, but will not be
restricted to those who have obtained their Certificate in the
Metropolis. The locality of the asylum in which candidates
have filled an official post is not limited by narrower bounds
than those of the British Empire and her Colonies. Further,
the two years’ service required need not have been continuous
in any one asylum, but may be in different ones.
The Honours Examination will be held annually.
The subjects upon which candidates will be examined are
as follows:—
1. Healthy and morbid histology of the brain and spinal
cord.
2. Clinical cases, with commentaries.
3. Psychology, including the senses, intellect, emotions
and volition.
4. Written examination, including questions on the
diagnosis, prognosis, pathology, and treatment of mental
diseases and their medico-legal relations.
The examiners reserve the right of withholding the prize
in the event of the qualifications of candidates appearing to
them to fall short of the standard regarded by them as
fairly representing an Examination for Honours.
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110
Occasional Notes of the Quarter.
[April,
University of London M.D. Examination.
Many inquiries have reached us in reference to the new
Psychological Examination at the London University. It
may be as well, therefore, to state that in lieu of the examina¬
tion in Logic and Psychology, the Senate introduced for the
first time at the M.D. Examination in November, 1886, the
subject of “ Mental Physiology, especially in relation to
Mental Disorders.” On the occasion referred to, a candidate
had his option as to taking the new or old subjects of
examination, but in future, Logic and Psychology will dis¬
appear from the Examination. This is certainly an im¬
portant step in the right direction, and aims at a much
more practical class of subjects—a class far more useful to the
physician. We should have been better satisfied, however, if
the terms of the subject now introduced had been differently
expressed. It is no doubt the result of a sort of com¬
promise—a little new wine in old bottles—but we hope that
before long only two words will remain, namely, Mental
Disorders. As it is, an examiner is hampered by the sense
that he cannot ask questions which do not more or less
directly spring from the cardinal point of Mental Physiology,
whereas it is to be desired that he should be able to examine
on the same lines as the pass examination of the Medico-Psy¬
chological Association. We have no wish to see the examina¬
tion made a difficult one, but questions should be asked in
regard to the diagnosis and treatment of Mental Disorders,
similar to those asked in the examination about other
diseases. This would not only be better for the candidate, but
would extend the area of subjects for the examiner, who
otherwise will find it almost impossible to ask fresh ques¬
tions from time to time.
The following Questions were asked at the Examination in
November:—
1. Mention phenomena occurring in health and disease
which indicate that mental operations can be carried on
and actions be performed, automatically, whether (a) con¬
sciously or (b) unconsciously.
2. What would lead you to conclude that one person is
merely the subject of an optical illusion or Bees ocular
spectra, consistently with mental health, and that another
has visual illusions or hallucinations in consequence of
mental disease ?
3. In a person presumably sane and managing his own
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Ill
1887.] Occasional Dotes of the Quarter.
aflairs, what circumstances, personal or otherwise, would
induce you to suppose that he has an insane diathesis P
4. Distinguish between the erroneous beliefs of a sane,
and the delusions of an insane man.
5. Contrast the mental characteristics of the idiot with
those of the insane.
6. What perversions of healthy sensation (common and
special) are frequently met with in the insane ?
The Lunacy Bill.
As we write, the Lunacy Acts Amendment Bill, which
was ordered to be printed January 31st, 1887, has passed
through Committee in the House of Lords, several amend¬
ments having been accepted by the Lord Chancellor. What
alterations the House of Commons may introduce, it is im¬
possible to foresee.
As is well known to our readers, the new Bill closely re¬
sembled that introduced by Lord Herschell, but a new
clause, upon which Lord Halsbury specially prided himself,
in reference to the notice served upon every patient before he
could be placed under care, giving him power to appeal to
and appear before a magistrate, has been withdrawn, and
a less perilous provision substituted for it. A more objec¬
tionable enactment could scarcely have been devised by the
wit of even a Lord Chancellor. Happily, both Lord Herschell
and Lord Selbome perceived its mischievous character.
Lord Grimthorpe, in moving the substitution of other words
for Clause 3, pointed out that it would facilitate the
escape of alleged lunatics from the country, or even from the
world. The noble lord had received a letter from a medical
practitioner stating that he had never known so many
suicides of alleged lunatics as had occurred during the last
two years; the result, he believed, of the fear of publicity.
Lord Selborne maintained that the clause as it stood in the
Bill would be absolutely destructive of its main object,
namely, the prompt placing under restraint and supervision
the alleged lunatic before he could injure himself or others.
To proceed against such a person as a criminal and to put him
upon his defence would be a perversion of the whole law of
lunacy. He considered the proposal a most ingenious device
to defeat the objects of the Lunacy Act. Lord Herschell,
with every desire to support the Bill, was unable to do so in
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112
[April,
Occasional Notes of the Quarter .
regard to the proposed alteration. He did not think they
were justified in running the risk of the alleged lunatic
putting an end to his life, or assaulting those around him,
or escaping, in consequence of the serving upon him the notice
proposed by the Lord Chancellor, who, in reply, observed
that he did not know why an examination before a magis¬
trate should be more injurious to the lunatic than that of
medical men before signing a certificate. His lordship was
at a loss to understand why a magistrate should not be quite
as competent to decide the question with a judicial mind as
a medical man! This is quite consistent with the general
style of lawyers, and notably of Lord Bramwell, who, as we
know, thinks that it does not require a surgeon to decide
whether a man is lame or not—in oblivion of the fact that
Sir James Paget would be more capable than Lord Bramwell
of deciding whether lameness, in a particular instance, were
real or feigned.
Lord Monks well moved an amendment, which was very
properly accepted and added to the Bill, providing that a
justice upon information that a person within his jurisdic¬
tion, not a pauper and not wandering at large, is deemed to
be a lunatic, and is not under proper care or control, or is
cruelly treated or neglected, shall “ either himself visit the
alleged lunatic, or, whether making such visit or not, shall
direct two qualified medical practitioners to visit and ex¬
amine the alleged lunatic.” This is a valuable addition to
the Bill, which will be one of its good points to set against a
good many which are either uncalled-for or positively detri¬
mental. Among the clauses of the Bill which will meet
with the approval of medical men engaged in lunacy, is the
provision in Clause 39 for commitment of the estate only
and not of the person of the lunatic, to which in Committee
the Lord Chancellor made some important additions. With
regard to private asylums, although new licenses will not be
granted, existing asylums can be transferred, and the
vested interests of the proprietors are studiously respected.
Although they will still have to compete with registered
hospitals, they will not have anything to fear now from the
establishment of other private asylums, and in this sense they
will enjoy a very valuable monopoly. Thus the fear which
at one time weighed heavily upon the minds of the pro¬
prietors of licensed houses is fortunately removed, and they
will in future enjoy unmolested that position of happy tran¬
quillity and assured rest, for which they will no doubt feel
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113
1887.] Occasional Notes of the Quarter .
deeply thankful after the troublous times of agitation, dis¬
turbance, and attack to which they have been subjected for
several years—that is assuming that the Bill passes into law,
and that the clauses providing for the future regulations
for private asylums remain in their present form. Other
clauses in the Bill advantageous to medical men, but clauses
by which those who sign certificates in lunacy in good faith
are protected from legal action will prove very beneficial,
and will restore the confidence lost by the numerous
actions brought in recent times against members of the
medical profession in consequence of signing these certifi¬
cates.
As we have pointed out in the first “ Occasional,” Lord
Monkswell succeeded in introducing an amendment, good as
far as it goes, in regard to the pensions of superintendents.
PART II-REVIEWS.
The Life of Percy Bysshe Shelley . By Edward Dowden,
LL.D. 2 vols. Kegan Paul, Trench, and Co. London,
1886.
Surely, if there ever were a subject for psychological
study, it is to be found in the mental organization of Shelley.
Standing in the first rank of poets, even if inferior, as
Matthew Arnold says, to Wordsworth, he is a great deal
more than a poet in the estimation of large numbers; and
in this character he attracts the interest and excites the
admiration of many who have but little taste for poetry,
and do not really admire Shelley because he was a poet.
The fact is, Shelley's mental constitution finds a response in
organizations similarly constituted, quoad his peculiar tem¬
perament, but destitute of his poetic gift. It is, we must
admit, a misfortune that a nature like his magnetizes many
whose dispositions do not require to be fed with the food
which Shelley's restless nature supplies, but require, on the
contrary, precisely opposite aliment.
Some, we suppose, will experience a sort of repugnance to
subjecting so transcendent a genius to the cold analysis of
psychological science. But what if it be found that such a
study throws great light upon Shelley's career?
The grandfather of the poet, Sir Bysshe Shelley, was a
handsome gentleman, clear-witted and wilful. When of
xxxiii. 8
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114
Reviews.
[April,
age lie married Miss Michell, the only child of a clergyman.
Her guardian not consenting to the marriage, a runaway
match took place, and the wedding was celebrated by the
parson of the Fleet. Nine years after her death, Bysshe
Shelley eloped with Elizabeth Jane Sidney. He was a
wealthy and avaricious man, but was indifferent to his
personal appearance and to his style of living. He was a
victim to gout. Although he passed some of his time in
the taproom of the Swan Inn, at Horsham, it was not for
the drink, but for the purpose of arguing in politics and
mixing with the frequenters of the hostelry. He wore a
round frock. His townsfolk thought him melancholy. “He
invited no friendships and lived apart from persons of his own
station, fearing not God nor regarding man, but enlarging
his rent-roll, and adding to his thousands in the funds—so
fine a gentleman, yet buried alive under his settlements and his
indentures** (p. 4). Shelley himself writes of his grandfather
that he “acted very ill to three wives.” One biographer.
Captain Medwin, writes s “ Two of his daughters by the
second marriage led so miserable a life under his roof that
they eloped from him—a consummation he devoutly wished,
as he thereby found an excuse for giving them no dowries;
and though they were married to two highly respectable
men, and one had a numerous family, he made no mention
of either of them in his will.” Then, again, he was un¬
fortunately on ill-terms with his son by his first wife (Miss
Michell), Timothy, the father of Shelley. This Timothy was
tall, very fair, and had the blue Shelley eyes. Although
his heart was better than his father’s, his head was not so
clear.
“ He had a wrong-headed way of meaning well and doing ill;
he had a semi-illiterate regard for letters, a mundane respect for
religion; his views on morals were of the most gentlemanly kind,
but not exactly touched with enthusiasm; he dealt in public
affairs without possessing public spirit, and gave his party an
unwavering vote when a member of the House of Commons; in
private life he was kindly, irritable, and despotic; in manners, an
aspirant of Chesterfield, yet one who could on occasions bustle
and fret and scold; when least venerable he insisted most on his
paternal prerogative; he was profoundly diplomatic in matters of
little consequence. Mingling with his self-importance there was
a certain sensibility, genuine though not deep, and tears of tender¬
ness or vexation came readily to his eyes; a kindly, pompous,
capricious, well-meaning, ill-doing, wrong-headed man ” (p. 5).
So writes Dr. Dowden, and we assume with good reason.
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Mr. Timothy Shelley’s wife, Elizabeth Pilfold, was
beautiful. Although a woman of strong good sense, “ Her
temper was violent and domineering. . . . She had a special
grievance against the boy (Shelley) because he was little of
what every country gentleman ought to be—a follower of
field sports.” We give this on the same authority.
The poet was the first child of his parents, and was born
on the day on which it was decreed by the National Assembly
that all religious houses in France should be sold for the
nation’s benefit (August 4, 1792). His self-consciousness as
a child is revealed in the following passage, to which he
refers in his earliest recollections : “ Let us recollect our
sensations as children. What a distinct and intense appre¬
hension had we of the world and of ourselves! . . . We
less habitually distinguished all that we saw and felt, from
ourselves. They seemed, as it were to constitute one mass.”
This confounding of the subjective and objective world
points to a constitutional tendency the reverse of healthy,
and liable to pass into a distinctly morbid phase of mental
life, if allowed to develop unchecked by wholesome training
and education. It was fortunate for Shelley that he had
sisters to play with, and it would have been still more so
had he had brothers. He showed abundant imagination
and love of mystification, and entered heartily into childish
E ranks and jests, although some of his biographers say that
e never laughed.
Shelley began to learn his Latin grammar from a Welsh
parson in his own parish, Wamham, Sussex. At ten he
went to Sion House Academy, Isleworth. Here he was sadly
teased by the boys because he preferred solitude to enter¬
ing into their games. It is stated that he “was highly
sensitive to pain, easily excited, and subject to paroxysms
of passion when thwarted or provoked ” (p. 15). Although
he was really amiable and generous, “ he passed among his
schoolfellows as a strange and unsocial being.” There
seems to have been a curious inconsistency of character in
the schoolboy, who is described as gazing at the passing
clouds during school hours, and indulging in such waking-
dreams as were followed by “much nervous excitement,
during which his eyes flashed, his lips quivered, his voice
was tremulous with emotion, and a sort of ecstasy came
over him $ ” we say there seems a kind of contradiction
between this character and the schoolboy who would “ blow
up the boundary paling with gunpowder, or his desk-lid in
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mid school-hours, to the amazement of masters and boys ”
(p. 16). Then, again, his neurotic constitution is indicated
by the following :—
“ His sleep was afflicted by frightful dream8. ,, [He was a som¬
nambulist.] “ One summer night he came gliding by moonlight
into Medwin’s dormitory, open-eyed, but wrapt in slumber. He
advanced to the window, which was open; his cousin sprang out
of bed, seized his arm, and waked him. ‘ He was excessively
agitated, and after leading him back with some difficulty to his
couch, I (Medwin) sat by him for some time, a witness to the severe
erethism of his nerves which the sudden shock produced ’ ” (p. 17).
The supernatural had powerful attractions for the youth.
“He had faith in apparitions and the evocation of the
dead” (Z.c.). Shelley formed a romantic attachment with
a boy about his own age. His friend’s tones of voice
were so soft (Shelley’s voice was painfully shrill) that every
word pierced into his heart; and in listening to him, says
Shelley —
“ The tears have involuntarily gushed from my eyes. I remember
in my simplicity writing to my mother a long account of his
admirable qualities and my own devoted attachment. I suppose
she thought me out of my wits, for she returned me no answer to
my letter” (p. 19).
Unfortunately, during play-hours, when he ought to have
been engaged in games, he was occupied in morbidly senti¬
mental talk with this youth, whose name has not come down
to us, though it may have been a fellow-countyman, Rennie,
who was regarded, like Shelley, as “ a peculiar character.”
From Sion House Shelley went to Eton.
“ An ordinary mortal,” says Dr. Dowden, “ would have learnt
what is called experience; he would have parted with some of his
singularity, practised the art of making concessions, held his
better self in reserve, and kept his secret; or he would have
learnt that there is a time for all things. . . . Shelley was in¬
accessible to such lessons of experience; he remained what he
was, or advanced upon lines of his own. . . . He stood convicted
as a rebel against authority, while to boys of his own standing,
except a few chosen friends, his refusing to join in the common
sports, his shyness, his singularity, his careless attire, his interest¬
ing strange studies, his gentleness, united with to unusual ex¬
citability of temper, pointed him out as a proper victim on whom
to wreak all the exuberance of their animal spirits. Singly they
dare not attack ‘ Mad Shelley.’ Once, in a paroxysm of rage, he
seized the nearest weapon, a fork, and stuck it into the hand of
his tormentor.”
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It is related by an eye-witness that “ an access of passion
made his eyes flash like a tiger's, his cheeks grow pale as
death, and his limbs quiver.” For such a boy as Shelley,
the heartless baiting which was thus carried on by his
fellow-Etonians must have operated most injuriously. Re¬
ference should here be made to an incident which occurred
during Shelley's holidays, immediately bearing, as it does,
upon the psychological inquiry in which we are engaged. It
appears that he was attacked with a fever which affected his
brain, and that his father had entertained the idea of send¬
ing him to a private mad-house. When Shelley heard this
intention from one of the servants, he communicated with
Dr. Lind, of Windsor, who had shown him kindness at Eton.
The doctor advised Sir Timothy not to adopt this extreme
measure. The strange instability of his character and his
perusal of books, like Godwin's " Political Justice,” now led
Shelley to preach a revolutionary gospel to his school-fellows.
The natural consequence followed. He was twice expelled
from Eton, but was, through the intercession of his father,
reinstated.
In some of his poems Shelley has depicted the romantic
speculations with which his brain was filled. He remem¬
bered the hour in which his spirit woke as from a sleep, and
he wept he knew not why, and clasping his hands he vowed
to be free and just. Thenceforward did he st heap know¬
ledge from forbidden mines of ore.” In his “Hymn to
Intellectual Beauty" he tells us how, while yet a boy, he
sought for ghosts amidst caves and ruins and starlight
woods, hoping to converse with the departed dead. Then it
was that the shadow of Intellectual Beauty fell upon him,
and he shrieked and clasped his hands in ecstasy, vowing
that he would henceforth dedicate his powers to her.
This precocious mental condition, continually fostered by
the youthful Shelley on account of the exquisite pleasure
which it no doubt afforded him, was to some extent relieved
on his removal to Oxford, where his bodily health appears to
have been good and his spirits buoyant. During the Christ¬
mas holidays, 1809-10, accompanied by his cousin Medwin,
he walked with a gun upon his shoulder in the Sussex
woods in search of something more substantial than the
ghosts of the departed he had previously chased. Still, with
an intense craving for authorship, he was far too much
given to lead a subjective life. His biographer very clearly
recognizes this danger —
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“Being urged as a boy by his own fervid thoughts and fancies to
give them utterance in prose or verse, he must forthwith put them
in a book and present that book to the world. He lived intensely
in his own imaginings, wise or idle, beautiful or feebly extrava¬
gant, and was insensible to those checks of common sense which
come from a power of passing in and out of our own imaginings,
and seeing many things, even imperfectly, at a single view. He
did not consider how crude in feeling and conception, how chaotic
through lack of motive and design, how feeble in expression his
work might be. ... It was his misfortune as a boy to fall under
the influence of detestable literary models, and to these he aban¬
doned himself with single-hearted zeal. With what is robust and
realistic in eighteenth century fiction, Shelley was out of sym¬
pathy ” (p. 42).
Our space will not allow us to describe the various
attempts at authorship made by Shelley, but it should be
recorded that while yet a schoolboy he was the author of a
romance for which a publisher, so it is said, gave the sum of
£ 4 °.
His affections were, while at Oxford, centred for a time
upon Harriet Grove, his cousin, when both were about 18,
but the attachment ended in disappointment.
It was at Oxford that Shelley became acquainted with
Hogg, with whom his friendship was of the warmest descrip¬
tion, although their mental characteristics differed exceed¬
ingly. Hogg has left on record that Shelley’s aspect was even
then remarkably youthful. He was thoughtful and absent,
ate little, and had no acquaintance.
“ His figure was slight and fragile, and yet his bones were large
and strong. He was tall, but he stooped so much that he seemed
of a low stature . . . then his gestures were abrupt and sometimes
violent, occasionally even awkward, yet more frequently gentle and
graceful. His complexion was delicate and almost feminine, of
the purest red and white. . . . His features, his whole face, and
particularly his head, were in fact unusually small; yet the last
aqypeared of a remarkable bulk, for the hair was long and bushy,
and in fits of absence, and in the agonies of anxious thoughts, he
often rubbed it fiercely with his hand or passed his fingers quickly
through his locks unconsciously, so that it was singularly wild and
rough. His features were not symmetrical—the mouth perhaps
excepted—yet was the effect extremely powerful. They breathed
an animation, a fire, an enthusiasm, a vivid and preternatural
intelligence, that I never met with in any countenance. Nor was
the moral expression less beautiful than the intellectual, for there
was a softness, a delicacy, a gentleness, and especially that air of
profound religious veneration that characterizes the best works
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and chiefly the frescoes of the great masters of Florence and of
Home. But there was one physical blemish that threatened to
neutralize all his excellence—his voice, which was excruciating.
It was intolerably shrill and harsh, and discordant, of the most
cruel intension; it was perpetual and without any remission; it
excoriated the ears ” (p. 62).
In the foregoing description the reader will have ob¬
served three striking facts, first the asymmetry of Shelley’s
face, secondly the unusually small head, and thirdly the dis¬
cordant, unmusical voice. This want of unison in the
physical features of the poet indicated but too truly the
strange contradiction between certain mental characteristics
and others.
We next have our attention drawn by Hogg to another
very remarkable peculiarity —
In the evening Shelley would be “overcome by extreme drowsi¬
ness, which speedily and completely vanquished him; he would
sleep from two to four hours, often so soundly that his slumbers
resembled a deep lethargy; he lay occasionally upon the sofa, but
more commonly stretched upon the rug before a large fire like a
cat, and his little round head was exposed to such a fierce heat
that I used to wonder how he was able to bear it. . . . His torpor
was generally profound, but he would sometimes discourse inco¬
herently for a long while in his sleep.
“When this lethargy ended, Shelley would suddenly start up, and
rubbing his eyes with great violence, and passing his fingers
swiftly through his long hair, would enter at once into a vehement
argument, or begin to recite verses, either of his own composition
or from the works of others, with a rapidity and an energy which
were often quite painful.” It should be added that after supper
“ his. mind was clear and penetrating, and his discourse eminently
brilliant ” (Hogg, quoted by Dowden, p. 67).
He was inconceivably careless with pistols, with which he
amused himself in firing at some mark on a tree, so much
so that his friend Hogg found it necessary to secretly
abstract Shelley’s powder flask. The trick was discovered
by Shelley, who was much offended.
There was much to admire in Shelley’s character at Ox¬
ford; he was gentle, and detested cruelty to animals. It
is said, indeed, by Thornton Hunt, that he had seriously
injured his health by “ tampering with venal pleasures,” but
this was followed by a reaction marked by horror (p. 77).
Again, he was generous in charity, and if he had no money
of his own would borrow from others. It is recorded also
that he did not lose his affections for his relations, and
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received a letter from his mother or sisters with manifest
joy (p. 78).
Shelley tested the doctrine of man’s pre-existence in a way
which exposed him inevitably to the suspicion of being alto¬
gether beside himself. Thus one day he and Hogg met a
woman with her baby in the middle of Magdalen Bridge.
The youthful Platonist seized the child, which the mother
held all the faster in her arms, in no little fear lest it should
be thrown over the bridge. Then with his alarmingly shrill
voice he asked u Will your baby tell us anything about pre¬
existence, Madam?” To this question, when repeated,
the astonished parent, having more mother-wit than the
academic questioner, replied, “ He cannot speak, sir.”
Shaking his long hair about his face, the disappointed under¬
graduate exclaimed “ Worse and worse, but surely the babe
can speak if he will, for he is only a few weeks old. He
may fancy, perhaps, that he cannot, but it is only a silly whim.
He cannot have forgotten entirely the use of speech in so
short a time; the thing is absolutely impossible” (p. 82).
As the couple walked on, Shelley, sighing deeply, exclaimed
“ How provokingly close are those new-born babes ! But it is
not less certain, notwithstanding the cunning attempts to
conceal the truth, that all knowledge is reminiscence. The
doctrine is far more ancient than the times of Plato, and
as old as the venerable allegory that the Muses are the
daughters of Memory; not one of the nine was ever said to
be the child of Invention.” To this doctrine, translated into
the modern teaching of organic memory, Dr. Wilks has
already referred in the pages of this Journal, and it does
not fall within the scope of the present article to enter upon
its consideration. All that we are concerned with is the
extraordinary and eccentric proceeding of Shelley, which,
while it certainly made him a companion whom we should
have preferred to the common run of Oxford undergraduates,
at that period, can hardly be brought within the ordinary
range of sane acts.
We have spoken of the odd contradiction which Shelley’s
character and actions presented. Here is another instance.
He appears to have been an in-born gentleman.
“ Yet with his grace of bearing there was strangely united/’ says
his biographer, “a certain awkwardness/’ and he quotes the follow¬
ing from Hogg : “ He would stumble in stepping across the floor of
a drawing-room, he would trip himself up on a smooth-shaven grass
plot, and he would stumble in the most inconceivable manner in ascend-
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ing the commodious, facile, and well-carpeted staircase of an elegant
mansion, so as to bruise his nose, or his lip, on the upper steps, or to
tread upon his hands, and even occasionally to disturb the composure
of a well-bred footman ” (p. 83).
And as if this contradiction were not enough, another
presents itself, for in contrast with this gaucherie —
t( He would often glide without collision through a crowded assembly
thread with unerring dexterity a most intricate path, or securely and
rapidly tread the most arduous and uncertain ways (Z.c.).
His appearance was singular, not only from his dress and
bare throat, but from his uncut locks “ streaming like a
meteor,” and Hogg says that “ the air of his little round
hat upon his little round head was troubled and peculiar”
(p. 84).
There is a curious reference in one of Shelley's prose frag¬
ments to what he speaks of as a remarkable event which
occurred to him when at Oxford. He was walking in the
neighbourhood, engaged in earnest conversation, when having
suddenly turned the corner of a lane, a commonplace scene
presented itself, but yet an unexpected effect was produced
on him. He suddenly remembered having seen the exact
scene in some dream ; and here the narration abruptly ends,
the reason assigned being “ Here I was obliged to leave off,
overcome by thrilling horror.” In reference to this, Mary
Shelley afterwards wrote: u I remember well his coming to me
from writing it, pale and agitated, to seek refuge in con¬
versation from the fearful emotions it excited,” This inci¬
dent would alone mark the excessive susceptibility of his
organization. As is well known, it is in the neurotic, and
often those actually epileptic, that the weird feeling of having
been in precisely the same mood and place at a previous
time of life, more especially arises. We have no doubt that
Shelley often experienced it, and that it originated the
doctrine which for him possessed so intense a fascination,
that, namely, of pre-existence, and of all knowledge being
merely reminiscence, 'lhe genesis of a dogma is here seen.
A review of one of Shelley's works in which the author
was reproved as a corrupter of youth and immoral, or some
other circumstance, opened his father's eyes to Shelley's
tendencies, and the consequence was a letter to his son, who
thus expressed himself with the exaggeration of morbid
youthful egoism : “ My father wrote to me, and 1 am now
surrounded, environed by dangers, to which compared the
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devils who besieged Saint Anthony were all inefficient.
They attack me for my detestable principles. I am reckoned
an outcast; yet I defy them, and laugh at their ineffectual
efforts. . . . My father wished to withdraw me from College;
I would not consent to it. There lowers a terrific tempest;
but I stand, as it were on a pharos, and smile exultingly at
the vain beating of the billows below/’ So wrote Shelley
to his friend Hogg in regard to his elders—he a youth of
eighteen ! His cousin, Harriet Grove, was, like his father,
alarmed by his views, and he now regarded her as leagued
with others against him. The result of “the twofold
misery of domestic strife and disappointed love” was “to
throw his whole nature into a state of nervous agitation.”
He wanders alone in the snow, and is “ cold, wet, and mad ”
(p. 99). He himself is conscious of his “delirious egotism.”
For nearly a whole night he paces a churchyard. Writing to
Hogg, he queries whether suicide is wrong, and relates how
he slept with a loaded pistol and some poison, but did not
die. When Harriet, failing to recognize Shelley’s fitness for
married life, was lost to Shelley, he writes excitedly, and
now vents his rage upon “the wretch Intolerance.” He
writes to Hogg: “ Here I swear, and as I break ray oath,
may Infinity, Eternity, blast me—here I swear, never will I
forgive Intolerance! ” And so he raves on. His sister
Elizabeth thought it necessary to watch her suicidal brother
narrowly, and he subsequently confessed that had it not
been for her and the sense of what he owed to Hogg, he
would have ended his days with his own hands.
Then comes the expulsion of Shelley, in consequence of
his pamphlet in praise of Atheism, which affected him
very greatly. “I have been with Shelley,” writes Hogg,
“ in many trying situations of his after-life, but I never saw
him so deeply shocked and cruelly agitated as on this occa¬
sion. ... He sat on the sofa, repeating with convulsive
vehemence the words, Expelled! expelledl’ his head
shaking with emotion and his whole frame quivering.”
Hogg’s expulsion, which followed, was intentionally precipi¬
tated by a generous desire to throw in his lot with Shelley.
Mr. Ridley, a Junior Fellow, writes: “I believe no one
regretted their departure, for there were but few, if any,
who were not afraid of Shelley’s strange and fantastic
pranks.” It appears from the same contemporary that
“ they had made themselves as conspicuous as possible by
great singularity of dress, and by walking up and down the
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centre of the quadrangle as if proud of their anticipated
fate.”
About this period, Shelley, in writing to a Mr. Merle, says
that he has been recently much troubled with dyspeptic
symptoms, and tormented with visions. Hogg, in reviewing
in after years, Shelley's escapade, does not speak of Shelley
as having suffered as a true martyr to his conscientious con¬
victions. Youthful bravado had much to do with the inci¬
dent. It was thought by Shelley to be consistent with his
convictions to take the Sacrament at church and write of this
as a capital joke.
Mr. Sharpe gives an account of Shelley at Oxford, under
date March 15, 1811, in which he says that the author of
certain poems (Mr. Shelley) is a great genius, and if he be
not clapped up in Bedlam or hanged will certainly prove one
of the sweetest swans on the tuneful margin of the Cher-
well (p. 125). It may be remarked, in passing, that there
would have been nothing inconsistent in Shelley graduating
at the Royal Hospital of Bethlem, and being a sweet singer
also, had its management and condition been then what they
are at the present day, when some of the inmates are poets,
and a literary magazine has from time to time been con¬
ducted within its walls by the patients themselves.
The biographer, Dr. Dowden, regrets, with his usual
judgment, that Shelley was thrown upon the world when
under nineteen, " as he might have obtained to juster views
of the world and human society.” A further storing of his
mind and a more prolonged check upon his will €t might
have saved others and himself from much future suffering.”
Medwin has recorded Shelley's arrival at his door in the
Temple at four o’clock in the morning the second day after
his expulsion. “ I think I hear his cracked voice, with his
well-known pipe, ‘ Medwin, let me in; I am expelled!'
Here followed a sort of loud, half-hysteric laugh, and the
repetition of the words, c I am expelled,' with the addition
of, c for atheism !' ” Lodgings had to be obtained after
breakfast, about which Shelley was more capricious and
hard to please than a young beauty. When, however,
rooms were found to his taste, he must stay there for ever —
an expression which afterwards became a joke, as no matter
how erratic were his movements they were always to conduct
him to some resting-place a for ever ” (p. 127). Mr. Timothy
Shelley, a kindly, and sorely puzzled, father, endeavoured to
separate the two friends Shelley and Hogg, who now resided
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together, and desired to place his son under a tutor, but
failed in his endeavour. Shelley altogether refused his
assent, and wrote of his father—who is “ old kill-joy,” and
an “ old buck ”—in a way that does not raise him in one's
estimation. “ A poetical epistle to Graham referring to his
father in odious terms is in existence,” says Dr. Dowden; a
circumstance scarcely comporting with the “ modesty, deli¬
cacy, generosity, and refinement of soul ” which, according to
his admiring companion Hogg, characterized Shelley, but if we
may judge from Hogg’s subsequent conduct, he would attach
somewhat different ideas to these adjectives from what most
people do. Shelley took a fancy at one time for medical
studies, but beyond attending some of his Abernethy’s
lectures, he does not appear to have made any progress in
medicine. His father destined him for Parliament, but his
unsettled and unpractical views rendered this impossible.
About this time Shelley apostrophized the Prince Regent in
relation to a magnificent ball at Carlton House in an ode,
which, when printed, the poet flung into the carriages of
persons calling on the Prince after the ball. Shelley was
now alone; he was in want of funds and his sisters sup¬
plied him with their own pocket money.
Shelley is, however, at home again before long, through
the kindly intervention of his uncle, Captain Pilfold. He
was to receive £200 a year, without any conditions, in the
first instance, as to his place of abode or his friends—not an
illiberal allowance for his father to make.
For a time Shelley was at Cwm Elan, in Radnorshire, the
residence of his cousin, Mr. Grove, from which place he
wrote many letters, full of enthusiasm and visionary phil¬
osophy. Among these were epistles to his future wife,
Harriet Westbrook, then a girl at school, and only 16 years
of age. One of Shelley’s sisters was her schoolfellow. He
had advised her to resist her father’s wishes and opinions,
and undertook to lecture the father himself for the measures
which he adopted, or which Shelley supposed he had adopted,
in order to influence his daughter. Harriet, wishing to
escape from the necessity of returning to school, and also
desiring to be free from paternal control, was only too
willing to escape, and to place herself under the protection
of a youth like Shelley, who took coach for London, and
speedily made his way to the damsel, with the natural result
not only of chivalrous protection, but of mutual love and
engagement. Of legal wedlock Shelley did not approve.
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Hogg, it appears, wrote to him, urging that it was desirable
to have a legal marriage, out of regard to Harriet, who
would otherwise obviously suffer. They were married in
Edinburgh, August 28, 1811, having eloped from London on
the 25th. In his usual style, Shelley had written three
weeks before, “ Gratitude and admiration all demand that I
should love her for ever .” Kor was this surprising, for we
are told that she was young, beautiful, and of a sweet and
pliable disposition. On these points all seem agreed.
Writing two months afterwards to Miss Bitchener, of
whom he became a passionate admirer, he says: “ Blame me
if thou wilt, dearest friend, for still thou art dearest to me ;
yet pity this error if thou blamest me. If Harriet be not at
sixteen all that you are at a more advanced age, assist me to
mould a really noble soul into all that can make its noble¬
ness useful and lovely” (p. 175). Mr. Timothy Shelley was
naturally indignant when he heard of his son’s precipitate
flight and clandestine marriage. He stopped the supplies.
Shelley had already been driven to borrow money of Hogg.
It was not to be expected that the bride’s father, Mr. West¬
brook, should assist a youth who had encouraged his
daughter’s disobedience and eloped with her. Uncle Pilfold,
ever indulgent, came, however, to the rescue.
Very shortly after settling in York, and during Shelley’s
absence in Sussex, his friend Hogg proved treacherous, or
was believed by Shelley to have been so, and endeavoured to
win Harriet’s love. When Shelley returned to York, all his
romantic attachment to his Oxford chum received a severe
shock, for had he not said that he had sometimes gazed on
his countenance till he had fancied that the world could be
reformed by gazing too ? Dr. Dowden, in passing from this
revelation of Hogg’s real character, and stating that Harriet
Shelley rose in her husband’s esteem, adds that “ now he
could no longer expend the wealth of his idealizing imagina¬
tion on one friend, he poured all its extravagant treasures
around the other, his heroine of a day-dream, Elizabeth
Hitchener.” Writing to her, he says : “ I could have borne
to die, to die eternally, with my once-loved friend (Hogg);
. . . earth seemed to be enough for our intercourse; on
earth its bounds appeared to be stated, as the event hath
dreadfully proved. But with you—your friendship seems to
have generated a passion to which fifty such fleeting, inade¬
quate existences as these appear to be but the drop in the
bucket, too trivial for account. With you, I cannot submit to
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perish like the flower of the field ” (p. 193). There is much
more written to this lady in the same rapturous, high-flown
strain which might be quoted, but this will suffice for our
immediate purpose, that of showing the strange and ex¬
aggerated attachments which Shelley formed, and the senti¬
mental effusions which flowed from his pen.
(To be Continued.)
Insanity Curable. Mental Disorders , and Nervous Affections
of recent origin or long standing. Their causes are now
successfully treated by a new especial method . By George
Moseley, F.R.C.S., L.S.A., etc., etc. London : J. and
A. Churchill, 1886.
One is almost weary of the painful uniformity of favourable
reviews and in this Journal the tendency to commend rather
than blame can hardly be denied. But there are limits to
the forbearance and kindly consideration of the reviewers of
even a The Journal of Mental Science,” and we must confess
it to be impossible to preserve in the present instance our
almost uniformly favourable notice of books falling within
our psychological domain. Mr. Moseley informs us in his
preface that his object is to explain the rise and progress of
insanity in the human body, and the certain methods of
treatment that have for their object not only the alleviation,
but the absolute cure of the malady. It was hardly necessary
for the author to state what is so very obvious on every page,
that the book is “ designed for the perusal of non-medical
persons/’ Mr. Moseley’s opinion of the medical profession
cannot be said to be very flattering when he asserts that
“ undoubtedly, its present feeling with regard to actual
treatment in such cases (those of insanity) is that not much
more can be done for the unfortunate sufferer than the se¬
curing of healthful surroundings and proper guardianship.”
Of those “ responsible for the treatment of the insane,” our
author’s estimate is still less flattering, for he declares that
“ the intimate relationship that is known to exist between
the state of the brain and the mode in which the various
bodily functions are performed, seems to be almost ignored
by them.”
Among the original discoveries of our author are: the
curability of insanity, the greater probability of its being
cured if treated early, and the fact that insanity is not a
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1887.] Reviews. 127
disease of the €t Spiritual Essence,” or “ Abstract Principle
of Mind.”
Mr. Moseley has discovered, too, that certain symptoms of
insanity frequently originate in “ failure of function in some
one or more of the Blood-making or Blood-purifying organs
of the body.” Hence, absolute cure or relief may be obtained
from remedies which secure “ the rapid oxidation and puri¬
fication of the blood ; and the alleviation of those processes
that are concerned in the excretion of waste deleterious
matters from the system.” Many years and much labour
has the late surgeon in the Royal Artillery Barracks at
Shorncliffe devoted to the study of Mental Disease, and he
now successfully combats it with ordnance charged with his
own “ special and peculiar methods of treatment.” It is
altogether contrary to the practice of this heroic practitioner
merely to prepare for the enemy and await his action. For
the listless, do-nothing treatment, known as “ The Expec¬
tant,” he has no patience. He only mentions it to condemn
it. The foe must be attacked and dispersed by the roar of
cannon and the discharge of artillery.
That some of Mr. Moseley’s remedies, including counter¬
irritation, galvanism, and baths, are useful in the treatment
of insanity, is quite true; but we were under the impression
that they had long been in use by medical men. Had he
urged their being used more frequently than they are, we
should have agreed with him. When we are on the brink of
expectancy as to what constitutes Mr. Moseley’s “ New
Especial Method ” by which mental disorders are “ now ”
successfully treated, our hopes are blasted by the statement
that the u use of all kinds of medicinal remedies in the treat¬
ment of insanity is too wide a subject for discussion within
the limits here at my disposal.” We get no further than the
statement that the blood is the true seat of mental disease,
and that our measures for its relief must be shaped accord¬
ingly. There is nothing very new or special in the direction
that measures must be employed to raise the vital tone of
the brain ; to suppress diseased action in those bodily organs
which evidence diminished or perverted activity; to induce
the blood-making and blood-purifying viscera to take on
healthy action, or, lastly, to promote the transference of con¬
gestion and irritation of the sympathetic ganglia to the skin.
A douche may be usefully applied to the head with or without
putting the legs in very hot or cold water. Artificial erup¬
tions on the skm, as in “ Baunscheidism,” are recommended.
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Also the Turkish bath, Sitz-baths, the application of mus¬
tard, prolonged warm baths, wet packing, &c. “ Perhaps
the reader will think,” concludes our author, “that in
this direction lie the remedies that will remove chronic
insanity out of the opprobria medicines.” Perhaps the
reader will also think, say we, that although this conclusion
is the result of a “confidence inspired by constant expe¬
rience on the living subject,” what is true in this produc¬
tion of sixty-three pages is not new, and what is new is not
true.
Hwme. William Blackwood and Sons, Edin. and London. 1886.
This is another carefully prepared biography of philoso¬
phers in the Classics for English readers, edited by Professor
William Knight, with a frontispiece representing an appa¬
rently excellent likeness of David Hume. The present
volume is written by the editor, who sketches the philosophy
of Hume with fairness and lucidity. He recognizes the
psychological inadequacy of the philosopher’s explanation of
many things. Take his contention in regard to Personal
Identity. Hume requires to be shown the “ impression ”
from which arises our “ idea ” of self. If this cannot be
done the alleged idea falls to the ground. Again, he de¬
mands how all our distinct energies can belong to and be
connected with the pretended self. Each of these may exist
separately, and where is the need of anything to support their
existence ? A man cannot enter into what he calls himself
without stumbling on some particular. Similarly, mankind
is “ nothing but a bundle or collection of different percep¬
tions which succeed each with an inconceivable rapidity, and
are in a perpetual flux or movement.” The identity of plants
or animals is analogous to ours. Hume held that men con¬
found the notion of a succession of objects which are in re¬
lation with the continuance of an identical object. The
following passage cited by Professor Knight contains the pith
of the contention on Hume’s side :—“ We feign the continued
existence of the perceptions of our senses to remove the inter¬
ruption ; and run into the notion of a soul, and self, and
substance, to disguise the variatiou.” Hume perceived
that the plant and the berry, the man and the child, were,
notwithstanding their different periods of growth, one and
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129
1887.]
the same. For all that, he maintained that their identity
was a figment of the brain, an imagination, and that the
oneness was not real. He supported his position of the fic¬
titious identity of the human mind by his doctrine of there
being no real causation amongst phenomena, only an asso¬
ciation of ideas, the result of custom. The memory of the
past and the union with the present is the main source of per- *
sonal identity, but only in the sense that it discloses it, the
disclosure itself being a mere illusion. The notion of causa¬
tion is acquired from such memory. Professor Knight regards
Hume’s position as inadequate, and as displaying analytic
poverty and helplessness. He says, “ A succession of states
of mind has no meaning , except in relation to the substrata
of self that underlies the succession, giving it coherence,
identity, and intelligibility. The states are different, but
the self—whose states they are—is the same. ... If all that
I am is this series of successive and detached * impressions/
which I subsequently recall and bring back upon the stage of
my experience as ideas—how are they my impressions—
and my ideas ? To make them mine , 4 1 9 must exist
beneath them or within them, and in a sense before them”
(p. 178). This may serve as an illustration of the intelligent
manner in which this little book is edited.
In concluding his philosophic sketch, the editor expresses
his opinion that the antidote to the one-sidedness of the
philosophy of experience as propounded by Hume, is to be
found not so much in its opposite—Idealism—as the Philo¬
sophy of History, proving as it does that no narrow sectarian
theory of knowledge suffices our human needs, and the study
of the chief idealistic poets, from Dante to the poet who so
greatly influenced John Stuart Mill, and who is able to hear
“authentic tidings of invisible things.” “Every mate¬
rialistic movement must sooner or later be followed by an
idealistic one, and every destructive theory be succeeded by
a constructive one ” (p. 238.)
What Hume said of Shakespeare, that he was a “ dispro-
portioned and misshapened giant,” might perhaps be applied
with more truth to Hume himself.
We have, in conclusion, only to speak in terms of praise
of this publication.
9
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XXXIII.
130
Rev tens.
[April,
The Philosophy of Art.*
This little book, with its simple title, will be found to
afford food for great and complicated reflections. It is a
translation of some of the preliminary statements of Hegel
and Michelet concerning the science of ^Esthetics, and is a
. forerunner of a more exhaustive treatise on the same subject.
The translator, who has wrestled successfully with the diffi¬
culties of Hegel’s style, writes with enthusiasm of the great
German master whose introductory remarks it is the purpose
of this book to set forth. In spite of this success, however,
the mind of the reader will occasionally revert to that
passage in the preface which speaks of “the common light
fading ” as one “ advances into the deepening chiaroscuro of
Hegel.” From this obscurity the reader partly emerges
when he reaches the second part, translated from Michelet.
But all such difficulties will only deter the frivolous; the
earnest student they will but put upon his mettle.
If, at the risk of speedy annihilation, one may venture to
cross swords with such renowned champions, it would be to
suggest that their subject is sometimes treated in too
abstract a manner. For instance, on p. 60, we read : “ While
the Greek colonnades which ran round the temple main¬
tained their relation to the outer world, the Gothic columns
and pillars were transferred to the interior of the building,
on account of its idea of seclusion from the surrounding
world.” Now, we venture to say that no such abstract and
philosophical idea actuated the Gothic builders; but that,
on the contrary, their arcades were the result of practical
considerations, and were evolved from a plain, solid wall
through various stages, the first of which is to be found in
Romanesque architecture, where the solid piers are as wide
as the open arches. As the desire for more spacious interiors
grew, and as the builders increased in knowledge of con¬
struction, so did the piers lessen and the arches increase.
It cannot be supposed that the Gothic architects adapted
the idea of piers and arches from a Greek colonnade, for
they never saw one; and it is rash to assume that they had
any but constructional and practical motives for the leading
characteristics of their work. But philosophers are apt to
* “ The Philosophy of Art, an Introduction to the Scientific Study of
^Esthetics,” by Hegel and C. L. Michelet. Translated from the German by W.
Hastie, B.D. Edinburgh : Oliver and Boyd. London : Simpkin, Marshall, and
Co.
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1887 .]
read much more into the work they criticize than ever was
in the mind of its authors. This, however, does not detract
from the interest of the book, for it is but dull reading
where you cannot sometimes disagree with your author.
On some forms of Paralysis from Peripheral Neuritis. * By
Thomas Buzzard, M.D. Lond. J. and A. Churchill,
1886.
The present small volume embodies the Harveian
Lectures delivered by the author in 1886, and subsequently
published in the “ Lancet.” Much, however, has been added
to these same lectures.
The subject of Peripheral Neuritis is one of very con¬
siderable interest; moreover, it is new. Dr. Buzzard gives
us first a few anatomical and physiological considerations,
of which one may say they are admirable in their clearness,
and of material assistance in leading up to the subject
proper. Neuritis is then defined both as to its morbid
anatomy and morbid physiology. With regard to the first,
the two forms of lesion, interstitial and parenchymatous,
are described, and, as it seems to us, very fitly. Dr. Buzzard
suspends his judgment “as to the propriety of the paren¬
chymatous form being considered as certainly of inflam¬
matory character.”
The author then leads off with a case of neuritis which is
so striking, so typical, that one jumps to the right conclusion
at once—paralysis, altered electrical reaction of the muscles,
pains, hypersesthesia, trophic changes in the skin, all are
present. One is sanguine, but, unfortunately, all cases of
neuritis are not thus stamped; and on p. 21 we find the
important statement: “ We are not yet in a position to
explain this important fact, but there would seem to be no
doubt that sometimes the motor, at other times the sensory,
and, perhaps, on the whole, least commonly, the vaso-motor
fibres, bear the brunt of the attack, with a corresponding
contrast in the symptoms.” This is, indeed, an important
statement, and, if true, as seems likely from the evidence
adduced, it offers another instance of the marvellous tissue-
affinities of disease. On p. 22 the author applies the
doctrine, and states : “ But even in mixed nerves, I feel
sure that neuritis may occur without pain.”
Gout—that protean disease—is then considered in relation
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Reviews.
[April,
to attacks of pain and numbness not uncommonly met with.
With this pain and numbness may be associated more or
less loss of power (and even trophic changes). Dr. Buzzard
thinks that many such are instances of a peripheral neuritis
of gouty origin, and he holds that electrical examination of
the muscles supports this view. Cases in illustration are
given.
The first chapter concludes with a quotation from Graves,
in which he describes a curious epidemic which occurred in
Paris in 1828. The symptoms of the disease consisted in
pain, hypersesthesia, then ansesthesia and powerlessness,
even to general paralysis. At the post-mortem no central
lesion was discoverable. The objection, of course, to this
evidence is, as Dr. Gowers points out,* that the means of
investigating the nervous system at that time were not very
efficient.
In Lecture II. multiple neuritis is considered more in
detail. Cases with a syphilitic history, and yielding to
syphilitic remedies, are given; but no particular cases are
instanced in which the chief morbid factor appeared to be
alcoholism. The group of symptoms which characterize
cases of alcoholic multiple neuritis present many resem¬
blances to the group of symptoms belonging to tabes. Thus
pains may be present, especially in the lower limbs, numb¬
ness, ataxy, loss of knee-jerk. The resemblance, indeed,
may be so close that only the further course may permit of
the diagnosis being made. A conclusive sign against tabes
is, according to Dr. Buzzard, recovery of the knee-jerk.
Stress is also laid on the symptom, “ dropped feet,” as very
suggestive of alcoholic paralysis; in fact, it is considered by
the author as almost as suggestive of this poison as dropped
wrist is of lead.
In Lecture III. instances of peripheral neuritis from other
causes are given; thus in sequence to malaria, to enteric
fever, and, notably, as following diphtheria. Of course,
diphtheritic paralysis is comparatively seldom fatal, and its
morbid anatomy is gathered from rather scanty materials;
but the view that it is really the result of peripheral neuritis
seems a very likely one.
In this chapter some space is given to the diagnosis of
multiple neuritis, and it demands it, for, with all care, the
disease, as it at present stands, will tax the diagnostic
powers even of a specialist.
* Gowers, w Diseases of Nervous System,” Yol. i.
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133
1887.]
We must add, in conclusion, that the subject of peripheral
neuritis is of the greatest interest, and that it promises to
make plain much that has hitherto been obscure in nervous
affections. True, the disease is not just yet in sharp focus,
but that will come. Meanwhile, we must express our in¬
debtedness to Dr. Buzzard for his valuable contribution to
this department of pathology.
DruitVs Surgeon 9 8 Vade-Mecum: A Manual of Modem Sur¬
gery. Edited by Stanley Boyd, M.B., B.S.Lond.,
F.R.C.S.Eng., Assistant-Surgeon and Pathologist to
the Charing Cross Hospital, and Surgeon to the Pad¬
dington Green Hospital for Children, &c. 12th Edition,
with 373 wood engravings. London: Henry Renshaw,
356, Strand. J. and A. Churchill, 11, New Burlington
Street. 1887.
Although this work may seem only remotely related to
Psychological Medicine, it is very certain that the medical
superintendents of asylums, as well as others, will find a
handbook of Surgery of essential use, and we know of no
book so well adapted for the purpose as the long-established
favourite — Druitt’s Vade-Mecum. The present edition,
almost rewritten, enlarged, and most ably and carefully
edited, by Mr. Stanley Boyd, leaves nothing to be desired,
and we confidently commend it to the favourable notice of
our readers.
The chapter, “Injuries of the Head,” deals with injuries
of the scalp, the skull-bones, general injuries of the brain,
including concussion, compression, injuries of intracranial
vessels, local injuries of the brain. The arrangement of
centres in the motor area is shown by a figure, and includes
a reference to the results reached by Horsley and Schafer.
Inflammation of the brain and its membrane, intracranial
abscess, traumatic epilepsy, and tumours of the brain are
next treated of, and operative interference in the light of
recent experience is duly noticed.
Now that Surgery is being more and more applied to the
alleviation of cerebral affections, it becomes of more imme¬
diate interest and importance to those engaged in the
treatment of diseases of the brain than at any former time.
We predict a very wide circulation for this useful manual.
It is admirably illustrated, and the letterpress is excellent.
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134
[April,
PART III.—PSYCHOLOGICAL RETROSPECT.
1. Scandinavian and French Retrospect.
By Dr. Hack Tukb, F.R.C.P.
A . The Copenhagen Congress.
Congres Periodique International des Sciences Medicates, 8 1 **
Session. Copenhague , 1884. Compte-Rendu Public au
nom du Bureau. Par C. Lange, Secr6taire-Gen^ral.
Tome ILL Copenhague, Librairie Glydendal (P. Hegel
et Fils), 1886.
This volume contains the Report of the Section of Psy¬
chiatry and Neurology at the Copenhagen Congress, and
extends over nearly 160 pages. Professor Steenberg, the
superintendent of the St. Hans Asylum at Copenhagen, pre¬
sided, and among the vice-presidents were Professor Kjellberg
(IJpsala), Professor Laehr (Berlin), Professor Ball (Paris), Dr.
Magnan (Paris), Professor Obersteiner (Vienna), Dr. Ramaer
(Hague). Of the four secretaries Dr. Pontoppidan (Copen¬
hagen) is known to many in this country, having visited
some of our best asylums since the Congress.
The President contributed a valuable sketch of the
asylums and the insane in Scandinavia, the population of
which amounts to 10,400,000. Of these 18,000, or 17*4 per
10,000, are insane, and are thus distributed:—
Sweden
Population.
... 4,600,000
Insane. Per 10,000.
7,100 15-6
Norway
... 1,800,000
3,160
18-5
Finland
... 2,000,000
4,400
21-2
Denmark
... 2,000,000
3,300
16-6
In Sweden 24 # 2 per 100 patients are in public establish¬
ments ; in Norway 32*9 per cent.; in Finland 10’1; in Den¬
mark 56*1.
Sweden has 10 hospitals with 2,250 beds; Norway 10
hospitals with 1,040 beds; Finland has two hospitals, a
house of reception, and a new hospital at Knopiv; Denmark
four asylums with 2,000 beds.
Thus Scandinavia has too few public establishments.
Even in Denmark there is only room for half the number of
the insane, whilst in England 61*5 per cent, and in Scotland
75*6 per cent, of the insane are in public institutions.
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135
1887.] Scandinavian and French Literature.
Patients wlio are outside asylums are mostly in their houses
or with their relatives, and most frequently are well treated.
and cared for.
The difficult problem of the best location for chronic
lunatics is discussed. Experience proves that frequently
many of this class can live comparatively happy outside the
asylum. On the other hand experience also shows that
many who in an asylum are quietest and best workers have
scarcely gone out of hospital before they are attacked with
an exacerbation of their disorder, and are sent back to the
asylum in such a state that the greatest regret is felt that
they were ever allowed to leave it. The abuse of brandy is
chiefly the cause of this, but it must be admitted that the
homes of the patients are sufficiently unfavourable to cause
an increase of the symptoms.
In the middle ages the insane in Sweden were placed in the
" Maisons du Saint-Esprit,” monasteries administered by
certain brotherhoods and supported by donations. When, in
1527, the reformation abolished the monasteries, the above-
mentioned Maisons alone remained in the same state, and in
the course of years they imperceptibly changed into asylums
for the insane. In 1773 the chevaliers of the celebrated
order of the Seraphims undertook the duty of caring for the
insane. They have acted with great energy and ability,
thanks specially to the well-known Dr. Magnus Huss, a
member of this order, and subsequently Director-General of
all the asylums in Sweden. This remarkable order of
Seraphims was dissolved in 1877, and the administration of
all matters pertaining to the insane was confided to medical
control.
Passing to Norway, a Royal order in 1736 compelled all
hospitals to provide one or two wards where the insane poor
might be treated or protected. But it was only in 1845 that
Norway began to perform its duty towards the insane by
purchasing the domain of Gaustad, near Christiania, and
constructing an asylum there. In 1871 another asylum was
built at Ratvold, near Trondhjem, and in 1881 another was
erected at Ey, near Christiansand. Professor Steenberg
says these three institutions are excellent, and are built
according to the enlightened principles of the present age.
For Finland there were, in 1771, 40 beds for the insane,
provided in connection with the old leper hospital at
Sjakl6. It was only on the foundation of the asylum at
Lappvik in 1841 that the insane began to be treated, and at
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136 Psychological Retrospect . [April,
the same time some cells in all hospitals were provided for
the temporary care of the insane. In addition to these two
old asylums there are five houses of reception and a new
hospital at Knopiv.
Lastly, in Denmark Christian the Fourth, in 1632, ordered
provision to be made for the insane to the extent of 30 cells
m the St. Jorgensgard. This house of St. George was
intended for lepers, and was dedicated to the patron saint of
these unfortunates, St. Jorgen. Towards the middle of the
16th century leprosy began to decline, and this house became
the hospital of St. Hans (John), and was appropriated to the
insane and the patients suffering from contagious diseases.
It was situated near Copenhagen, but after having been
destroyed by fire, once by the Swedes and once by the
English, it was transferred in 1816 to Roeskilde, where it
now is. Later on the Government has shown its solicitude
for the insane by establishing several asylums.
There are no inspectors of asylums in Scandinavia. In
Sweden all relating to the insane depends upon medical
government. In Norway, State Asylums are placed under
the ministers of justice, whilst all the Communal Asylums
are conducted by the commune to which they belong. This
holds good for Denmark also. In Finland all the asylums
are under State control, and depend upon the medical
administration. Sweden possesses only two small private
asylums.
As to lunacy legislation, Norway, Sweden, and Finland
have laws, it is true, but these are principally concerned
with the forms necessary to be observed in admitting or dis¬
charging patients. Sometimes they maintain the rights of
society in regard to lunatics; but no law exists which main¬
tains the rights of the insane in regard to society, which, as
is pointed out, is a great defect. There is wanting a law to
decide in what manner and up to what point the insane even
when they are interred in an asylum may employ their fortune
as they wish, and dispose of it by will.
Denmark has no lunac^laws^a happy state of things, it
may be thought, by those In England who are worried by
fussy legislation relative to the insane calculated to cramp
the action of medical men.
In Sweden the study of psychiatry is obligatory, and
students cannot pass their last examination without possess¬
ing a certificate of having attended a psychological clinique .
As early as 1859 a course of lectures in psychiatry was de-
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137
1887.] Scandinavian and French Literature .
livered in the hospital of Upsala, and later in the hospitals
of Stockholm and Luna.
In the other three countries of Scandinavia medical
psychology is not obligatory; but courses of insanity are
delivered for the benefit of the students. Especially young
medical men have had the opportunity of attending the post
of interne in the chief establishment of the country. Never¬
theless there is a general desire among the mental physicians
of Scandinavia that psychiatry should form a part of the
University examinations.
A map representing the distribution of the insane and
idiots in Scandinavia is given, and will be of great use to any
of our readers intending to visit that region.
Our space allows of little more than an enumeration of the
papers read at this section :—
1. Anatomical Changes in Tabes Dorsalis , by Prof. Adamkiewicz
(Vienna).
2. Morphinism and its Treatment , by Prof. Obersteiner (Vienna).
3. Psychological Analysis as a basis for Psychiatric Diagnosis , by
Dr. Ramaer (The Hague).*
4. On the Religious Exaltations of the Orient , by Dr. Zambaco
(Constantinople).
(We hope to find room for this interesting paper in a
future number of the Journal. It forms a most important
contribution to the study of Hysteria.)
5. The Value of Agricultural Colonies in the Treatment of the In¬
sane, by de Paetz (Alt-Scherbitz).
6. The Influence of Schools in inducing Mental Diseases , by Prof.
Kjellberg (Upsala).
7. The Curability of Tabes Dorsalis, by Prof. Eulenburg (Berlin).
8. Influence of Heredity in General Paralysis of the Insane by
Prof. Ball (Paris).
The author concludes that direct heredity is rare. The
families of paralytics generally present very characteristic
features, namely, longevity of ancestors; a large number of
children ; infrequency of mental diseases properly so-called;
great frequency, on the contrary, of cerebral diseases ; high
rate of mortality among the children. General paralytics
inherit, then, a special tendency to brain trouble, but do not
inherit the special malady with which they are attacked;
and their families, taken as a whole, are in several respects
distinguished from the population by which they are
* Reviewed in this Journal, January, 1886.
Digitized by L^ooQle
138 Psychological Retrospect. [April,
surrounded. General paralytics are the outcome of a noble
not a degenerate race.
9. The Role of Syphilis in General Paralysis , by Dr. Rohmell
(Copenhagen).
The author attaches great importance to the etiology of
Syphilis, but concludes that specific treatment seems only to
retard the progress of the disease. Hence he presumes there
is some special modification of Syphilis. Dr. Rohmell con¬
siders it highly important to employ anti-syphilitic remedies
assiduously if the disorder is seen in its early stage. Professor
Steenberg maintained in the discussion that paralytic de¬
mentia has only syphilis for its cause. This is what he says
he has been compelled to conclude from his large experience.
“ He who has never had syphilis will never be attacked by
general paralysis.” It is hardly necessary to say that the
conclusions of Rohmell and Steenberg were combatted by
other speakers, as Ramaer, Magnan, and Lunier.
10. The Vaso-Motor and Trophic Neuroses, by Prof. Eulenburg
11. The Local Treatment of Chronic Congestion and Exudations of
the Meninges by Ventouses Vesicantes, by Dr. Baraduc (Paris).
12. Wasting Palsy and Amyotrophic Lateral Sclerosis, by
Wladimir Roth (Moscow).
13. Anatomical Lesions in Amyotrophic Lateral Sclerosis, and its
relation to Wasting Palsy, by Dr. Friedenreich (Copenhagen).
14. On the Histological Character and Development of the
Secondary Degeneration of the Spinal Cord, by Dr. Hom6n (Hel¬
singfors).
15. On Compression and Lesions of the Brain, by Prof. Adam¬
kiewicz (Cracow). On the Role of the Dyscrasies in the Etiology
of the Neuroses and Psychoses, by Dr. Otto Muller (Blankenburg).
16. The Role of Exercise in the Treatment of Mental Diseases, by
Prof. J. Kjellberg (Upsala).
17. On the Psychic Equivalent of Epilepsy, by Dr. Fr. Hallager
(Viborg, Denmark).
The author maintains that the so-called psychical equiva¬
lent of an epileptic attack is not proved, and that careful
examination would reveal unobserved epileptic attacks.
18. On the Pathogenesis of Epilepsy, by Dr. P. Rosenbach (St.
Petersburg).
19. On the Etiology and Treatment of Megrim and Nervous Head¬
ache, by Dr. 0. Storch (Copenhagen).
20. On Salivation in Nervous Diseases; Physiological Examination
of the Secreted Fluid, by Dr. Gilles de la Tourette (Paris).
The whole forms a very valuable collection of articles,
Digitized by A^OOQle
1887.] Scandinavian and French Literature. 189
is of practical importance in the treatment of the insane,
and for the most part possesses permanent interest.
B. French Psychological Literature.
L'Encephale. Journal des Maladies Mentales et Nerveuses.
This journal continues to supply its readers with excellent articles.
In the first number of 1886, which, by-the-bye, is the 6th year of its
existence, are articles on “ A New Region of Grey Matter at the
Base of the Brain,” described by Luys; “ Syphilomata of the
Encephalon,” by the same physician ; u Syphilitic Myelitis,” a case
which recovered under iodide of potassium and mercurial inunctions,
by G. H. Roger; “ Hystero-traumatic Paralyses,” by H. Poupon ;
“ Study of the Mental Condition of Louis Riel,” by H. Gilson ; and
“ The Insane Painted by Themselves,” by R4gis.
The article on Riel is full of information, and should be carefully
read by those who doubt his unsoundness of mind and irresponsibility.
He was in daily communication with angels, and never took any
decision without consulting them. Even his companions in arms
blame him because he placed obstacles in the way of the most rational
military operations, on the pretext that his voices had ordered it.
One day when he was present at mass, he understood the sermon in a
sense very different from the preacher’s. After the mass, Riel passes
through the congregation and the sanctuary, mounts the steps of the
altar, takes up the Gospels, and, turning towards the congregation,
says : “ When the priests tell you the truth, they put this book on this
side—” showing the Gospel —' li and when they wish to humbug you they
show you that”—pointing at the same time to the Epistles. He had
the following conversation with Father Andre : “ I ask you a favour,
Father, and I venture to hope that you will not refuse it.” “ And what
is that ? ” enquired the priest. Riel replied, “ It is to require Mgr.
Tach4 to permit me to celebrate the mass.” “ But who has ordained
you ? ” “ The spirits 1 ” answered Riel. He constantly opposed the
plea of insanity raised in his favour. Four physicians were consulted
as to his insanity; two pronounced in favour of it and two against it.
The comment made by the author on the execution of Riel, is that
if it shows once more the imperfection of the English law in questions
of insanity. The English alienists are, besides, in accord with
ourselves upon this point. Let us then recognize and say to the non¬
medical public that the insane are better protected in France than
anywhere else, for in our country a man like Riel would be still living,
but placed in an asylum and protected by the law.”
M. Regis, in the article whose title we have given, reports a case
which he classifies as manie raisonnante or folie morale . The
patient, who was an inmate of the Sainte Anne Asylum in Paris, pre¬
pared a work with the title of “ Natural Philosophy,” in which he
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140
Psychological Retrospect . [April,
treated of the origin of worlds, the atomic state, magnetism, sound¬
waves, and the theory of inductions. Moreover, 200 pages were
devoted to “ insanity,” in which there were chapters on the mind, the
theory of material propagation of thought, reflection, and ideas,
hallucination, mental communications at a distance, natural causes
of insanity, nervous disorders, delirium, extravagance, rambling,
dementia, general paralysis, divorce, &c.
A long extract is given from his description of inductive correlation
which is very curious, and justifies the description of folie raisonnante,
illustrating, as the author maintains, how the mind may be dis¬
ordered without the syllogistic faculties and the reason being affected.
The case also shows how patients’ productions may betray them
when a very long conversation fails to elicit their mental trouble. M.
K^gis well may ask how we can wonder at the extra-medical public
obstinately refusing to see anything unreasonable with such patients,
when even some specialists themselves do not hesitate, for want of
sufficiently attentive study of these insane persons, to declare them
sane. This particular patient was transferred from the clinique in
the asylum to another division, in the same mental condition, and was
shortly set at liberty as not being (legally) insane.
No. 2 contains an elaborate article by M. Jules Soury, on the
functions of the brain, as held by Goltz. The subject has been now
so frequently discussed, and in our opinion with the result of
disproving these particular doctrines, that we do not think it
necessary to analyze this article. The number of experiments upon
animals by Goltz and by Munk appear to be endless, and, in con¬
sequence of the manner in which they are performed, inconclusive and
contradictory. It has now, in fact, become a matter of mere personal
feeling and pique. A more pitiable exhibition of temper than that
witnessed at the recent meeting of German physicians and naturalists,
cannot well be conceived, and the worthy Dr. Watts’s permission to
dogs to “ delight to bark and bite,” appeared to be by a singular
Nemesis transferred from the subjects of the experiments to the experi¬
menters themselves. Professor Ball makes an editorial note that he
dissents from the views of M. Soury on the subject of cerebral localiza¬
tion, and prefers to follow his master, Brown-S4quard.
An article upon la folie d deux , by Ball, raises the question whether
insanity is contagious. Two opposite opinions are noted. For the
general public it is fully established that one becomes a lunatic him¬
self who listens to the ravings of others, and that it is sufficient to be
shut up in an asylum to completely lose one’s reason. Altogether op¬
posed to this is the opinion of specialists. The insane usually feel an
antipathy to one another. Hence the appropriateness of the French
aliene —a stranger to the world in which he lives. But do they not
exert an influence on the sane ? Many facts, including the apparent
immunity of doctors and attendants, in spite of being constantly
thrown among them, seem to favour a negative reply. Las&gue and
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141
1887-3 Scandinavian and Trench Literature.
Falret have, however, by their works added to the nomenclature of
mental disorders, by recognizing the influence under certain circum¬
stances of a lunatic upon the sane. R4gis has contributed an able
thesis on the folie a deux of these authors, when it is developed
simultaneously, and it receives the name of folie-simultanSe from one
writer. When twins are insane, we have the term folie gSmellaire .
Again, M. Chpolianski presents us, in a thesis, with suicide d deux.
The type described by Las^gue and Falret may be thus indicated: It
usually arises from the influence exerted by one person over another,
and is due to the intimacy of family life. Generally the one who
exerts the influence occupies a superior position to the other. A
master, for instance, affects his servants, or the better educated and
more energetic brother or sister affects the other members of the
family. The passive subject is only the feeble echo of the agent.
Again, it is needful that there should be a certain amount of
coherence and plausibility in the lunatic. A general paralytic or a
dement would fail to exert an injurious influence. It is the
systematized delusionist or the mystical preacher who produces
conviction. The passive agents, on the other hand, are in general
those easily influenced by their surroundings, the feeble-minded
children, old people, and the effaces. According to M. R£gis, this
form of insanity happens to those who are badly organized, and who
have already a proclivity to the disorder. If in the same family there
are, in short, two heads in the same bonnet, and apart from heredity,
the facts brought forward by Lasagne and Falret preserve their
value, while the simultaneons insanity in two predisposed persons, as
prominently indicated by M. R^gis, forms an interesting variety.
Professor Ball hesitates to admit Dr. Kieman’s idea of the communi¬
cation of insanity to several by the transmission of illusions, among
the insane , for, as already pointed out, lunatics do not feel drawn to
one another, but the reverse.
The conclusion arrived at by Dr. Ball, is that the contagion of
insanity is one of the most indisputable facts, and ought to be
recognized, but does not favour the common notion that this occurs
inside asylums. The only efficacious treatment is the complete separa¬
tion of the two affected persons. We agree with Dr. Ball’s conclusions.
We pass over the new experiments in reference to the intracranial
motion of the brain by M. Luys, who shows that in the horizontal
position of the head, its relation to the skull is not the same as in
the vertical position, these movements being favoured by the sub¬
arachnoid fluid. The next article is by M. Motet, on the boundary
lines of insanity, in which he reports a case of a man found guilty of
swindling. M. Motet could not say that he did not know that he had
done wrong, but that he thought that at the moment when he swindled
he was in the midst of an attack of excitement, of which there were
proofs of his having had similar attacks in the past. The tribunal ac¬
cepted these conclusions.
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142 Psychobgical Retrospect. [April,
Dr. Descourtis contributes a valuable article on the cephalic ther¬
mometer. He draws the following conclusions:—
1. Along with the rare cases in which the temperature reaches its
maximum in 15, 20, or 30 minutes, there are others in which it follows
an ascending scale during one, two, three, and even four hours.
2. Sometimes the temperature follows a pretty regular line, either
horizontal or oblique from below upwards ; sometimes it presents
actual oscillations.
3. The oscillations usually follow no rule. However, there remain
cases where they seem to follow at regular intervals.
4. There are sometimes considerable and sudden falls of temperature,
which nothing so far explains.
5. Instead of pursuing a parallel course, the temperature of the left
and that of the right side are often independent of each other.
6. The temperature may remain stationary on one side of the head,
whilst it undergoes variation on the other.
7. The same oscillations may occur inversely, the temperature ris¬
ing on one side while it falls on the other.
8. There is a certain relation between the deep cephalic temperature
and that of the axilla. When the one rises or falls the other rises or
falls, although not exactly in the same proportion.
9. Usually, the discrepancy between the axillary temperature and
the frontal is less considerable in proportion as the former is elevated.
10. It is even possible that the difference of temperature between
the left and right side of the head may be more accentuated in low
temperatures.
11. The degree of temperature, the relative superiority of the left
or the right side, the characters of each curve, the discrepancy which
they present, vary with the activity or the repose of the brain, with
health or disease, and form of the disorder.
12. In general paralysis and inflammatory affections of the brain or
its membranes, the temperature appears to be invariably high. It is
the same in mania. On the contrary, in melancholia and mental
6tupor, there is sometimes a rise and at others a fall of temperature
without any apparent reason. The latter fact is of great importance
in regard to treatment.
We are glad to observe that Dr. Descourtis confirms the results
arrived at by Lombard, and pays a high tribute of praise to his
extreme accuracy.
Artificial Somnambulism.
Le Somnambulisme Provoque; Etudes , Physiologique et Psychologiqus.
Par H. Beaunis, Professeur de Physiologie a la Faculty de
Mfcdecine de Nancy. Paris, 1886.
This contribution to the literature of hypnotism has already at¬
tracted considerable attention, and ought to be read in connection
with Cullerre’s work, Magnetisme et Hypnotisms, expose dee pkenomenes
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143
1887.] Scandinavian and Trench Literature .
observes pendant le sommeil nerve use provoque , au point de vus cliniqve ,
psychologiqve, therapevtique et medico-legal, avec un resume histortque
du magnetisms animal. Paris, 1885.
M. Beamris acknowledges the influence of Charcot, Richet, and
others, in obliging men of science to take up the study of hypnotic
phenomena instead of foolishly leaving them to charlatans and
pseudo-scientific observers. The author controverts the popular
notion that the hysterical only are susceptible to hypnotism, whereas
it can be readily reduced in men of all temperaments, the old and
children. It is worthy of remark that he has not been able to repro¬
duce Charcot’s three states of hypnotism, witnessed in the hystero-
epileptic at the Salpetri&re. As regards neuro-muscular hyperexcita¬
bility and sensation in artificial somnambulism, the author does not
enter upon the former, and his observations of the latter have been
somewhat variable. He is acutely alive to the disturbing element of
suggestion—that perpetual source of fallacy unless due precaution is
taken—and he adopts Bernheim’s motto, Mefiez-vous de la suggestion.
To produce sleep by the various methods in vogue it suffices that
the subject has present to his mind the idea of sleep. The sleep of
somnambulism is not, however, the natural normal sleep. Can the
former be induced in a person asleep without first waking him? It is
possible. Hence, as the hypnotic sleep is produced with difficulty
among the insane, it might be hoped that this could be done with
greater facility during sleep. In spite of the opinions of Braid and
Bernheim to the contrary, M. Beaunis holds that persons may be
hypnotized against their will, it being a condition, however, that they
have been previously hypnotized. For some of these, resistance
becomes impossible, although they may avoid the gaze of the
operator. Even in such cases, however, it is sufficient to suggest to
them that no one can send them to sleep during a certain time to
prevent any attempt being successful.
The non-susceptible are in a minority. Possibly with sufficient
perseverance there is no one who might not eventually be thrown into
the hypnotic sleep. Not that we desire this.
As to the dangers of hypnotism, the greatest is that of making
anyone absolutely subject to the power of some hypnotizer. This is
no doubt a real moral danger. The only answer to this objection is
that everything may be abused ; that, for example, we cannot prevent
ill-disposed people employing the poisons which medical men make
use of for curative purposes. As to the dangers to the individual
arising out of frequent experiments made upon him or her, they
appear to consist of a little headache, flying pains, nervous attacks,
and a tendency to syncope.
Sphygmographic tracings are given showing the effect of hypnotic
suggestions upon the beats of the heart. The first tracing is taken in
the waking state, and is very regular. The pulsations were 96 per
minute. Bleep being induced, the character of the pulse becomes that
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144 Psychological Retrospect. [April,
of high tension, its fulness is diminished, and the tracing is scarcely
dicrotic. Pulsations are now 98*5 per minute. A few moments
afterwards, it was suggested to the somnambulist that the pulse had
become slower. The tracing then taken shows at two points—the
beginning and the end of the suggestion—a more accentuated slowing
and a sort of arrest of cardiac pulsation. The pulse was 92. Sug¬
gestion is no longer made, and the pulse returns to its normal condi¬
tion. The pulse beats 102 per minute, the subject being still asleep.
The suggestion was made that the pulse was more frequent, and now
the tracing shows scarcely the slightest dicrotism. The pulse rises to
115. The subject’s pulse then returns to its normal state, and on
being aroused it is found that the pulsations number 100. In short,
slowing and acceleration of the pulse immediately succeeded suggestion.
The author records several interesting instances of voluntary accelera¬
tion, but not slowing, of the heart’s action, without hypnotism, but he
does not believe that these cases belong to the same category, and he
insists upon the instantaneous influence of suggestion under hypnotic
conditions, which, according to Beaunis, acts upon the inhibitory centre
rather than upon that of acceleration. The mind of the subject, in
ready obedience to the suggestion made, acts immediately in exciting
or in paralysing the centre of cardiac inhibition, and produces in the
former case slowing, and in the latter increased frequency of the heart.
Great stress is laid upon the instantaneous effect of suggestion upon
the heart.
Experiments causing a blush of the skin by hypnotic suggestion are
given. This is done by saying to the subject that on waking there
will be a red spot at the point then touched. Ten minutes after, a
blush, at first very slight, appears, which increases gradually, and after
having lasted for about a quarter of an hour, slowly disappears. By
conditions it could be made to last much longer, namely, for 24
or 48 hours. Vaso-motor changes cannot, of course, be induced
voluntarily in ordinary conditions, but it is well established that in
some susceptible persons analogous results follow emotional excite¬
ment directed in a certain channel without hypnotism. Again, sug¬
gestion will produce not only local vascular congestion, but considerable
swelling. Still more striking is the production of a blister by the
same mental influence. A remarkable instance of this is given, in
which every precaution seems to have been taken to prevent decep¬
tion. It is vouched for by Professors Bernheim, Liegeois, as well
as Beaunis, Drs. Ltebeault and Simon, and two other witnesses.
Most if not all of the secretions have been excited by suggestion.
The lachrymal secretion was excited on only one side through the same
influence. Again, epistaxis and sanguineous perspiration on areas
determined by suggestion, have been induced; the latter experiment
being, of course, full of interest in relation to the well-known “ stig¬
mata ” of past and present days. These are splendid results.
Experiments made with the dynamometer before artificial sleep is
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145
1887.] Scandinavian and 'French Literature .
induced, during its presence and after waking, show that the grasp is
feebler during the sleep than before it. And, as the sleep is deepened
the proportion of the cases in which the force diminishes during the
sleep becomes less. In the majority of cases tested after waking the
force was greater than before the sleep was induced, as well as greater
than during the sleep. To some extent that marvellous agent, " sug¬
gestion,” could be made to augment the dynamometric force.
Acuteness of hearing is usually intensified during the sleep.
Tactile sensation requires further elucidation.
We now come to the state of the memory in artificial sleep. M.
Beaunis concludes (1) that the memory of conscious states (sensations,
acts, thoughts, &c.j, daring artificial sleep, is abolished when the
patient wakes, but this memory may be revived by suggestion either
temporarily or permanently. (2) That the memory of conscious states
during artificial sleep returns when the subject is again hypnotized;
but it may be suspended by suggestion. (3) That the memory of con¬
scious states during the period of being awake, or of natural sleep,
remains during the hypnotic condition; but this memory may also be
suspended by suggestion either temporarily or permanently. It is
scarcely necessary to observe that the forgetfulness (on waking) of the
acts performed during the hypnotic sleep holds good for the most part
in natural somnambulism.
Memory, we know, may be rendered more acute by natural somnam¬
bulism, as in the example of the servant who in this condition talked
Hebrew which she had heard from her master. So likewise in the
hypnotic sleep the memory is intensified, the subject remembering
the details of events which entirely escaped the memory when
awake. The question is discussed whether there is more than an
exaltation of recollection, or whether the facility with which impres¬
sions are fixed in the brain is increased. So far as M. Beaunis' ex¬
periments have gone, there is no evidence of an augmentation of the
latter faculty.
As the author says, the facility with which temporary amnesia can
be induced is one of the most curious features of hypnotism. As is
well known, the subject may be made to forget vowels, consonants,
numbers, or powerless to count beyond a certain number fixed upon,
made to lose the notion of substantives, names, and even his own, and
to no longer remember whole periods of his life, to cease to have any
notion whatever of his own identity, and, in a word, wholly part with
his memory. Every form of difficulty of speech now so well known in
clinical medicine, can be produced instantaneously, as the experimenter
in suggestion may desire. More singular still are the phenomena of
unconscious memory. An act is suggested during artificial sleep to
be performed when the patient is awake, at a period fixed upon by the
bypnotiser. An instance is given of this occurrence 172 days after
the suggestion. This is much more extraordinary than the common
experience of a name suddenly occurring to us which we have forgotten
xxxiii. 10
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146 Psychological Retrospect. [April,
for the hypnotic suggestion is realized at a fixed moment, neither sooner
nor later.
The facility with which, on certain conditions, various mental
faculties and feelings, such as anger,-pride, jealousy, &c.,are aroused,
is a fact of obvious interest to the psychologist, and it is maintained
that not only temporary modification of character may be induced, but
that the same may be even rendered permanent. Thus, a young lady
who bad melancholy ideas, became much happier after she was hypno¬
tized, and was well aware herself of the change which had occurred.
Again, M. D. was a great smoker and beer-drinker, so that his health
gave way and his friends were alarmed. He was hypnotized, and it
was suggested to him that he should not smoke or drink any more. The
result was excellent, although all the advice of his friends, combined
with his own will, had been unable to bring it about! The author is
indeed convinced that hypnotism will one day become a powerful
friend of morality and education. We are sorry we cannot feel equally
sanguine.
A chapter is devoted to the well-known condition of sleep-walking,
that condition of biologized subjects which, to some extent, affords a
parallel to insane conditions, for the eyes of the subject are open, and
he looks and walks about very much like ordinary persons, but may
have at the same time some extraordinary delusion, one having sole
reference to a suggestion impressed by the operator upon the subject,
or there may be a partial loss of memory. M. Beaunis cannot tell us
what changes have taken place in the brain; all he can say is that
the condition present differs from the merely incomplete hypnotic
sleep which is observed in some subjects.
Suggested hallucinations, especially those of hearing and sight, have
been induced in a very definite and interesting manner, and the phe¬
nomena raise many interesting questions, such as whether they have
the clearness of sensations caused by external stimuli. Four experi¬
ments were made in order to decide this point. One was on a peasant
woman, who probably had never made an attempt to draw before M.
Beaunis suggested to her to sketch a dog, when she was hypnotized.
When awake it was with difficulty that she succeeded in tracing a
rough outline in which it is hard to recognize the form of a dog.
The second experiment was made upon a young lady who could not
draw, and to whom Punch was suggested. The result was almost nil.
In the third experiment the result was rather more successful. Beaunis
suggested to Louise a bird, and she drew a very imperfect sketch, in
which, however, some of the features of the animal appeared. Then
followed an experiment of control. M. Beaunis made her draw a
design representing a dog; it was executed pretty well. Then he
said to her that she must sketch a bird without a copy, from her own
idea. She made a very rough drawing, but one which resembled a
bird, and of which the proportions were fairly preserved. The fourth
experiment was made with Madame H., who had not learnt to draw,
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147
1887.] Scandinavian and French Literature .
bat had good taste and natural abilities, and to her Beatmis suggested
a dog standing, and in profile. The result was better, namely, an
animal somewhat heavy in appearance, but not badly executed. All
that could be inferred from these experiments was that a suggested
hallucination does not possess the reality and clearness of an objective
image, and that the subject’s imagination plays a considerable rdle.
The author compares a visual hallucination to the general view which
one has of a person or object at which one looks in passing. One has
a general impression, but the details escape us. He thinks it possible,
however, that by practice these hallucinations may acquire the pre¬
cision of reality, as sometimes happens in a dream, and doubtless with
the insane. It is rare that a suggestion succeeds fully in producing a
hallucination the first time it is attempted. One thing is clear, that
to go on suggesting very long would not be right, inasmuch as it
might cause a really insane hallucination.
(To be continued.)
Insanity and Degeneration .
Du Delire chez les Degeneres: Obsei'vations prises a VAsile Sainte-
Anne, 1885-1886. Par le Dr. Legrain. Paris, 1886. A.
Delahaye.
Dr. Legrain proposes, to substitute for hereditary insanity the term
degenerative insanity (folie des ddgendrds). The book, an octavo of
290 pages, contains a careful study of a variety of cases falling under
this definition. He describes the physical marks (stigmata) and the
mental peculiarities which accompany such patients. It cannot be held
that these stigmata are uniformly present in all cases of hereditary
insanity, and when Dr. Legrain assures us that the mental symptoms
of the degenerated offer a clinical aspect which is characteristic, we
naturally look for a definition by which they might be recognized.
The degenerated may, he says, present all the possible varieties of
mental derangement. A fit of insanity coming on suddenly, progress¬
ing rapidly, and often ending by a speedy recovery, is pathognomonic
of the state of degeneration. This form of insanity evolves slowly and
progresses in an irregular manner, taking on different forms, succeed¬
ing one another more or less quickly with delirious ideas suddenly
inteijected. It often ends by recovery, but is liable to relapses.
Sometimes, again, it falls into dementia. The heirs of this degenera¬
tive tendency often inherit a predisposition to drink to excess, which
again acts as an exciting cause of insanity. There is no question
about Dr. Legrain’s close acquaintance with insanity. His descrip¬
tions of particular cases are vivid and life-like, but his generalizations
are somewhat vague. We do not say that another observer could
have given them better definition, but one expects him to make good
his claim of indicating something distinctive in hereditary insanity.
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148
Psychological Retrospect .
[April,
2. American Retrospect .
By D. Hack Tuke, F.R.C.P.
T/ie Curability of Insanity .
The Curability of Insanity . A Series of Studies by Pliny
Earle, A.M., M.D. Philadelphia : J. B. Lippincott
and Company, 1887.
We have so frequently taken notice in the pages of this
Journal of the valuable researches of Dr. Pliny Earle in
regard to the results of care and treatment of the insane,
that it is scarcely necessary to do more than to draw the at¬
tention of our readers to the collection in one volume of the
essays on the “ Curability of Insanity,” extending to two
hundred and thirty pages. The volume forms, as a whole, an
important contribution to the study of mental disorders—
that branch of it which is, indeed, of radical import, for
it grapples with the questions to what degree insanity is
curable, whether it is cured to the extent which has been
generally believed, and whether the results of treatment are
more or less favourable than they were formerly. These
essays extend over a period of close upon ten years. There is
amongst us a singular and exclusive employment of the word
“ scientific,” which would seem to refuse to comprise within
its circle statistical inquiries. This is surely as unfair as it
is absurdly unfounded. We have no hesitation in includ¬
ing investigations and carefully-drawn conclusions like
those of Dr. Earle, under the head of Scientific Work; and
were he in our own country, such work ought to entitle him
to the coveted letters granted by the Royal Society as much
as minute observations on a drop of water taken from a
dirty pond. How such distinctions as to what constitutes
the claim to be a successful worker in one department of
knowledge rather than another can be made, we have always
been at a loss to understand.
In the January number of the Journal for 1886 will be
found a brief summary of the chief scientific results arrived
at by Dr. Earle; but we may, in conclusion, and with the
advice to our readers to possess themselves of a copy of this
now classical work, cite from the last page of this book the
following paragraphs :—
“The most important general conclusions to be derived from the
statistics included in this study are, first, that the old claim of
Digitized by t^ooQle
1887.] American Retrospect . 149
curability in a very large majority of recent cases is not sustained,
and that the failure to sustain it is more apparent and more
striking than at any antecedent time; and, secondly, that the
percentage of reported recoveries of all cases received at the
hospitals in this country still continues to diminish.
“ It is believed that this diminution is, in part, to be attributed
to the admission of a larger proportion of chronic cases, and of
cases of greater degeneracy from their origin; in part, from the
increasing—though, as there is good reason to believe, still far
from universal—practice of not reporting, as recoveries from
insanity , either mere restorations from a drunken debauch or
forced temporary suspensions from habitual intoxication; and in
part, perhaps, from the adoption of a higher degree of improve¬
ment as the standard or criterion of recovery. It may be that
there is still another cause of the diminution. Drs. Bucknill and
Take, in their treatise upon insanity, mention what they call
‘cooked* statistics. It is possible that in the United States
this class of published results is decreasing, and that the reported
statistics are more generally given to the public in the spirit of a
conscientious loyalty to scientific truth. In conclusion, I would
express the hope that the time is not far distant at which the
American Association of Superintendents will so perfect its
statistical system as to make a distinction between persons and
cases, and enable the reader to learn how many of the reported
recoveries are first recoveries and how many subsequent to the
first. This improvement was made in the Massachusetts statistical
tables, as already mentioned, in 1879; and in those of the British
Medico-Psychological Association in 1883. Surely the American
Association ought not to lag far behind in the matter. It ought
to have been the pioneer.”
The Question of Increase of Insanity in Massachusetts .
We have before us the Report of the Massachusetts Board on
Lunacy, which treats of the number and accumulation of the
insane in Massachusetts for the last thirty years, along with tables
in the appendix which relate to insanity and are referred to in
the text of the report. They are of great interest, based, as they
are, upon returns of the insane much more exact since 1880 than
any which have been collected in America for so long a period as
seven years. Mr. P. B. Sanborn, the able Inspector of Charities
appointed by the State Board of Lunacy and Charity, to whom we
are indebted for the report, informs us, in an important letter
received from him, that the statistics of New York and Penn¬
sylvania are, perhaps, equally exact now, but for a shorter time.
He observes that the Massachusetts figures appear to show that
there has been a considerable increase, even in recent insanity, out
of proportion to the gain in population. This he ascribes chiefly
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160
Psychological Retrospect.
[April,
to these causes: the great increase of our urban population and the
accumulation in Massachusetts of recent immigrants and their
children. The Irish and Scandinavian races, which make up so
large a part of this immigration in Massachusetts, are peculiarly
liable to insanity in their native country; emigration appears to
develop this tendency, and the change of life from rural districts,
where they were bred, to crowded cities in this country, intensifies
the risk of insanity. Statistical tables have shown for some years
a great excess of commitments in cities and large towns over the
rural districts; and they also exhibit an increase in the insane of
foreign parentage, coincident with the general growth of insanity.
According to the reports of the New York State Board, the
increase of insanity in that State is mainly ascribed to foreign
immigration, the result of accumulation, to which the increase of
insanity in England is so properly ascribed, not being sufficiently
recognized in New York. It appears that it is fashionable in the
United States just now to regard the insane of foreign parentage
as having been brought directly from Europe, but the Massachusetts
figures do not indicate this to any great extent, and Mr. Sanborn
cannot believe that things are very different in New York or
Michigan.
Mr. Sanborn says that what is most needed in the United States,
and he supposes in Great Britain, is an exact registration of the
insane, wherever they are brought, in a separate list and easily
accessible for reference, when cases present themselves in the
hospitals, etc., as “ recent.” He proceeds i—“ Had we such lists
we could easily strike off from the catalogue of recent cases those
who stood on the register as chronic cases ; but until we have such
means of correction we cannot escape uncertainty in this matter.
The new census of Massachusetts for the year 1885, although it
will not give the number of our insane accurately, will furnish us
with a register of about 5,200 different persons, who on the 1st of
June, 1885, were enumerated as insane, with such particulars that
we can readily trace back cases assumed to be recent to this list.
I myself established a list of about half this number seven years
ago, which I have been watching during the intervening time,
with results that may be of interest. The whole number of
persons named in this list was 2,598, and these were, on the 1st of
October, 1879, actually resident in our four State hospitals at
Danvers, Northampton, Taunton, and Worcester, and in the two
chronic asylums at Tewksbury and Worcester. Seven years after¬
wards, 1,230 of these patients were still living in these same
establishments, and 119 were known to be living in other asylums
and almshouses ; so that more than half the original number, after
a lapse of seven years, w'ere still insane in public establishments.
Of the known deaths in seven years, 752 in all, not less than 711
had died in some one of the six establishments where they were
living when the list was made out; 21 had died in almshouses
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1887.]
and 20 in other places. Of the original 2,598, fourteen have been
boarding in families as insane persons (under a new policy), and
12 were thus boarded last October. At that date then, 1,361, or
52 per cent, of the whole number, were known to be living in a
state of insanity, which had continued in their case for at least
eight years, although in some instances there had been lucid
intervals, during which they had gone forth only to return again
to the hospitals. All those who died may be said to have died
insane; so that no less than 2,113 persons out of 2,598 did not
recover during a period of seven years. Of the other 586 the
majority were discharged from the hospitals unrecovered, and
there is no reason to suppose that more than 200 of them did
recover.
“ In addition to the figures given on page xciii. of the report,
I have collected the figures for a dozen years earlier, as regards
first admissions, and I have also tabulated for the same years the
number of discharges, without recovery, from all the hospitals and
asylums in Massachusetts, with the readmissions in each year, and I
now send the figures. As the readmissions include a considerable
part of the ‘ discharges without recovery/ and, in particular, in¬
clude persons transferred by the State Board from one establish¬
ment to another during the year, it will be safe to deduct an
average of 175 a year from the second and the fourth columns for
duplication
Whole namber
admitted.
First Discharged
admissions, without recovery.
Head mis¬
sions.
1868
1021
616
370
405
1869
1142
695
663
447
1870
1324
813
605
511
1871
1344
. 854
695
490
1872
1372
784
737
588
1873
1282
739
747
643
1874
1321
.828
774
493
1875
1255
. 838
623
417
1876
1350
852
681
498
1877
1310
884
586
426
1878
1754
959
... 969
795
1879
1297
849
677
448
1880
1388
900
632
488
1881
1445
949
722
496
1882
1605
. 1005
755
600
1883
1633
. 1101
736
532
1884
1634
. 1093
837
541
1885
1642
. 1100
755
518
1886
1845
26964
. 1120
16979
... 1017
13381
677
9913
“ It will be observed that the figures of first admissions, though
far from uniform, and varying for reasons which it is a little
difficult to explain, do show an increase, in 19 years, of 504 per
year; which is about 80 per oent. on the first admissions of 1868,
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Psychological Retrospect.
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Or, if the first two years are averaged, and the same is done with
the last two, the increase in first admissions will be from 656 to
1,110, that is, 454, which is an increase of 69 per cent. Now
during this period the population increased in the whole State less
than 35 per cent., so that the gain in first admissions was double
the gain in population. Now observe further that the increase in
readmissions, if the first two and the last two years are averaged,
is only from 426 to 609, or 42 per cent., which is but little greater
than the gain in population; from which I infer that the increase
of insanity during the period, beyond the ratio of population, was
mainly in the first admissions.
“ I will not comment at present on the discharges without recovery,
which in the 19 years aggregate 13,381, further than to say that
about 3,500 of these were probably transfers from one institution
to another; 1,900 were persons removed from Massachusetts by
the State Board, and 1,100 were persons removed to town alms¬
houses and other establishments, corresponding to the English
workhouse asylums. This would leave 6,700 (nearly) who re¬
mained in the community of Massachusetts subject to readmission ;
while, applying the same reduction to the aggregate of re¬
admissions, so far as it is allowable, the latter become 6,413 read¬
missions from the general community. It is to be noticed, however,
that what are here called 4 readmissions * are persons previously
admitted to seme other hospital anywhere in the world, so that they
must include at least 500 persons who were never in any Massachu¬
setts Hospital before. This would reduce the Massachusetts re¬
admissions from the general community to about 5,900, or an
average of 311 in each of the nineteen years, while the annual
average of first admissions would be 893.’*
PART IV.—NOTES AND NEWS.
THE MEDICO-PSYCHOLOGICAL ASSOCIATION.
The Quarterly Meeting of the Medico-Psychological Association was held
at Bethlem Hospital, on the 23rd February, 1887, the President (Dr. Savage)
in the chair. Present: Drs. Robert Baker, T. W. Brushfield, D. Bower, H.
Chapman, E. East, C. T. Ewart, J. E. M. Finch, S. Forrest, B. B. Fox, T. D.
Greenlees, H. Hicks, W. M. Harmer, M. MacLeau, J. D. Mortimer, James M.
Moody, P. W. MacDonald, H. Hayes Newington, A. Newington, J. H. Paul, S.
It. Philipps, H. Rayner, G. M. Robertson, A. H. Stocker, H. Sutherland, H.
Stilwell, D. Hack Tuke, D. G. Thomson, T. Outterson Wood, E. S. Willett.
The following gentlemen were elected members of the Association:—G.
Dickinson Symes, M.R.C.S., City of London Asylum, Stow, near Dartford ;
Rothsay C. Stewart, M.R.C.S., Ass. Med. Off., The County Asylum, Leicester ;
William Harding, M.B., C.M.Ed., Ass. Med. Off., County Asylum, Lancaster;
G. M. Robertson, M.B., C.M., The Palace, Falkland, Fife ; John Kennedy Will,
M.B., C.M., Bethnal House, Cambridge Road, E.; Fred. W. Melson, M.D., Ass.
Med. Off., Durham County Asylum, Sedgefield.
Dr. Baker exhibited a model of a crib-bedstead which he had seen in the
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1887 .]
Utica Asylum. He said that he had never seen suoh a bedstead in England,
but he believed there was one in Scotland. In America, where, in company with
Dr. Hack Tuke, he visited the asylums, they were very largely used, many of
the superintendents there defending their use as being highly beneficial,
especially in cases of restless senile dementia. The bed being made, the side
is taken down for the patient to get in, and all being complete, the bed is closed
up again, the lid coming over and fastening by a spring lock at the top. He
(Dr. Baker) had seen one of these beds in occupation, and had conversed with
the patient confined in it. It was very much like talking to a wild animal in
a cage. The patient was, undoubtedly, in a very excitable condition, but when
he asked her questions she said she was very comfortable, and, as far as he
could learn, she was quite happy ; so that in this particular case in which he
witnessed it in operation, he did not think that the bedstead was doing any
harm, and it might have been doing some good. He was not saying this with
the belief that it would ever be used in English asylums. Anyone who had
visited a country where restraint was used in asylums would come back with
the feeling that, as a rule, for the body-politic, it was a mistake.
Dr. Hack Tuke said that Dr. Baker had forgotten to give his personal
experience of the crib-bed. Having seen Dr. Baker himself enclosed in one at
the Utica Asylum, New York, he should like to say that he looked quite as
comfortable as the patient referred to had appeared to be. Dr. Gray, of Utica,
who had now gone to his rest, had taken some little exception to the reference
to this incident which he (Dr. Tuke) had made in his book on the American
asylums, but what he had written was, of course, meant only as a joke. He
might mention that he had been informed, on good authority, that the use of
the crib-bed is now discontinued at this asylum. No one could say that there
was any sin in using such a thing occasionally. Certainly not. But the cage¬
like appearance made it undesirable. In some cases of senile dementia it might
no doubt be of use, and might do no harm, so long as the patient was not
neglected. As showing how much a thing of this sort might be abused, he
might tell them that at one asylum in America he counted fifty crib-beds,
exactly similar to that now exhibited by Dr. Baker. A short time ago, how¬
ever, he had received intelligence that this bed was no longer in use in this
institution. In fact, the superintendent, who had not been many years in
office, had not introduced them, but found them in use.
Dr. Brushpield said that he w*ell recollected an engraving* of ft crib-bed¬
stead, very similar to that now exhibited, which was invented by Dr. Wood at
Bethlem Hospital, for use in certain oases.
Dr. Savage said he would take an opportunity of looking at it Probably
the remarks which he was about to make in his paper on strong clothing would
apply to the question of the crib-bed. He had now to submit to them for their
inspection two samples of material for strong clothing. Coarse reality did not
look so well as a pretty little model, and when one came to look into these
dresses the subject was rather repellent. Of course, if it were decided that no
one in future should use strong clothing, the patterns now submitted might be
sent to the British Museum, but he thought that some kind of clothing which
would not readily tear might still be required, and the patterns before them
might therefore be worth examination. The materials were of two sorts. One,
which Dr. Hack Tuke had taken a great deal of trouble about, was specially
made for the purpose at Belfast (Messrs Ewart). The result had been a material
which was eminently satisfactory so far as strength and appearance were con¬
cerned. It was hoped at one time that the colour would last, but it was found
on further experience that, although it washed better than many dresses, the
colour did wash out before long. The second sample washed better, and was
therefore, to that extent, more satisfactory.
Dr. Savage then read a paper on the question “ Whether there is ever
sufficient reason for the use of strong clothing and side-arm dresses/’
* Bee •* Journal of Psychological Medicine/' Vol. v. (1852), p. 395.
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Notes and News.
[April,
Gentlemen,—The first object of this paper is that it should be really
practical in its bearings. We are, perhaps, usually too ready to dis¬
cuss the political and more general aspects of our branch of the pro¬
fession, neglecting the more domestic details. I think this is due to
several causes, some of which will be alluded to in the following paper.
As a rule each superintendent either inherits or develops certain
principles of management, which he gets to look upon as perfect,
because they are very rarely if ever met by perfectly unbiassed
criticism.
The position of the superintendent is rather likely to produce
dangerous self-satisfaction from his autocratic power, and his isola¬
tion. I write thus, as I feel the danger even in a large city with
constant visitors, and I write it, further, because I feel that the paper
has its real origin in such outside criticism. Sons returning to their
parental home are in the habit of finding the quiet domestic habits
old-fashioned ; and in my asylum-life I have frequently found that old
Bethlem students, having started in other spheres, when they return
are in the habit of finding some faults with their early home. Of late,
so frequently has the complaint been of the same kind that I found it
necessary to ask whether it was not probable that I was wrong and
old-fashioned.
The form of complaint was that they, in their new homes, never
saw the use of strong clothing, and what I wish now is not so much
to discuss the reasons for or against as to see what the alternatives
are, and whether they are the best, for I pledge myself to follow that
which I find to be for the good of the patients. I shall avoid going
into the whole question of non-restraint, and accept as axiomatic
that theoretically “ non-restraint fi is desirable, though in practice
cases may possibly arise in which some mode of restraint has to be
followed.
The next axiom I insist upon is that none of us would willingly
give a powerful narcotic with no other object than that of producing
quiet. I know here the practice differs widely, so that one superinten¬
dent’s habit, I was going to say conscience, allows him to give a great
deal of quieting medicine, while another allows none at all. Both are
at fault.
It being granted, then, that much liberty and little depressing
medicine be given, the next object must be to make the patients as
comfortable as possible, and this involves making them as neat and
tidy as one can, not alone for themselves, but for their neighbours as
well, who may suffer by seeing others in discomfort or restraint.
As to dress, I think we should all prefer to have our patients
dressed as nearly like their old selves as we can, but here at once we
meet with difficulties, for the pauper patient may be happy in mole¬
skin, while the refined person would look upon this as strong clothing.
First of all, as a question, I want to know what must be done with
patients who persistently remove or destroy their clothes ? I find, in
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Notes and News .
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1887.]
the latter case, the greatest difficulty is that the friends of patients in
a hospital, having to provide the garments, complain very strongly if
they are frequently called upon to replace what has been destroyed.
They would be at once ready to go in for any amount of restraint to
save their pockets. This is not unnatural. There being this difficulty,
I find it easier and productive of better feeling toward me, and also
toward the patient, by his friends, if I provide some clothes which are
sufficiently strong to resist the ordinary destructive patient. In such
strong clothing it is impossible, I think, to get anything like a good
fit, and thus all such clothes approach the sack sooner or later ; and,
this resemblance is increased by the fact that though we have tried
far and wide for all sorts of materials which would resist
violence, easily wash, and yet retain a pattern, we have failed; so
that without great cost, I fear, these dresses must look repulsive.
We have then got to this, that if strong clothing be used we at
once get an unpleasant appearance introduced, and those superinten¬
dents who pride themselves on the outward look specially, are neces¬
sarily adverse to its use, and would do away with it altogether. In
looking at the two sides I admit frankly that this strong clothing is
often uncomfortable and irritating to the patients or their fellows,
always unsightly, and some would 6ay unnecessary.
What I have to say on the other side is that I do not consider that
the slight amount of discomfort and unsightliness are worthy of
serious consideration, if any greater end is attained by its use. I
believe, however, that in nsing it I am able to give a greater
amount of liberty, and this is my chief defence. Anyone who has been
much about Bethlem must have seen many very contented, but eminently
grubby, patients in strong clothing in our airing courts. They do just
what they like from breakfast time till near dinner time, when they are
washed and redressed. After dinner they are allowed once more to
make a mess of themselves, if they like, and after tea they are usually
quite ready for bed. I think these people, though not pretty objects,
yet sleep better and eat better than if they looked prettier. Some
will say we might attain the same end if we sent them walking
round the grounds with two attendants for some hours a day. Well,
I must say I do not like the look of the troops of such cases I have
seen marching about like the wild elephant between the two tame
ones, and I do not think the washing of clothes so costly as extra
attendants.
But still more I think the freedom from control is the very best
treatment. As a rule, of course, I admit there are some patients in
whom we wish to break through bad, and establish new and good,
habits, and in such it may be better to try the walking parties rather
than the freedom of strong clothes.
We shall differ, I suppose, as to which is most irritating to the
patient: the manual control, or the control by clothes ; and each of
us surely can decide separately which will serve best in different cases
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156
Notes and News.
[April,
without being angry because others do not quite agree with him.
Strong clothing is needed, I think, in cases in which the chief symptom
is the constant stripping ; either you must have the constant, ever-
watchful attendant, or you must have locked boots and locked gowns.
Well, I again have an aversion to the rows of patients sandwiched
with attendants on long forms. I should prefer to see the patient
occupied, even in trying to get out of her things.
Each asylum must differ as to its needs, and, without for a moment
wishing to speak apologetically, I must say that at Bethleui I believe
strong clothing is, if not necessary, at least useful, and a saving of time,
energy, and irritation.
First we have daily admissions of acute cases, in the earliest stages
of their disorder ; then, though we have a large staff of attendants in
proportion to patients, we have an enormous area in which the patients
have freedom to move. This means either more attendants than are
really needed to control patients, or a greater crowding together of
the insane. I think that we have in the very long galleries, with the
scanty population, the very best means for curing the acutely insane;
for, whereas we can have several groups of patients, each indepen¬
dently occupied, there is space for exercise as well.
To proceed, I consider that there are certain patients who must not
only have strong clothing by day, but need also side-arm dresses at
night.
Some will deny the necessity, and for those I have simply no answer,
as I cannot manage without their use from time to time.
What is to be done with a case who will endeavour to gouge out
her eyes, or for the man who wishes to emasculate himself? I do not
think a man suffers any more from the restraint of a dreBS than that
of four hands.
I claim the freedom, then, to use such restraint as I think will give
the patients the best chance of recovery.
I know that restraint and its beginning is like wrath, and letting
out of water. The danger is in the beginning it, the natural
tendency of attendants being to do mechanically what will save them
trouble. I would sum up, then, that in my opinion some such
restraint as has been suggested may be useful, provided the higher
restraint of the superintendent is constant over the attendant's.
Dr. Rayner said that he had received a letter from Mr. Rooke Ley (Prestwich
Asylum), in which he wrote as follows :—
“ Who proposes to defend strong dresses and other ingenious
mechanical contrivances ? I was under the idea that such appliances
were things of the past, out of fashion, out of harmony with modern
psychological opinion. Is their revival the outcome of the scientific
spirit about which so much twaddle has been written and spoken of
late ? I am by no means opposed to restraint, when there is a purely
medical purpose to justify its use, and then I stipulate that it shall be
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1887 .]
used * in camera,’ in the privacy of a single room. To see a patient
stalking about in a modified strait-jacket offends my taste.”
Dr. Hayes Newington said that be probably used as little strong clothing
as anyone, being able to substitute other means. The subject was a very difficult
one, but he thought that Dr. Savage had looked at it in the right way. As
regards Mr. Ley’s letter, he should agree that their ingenuity should be shown
in the direction of devising means of avoiding strong dresses, rather than in
devising the construction of such dresses. There were, of course, many objec¬
tions to using these distressing dresses, but still it did seem necessary sometimes
to use them, however rarely. One additional reason for their occasional use was
to deter patients, by the sight of them, from bad habits.
Dr. S. R. Philipps- said that he had had the honour of opening the last
hospital for the insane, and his experience there was that restraint, more or less,
was absolutely essential; partly from the reason suggested, that friends were
unwilling to pay for the expense of new clothing, which must fall upon them if
the hospital funds were limited, and partly because they had so many suicidal
patients. He had several attendants who sat up all night, but they had at the
present time two ladies with whom no two nurses were willing to sit up unless
there was some sort of restraint, such as a jacket or other dress. In the daytime,
with ladies, a shawl of loose and simple texture thrown lightly round the jacket
took off the disagreeable effect. With gentlemen it did not so much matter,
and in some cases an example might do good as a deterrent. Speaking of the
crib-bedstead, which was on all-fours with the subject of Dr. Savage’s paper, he
said he had under his charge an old lady for whom that bedstead would be
invaluable, as, although an attendant sat up with her, it was almost impossible
to keep her in bed unless she had a jacket on.
Dr. Fox said that the question was very interesting, but, as an asylum
superintendent, it seemed to him that one was almost without an alternative.
The test which he might propose with regard to the justification of restraint
would be, if they could find any asylum in England which entirely disused
restraint, and took a fair average of acute cases—and to compare the results of
treatment in that asylum (proportion of cures and so forth) with any other
asylum under like conditions which used the ordinary modes of restraint. He
was bound to say that, until he was satisfied that constant struggles with
attendants and seclusion in rooms did not do more harm than wearing a
garment of a particular texture or cut, so long should he continue to make
use of strong clothes. Would not a man walking with attendants on each side
of him be more likely to struggle with those attendants than he would be to
struggle with a mechanical contrivance which he must feel was his master for
the time being ? His own experience had taught him that any manual restraint,
or physical encounter with attendants, not only did very great harm, raising
difficult relations with those with whom, above all others, patients should be on
good terms, but also, in many cases, aggravated maniacal attacks. It was much
better to let a patient be clothed and run about and have his liberty than let him
have constant struggles, and he believed that an asylum adopting Dr. Savage’s
practice would have a much better record to show than an asylum which shut
up its destructive patients within four walls all day long, and never let them go
out without an attendant on each side of them. Referring to the crib-bed, he
said that in the early years of the present century—about 1810—there was in
use at the asylum with which he was now connected a much ruder contrivance,
in the form of a padded box which slipped up and allowed the patient’s head to
move freely. The tradition remained that the patient always spoke gratefully
of that treatment, but of course it was handed down as a curiosity, and he should
be very sorry to see any such mode of treatment introduced now.
Dr. Moody said that, having been an assistant medical officer under Dr.
Brushtield, he had been taught to use restraint as little as possible; in fact, he
thought that the only restraint used at Brookwood during his six years there
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158 Rotes and Rows. [April,
was in one case for surgical reasons. At Cane Hill he found no need for it, and
his recovery rate was 47 per cent., with few accidents. In certain cases strong
clothing was necessary. He found that the moral effect was very good, for
when it was put on for a short time the other patients laughed the wearer out of
bis habits.
Dr. Brushfibld said that he came simply as a spectator and not as a speaker,
but, as he had been asked to say a few words, he might say, in the first place,
with respect to the paper, that he thought it was one of a class of papers which
would do very great good to the Medico-Psychological Association, especially in
the way of exciting disoussion. He thought that such a paper was rather new
in the annals of the Association. Certainly, in past times, they had papers on
mania and acute forms of insanity, but not papers of the sort now under dis¬
cussion. No one could have heard Dr. Savage’s paper without coming to the
conclusion that he had made out a very good case for the use of strong dresses
in certain classes of cases—recognizing it as an exceptional form of treatment.
In his younger days (which took him back to Dr. Conolly) one of his first
superintendents was a regular “ restraint man.” The number of dresses was
wonderfully large, and he (Dr. Brusbfield) attributed it to the principle of
restraint being then in vogue. Directly he became superintendent he abolished
a very large proportion of the strong clothing, finding that by giving more
liberty in the wards and airing-courts there was far less need for it. Strong
clothing was certainly very unsightly, but this was due partly to the circumstance
that, as a rule, it was not made for the individual, but for the class, and if any
patient required it the stores would be ransacked for the best-fitting garment
that could be found. It should not, moreover, be forgotten that it was not used
per se. It should be rather superadded to than replace common clothing. He
(Dr. Brushfield) had certainly very rarely had cases of acute insanity requiring
such treatment. His custom had been rather to order it for chronic cases.
While a superintendent might be driven to use strong clothing, it did not follow
that the patient shoul i continue in that clothing for any length of time. He
should be tried with ordinary clothing again and again. He recollected that at
Ilanwell the patients used to be taken to the store and allowed to choose their
own dress, which was a very good plan. Wearing strong clothing gave a larger
amount of liberty, if the patients were out more in the sunlight, and were thus
able to enjoy exercise and digest their food better. It was frequently a remedy
to use instead of employing opiates and seclusion.
Dr. Hack Tukr was bound to say that, looking back some forty years, he
could remember asylums in which the abuse of strong dresses at that time was
very marked, and the effect very unpleasant. Since that period he had been
much gratified to see the improvement in this respect, and therefore, without at
all condemning their use, he might say that he thought that in visiting asylums
the large resort to strong dresses would strike one unfavourably in estimating
the character and management of a given asylum. If, on the other hand, one
went to an asylum where the use of strong dresses was small, and they were
made as neat as possible, where the patients were at the same time well looked
after by attendants, and where there was not over much grovelling on the
ground in the courtyards, one’s opinion would be more favourable than in regard to
those asylums where patients in loathsome strong dresses might be seen roving
and raving about of their own sweet will in the galleries or airing-courts all the
day. Besides, patients in strong dresses are often in seclusion also. It was
certain, at all events, that strong dresses might be abused. One thing certainly
puzzled him: where no Btrong dress was used it might be supposed that the pro¬
portion of attendants would be much greater, and the amount of seclusion
much larger. Now, in regard to Prestwich Asylum, he had once visited it with
great pleasure, and he had the impression that the percentage of attendants was
not extraordinarily large, and that seclusion was not more resorted to than in
other asylums. He was rather at a loss, therefore, to understand how Mr. Ley
could do without strong dresses, and yet not have a larger number of attendants
to look after the patients to keep them in order.
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1887 .]
Dr. Rayner said that it was to be gathered from Mr. Ley's letter that he
used strong dresses, but objected to their use while the patient was about,
saying they should be used in camerd .
Dr. Hack Tuke thought he remembered that in going through Mr. Ley's
asylum he saw scarcely any patients either in the airing-courts or in seclusion
in strong dresses, and yet Mr. Ley had, as he believed, no more attendants than
were required elsewhere. In regard to the patterns of the strong clothing
material, that from Belfast was from Ewart’s extensive manufactory there, who
had, at bis suggestion, taken great interest in the production of a satisfactory
material. Fresh samples, which, it was hoped, would wash better than those first
tried, were now being tested by the Steward of Bethlem Hospital, who was a
little conservative as to the past, and sceptical as to the future. He had informed
him to-day that he thought the new patterns were more likely to succeed than
the old ones, but he was not altogether satisfied yet. He (Dr. Tuke) was at the
Dublin Asylum some few days ago, and the medical superintendent, Dr. Conolly
Norman, had found that the dress in use there, of which he now showed a sample,
did not wash well, though it was very neat. Dr. Norman had at the present
time 580 female patients under care, and only four had strong dresses. Many
were of an excited class. The other patterns which he exhibited were mainly
from Dr. Deas, who spoke strongly of their washing quality. They did not
seem, however, to be very strong in texture. He (Dr. Tuke) did not dissent from
the view expressed in Dr. Savage's paper, that strong dresses should occasionally
be used, and it was for that reason he desired to see them, not of the ticking
material and looking like a sack, but with a neat pattern, and easily washed.
He was not speaking of the strait-jacket, but simply of dresses of very strong
material, for these were distinct subjects, and ought not to be confounded to¬
gether. The latter, in fact, would lessen the necessity of resorting to the
former.
Dr. Rayxeb said be could have wished that Mr. Ley, or some gentleman
present, could have given them some information as to the best mode of
avoiding the use of strong dresses, and overcoming the habit of destructiveness
in patients.. To some extent, strong dresses were not avoidable. Even Mr.
Ley acknowledged that he must use them under certain conditions. They were
all agreed that they should be used as little as possible, and they must also agree
that there were cases in which it was very difficult to break through destructive
habits. At Hanwell, he had two or three cases at the present time which were
chronically destructive. One man had periods of destruction. The cases he
referred to were old cases, which had come to him second-hand. He had tried
his very best to break them of the habit, but without success. He had fre¬
quently found that in cases of this sort great attention to health would be
successful. Sometimes improvement could be effected through nutrition—
making them fat. In other cases—the most numerous class—ill-looking indi¬
viduals, with no capacity for fat, something had been done by putting their
energies into the best directions. He had, however, at that time an imbecile he
could neither get fat nor in any other way break of his destructive habits.
This patient had been put under special care, but, in spite of everything, he
would, whenever he had the slightest opportunity, destroy his clothing. It had
not been possible hitherto even to make a break in his tendency. In acute
cases of insanity, the use of strong clothing might be absolutely necessary, and
he quite agreed with Dr. Savage that it was much better to let the patient get
into any amount of dirt rather than keep him living in a close room. Some¬
times a patient might get out too soon, but, as soon as a patient was fit to get
out of doors, it was much better that he should go out in a strong dress than
remain some time longer in a single room because it was thought to be dis¬
creditable that he should be seen in strong clothing.
Dr. Savage, in reply, said that he fully realized the advantage of having
more than one course open in the treatment of patients of destructive habits.
To say continually, “ No restraint! no restraint 1 ” would be to imitate those
people who, not having very strong faith, repeated the Creed constantly. It
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was necessary, however, to remember what restraint had meant in times past,
and he felt a certain danger in approaching snch a subject as he had done that
day, lest, by so doing, he should loosen the better feeling which now prevailed
in regard to it. Undoubtedly, enormous harm had been done in the past.
There were still patients in Bethlem who could tell of a time when on Saturday
night a patient would be chained to a pallet of straw, and there left with a
cruise of water and a crust of bread till Monday morning. He need hardly say
more than that he fully appreciated the criticisims and suggestions which had*
been made. He regretted the absence of Mr. Ley, with whose remark that
strong clothing was bad taste he could to some extent sympathise, but when
Mr. Ley went on to say that it should be used only in camerd he must dis¬
agree. He could agree with Dr. Rayner as to not stirring up a patient too soon.
It was a disease, and could not be talked into order. The first treatment
should be a certain number of days in a padded room. The patient would
make a nice mess, but would very likely eat well and sleep well, and at the
end of a certain period the patient went out of doors in strong clothing! He
quite agreed with Dr. Hayes Newington as to the effect of strong clothing
looked upon as a “ bogey ” dress. Patients frequently had to be treated as
children, and a “ bogey ” dress mightfrighten a patient into self-control.
Dr. Percy Smith read a communication on “ The Results of an Epidemic
of Typhoid Fever in the Insane.” (See “ Clinical Notes and Cases.”)
Dr. Savage said that the paper just read was one in which he, of course, felt
deeply interested, but, unfortunately, in one respect it did not bear much dis¬
cussion. It was a most lucid description of what had occurred. The success
in the oases which Dr. Percy Smith had modestly attributed to nursing, was
largely attributable to Dr. Smith, and certainly the care with which the cases
had been recorded made them standard cases. It was an extremely interesting
question, why, under certain conditions, should fevers effect cure or facilitate
recovery, whereas in other cases they did not do so at all. Of course, there
were the dogmas which he had laid down in his Presidential address, and which
would seem to show that except in cases in which organic disease of the brain
did not take place, they could not expect events like fever to do any permanent
good. He had never yet seen a case of general paralysis benefited by fever.
He had seen one or two cases of general paralysis attacked by scarlet fever or
small-pox, but he had never seen any definite gain. The only case he could
cite in this connection was where improvement in a general paralytic case
followed immediately upon the development of an enormous carbuncle, and it
seemed to follow that, as a rule, improvement only occurred in the so-called
functional or emotional instances. In one of the present month’s medical
papers, there was a paper on anti-pyrin. It was stated that this was not only
good in cases where the temperature was high. He should be inclined to try
it in some cases of delirious mania. The only real point of encouragement in
their recent troublesome experience at Bethlem was that good had come out of
evil. They had gone through a great deal of trouble and anxiety, but they had
got the drains put right, at any rate for the present.
Dr. Hack Tuke referred to the cases reported by Dr. Colin M. Campbell as
having recovered at the Durham Asylnm, which he had always thought of
great interest. He said that there was in the early experience of the York
Retreat a striking case which had been placed on record in the history of that
institution. Dr. Maudsley had thought it of sufficient importance to employ it
as an illustration in one of his works. It was another proof of the influence
of fever on the insane This case was one of fatuity or dementia, in which a
young woman for a time recovered her mind entirely, and then, when the
fever passed away, the insane condition returned. The practical lesson seemed
to be that as we were not warranted in giving patients fever, or in having bad
drainage, counter-irritation in some cases was useful, and ought to be tried.
Why it was useful in some cases and not in others, in which there was no more
evidenoe of organic disease, it was impossible to say.
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Dr. Fox quoted a case of a man undoubtedly suffering from brain disease.
He had not only all the symptoms of general paralysis, but they were able to
watch the conditions of his gradual declension. He had a well-marked attack
of pyaemia. His friends were summoned to see him die, but they stayed long
enough to see him walk across his room, and well enough to be a certain
pleasure to them, and to have regained a certain amount of mental power.
There was no doubt that to a great extent enormous improvement for a time
9 in this case of general paralysis did follow a very well-marked attack of
pyaemia.
Dr. Moody said that he could recall sixteen cases of typhoid fever, and
in many of them a marked improvement took place, and was permanent. He
also remembered a case of pneumonia, where the patient had been in an
asylum fully a year. The patient quite recovered. There was also a case of
general paralysis in which the patient showed a marked improvement after an
ulcer of the leg, and he (Dr. Moody) was so impressed with this that he put
large blisters on to keep it open.
Dr. Hayes Newington said it was quite possible that the mental disorder
frequently resulted from the effects of retention of abnormal material in the
blood. He could quote a case where the patient gradually got more silly,
becoming water-logged, aud getting those heavy, stuffy features which one
sometimes saw. At length, to his (Mr. Newington’s) great alarm, it was found
that the patient had passed a large quantity oi blood, but from that time he was
quite a different man. He began to write letters, and improve in many ways.
Next time that patient got into a similar state it would perhaps be desirable to
try the effect of bleeding him.
Dr. Percy Smith said that he had referred to Dr. Campbell’s paper alluded
to by Dr. Hack Tuke, and he found that out of twenty-one cases, at least four,
appeared to have commenced mental improvement during the course of the
fever which proceeded to ultimate recovery, and there was marked improve¬
ment in other cases.
SCOTTISH MEETING.
A Quarterly Meeting of the Medico-Psychological Association was held in the
Hall of the Faculty of Physicians and Surgeons, Glasgow, on the 10th March,
1887.
There were present Dr. Wickham (Newcastle), in the chair, Dr. Campbell
Clark (Bothwell), Dr. douston (Edinburgh), Dr. C. M. Campbell (Murthly), Dr.
Dodds (Montrose), Dr. Carlyle Johnstone (Melrose), Dr. Keay (Maribank), Dr.
Ireland (Prestonpans), Dr. Blair (Lenzie), Dr. Alex. Robertson (Glasgow) Dr.
Rutherford (Dumfries), Dr. Skae (Ayr), Dr. Yellowlees (Glasgow), and Dr.
Urquhart, Secretary.
Byron Bramwell, M.D., F.R.C.P. Ed., 23, Drumsheugh Gardens, Edinburgh,
was elected a member in conformity with the Rules of the Association.
The minutes of last meeting were read, approved of, and signed by the Chair¬
man.
The Secretary gave notice of the regulations respecting the Prize Disserta¬
tion and the examination for the Certificate in Psychological Medicine to be
held in Edinburgh in July next. He also intimated that the Gaskell* and Elliot
Funds are not applicable to Scotland.
A letter from Dr. Conolly Norman regarding the forthcoming British Medical
Association Meeting in Dublin was laid on the table. It was resolved to hold
a meeting on some convenient day next summer at Aberfoyle, or some such
place, where the insane are boarded out in considerable numbers.
* The examination is restricted to England, but Candidates who have paasa 1 the Past
Examination in Scotland or Ireland are elegible.—[E ds. j
XXXIII. 11
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A letter of apology for non-attendance from Professor Gairdner was read by
the Secretary.
Dr. Yellowlees read a paper entitled “ Moral Perversity or Insanity ?”* It
set forth in graphic detail the life histories of two young men.
Dr. Wickham said that he happened to have had personal experience of a
case very similar to the first referred to by Dr. Yellowlees. It was a lad who
came to the Newcastle Asylum with a circumstantial story of his being ^
adopted son of another asylum superintendent. He kept the youth for a day or
two, when he proved a clever musician and an amusing story-teller. On his
departure, however, he found that he was the son of a patient born in the
Asylum from which he said he had come, and that he had been going the round
imposing on other people, had afterwards been placed in a reformatory, and
ultimately completely disappeared.
Dr. C. M. Campbell then read a clinical study of a “Case of Moral Insanity "
(see “ Clinical Notes and Cases”).
Dr. Ireland said that the expression “moral insanity” suggested a doctrine
that he thought it would be difficult to uphold logically. Were morals intuitive or
utilitarian ? Utilitarians considered it was the best plan of life for a man to behave
in a moral manner, that it was to his best interest to do so, and hence morality was
an intellectual exercise, and the man who behaved so badly as to be brought
into an asylum would be a grossly stupid person. There were cases, no doubt,
where moral perversity was much more marked than intellectual deficiency,
but so far as he knew there was no case where there was not some intellectual
weakness, or if not that, there was a deficiency of the will power. He believed
that all such cases, when carefully examined and analysed, showed such intellec¬
tual deficiency. Dr. Yellowlees, for instance, recorded that “C. S. A.*' got
fifteen overcoats from a tailor “ because he was going to Africa.” That was
surely a proof of intellectual weakness. A man might be moral as the result
of training, as the result of holding certain theories, or as perceiving proper
conduct to be to his best advantage. If those failed to control him, there must
be a mental deficiency ; his mental system must have a flaw in it.
Dr. Robertson agreed with Dr. Ireland that in cases of moral insanity some
intellectual defect could be almost always ascertained—in his own experience
he never failed to find such to be the case. The name “ moral insanity ” had
often brought lawyers and doctors into conflict; and he would not advise anyone
to use it in a court of law for his own comfort. He had noted the top-coata
incident, and believed that it indicated intellectual weakness. The judgment in
these cases was not up to the standard, aud they therefore used the word
“ moral” by way of excluding the other faculties of the mind. He had
generally found these cases, when occurring in youth, to be hereditarily predis¬
posed to insanity, and was surprised that Dr. Yellowlees found no such tendency.
He w'ould lay some stress on the fact of the forceps having been used at the
birth of one of the cases. Dr. Robertson went on to refer to cases of simple
mania where there was not much intellectual derangement and scarcely any
delusion, but. merely mental instability and an inability to look at things in
their proper light. In childhood this generally showed itself in erratic conduct,
and in such children as had fits he often recognized a certain amount of
perversity. Where there had been previous attacks of insanity a twist in the
mental nature was often left—sometimes leading on to criminal actions, as in
the case of Tierney. And, in conclusion, there were cases where the moral
power was markedly deranged during a long preliminary stage of mania or
general paralysis.
Dr. CloustoN believed that not many had set up moral insanity as
existing absolutely without intellectual deficiency. He thought that the general
opinion was that moral perversity, lack of self-control, impaired volition, and
perverted moral impulse together constituted a case. The intellectual power
would be such that the man, but for the moral perversity, would be regarded as
a sane member of society. He might be a little deficient in intellect—all were
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a little defioient in intellect; he might be perverted- volitionally—all were per¬
verted volition ally ; but the deficiency and the* perversity would not amount to
legal or medical insanity. The moral perversity constituted the essence of the
case, and the only part that was really insanity. Looking at morality in a
practical way, they found the moral sense a physiological brain quality, de¬
veloped as the muscles were developed, perfected as the muscles were perfected
yet differing in different individuals. Certain predisposed children were capable
of development intellectually and morally to a certain extent only. Their brains
did not seem capable of attaining to the finest moral sense which constituted
the mind of the present day. They were only capable of development up to a
kind of semi-savage stage in this direction, while their reasoning powers were
as acute as those of other children. It had been long recognized that the moral
powers were the first to go in an attack of insanity. Dr. Clouston referred at
length to De Qaincey and Shelley, whose intellectual abilities were far above the
average, but whose moral qualities and volitional powers were twisted and
perverted. He would regard Dr. Campbell s case as belonging to that class which
Dr. Robertson had referred to, where the actual attack of insanity (probably in
that case mild melancholia) had left a mental twist.
Dr. Yellowlees briefly replied. He had not used the expression “ moral
insanity/* and did not feel bound to defend it. It was a term he rarely
employed. He thought, however, that moral insanity was a brain disorder
which took the direction of immoral developments, and that it might do so
together with an intellectual disturbance by no means sufficient of itself to
constitute insanity.
Dr. Robertson read a paper on “ A Case of Catalepsy with observations on
the Mental Condition in the Cataleptic State.”*
Dr. Clouston referred to a case of catalepsy in a boy in whom that state
supervened after an attack of convulsions. He said that he had often had
what Dr. Robertson proposed to call cataleptoid cases, where any position in
which the patient might be placed would be maintained for a considerable time.
He described two kinds, where the patient would readily assume the attitude to
which he might be moulded, and where the patient strongly resisted any change
in the position assumed by himself. The question was, in the latter class, was
the brain condition the cause of the rigidity, or was it owing to a delusion ?
The case he described was probably conscious during the whole time, but it
would not be the same in every case. Its connection with epilepsy would
rather point to a pathological condition, and he believed that many of them
primarily owed their origin to a derangement in the convolutions.
Dr. Urquhart thought that there was very great difficulty in assigning
cataleptoid conditions to the influence of a dominant delusion. His experience
had led him to believe that, if a patient assumed a rigid attitude, it was most
probable that he was under the influence of such a delusion, while, if he were
plastic and could be made to assume and preserve attitudes, no such influence
could be proved.
Dr. Ireland believed that Dr. Robertson had proved the existence of con¬
sciousness during the course of the case, and that there was a certain delusion.
He went on to refer to the hypnotic state and the analogies between that and
catalepsy.
Dr. Yellowlees referred to a case of cataleptoid nature at present under his
care. The man had a want of volitional power, and seemed unable to complete
actions which he had begun. He would remain with a foot in the air, poised,
until someone touched him, and he required to be stimulated similarly when at
meals.
Dr. Robertson replied briefly. At first the pricking of the skin in his case was
not followed by bleeding, but afterwards such wounds bled freely. There was
no doubt great torpidity of the circulation in the early stage of his malady, but
he believed that it was caused by the nervous disorder. Notwithstanding the
* These papers will appear in the July number. -[Eds.]
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application of beat and oold to the head had been followed by benefit. Dr.
Robertson showed the original apparatus for this purpose be had deviBed and
shown at a former meeting of the Association here some sixteen years ago.
Dr. Dodds read clinical notes on “ A Case of Epilepsy.”
Dr. Wickham said that he had tried everything that was recognized as a
remedy in the treatment of epilepsy with very different results in different cases.
He had found nitrite of amyl of service in one case, and in another it was a.
complete failure.
Dr. Ybllowleeb asked if anyone had tried the plan of bleeding during a
succession of fits as advocated lately by Dr. Wallis ?
Dr. Urquhart had bled a patient quite lately. He was admitted labouring
under alcoholic insanity, with an enlarged liver and an engorged circulation.
Shortly after his arrival he had a succession of epileptic fits, which were
promptly stopped by venesection to six ounces. Unfortunately he developed
double pneumonia some time after and died.
Dr. Yellowlees showed a skull-cap with very great and irregular thickening
in its anterior half. The bony deposit occurred in rounded wavy protuberanoes,
and the thickness of the cranial vault at two of these was 4£ths of an inch. A
similar condition, though not so well marked, is figured in Dr. Clouston’s book.
Such thickening of the bone is usually regarded as compensatory for loss of
brain substance, and it is supposed to occur only with prolonged dementia. In
this case the patient was not demented, but exceptionally intelligent. She died
from abdominal disease at the age of 57 in her second attack of melancholia,
the previous attack having been climacteric. There was no paralysis of any
kind, and although the convolutions were flattened by the bony growths, there
was no disintegration or manifest wasting of brain substance.
The members dined together at the Bath Hotel after the meeting.
The next business-meeting of Scottish Members will be held on the seoond
Thursday of November.
THE LUNACY ACTS AMENDMENT BILL.
The following has been addressed by the Honorary Secretary of the Medico-
Psychological Association on behalf of the Parliamentary Committee, to the
Lord Chancellor:—
To the Right Honble. the Lord Chancellor.
My Lord, — I am instructed by the Parliamentary Committee of the above
Medico-Psychological Association respectfully to submit for your consideration
their views with regard to some of the provisions in the Lunacy Acts Amend¬
ment Bill (1887).
The most important is the provision in Clause 8, s-s. 9 (p. 4,1. 7, et seq .), that
notice of petition be given to the alleged lunatic by the magistrate, &c. This
procedure the Committee is of opinion would be most inimical to the welfare
of the insane, and would lead in some cases to the suicide of the patient, in
others would induce homicidal assaults, and in many would enable the lunatic
to escape from the jurisdiction of the magistrate.
The extent of the jurisdiction of the various magistrates, Ac., and their
power to control an alleged lunatic under petition, would appear to require
definition, as well as the power of friends to exercise control over an alleged
lunatic during the consideration of a petition.
This sub-section (Clause 3, s-s. 7) appears to the Committee to reduce the
question of insanity to a legal prosecution, in which the relative or friend is
the prosecutor, the sick man is the defendant or criminal, and the magistrate is
the judge, in the place of being the guardian of the patient’s interest.
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1887 .]
This treatment of bodily infirmity as criminality would greatly obstruct and
delay the prompt and early treatment of the diseased condition of which insanity
is a symptom* and would lead to evasions of the law, neglect of treatment,
more frequent suicides, and other deplorable results.
The power given to the magistrate of postponing the petition in any doubtful
case would appear to give every necessary protection to the alleged insane
person.
If this clause is allowed to stand, some provision should be made for the
care of patients in the interval between petition and examination, as well as
doring the postponement of a petition, and for defining the status of the alleged
lunatic during such intervals.
This Committee beg to reiterate their objection to the power given to the
magistrate to interview the sick person as unnecessary and undesirable.
Cases of insanity after child-birth may be taken as examples.
This provision would seem to indicate to the magistrate that his duty
oonsisted in determining the question of the presence or absence of disease, or
of determining whether a certain line of treatment should or should not be
adopted, and it is probable that if, consequent on such a decision, a suicide
or homicide occurred, public opinion would be strongly expressed on the
decision of a medical question by a legal authority.
The following points are also suggested for your lordship's consideration :—
Clause 3, s-s. 7 (p. 3, 1. 30).—The exclusion of the signatory of an urgency
certificate from signing a certificate on the subsequent petition, is objected to.
It is not in accord with the Scotch practice from which this is copied. It
would involve obtaining the services of three medical men, difficult in country
places.
Clause 3, s-s. 15.—A penalty for the infringement of this clause would
appear to be desirable.
Clause 3, s-s. 19.—Does 1 delivered * include ‘by post? *
Clause 3, s-s. 8.—Does this prevent consultation after one certificate has
been signed ?
Clause 4, s-s. 6.—By whom is the copy of urgency order to be sent ?
Clause 8, s-s. 3 (p. 11,1. 18).—The member of the Managing Committee
may certify for any other asylum : the omission of this clause is suggested.
Clause 27.—Protest is made against the houses of medical persons being
singled out, and the opinion is expressed that this clause would greatly militate
against the welfare of the patients, who are specially benefited by this plan of
treatment.
The clauses (45 et seq.) relating to hospitals are specially recommended to
your lordship for consideration, as in many ways militating against the welfare
of these institutions.
Clause 53.—The power given to the Lunacy Commission, compulsorily to
close hospitals, is specially commended to your lordship’s attention, and it is
suggested that such closure be only effected by the Home Secretary after
special inquiry, on a report from the Commission.
The Committee ventures to suggest that a clause should be introduced to
facilitate the removal of patients from Hospitals and Licensed Houses to
County Asylums, which at present is attended with great difficulties. This
might be met by giving power to the Superintendents of these institutions, to
give notice to the relieving officer of the district in which the patient's friends
reside, on which the relieving officer should act within seven days, as if the
patient were resident in the district.
I have the honour to be,
Tour obedient Servant,
H. Bayneb
Hon. Gen Sec.
Hanwell, 18th February, 1887.
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On the order for the third reading of this Bill, (March 17).
The Lord Chancellor said he intended to move the insertion of a new
olause, the general effect of which was the result of an understanding which
had been arrived at between himself and other noble and learned lords. He
should do no more than ask their lordships to adopt the clause. He could not
aocept the amendment of which Lord Selborne had given notice.
On the question “ That this Bill do pass,”
The Lord Chancellor moved the insertion of the following clause :—
Page 8, after Clause 4, add a new olause:
1. When a person has been received as a lunatic in an asylum, hospital, or licensed house,
or as a single patient, under an order of a judge of county courts, magistrate, or justioe,
without having been personally seen or examined by such judge, magistrate, or justice, the
person shall (subject as hereinafter mentioned) have the right to be taken before or visited
by a judge, magistrate, or justice, other than the judge, magistrate, or justice under whoee
order he has been received, except so far as the medical superintendent of the asylum or
hospital, or the medical proprietor or attendant of the house, or the medical attendant of
the single patient, within twenty-four hours after his reception, in a certificate signed and
sent to the Commissioners (in the Form 3a in the First Schedule), shall state that the
exercise of such right would be prejudicial to the person so received.
2. Subject to any such certificate, the superintendent or proprietor of the asylum, hos¬
pital, or house, or the person having charge of the single patient, shall, within twenty-four
hours after reception, give to the person so received as a lunatic a notice in writing, in the
Form 3 b in the First Schedule, and shall ascertain whether he desires to exercise such right
as aforesaid ; and if he, within seven days after his reception, expresses his desire to exercise
the right, such superintendent, proprietor, or person shall procure him to sign a notice in
the Form 3c in the First Schedule, and shall forthwith transmit it by post in a registered
letter to the judge, magistrate, or justice, who shall thereupon arrange, as soon as con¬
veniently maybe, either to visit the person giving the nolice, or to have him brought
before him tlvT t-pvintflMfintii proprietor, or person as the judge, magistrate, or justioe
may think fft. After any such personal interview, the judge, magistrate, or justice shall
send by post to the Commissioners a report thereupon, and the Commissioners shall take
such steps as may be necessary to give effect to the report.
3. For the purposes of this section, the notice shall be sent to, and the jurisdiction
exercised by, any judge, magistrate, or justioe, other than the judge, magistrate, or
justioe who made the order for reception, then present within the petty sessional division
or borough where the person received is, who shall be in such notice named by the person
desiring the inteiview, or if no judge, magistiate, or justice is so named, any justice who
shall, under arrangements which shall be for that purpose from time to time made amongst
themselves by the justices in such division or borough, undertake such jurisdiction; and
the notice shall, in such last-mentioned case, be sent to the justices’ clerk of such division
or borough for transmission to the justice.
4. The judge, magistrate, or justice shall be entitled, If he desires so to do, before making
his report, to see the medical certificates and any other documents upon the consideration
of which the order for reception was made.
6. If any superintendent of an asylum or hospital, or any superintendent or proprietor of
a licensed house, or any person having charge of a single patient, omits to perform any duty
imposed upon him by this section, he shall be guilty of a misdemeanour.
The Earl of Selborne moved to omit from sub-section 3 (lines 2 and 3) the
words “ any judge, magistrate, or justice other than.* The effect of the
amendment was to require the magistrate who had Bigned the order for the
detention of an alleged lunatic to perform the subsequent duty of examination.
On a division the Earl of Selborne’s amendment was negatived by 40 to 22.
Lord Herschkll took exception to that part of the Bill which provided
that the magistrate who should be required to make the examination should be
selected by the alleged lunatic himself. He was of opinion that the county
court judge, magistrate, or justice should be selected by the justices of the
county or borough. He moved the insertion of words modifying the measure
in this sense.
The Lord Chancellor assented to the amendment on the understanding
that Lord Herschell had satisfied himself that the alteration could be effected
without injuring the machinery of the Bill.
The amendment was agreed to.
Several verbal amendments were agreed to, and the Bill passed.
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LUNACY REPORT OP THE SCOTCH COMMISSIONERS.
On reference to Appendix A of the last Scotch Lunacy Bine Book, the Com¬
missioners, in dealing with percentages, give only those for males and females,
but no totals. (See Tables 7, 8 and 9.) Now these tables contain most of what
the reader wishes to know for purposes of comparison, but we cannot compute
the totals of percentages without knowing the general figures upon which they
are calculated. This leads to considerable inconvenience, and we feel sure that
when attention is drawn to the fact, it will be corrected by those who prepare
these tables. It is because we attach so much value to the Statistical Tables
which the Scotch Commissioners prepare, or cause to be prepared, that we ven¬
ture to make a suggestion which, if adopted, would add to their usefulness.
Obituary .
ROBERT BRYCE GILLAND, M.D., L.F.P.S. Glasgow, M.R.C.S., and L.S.A.
We record with regret the death of Dr Gilland, late Medical Superintendent
of the Berks County Asylum, at the age of 49.
He was born in Ayrshire, and graduated at the University of Glasgow in
1860. He was then appointed house surgeon in the Royal Infirmary there, and
published reports of many interesting surgical cases in the local medical
journal. In the year of his graduation he was placed on the staff of the Glas¬
gow Royal Asylum by Dr. Macintosh, and he served in that institution till
1864, when he resigned in order to prosecute his medical studies in Paris for a
year. On his return Dr. Gilland was appointed assistant medical officer to the
Essex County Asylum, and from that post was chosen medical superintendent of
the Berks County Asylum in 1870. He was fortunate in securing that appoint¬
ment before the building was completed, and he forthwith set about developing
the resources of the institution over which he was placed, with the careful
solicitude of his painstaking nature.
How he succeeded is best known to those with whom and for whom he
worked. His was not a temperament to be known and read of all men. He never
had more than a few intimate friends, and the absorbing cares of his asylum
engrossing his time and thought more and more as years passed away, steadily
diminished the circle of his acquaintance. The asylum became his only interest
in life, and the constant care fretted his sensitive mind beyond endurance. For
some years he avoided society, and gave up attending the meetings of the
Association. In the autumn of last year his health broke down completely
under the continuous strain, for he felt it to be impossible for him to take a
holiday of anything like sufficient duration. Evil days had come upon him.
The matron and the assistant medical officer, who had ably and devotedly
aided him for years, had both resigned on account of ill-health. The end came
speedily. In spite of the services of the best medical skill and nursing art, he
died on the 8th March, worn out and exhausted while yet in the prime of life.
Correspondence .
TO THE EDITORS OF The Journal of Mental Science .
Sirs,—W ill you kindly allow the following correction of the report for¬
warded to you of my remarks on “An Asylum Service Provident Scheme” in
the Journal for January (p. 624, top paragraph). I made no such sweeping
assertion regarding the arbitrariness of asylum superintendents as is attributed
to me. What I meant to imply and said was, “ that the difficulty referred to by
Dr. Ireland of discharging an attendant who had a vested interest in his
situation was not altogether a drawback, for some superintendents were too
arbitrary in the discharge of attendants, and it might be well if they were
Digitized by L^ooQle
168
Notes and News ,
hampered in the manner spoken of by Dr. Ireland.” These are probably not the
exact words, but they convey the sense of what I meant. I should be sorry
indeed to convey such an impression as the report of my remarks appears to
me to do, and I regret that they should have been so misconstrued.
Yours truly,
Glasgow District Asylum, A. Campbell Clabk.
Both well, 17th February, 1887.
EXAMINATIONS OF THE MEDICO-PSYCHOLOGICAL ASSOCIATION.
T he P a ss E xamin ation for the Certificate of Efficiency in Psychological
Medicine wtTTbe held for England and Wales at Bethlem Royal Hospital, July
and 26, 1887.
"The Honours Examination will be held at Bethlem on the 29th and 80th
of the same month. (See “ Occasional Notes of the Quarter.”) ~
The Pass Examinations for Scotland and Ireland will be held in due course, in
the month of July. Candidates should communicate with Dr. Urquhart, Murray
Royal Asylum, Perth, Honorary Secretary for Scotland, and Dr. Courtenay,
District Asylum, Limerick, Honorary Secretary for Ireland, from whom further
particulars can be obtained. For information in regard to the English exami¬
nation, application should be made to Dr. Ravner. HanwelL W.
Appointments.
Douty, J. H., M.R.C.S., appointed Med. Supt. of the Berks County Asylum
vice R. B. Gilland, M.D.
Findlay, G., M.B., C.M., appointed Assist. Med. Officer to the James Murray’s
Royal Asylum, Perth.
FitzGerald, B. A., M.B. B.C. Cantab., M.R.C.S., appointed Jun. Assist. Med.
Officer to Cane Hill Asylum, Surrey.
Grant, John, M.B. and C.M. Edin., late Assistant Medical Officer, Inverness
District Asylum, Inverness, has been appointed Assistant Medical Officer to
the East Riding Asylum, Beverley, Yorks.
Graham, Wm., M.D., Roy. Univ., Irel., L.R.C.S.Ed., appointed Med.
Supt., of the Armagh District Lunatic Asylum.
Greenlees, T. D., M.B.Edin., Assist. Med. Officer, to the Counties Asylum,
Carlisle, appointed Assist. Med. Officer to the City of London Lunatic Asylum,
Stone, near Dartford.
Hill, H. G., M.R.C.S., L.S.A., appointed Sen. Assist. Med. Officer, Surrey
County Asylum, Cane Hill, Purley.
Little, A. N., M.R.C.S., L.S.A., appointed third Assist. Med. Officer to the
Worcester County and City Lunatic Asylum.
MacDonald, P. Wm., M.D., C.M. Aberd., appointed Med. Supt. to the Torset
County Asylum, vice J. G. Symes, M.R.C.S.
Mrkzies, W. f;, M.B,, C.M. Edin., appointed Assist. Med. Officer to the
County Asylum, Rainhill, Lancashire.
Reynolds, G. H., M.B., C.M., appointed Jun. Assist. Med. Officer to the
Hospital for the Insane, Barn wood.
Spence, J. B., M.A., M.B., Assistant-Physician Royal Edinburgh Asylum,
appointed Medical Superintendent of the Ceylon Asylum.
Symes, G. D., M.R.C.S., appointed Assist. Med. Officer to the Lancashire
County Asylum, Rainhill.
Thomson, D. G., M.D. Edin., Sen. Assist. Med. Officer, Surrey County
Asylum, Cane Hill, appointed Med. Supt. of the Norfolk County Asylum,
Thorpe, near Norwich.
Tyrell, E. M., M.B., C.M. Edin., appointed Jun. Assist. Med. Officer to the
Counties Asylum, Garlands, near Carlisle.
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VoL XXX III., No. 142. (New Series, No. 106.)
THE JOURNAL OF MENTAL SCIENCE, JULY, 1887.
[Published by authority of the Medico-Psychological Association.]
CONTENTS.
PART l.-ORIGINAL ARTICLES.
Ns A. Campbell Clark, M.D.—iEtiology, Pathology, and Treatment of Puerperal
Insanity. . . . . . . . „ .169
Jas. G. Klernan, M.D.—Am erican Problems in Psychiatry, illustrated by a
Study of Cook County Insanity Statistics. .... 190
P. J. Kovalewsky.—Folie du Doute. ...... 209
Rev. W. Gk Davies, B.D.—The True Theory of Induction. . • . 219
C. Heimann.—Cocaine in the Treatment of Mental Disorders. . • 230
leal Notes and Case8.^Case6 of Masturbation (Masturbatic Insanity) ; by
E. C. Spitzka, M.D.—A Case of Imbecility with Choreoid Movements ;
by Fletcher Beach, M.R.C.P. (with Illustrations ).—On Catalepsy,
px with Cases. Treatment by High Temperature and Galvanism to Head ;
by Alex. Robertson* M.D.—A Case of Prolonged Sleep; by J.
Y^Kjcsrr, M.D. ....... 238—278
Occasional Notes of the Quarter.—Lunacy Acts Amendment Bill.—A Theistio
Monomaniac's Suicide.—The Houghton t ragedy. . . 276—282
PART II.—REVIEWS.
The Life and Work of the Seventh Earl of Shaftesbury, K.G.; by Edwin
Hoddkr.—D iseases of the Nervous System ; by W. R. Gowers, M.D.—
Observations on the Spinal Cord in the Insane ; by R. S. Stewart, M.D.
—Influence of the Sympathetic on Disease ; by Long Fox, M.D.—On
Aphasia; being a contribution to the subject of the Dissolution of
Speech from Cerebral Disease ; by James Ross, M.D.—A Text Book of
Pathological Anatomy and Pathogenesis; by ERNEST Ziegler.—O ur
Temperaments: their Study and their Teaching. A Popular Outline;
by Alexander Stewart, F.R.C.S.—The Healing Art; or, Chapters
upon Medicine, Diseases, Remedies, and Physicians, Historical, Bio¬
graphical, and Descriptive.—Gedenktage der Psychiatrie und ihrer
Hulfsdisciplinen in alien Landern; von Dr. Heinrich Laehr.—
Monomanie sans Del ire: An Examination of the Irresistible Criminal
Impulse Theory; by A. Wood Renton, M.A.—Lemons bui* les Maladies
du Syst&me Nerveux faites a la Salp6triere ; par J. M. Charcot.—L es
D£moniaques dans Part; par J.M. Charcot etP aul Richer.—H andbook
of Practical Botany for the Botanical Laboratory and Private Student;
by E. STRASBURGER.^-An Elementary Text Book of British Fungi,
Illustrated ; by William Delisle Hay, F.R.G.S.—L’Enc6phale. Struc¬
ture et description iconographique du Cerveau, du Cervelet et du Bulbe;
par E. Gavoy.—T he Life of Percy Bysshe Shelley; by Edward
Dowden, LL.D. ....... 282 — 310
PART III.—PSYCHOLOGICAL RETROSPECT.
Asylum Reports, 1886. ........ 310
PART IV.-NOTES AND NEWS.
Quarterly Meeting of the Medico-Psychological Association, held at Bethlem
Hospital, London.—Suggestions for Asylum Pensions.—Scottish Meet¬
ing.—Mrs. Lowe's Appeal to the House oi Lords.—Pharmaceutic and
Therapeutic Memoranda.—The Games Memorial Fund.—Sydney Dili¬
ps versity.—Correspondence.—Obituary.—Appointments.—Honours Ex-
animation (Gaskell Prize), July, 1887—Notice of Annual Meeting for
Vr V^ 1887.—Conditions and Regulations respecting the Examination for the
^ certificate in Psychological Medicine, Ac. . . . 321—342
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The Journal of Mental Science .
Original Papers, Correspondence, &c., to be sent direct to Dr. Hack Tukb,
Lyndon Lodge, Hanwell, W. (Town address, 63, Welbeck Street, W.)
English books for review, pamphlets, exchange journals, &c., to be sent
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Authors of Original Papers {including “ Cases”) receive 26 reprints of their
articles. Should they wish for additional Reprints they can have them on
application to the Printer of the Journal, H. Wolff, Lewes, at a fixed charge.
The copies of The Journal of Mental Science are regularly sent by Book-post
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Editors will be glad to be informed of any irregularity in their receipt or
overcharge in the Postage.
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Ci^y i llo yu i y is
£ (. j .cc i / ('t'ij y'
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THE JOURNAL OF MENTAL SCIENCE.
"c cWk*'
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[Published by Authority of the Medico-Psychological Association]
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No. 142. "VX™- JULY, 1887.
Vol. xxxni.
C )
PART 1-ORIGINAL ARTICLES. V / -
JEtiology , Pathology , and Treatment of Puerper al Insa nity ,
—BpA: -eqrra^ ^ Medical Super¬
intendent,Glasgow District Asylum, Bothwell.
Puerperal Insanity has been my chief clinical study for
the last seven yea rs, and the present paper comprises the
results of this experience^ My observations will be founded
on a minute study of forty cases.* — ~
First as regards iEtiology.
All conceivable contributory causes have been quoted in the
literature of the subject; but their relative value as factors
of the disease has been loosely stated or simply ignored.
The precise influences which tend to produce it are some¬
times difficult to ascertain, and their name is legion. At
the very threshold of the inquiry we are met with such ex¬
planations as heredity, previous attacks (puerperal or other-
wise), e pilepsy, dise ases of pregnancy , the use of inst rumen ts. \
acciden ts of labour, e xposure to cold, and^so forth.
Unfortunately these are mere outposts of the inquiry, and
it is clear that they are indiscriminate elements of the
causation rather than the causation itself. The laws of
cause and effect have not been clearly appreciated here;
many of the factors on record may separately be regarded as **
coincidents, while under" other circumstances and m certain
serial combinations they undoubtedly operate in the scale of
causation.
The question must be studied on definite lines. Is the
disease purely cerebral in its inception and development; or
is it essentially peripheral in its origin ? A moment’s con¬
sideration shows the instability of either of these positions;
# In a large number, the histories—prepared on a uniform plan—were kindly
contributed through the courtesy of many medical friends engaged in private
practice.
xxxni. 12
Digitized by
170 ^Etiology, Pathology , fc. of Puerperal Insanity , [July,
for if the first is sound the disease is not puerperal, and the
designation puerperal is a misnomer; while if the latter has
weight then like conditions of the parturient and puerperal
state must invariably produce like results, ergo puerperal
insanity must be a frequent and necessary sequel of puerperal
irritations.
A scheme of causation and development can only be framed
on reflex principles of the utmost complexity; and a reference
to the phenomena induced by peripheral stimulus of the de¬
capitated frog, furnishes a rudimentary analogue of the
mechanism of causation in puerperal insanity. It is a mere
truism to state that exposure to cold can no more be re¬
garded per se as a cause of puerperal insanity than the pinch
of a frog’s foot can be regarded as the cause of its convul¬
sions ; yet under cerebral conditions, which we shall presently
consider, it is as surely an excitant as the stimulus of a pinch
in the case of a decapitated frog. While in either case the
central condition is always the same, there is nothing specific
in the peripheral stimulus; for we may substitute for ex¬
posure to cold, laceration of perineum, pelvic peritonitis,
post partum haemorrhage, constipation, piles, and a host of
other peripheral excitants as numerous as those of experi¬
mental physiology. The seductive sophistry to which we
are exposed in reasoning from analogy is here kept in view,
and we know as a matter of fact that the phenomena of
physiological experiment and pathological processes are in
many respects sui generis .
If the peripheral stimulus cannot be defined as specific, it
can yet be regarded in respect of its intensity and duration,
and these attributes are of special significance as bearing on
the question of causation, for it will be found on analysis of
the subject that the same peripheral irritant is operative at
one time and abortive at others, in proportion to its
momentum and the degree in which it is involved with
other momenta acting in a like direction.
The frog’s convulsions are a definite effect of a definite
stimulus; the stimulus and effect are of the simplest reflex
character; the sequence is certain and invariable; and the
intervening pause is momentary. Yet, in so comparatively
low a type as the frog, we know that the resultant of the
stimulus is expressed in something more than convulsions,
though that something more may elude the vigilance not only
of the unaided senses but even of microscopic research. The
irradiation of nerve-force does not merely enter the muscular
Digitized by L^ooQle
1887.]
by A. Campbell Clark, M.D.
171
system, nor is the cessation of visible movement a sufficient
indication of the normal calm of the nervous system.
If the inherent complexity of the experimental process is
greater than at first sight appears, how much greater must
it be in the higher organization labouring towards puerperal
insanity ? Here the peripheral excitant is less definite in its
quantity and quality; it is not specific or certain in its exe¬
cution, and it is contributory but not all-sufficient. It is only
operative in proportion to its intensity and duration, and yet
more so in proportion to the sum of its morbid associations.
These are of two kinds: (a) peripheral, (b) central; the
former comprising all peripheral irritants capable of inducing
morbific centripetal currents; the latter embracing all un¬
stable conditions of the central nervous system. The various
lights on the subject are here brought to a focus, and we
proceed to consider in detail the peripheral and central
elements in the aetiology of the disease.
Let it again be affirmed that there is a multiformity of
peripheral stimulus. It is of no genus or species ; it is an
intrinsic factor of no fixed quantity, of varying intensity and
duration, and of varying complexity in respect of the centri¬
petal currents which may arise from it. Moreover, these
may reach the brain through vascular as well as nervous
channels.
The vascular system generally, and therefore the cerebral
circulation, may from peripheral sources be poisoned or im¬
poverished, and as a matter of experience, either or both of
these conditions are exceedingly frequent in puerperal pyrexia
and notably rare in its absence.
Toxaemia may be the result of (1) diminished, arrested, or
altered secretions and discharges; (2) septic absorption;
(3) zymotic infection ; (4) alcoholic excess; and the first of
these may be secondarily induced by any of the others.
Using'the term in its broadest sense, blood-poisoning is
extremely prevalent as an antecedent and concomitant of
puerperal insanity. ^
The catalogue of arrested secretions and discharges in-^
eludes the following: the mucus and digestive, but notably
the bile secretion; the urine and sweat, the lochia and milk.
In 80 per cent, obstinate constipation or very exceptional
diarrhoea preceded the mental attack; the stools were as a
rule hard and stony, usually very dark, more rarely clay-
coloured—dry, irritant, or putrescent, and of extremely offen¬
sive odour. They lacked the antiseptic action of the bile,
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172 ^Etiology, Pathology , $c. of Puerperal Insanity , [July,
( and the mollifying influence of the intestinal mucus. The
gaseous products of putrefaction are themselves of no small
I account in this connection. An examination of the urine
\ demonstrated bile in several cases, yet not so frequently as I
was led to expect from the colour of the skin and the putre¬
factive state of the fseces. Sometimes where little else was
found, pigmentary deposits were sparsely distributed over
the microscopic field. Bile vomits have not been infrequent
in the early history of my puerperal cases, occurring very
soon after labour, and not being always explicable in the
l same way. The stomach was in such instances very irritable,
and bile was more frequently ejected than anything else;
nervous reaction, portal congestion, or a loaded colon and
rectum, separately or in combination, probably accounting
for this.
I The pharynx and fauces were often found relaxed, atonic,
1 and irresponsive to reflex stimulus, the same conditions pro-
\ bably existing in all the involuntary muscles. The tongue
r was, with rare exceptions, pale and flabby; in 40 per cent,
creamy; in 10 per cent, brown, dry, and “ typhoid ; 99 in 4 per
cent, red and irritable. The mucus tract from mouth to
anus was natural or clogged with inspissated and greenish
mucus. The effect on the other secretions of such altered
mucus is known to be serious, and it is not unreasonable to
expect chemical instability of the gastro-intestinal fluids, and
putrefactive changes in the faecal accumulations, especially
where these persisted, as they sometimes did, for ten days or
a fortnight in the colon and rectum.
( Retention or very scanty urine was found in over 60 per
cent, on admission ; it was high-coloured, and of high specific
gravity. The percentage would certainly have been greater
if taken earlier or before the onset of the attack. Albu-
I minuria was found transient in 30 per cent, on admission—
too late to find the maximum statistic, the early histories in
this respect being defective.
i The skin was frequently dry, sallow, or jaundiced, and
1 sometimes had a repulsive odour. A very uniform state on
admission was a profuse crop of acne pustules over the
buttocks, but rarely extending further. The milk in 70 per
cent, was arrested; the lochia scanty or suppressed in 75 per
cent.; profuse in 6 per cent.; and when it existed at all in
l any degree it was intolerably offensive.
The changed appearance of these secretions and discharges
was found to have a varying significance with reference to
Digitized by L^ooQle
173
1887.] by A. Campbell Clark, M.D.
causation in different cases and under different circum¬
stances. The effect was more evident and indisputable in
the case of the secretions of the primce vice, kidneys, and skin;
but for simple retention of urine an hysterical cause, as
might be expected, was usually found. These abnormal
conditions usually precede the mental outburst by days or
weeks, and may be taken as evidence of a widespread
neurosis of the visceral reflexes; they may have a central
origin, but they react through vascular channels as well as
nervous; and as a general rule where they do exist, they
have antedated the mental attack. The arrest of milk and
lochia is either premonitory or coincident; and only where
induced previously by pelvic or other inflammations can it be
regarded as having a causative relation.
The late Sir James Simpson directed attention to the
frequency of albuminuria at the outbreak of puerperal in¬
sanity. He found it in four consecutive cases before
suggesting this track of investigation; and observing how
quickly albumen disappeared from the urine after the
mental symptoms had developed, he endeavoured to
account for it metaphorically thus:—“The fire of
disease goes on burning in these cases of insanity after
the lighted match is merely applied, and the strange
morbid clockwork runs on, as it were, after the key that
wound it is withdrawn.” His theory has been frequently
disputed, sometimes with good reason, but his facts
have been proved again and again. Out of his suggestion
has grown a broader conception of peripheral causation
than was previously obtained; it has brought clearly into
relief somatic views of the subject; and opened up more
logical methods of investigation. That an arrest of any of
the renal secretions can account materially for the onset of
the disease is an idea which is now excluded without re¬
serve ; nor is it conceded that a general arrest of secretions
can alone account for it. Yet it cannot be denied (1) that
there is a fertility in the sources of puerperal blood poison¬
ing, and (2) that in proportion to the number of the sources
—and more serious still—to the intensity of the poisoning is
the ratio of potentiality of mental disease.
Septic absorption has been credited with a considerable
share in the production of puerperal insanity. In some
cases I have found septicaemia and insanity develop almost
coincidently, and except on the theory of direct nervous
propagation, it was difficult to prove their relations as cause
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174 Aetiology, Pathology , tfc. of Puerperal Insanity , [July,
and effect. In one series of cases it was evident that septic
absorption appreciably preceded the mental overflow, while
in another series it was equally evident that the mental
symptoms were pre-existent and became intensified after the
inception of the septic process. My collection includes
I records of eight well-marked cases of septicaemia out of a
total of 40; and of inflammations affecting the uterus or its
neighbourhood, with or without mild septicaemia, in 10 more.
I In addition were two cases of acute phthisis pulmonalis
(with extremely offensive lochia), which in a sub-acute form
preceded parturition, and after it, made rapid and fatal
( progress. In a series of clinical papers published in the
“ Lancet,” Volume ii., 1883, I regarded these as possibly
septicaemic considered in the light of Koch’s researches on
the tubercle bacillus which have since attracted so much
notice in this country.
1 Typhoid and scarlet fever were each associated with one
V case. Both had neurotic histories, especially the scarlatina
case; and the typhoid patient had insanitary surroundings
and an exciting puerperium. It was impossible in either
case to fix the date of infection; but it is almost certain (a),
judging by a very full history, and a post-mortem examina¬
tion, that the typhoid patient succumbed to fever induced
some days before the mental attack appeared. Intestinal
ulceration was far advanced at death; she lived only 19
days after the first mental symptoms were evident; and the
typhoid incubation is believed to be usually about 21 days;
(b) that as the scarlatina patient was admitted after the
mental attack had lasted 14 days, and the fever only
appeared after admission, it is obvious that she had become
infected subsequent to the invasion of mental disease.
Such cases are probably more frequently associated with
puerperal insanity than is generally supposed. The clinical
phenomena of the respective exanthematous types were not
accurately or even approximately produced in either case.
The typhoid characters of the one were not conclusively
demonstrated till post-mortem; and the scarlatina patient
presented symptoms in irregular sequence, and, despite a
medical consultation, the diagnosis was not absolutely clear
till the stage of desquamation was reached.
^ Alcohol is the last of the blood poisons, with the excep-
tiorfdFcertain drugs, which, however, do not call for notice
here. In the lower ranks of life alcohol is a favourite pre-
\ v scription with the patient and her friends. I have clear
Digitized by L^ooQle
1887.] by A. Campbell Clark, M.D. 175
evidence of its influence in precipitating puerperal insanity j
in two cases. One patient, with a well-marked hereditary »
history of insanity and suicide, developed an intense craving
for stimulants after the birth of her last child, and, not many
hours after labour, obtained and drank an inordinate quan¬
tity of whisky (two pints within a few hours); while
another was intoxicated by an indiscreet relative with wine
and whisky. Insanity appeared after the indulgence in )
both cases, but most probably the dipsomania in the one
case was the first symptom of mental unsoundness, as I
have found the drink craving a frequent symptom of puer¬
peral insanity.
The effect of any or all of these arrests or poisonings is I
to overcharge the blood with excrementitious matter; septic 1
absorption intensifies the blood poisoning more than the \
others; and alcohol, for the time being, if in large quantity, I
so far as the brain is concerned, intensifies most of »jl- (
Whatever the poison or poisons and whatever the intensity
or duration, the result is to poison structures functionally
active and to induce irritation of the nervous system.
Puerperal delirium and hallucinations, whether or not they |
amount to insanity, are due to cerebral toxaemia, as the )
evidence of asylum practice and private practice can abun- i
dantly testify. The experience of private practitioners will J
furnish illustrations of toxaemia with hallucinations of the I
special senses, sometimes coherent, often delirious. Thus a
lady heard a bell ringing in one ear, and a railway whistle
in the other, while another had on one side hallucinations
of the sound of paddle wheels, and bagpipe music on the
other. They were both cases of puerperal fever, exanthe¬
matous and septicaemic respectively.
With a view to confirm or correct my conclusions regard¬
ing the mutual relation of mental disease and blood poison¬
ing, particularly that due to septic absorption and zymotic
contagion, I consulted the tables of the British Medical
Association Collective Investigation Committee on Puerperal
Pyrexia. They furnish three kinds of evidence bearing
upon the present inquiry, and as they are not prepared with
reference specially to mental disease, the evidence cannot be
regarded as garbled. Symptoms of the first kind are in the
order of their appearance mental-pyrexial, of the second
pyrexial-mental, and of the third mental-pyrexial-mental.
In 65 cases out of 354 (18*3 per cent.) the mental ante¬
cedents of puerperal pyrexia were unfavourable. These
Digitized by
176 ^Etiology, Pathology , Sfc. of Puerperal Insanity , [July,
appear under the names of (1) previous insanity; (2) in¬
sanity of pregnancy; (3) hereditary history of insanity;
(4) mental depression; (5) shock or emotion; (6) mental
worry; (7) nervous excitability; (8) illegitimacy, causing
nervous excitement; (9) anxiety and overwork; and (10)
news of the death of a friend in childbed.
The classes of pyrexia, and the percentages of mental
antecedent are as follows:—
Total Mental
Number. Antecedent.
Class
I.
Of local origin
... 42 cases—
19 per
cent.
»
II.
After difficult labour
... 18
99
22-2 „
9«
>>
III.
Originating in or after
ex-
posurc to contagion
... 162
99
13 „
»
99
IV.
After cold and exposure
... 13
>9 '
7-8 „
99
91
V.
After shock or emotion
6
)) ■"
100 „
19
»
VI.
From un assigned cause
... 114
99
21 „
19
The ratio of the second and third kinds is less than what
has now been given. Of cases of well-pronounced mental
disorder following on puerperal pyrexia the proportion is
eight per cent.; and of alternating mental-pyrexial-mental
cases, the proportion is 4*3 per cent.
The last of the blood-conditions which we have to consider
is a state of poverty and anaemia. Such a condition, in
order to keep within the range of the argument, must either
be parturient or puerperal in its origin; and it is obvious
that it will find most typical expression in anaemia resulting
from accidental haemorrhage, placenta praevia, post partum
haemorrhage, and puerperal abscess formations. Anaemia
usually complicates the blood-conditions already described,
and increases the excitability of the nerve-centres, inducing
sleeplessness, giddiness, headache, irritability, emotionalism,
mental lassitude, loss of memory, and incoherence. The
physical signs of it are unmistakable; occasionally but not
always, haemic murmurs were audible over the heart, and
the bruit de diable over the veins at the root of the neck.
^The consideration of nervous routes of centripetal dis¬
turbance! opens out a wide vista of ordinary visceral and
special sense irritations, the scheme of which is limitless,
but sufficiently intelligible by means of typical illustrations.
Laceration of the perinaeum and cold shock are examples of
the first; clots in the uterus, pelvic inflammation, and con¬
stipation of the second; and disagreeable tastes, smells,
sounds, and sights of the third. The gravity of any of these
Digitized by L^ooQle
177
1887.] by A. Campbell Clabk, M.D.
will depend on its intensity and persistence, and even more (
so on the degree of emotional disturbance which it calls I
forth. ’
It will be already evident that one single peripheral stim- I
ulus may be productive of others. A stimulus of cold I
produces: 1st, the sensation of chill; 2nd, fright; 3rd,
possibly inflammation, septicaemia, or both; 4th, arrest of
secretions and discharges. In proportion to its sequences is
its potency, and especially so in proportion to its emotional
effects. Three clinical illustrations will suffice: (1) a case
of flooding, which, exciting alarm, was followed by a chill
(probably a reaction of fear), then by inflammation, sep¬
ticaemia, and finally insanity; the patient had a mild neurotic
heredity, and the history of the case clearly marked the
sequences described; (2) a case of chill after first child¬
birth without serious consequences to mind or body; after
second parturition she had a chill on third day, followed by
pelvic inflammation, arrest of lochia, and gradual excitement,
culminating by 8th day in an attack of acute and violent
mania; no hereditary history was ascertained beyond in¬
temperate habits of father; (3) a patient had rigor on 6th
day, within an hour after she burst into a paroxysm of
hysterical excitement; abscess of mamma soon after
appeared; the child was illegitimate.
Apart from the question of insanity, the susceptibility of I
the puerperal female to rigors is well-known. They may be *
due to septic or central causes, or to caloric deficiency; but
an intimate acquaintance with the subject will clearly
establish the fact that there is an inherent tendency—
central in its seat—which in nervous cases is almost phe¬
nomenal, and which is remarkably prevalent, either as a
primary factor or as a secondary symptom (possibly both),
in the history of puerperal insanity. Rigors, generally
anticipated by sleeplessness, often precede the mental
attack: they frequently signify an infective process or a
simple inflammation; but in a large proportion of cases,
whatever their direct significance, they appear in advance of
the mental symptoms. Moreover, they recur frequently as
accompaniments of the insanity, not only where there is
septicaemia, but where either it does not exist or its existence
is extremely doubtful. When mental disease is fully estab¬
lished, a chill arrests for a time the psychic paroxysm; this
has been seen even in acute delirious mania. A chill occur¬
ring before the liberation of the mental discharge, will pro-
Digitized by L^ooQle
178 JEtiology , Pathology , tfc. of Puerperal Insanity , [July,
bably operate by conduction upwards from the medulla to
the cerebrum, and by peripheral conduction as well. The
pathology of rigor is however, outeide the present question ;
and the corollary of cortical disturbance as a result of the
nervous discharge (of rigor) in the medulla oblongata can be
affirmed from clinical evidence as well. Indeed, taking the
rigor as the equivalent of an epileptic seizure, puerperal
insanity might in many cases be regarded as a psychic
epilepsy.
Of visceral irritations, those having their seat in the
uterus or its neighbourhood, naturally take a leading place,
and none is more serious than the retention of clots in the
cavity of the uterus. A case of sub-acute depression—the
“ dregs ” of a previous puerperal attack—came under my
care when again pregnant. History repeated itself, and she
miscarried. Her mental condition thereafter was an accurate
mercurial expression of the uterine conditions. The uterine
cavity retained clots from time to time, and it was invari¬
ably observed that with the retention of a clot excitement
rose, with its expulsion a calm ensued. Cause and effect
were never more strikingly demonstrated. The mania tran-
sitoria of labour is an example of fleeting delirium occa¬
sionally seen during the third stage, and marking the effect
of peripheral irritation; but I have one case recorded where
the mania began in the second stage, and lasted for many
weeks after labour. During labour it was acute, but soon
after, dementia ensued, and ultimately recovery was estab¬
lished. A loaded rectum is a more serious visceral irritant
than might be supposed; many cases are excited or exag¬
gerated by this condition; some recover promptly on removal
of the cause, and many are much relieved by evacuation of
the bowels. I have frequently observed the first refreshing
sleep occur after defecation. The results of treatment
of local conditions, such as those described, as also pelvic
inflammation and mammary abscess, give indications calcu¬
lated to strengthen the belief that in these peripheral states
we find grave sources of irritation.
By reason of their close anatomical relation with the
higher brain-centres, and their almost psychic functions, it
will easily d priori be expected that the special senses may
have much to answer for in the production of puerperal
insanity. Their functions are inseparably associated with
mental functions, and the whole well-being of the organism
depends so much upon the impressions which they receive
Digitized by L^ooQle
1887.]
by A. Campbell Clark, M.D.
179
that their share in the causation should as far as possible, be
carefully ascertained. The ear takes in bad tidings, and at I
this critical period conducts noises intensely; the eye is /
open to distressing sights and exciting literature, and the I
functions of taste and smell are apt to be disordered. The |
nerve-centres of special sense are hyper-sesthesic. The most I
usual excitements of this class are those affecting sight and I
hearing. One lady's temperature rose, and she became 1
excited for twenty-four hours, without inflammation, as a
result of reading an exciting novel, and another puerperal
lady, hearing outside the voice of a most unwelcome visitor,
was similarly affected. One patient was upset by hearing
“ a neighbours' row ” on the stair, another by a quarrel
between the husband and his mother-in-law. The perverted
state of the nasal and oral secretions is apt to give rise to a
bad smell and taste, which can readily be misinterpreted in
the querulous and irritable state of the patient.
In proceeding to consider the morbid associations of
central origin, which may be productive of the disease, it
must be recognized at the outset that it is not possible to
absolutely separate the one group from the other. Anaemia,
for example, must again be considered; but in this instance
a distinction can easily be drawn between post-parturient
and ante-parturient, the former occurring rapidly, the other a
slow undermining pathological condition.
The cerebral conditions in the puerperal female, pre- I
paratory to an outbreak of insanity, find expression in the I
following symptoms : (1) acuteness of sensory impressions ; *
(2) a state of nervous tension; (8) emotional irritability— 1
easily induced—worry, anxiety, peevishness, and fretfulness,
explosions of passion, extremes of feeling; (4) loss of memory;
(5) diminished self-control; (6) restlessness; (7) sleepless¬
ness. The relative antagonism of force and resistance is
altered by excess of functional activity, nutritive deficiencies,
or probably both; resistance is yielding before the hitherto
latent energies which are accumulating in excess, and
insanity is on the verge of precipitation. The physio¬
logical resistance to explosive discharges, in nerve-structure,
whether these be motor, psychic, or otherwise, is revealed
in the inhibitory strength of the individual. Erratic ideas
of the most extravagant kind, morbid thoughts and im¬
pulses, absurd motor suggestions are physiological to
humanity at large; but not less so is the inhibitory antago¬
nism to these impulses, which is the physiological safeguard
Digitized by L^ooQle
180 JEtiology, Pathology , $c. of Puerperal Insanity , [July,
of sanity. There is no absolute identity of mental habit in
all cases; there are diversities of emotional, moral, and
intellectual character, of appetites and desires, and of self-
control, and a complete mental analysis is therefore out of
the question in our present inquiry.
The following statement embraces all that need be said
upon the subject: (a) sensory perceptions are accentuated
or perverted—frequently both ; (b) emotional impressions are
extremely acute and variable; (c) there is a partial suspension
of the action, i. e., a disturbance of the balance of inhibitory
forces; ( d) there is loss of intellectual vigour, and transient
blank of consciousness. Thus a condition is obtained
nearly allied to insanity or widely removed from it, accord¬
ing to the sum of these results; a condition which waits the
events of the parturient and puerperal condition to prove
abortive or otherwise. This potentiality may be of recent
acquisition, or it may be a morbid habit gradually acquired
or inherited. In its simplest and least dangerous form it is
induced only during pregnancy; in its graver significance
it is the result of previous attacks of insanity, or it is the
insane diathesis of heredity.
A natural tendency is noticed, especially in neurotic
subjects, to nervous and mental disorders during pregnancy.
These are usually of the mildest character, and rarely do
they find expression in actual insanity of pregnancy. If
prolonged, they react injuriously on the highest centres of
the nervous system, and seriously affect the prognosis when
labour is imminent. I found that mental causes were in¬
sidiously at work for weeks or months of pregnancy in many
of my puerperal cases. A morbid habit was created, a dis¬
position to brood over and magnify the anxieties, disappoint¬
ments, and bereavements of the past, or to foster the re¬
ligious emotions up to a state of morbid exaltation. When
a mother had lost a child the subject was sure to engross
her thoughts, to prey upon her mind with the intensity of
disease, and to colour her delusions afterwards. I was
struck with the remarkable frequency of such bereavements
in the history of my puerperal cases. The otherJcauses of
mental disturbance not amounting to insanity during
pregnancy were: (1) desertion by husband; (2) poverty;
(3) illegitimacy; (4) fright; (5) dread of confinement; (6)
various disorders of health during pregnancy; (7) insuffi¬
cient pause or none after lactation, and frequent pregnancies;
(8) frequently recurring miscarriages.
Digitized by L^ooQle
181
1887.] by A. Campbell Claek, M.D.
In 7 cases of puerperal insanity out of 40 there was a l
history of hysteria, and in 6 others of previous attacks of j
insanity, 3 of which were puerperal. It does not by any ■
means follow that where insanity had occurred previous to
marriage, and was completely recovered from, it should re¬
appear with the first pregnancy or puerperium. It is well
known that it misses many opportunities of breaking out
afresh, but yet the a priori inference is sound that these
crises are of grave import, and must not be lightly regarded.
The insanities of puberty and early womanhood are very apt I
to relapse, and they are grave antecedents in puerperal I
cases. 1
The question of heredity in the literature of puerperal in-
sanity has received considerable attention from Dr. Batty
Tuke and others. I found it difficult to get a full and
candid statement on the subject when ascertaining from the
friends the history of each case, but by inquiries pursued
further afield, and information afforded after recovery by the
patient herself, I have been able to prepare a reliable state¬
ment of hereditary histories so far as it goes. It is not so
exhaustive as it might be, had questions suggested by a
study of some later cases been anticipated earlier.
Heredity may be studied in: (a) the history of pro- i
genitors and collaterals; and (b) in the health of the (
progeny. The history of progenitors and collaterals must
be regarded beyond the mere question of nervous disease
and int emper ance; u terin e and allied affections must also
have a place in this calculation; for, undoubtedly, whether
latent or active, they originate a nervous impression in the
mother which finds expression in the nervous formation of
the offspring. Out of 40 cases, many of which could not be
satisfactorily investigated in this respect owing to lapse of
time or otherwise, I found four well-marked cases of uterine
disease in the mother of the patient, two being cas£&-of
c ance r; a fifth (cancer of throat in the mother) may be
regarded as irrelevant.
Where an hereditary history of insanity could not be
traced in preceding generations, heredity became almost a
certainty by reason of the collateral evidence of insanity in
other members of the same family, insanity or an insane
diathesis being known in one or more sisters of six cases.
Further, in some cases a suspicion of heredity was aroused, /
either on admission or after recovery, by the size, form, and
symmetry of the cranium, the facial development and ex-
Digitized by L^ooQle
182 JEtiology , Pathology, ffc. of Puerperal Insanity , [July,
I pression, the physique generally, the degree of intelligence
and mental vigour evinced on recovery. Two of the patients
who recovered could never, at their best, be very much
exalted above the type of educable imbeciles, although their
mental and physical development were sufficient to allow
them “ a bare pass ” in the world at large.
I In the ^fllt i ^ f there is often a foreshadowing
1 of the future nervous history of the mother, a latent neurosis
I in the latter finding early expression in the child, years
1 before there is any suspicion of mental disease in the parent.
In this vicarious way, what is potential in the parent be¬
comes kinetic in the child ; and in my more recent inquiries
into family histories this progenetic feature has been
sufficiently frequent to render it probable that had the
matter been as thoroughly sifted in the beginning as at the
end, evidence of this kind would have considerably increased.
Putting aside primiparous cases, which numbered 13 out of
40, and 7 multipart, whose histories are in this respect
defective, it was found that out of the remaining 20 multi¬
parse 9 showed in their families distinct evidence of neurotic
disease. Idiocy, imbecility, epilepsy, acute hydrocephalus,
I and cerebral congestion were the varieties recorded, hydro¬
cephalus being the most frequent. This represents forty-
five per cent, of gross neurosis in the progeny of multiparous
| cases; but I am disposed to look on it as a minimum.
Having regard to all these phases of the question of
heredity, I have prepared the following tabular statement of
the facts which I have been able to ascertain. (See pp.
184-185.)
Heredity is here represented from many points of view,
and in a variety of combinations, which do not however
include epilepsy, of which in its hereditary form I have no
statistics. The snm total of heredity is .probably still under¬
estimated despite all my efforts to get at the root of the
matter. The “nervousness and excitability” which was
sometimes sparingly conceded by informants, have in my
experience been another name for mild attacks of insanity
which were transient, and had been successfully treated at
home.
* Twenty-six out of a total of thirty-eight known cases had
therefore a basis of heredity great or small, and yet I must
repeat that I consider this statement is an under-estimate
for the reason that it has been amplified from time to time
after the patients in question had passed from under our
Digitized by L^ooQle
1887.]
by A. Campbell Clark, M.D.
183
care. Many additional facts were incidentally communicated
by strangers or discovered by personal investigation made at
the patient's home. Dr. Batty Tuke found heredity in 22 I
out of 73 cases, and he found what the foregoing statement |
does not determine, that in a greater proportion of cases it
exists on the female side of the family.
There are many acquired brain-conditions which may
precede and aid in developing puerperal insanity, and which
might appropriately be dealt with here. Such are for
example epilepsy, brain-injury, and meningitis; but, as
they have not come within my experience, and as I believe
they have only a rare connection with puerperal insanity,
they need not occupy further notice.
In determining cause and effect we cannot always grasp I
mathematical certainties. Puerperal insanity is not so ■
beautifully simple as a case of irritant poisoning, nor so I
definite in its sequences as a case of zymotic disease. The I
lines of causative conduction are so innumerable, reflective, I
and interminable, that finality of research is not to be looked }
for. Holding in his hand the various threads of causation,
so far as they are disentangled, the physician's power of
directing the puerperal course of his patient is greatly
increased. He can anticipate and thus avert strokes of
causation, or minimise their force and effects.
I now pass on to the pathology of puerperal insanity.
This has been the least investigated branch of the subject,
and many of the older records are of doubtful value. The
earlier writers on this disease inferred the pathology from
the clinical features; some contended that furious mania,
which was their only conception of puerperal insanity, was
a convertible term for meningo-cerebritis; while GiiGch laid
down the law rather paradoxically, “ that the disease is not
o n# of co ngestion or infl ammatio n, but one joLjejudteJug/it
without Tyler ~Smith obseFves : “ No constant
morbid changes- are found within the head, and most
frequently the only condition found in the brain is that of
unusual paleness and exsanguinity. Many pathologists have
often remarked upon the extremely empty condition of the
blood-vessels, particularly the veins."
Si mpson^ suggestion that there is an essential connection
bet ween puerperal insanity a,nd. re nal disorder has already
beeiT referred to. HiT supposed it probable that certain
changes in the renal secretion might induce secondarily
chemical changes in the blood. Several theories have been
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In two of these cases (Cases I. and XIV.) there was in the patient herself an inferior type of mental development.
186 Mtiology , Pathology , fc. of Puerperal Insanity, [July,
evolved from this idea, giving prominence especially to the
supposed septic acti on on . the hra.in. nf urea and carbonate of
ammonia. Sir James gives prominence to this view of the
subject as follows :—“ In the blood of the puerperal female,
greatly modified as it is in the normal states of pregnancy
and delivery, and containing, as it does after parturition,
the effete elements of the involving or disintegrating uterus,
and the materials for the new lacteal secretion, ferments
and agents may possibly exist, which are more apt to
develop special morbid poisons out of the retained renal
secretions than happens in other states of the system. But
I repeat the whole subject is yet quite dark and conjectural,
and will remain so till pathological chemistry is able to cast
some light upon it.”
My observations on the pathological aspect of the question
will be arranged as follows:—
I. A study of the naked eye and microscopic appearances
of the brain; II. A report of urine analysis and microscopic
examination; and III. A statement of pathological com¬
plications.
The conclusions hitherto arrived at regarding the condi¬
tion of the brain have been mainly obtained by inference
from clinical evidence. Nor was the inference of common,
acceptance sound, because general anaemia and exhaustion
cannot legitimately pre-suppose local anaemia where func¬
tions are abnormally active, or where there exist seats of
irritation, septic or otherwise. Asthenia does not contradict
congestion and inflammation; it rather favours the develop¬
ment of such pathological processes. Witness the inflamma¬
tory conditions of low asthenic types; erysipelas in exhausted
and moribund cases, congestions of trophic origin, hypostatic
pneumonia, tonsillitis, stomatitis and other inflammatory
varieties induced in depressed states of the system. That a»
sthenic phrenitis does sometimes prove the pathological
equivalent of puerperal insanity has been too evident to be
disputed; but the great bulk of cases, as a rule, have been
classed pathologically under cerebral anaemia. There is no
certain or sufficient evidence to justify this statement, the
inferences from symptomatology are not to be depended on
without pathological confirmation.
It must however be admitted that it is easier to mistake
anaemia for congestion than the converse, by confounding*
the venous with the arterial system, especially in an ex-
Digitized by L^ooQle
by A. Campbell Clark, M.D.
187
1887.]
animation of the pia-inater; but on the other hand, though
less evident, it is no less true that congested zones and
patches may be overlooked in brains, which are in many
convolutions anaemic. My post-mortem records include
three cases of cerebral congestion (one with meningitis), two
of which will be more particularly detailed afterwards,
especially with reference to histological appearances. The
late Dr. Boyd , of Somerset Asylum, in three out of five post¬
mortem ^xafflfnations found cerebral congestion (one with
meningitis). He was a careful branFJferthologist, and his
statements are worthy of reliance.
When the dise ase becomes c hron ic, or death ensues from
pneumonia, or some other serious inflammation in the body
cavity, or as in one of Dr. Boyd’s cases, where the patient is
literally reduced to skin and bone (she weighed 52 lbs.), it is
not surprising to find palen ess ft nd exaapguinity. Further,
where heredity is strongly marked, witlhout prolonged acute
excitement, hypersemia is probably rare. But where, as is
the usual experience, mental and motor excitement, delirium,
and hallucinations of the special senses are prominent symp¬
toms, especially with concomitant toxaemia of some kind or
another, I believe the facts of pathology abundantly demon¬
strate cerebr al conge stion, and sometimes phrenitis.
My most e xhaustive record of puerperal brain pathology is
furnished by the typhoi d case alread y quoted. The naked -
eye description ts as follows
Cranium . Removed with difficulty, owing to dura-mater
adhesions of recent origin. Bone appeared normal, but inner
table was blood-stained around the terminals of the blood¬
vessels.
Dura-mater . Flaccid; a little escape of arachnoid effusion
when opened into anteriorly. No notable structural or vas¬
cular changes.
P ia-ma ter. E xtreme congestion in parts : normal condi¬
tion in others. Very fine network of arteriole injection,
almost invariably over left cerebrum, being scarcely notice¬
able however on inner aspect of occipital lobe. On right
cerebrum the congestion was rare, and chiefly observed
over angular gyrus and calloso-marginal convolution. The
consistence throughout very good.
Section . The marked congestion of left cerebrum, as com¬
pared with right, is still more evident, especially affecting
the inner cortical layer of grey matter, but it is again absent
Digitized by
188 Mtiology , Pathology, $'c. of Puerperal Insanity , [July,
in the inner occipital convolutions. The right cerebrum
before and after section was laterally, and at its base, with
the exceptions above noted, found to be pale.
Weights. Cerebellum, pons, and medulla, 5f oz. Right
cerebrum, 20£ oz. Left cerebrum, 23£ oz.
After naked eye examination, the brain was preserved for
section by Hamilton’s method, viz., in Muller’s fluid and
spirit for three weeks, changing it weekly. After three
weeks it was preserved, week after week, in the graduated
solutions of bichromate of ammonia, recommended by
Hamilton ; it was then treated with a saccharine solution,
\ and afterwards placed in mucilage, according to the same
^ direction. Finally, it was cut into sections, by means of
I * ice and ether microtomes. Some of these were mounted
unstained; others were stained with carmine, logwood,
1 aniline, and chloride of gold, rendered semi-transparent with
oil of cloves, and mounted in dammar. The most successful
stains were those of carmine and aniline.
Sections were made of all the convolutions, so that no part
shoUldTescape scrutiny. AThe cerebellunCpons, and medulla
were in like manner prepared and examined. The result is
brought out as follows:—
(a.) Extreme v ascularity extending frofti the pia-mater
inwards, particularly noticeable in_ the inn ermost , and
by its effects on the outermost layer of the grey matter;
this statement is susceptible of modification with regard
to the anaemic convolutions, notably those of the right
hemisphere.
(b.) Tor tuous and ir regular ve ssels, but no thickening or
other morbid alteration of coats, often found extremely
engorged, almost to absolute blocking.
(c.) Dilatation of perivascular spaces jo_inarked as in
some parts to give an almost honeycomb appearance; walls
of spaces dense and fibroid.
(d.) Pftrivn.flanln.r ahftaH ttu w ith small qe 11s, and
here and there impregnated with crystals ansL pigment
granules^; minute extrn.v nsfl^inna sopn in brain substanc e
near the veaaels*
(e.) The nuclei of neurog jia, exceedingly numerous,
appearing in linear, circular, or semi-circular clusters along
the course, or near the bifurcation of the blood-vessels.
(/.) In several convolutions the superficial layer of grey
matter was densely crowded with neuroglia cells.
Digitized by
Google
1887.]
189
by A. Campbell Clark, M.D.
(g.) Except in the medulla, there was no evidence of
nerve-cell degeneration; the nuclei were prominent and
distinct, and the cell processes were well defined in their
length and branches.
(h.) There was no evidence of gross lesion, but in the
nerve-structure were scattered very minute, finely-granular
clusters, which stained with carmine. °
(i.) The changes in the medu^la-oblongata were Jess
ma rked, but not different in kind from those already stated,
with this exception, that in the medulla the nerve-cells were
undergoing fuscous degeneration. It is no uncommon thing
to find this latter change in the medulla, while the integrity
of the cerebrum is unimpaired. The cells were also unshapely
and irregular in many instances. The enlarged perivascular
spaces were here unusually frequent, and involved the folds
of the olivary body.
O'.) The changes in the cer ebellu m are a faint '•efl ftv
of what has been already described; they are purely vas¬
cular.
The lesion is, therefore, widespread; it is in some parts
more accentuated than in others, and microscopically the
congestion is more evident than the naked eye appearances
would lead us to expect. I was led from the clinical symp¬
toms (hallucinations especially of sight and hearing) to
expect a greater intensity of congestion, and its effects in
the convolutions believed to subserve the functions of special
sense, and it was found on reference to the sections of the
angular gyrus and superior tempero-sphenoidal convolution
and tip, that congestion and its concomitants were extremely
well marked.*
(To be concluded in the next number.) . !
<U. JJtur-i Wrf.
• It would be mere iteration to go over the histology of the second case, for
the condensed statement immediately preceding would, in all important parti¬
culars, identify the second case as well. The latter was one of puerperal
septicaemia, with maniacal symptoms; the vascularity was even more extreme
than in No. 1, and the capillary haemorrhages more marked and frequent.
There were many attenuated and vacant spaces, mostly perivascular, which
were densely surrounded by neuroglia tissue.
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190
[July,
American Problems in Psychiatry, Illustrated by a Study of
Cook County Insanity Statistics.* By Jas. Q. Kieknan,
M.D., Chicago, Ill. 1
(Bead before the Chicago Philosophical Society t Not. 18, 1886.)
The problem* which present themselves to any community
in regard to insanity at the present day, are much more com¬
plex than that presented to primeval society—which* was
simply self-protection. Primeval society canonized or ex¬
terminated the insane as they were given to ecstatic visions
or violence. Even in Anglo-Saxon lands at the present day,
while one portion of the community starves and freezes the
insane and calls out for their blood, another portion makes
them its religious leaders.
With the evolution of the virtues of which Jesus Christ was
the best exemplar and the development of law and order,
Spartan creeds ceased to dominate public opinion, and it
dimly dawned on society that even madmen had rights it
was bound to respect. But the only right recognized down
to the middle of the eighteenth century was that of bare
existence. Shut off from the outside world by thick, high
walls, mouldering in dank, dark cells, chained to cold stone
floors, lashed into alternate rage and submission by callous,
ignorant attendants, mediaeval madmen presented that hardly
credible picture of fury of which Cibber’s raving madman
at Betblem’s gate was a feeble representation.
Half a century ago many insane were thus treated in
Great Britain and on the European continent, and are thus
treated to-day in most county and even some State institu¬
tions in the United States. Under the pressure of the teach¬
ings of Chiarrugi, Pinel, Tuke, Push, Gardner Hill, Conolly,
and Dorothea Dix, the world was driven to concede that the
insane had a right to comfort, medical treatment, and to the
protection of character, property, and life against the conse¬
quences of insanity. Around these rights of the insane must
centre all discussion of the many problems connected with
insanity in a given locality.
The history of insanity in any locality in the United States
is an epitome of psychiatrical history in the country as a
whole. The increase of insanity, its causes, its prevention, the
* By Cook County, Dr. Kiernan implies Chicago and its suburbs.—[E ds.]
Digitized by L^ooQle
1887.] American Problems in Psychiatry , 191
provision made for the insane, the protection given the sane
and insane members of the community against the conse¬
quences of insanity, constitute problems which interest every
community.
Insanity is increasing enormously in Cook County. Of
every 360 denizens one is insane. The causes of such increase
are best studied through an analysis of the psychoses which
make it up, and for which provision is needed. Insanities
are roughly divisible into three great classes. First: Psy¬
chosis arising from an acquired or congenital neuro-degene-
rative taint transmissible in diverse forms to descendants.
Second : Those which are isolated phenomena in the life of
the individual or his family; usually of a curable nature.
Third: Those which are the secondary consequences of a
primary brain disease, not directly transmissible to descen¬
dants, but permanently destructive of life and mentality.
The influence of Cook County is traceable chiefly in the pro¬
duction of the second and third classes, since for the produc¬
tion of any large number of the first class more than one
generation is needed.
Cook County customs and business habits have produced
a disproportionate increase of the third class : paretic de¬
mentia, paralytic dementia, typhomania, primary mental
deterioration (the atheromatous insanity of Voisin, the male
climacteric insanity of Clouston, Skae, Bucknill, and Tuke),
etc. That the increase in these psychoses is mainly due to
Cook County influences, is demonstrable by their dispropor¬
tionate increase among certain races as compared with them¬
selves elsewhere. Paretic dementia, as Dr. Ashe and others
have shown, is rare among the Irish in Ireland. It is twenty
times more frequent among them in Cook County than in
Ireland, and twice as frequent as in New York. 3 Irish women
are free from this psychosis in Ireland, but in Chicago are
attacked twenty times more frequently than in New York.
Negroes free from it in the South suffer from it ten times more
frequently in New York, and naturally so since all races are
equally exposed to a speculative emotional business atmo¬
sphere. The struggle for precedence in school, academic,
financial, and political honours, produces its natural result,
and is aided by the tendencies it fosters to excessive
emotionalism arising from alcohol, sexual vice, and re¬
ligiosity, agencies having much in common, resulting from a
disturbed emotional equilibrium, and alternating in the
role of cause and effect in connection with insanity.
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192
American Problems in Psychiatry , [July,
Financial misfortunes, resulting from the blunted moral
tone consequent on these psychoses, frequently befall the
community. More than one business firm—more than one
bank—has fallen victim to the insanity of its head, who ex¬
hibited, conjoined with moral obliquity in the earlier stages,
a brisk buoyancy which saw every speculation in a rose-
coloured light. So long as the struggle for financial exis¬
tence is carried on amongst the bulls and bears, so long will
these psychoses disproportionately increase. The curable
psychoses are relatively insignificant in the burdens they
throw upon a community. They form less than one-fifth the
whole.
The first class of psychoses always presents the most serious
problem to a community, since these psychoses are chronic
or rapidly recurrent, and hence entail an enormous financial
burden, which, however, might be borne with complacency,
were it the only evil resulting from them. The institutions
of Cook County make the victims of such psychoses as these
the ready tools of unscrupulous politicians. More than one
county election has been carried by the aid of the insane.
That such dangers are possible will readily be admitted
when the character of the chief neuro-degenerative psychosis
paranoia is remembered. [So designated by Kohlbaum.] 3
Paranoia, a high-sounding but not a new term, has been
used for centuries in nearly its present sense. It consists
essentially in a twist of the intellect, which, however, is a
more serious matter to the individual and the community
than the seemingly more terrible raving madness, since the
man with a mental twist can see distorted things only, while
the raving lunatic very likely sees everything straight but can¬
not control his unruly ideas,emotions, body,limbs, and tongue.
The raving maniac is soon put where he can do least harm,
and very likely recovers, while the man with the twisted intel¬
lect remains free to ruin a family, a commercial enterprise, or
found an eccentric, dangerous, political or religious sect. It
is a form of insanity manifesting itself in “ primary dis¬
sociation of the mental elements, in a failure of the logical
inhibitions or in both.” That is, there is a “ twist 99 (the
Teutonic word “ krank” means twist) which may involve the
will, the perceptive faculties, the judgment, or all of them.
These people have a peculiar tendency to perceive things
crooked, and to govern themselves accordingly. Between
these beings and the imbecile, idiot, congenital criminal,
bom pauper, or “ ne’er-do-weel,” there are numerous con-
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by Jas. G. Kiebnan, M.D.
193
1887.]
necting links, and the same family often gives birth to all
of them. Gifted though many of these beings are in special
directions, yet their minds are openly or insidiously con¬
trolled by the twist. 4 “ There is a mental undercurrent of
perverted action peculiar to the individual noted, running
like an unbroken thread through the whole mental life;
obscured, it may be, for these people are often able to correct
and conceal their insane symptoms, but it nevertheless
exists, and only requires friction to bring it to the surface.
Because an individual of this type imagines himself watched,
he concludes he must be a person of some importance.”
“ Some great political movement takes place, he throws him¬
self into it either in a fixed character that he has already
constructed for himself, or with the vague idea that he is an
influential personage. He seeks interviews, holds actual
conversations, with the* big men of the day, accepts the
common courtesy shown him by those in office as a tribute to
his value; is rejected, however, and then judges himself to
be the victim of jealousy or of rival cabals; makes intem¬
perate and querulous complaints to higher officials, perhaps
makes violent attacks upon them, and being incarcerated in
a gaol or asylum looks upon this as the end of a long series
of persecutions.”
These degenerated lunatics hence constitute serious social
dangers, not only for the reasons just mentioned, but for
other reasons of a more serious character. As Macaulay 6
has pointed out, they are the agents chiefly chosen by
political conspirators, to effect political changes by means of
assassination. Henry IV. fell a victim to the paranoiac
Ravaillac, expelled from his cloister because of insanity;
Mr. Percival was killed by the paranoiac Bellingham ; Pre¬
sident Jackson was shot at by the paranoiac Lawrence,
whom “ Old Hickory ” looked upon as a tool of the great
monopoly of the day, the United States Bank; President
Lincoln was shot by the paranoiac Booth ;* President Gar¬
field was killed by the paranoiac Guiteau ; President Hayes
narrowly escaped the same fate at the hand of the paranoiac
“prophet” Meyers. 6 Only a timely arrest prevented the
paranoiac Macnamara from killing Mr. Blaine ; 7 the
paranoiac Pinchover 8 from killing Mr. Randall; and the
paranoiac Allen 9 from killing President Cleveland. Nor
is this danger lessened by the fact that mock deference will
* My childish recollection of Booth associates with him decided insanity of
manner.
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194 American Problems in Psychiatry, [July,
render the paranoiac the unflinching slave of party leaders.
Their egotism, pertinacity, and plausibility enable these
people to impose their delusions on large communities.
More than one religious, political, social, and financial con¬
vulsion has thus been brought about. Europe, as Dr.
Spitzka has said, poured out its best blood for decades in
crusades under Peter the Hermit. John of Leyden controlled
large communities, and ofliered up human sacrifices; as did
in the later part of the nineteenth century, in civilized
Massachusetts, the paranoiac Freeman, of Pocasset. 10 The
paranoiac “ Mother Anne ” founded the Shakers; the
paranoiac Ludowick Muggleton founded another sect ; u
the paranoiac Noyes founded the Oneida community; the
paranoiac Say 12 offered his mother up as a sacrifice, and
imposed his delusion on several people. A female paranoiac
is to-day worshipped as God in Cincinnati, Ohio. In Troy
(New York) a family were arrested by the police who had
eaten nothing in several days, although there were plenty of
good provisions in the house. The father and his wife said
they would neither eat nor sleep until God told them to, and
both said they were not hungry. The house was neat, but
bad air permeated everything. God had told them not to
open the doors or windows. The children said they were
not very hungry. The whole family spent the time in pray¬
ing and shouting all day and all night. The father said he
would kill his whole family and himself if the Lord told him
to do so. On any subject, other than religion, he and his
wife talked intelligently. In the police-station the man and
woman stood on their feet in about one position for nearly
four hours, and force had to be used to compel them to be
seated. They said God had told them not to sit down. 18
Dr. Clouston 14 has called attention to the fact that a
lunatic under his charge, but on parole, was able to dupe
sane people into buying his “ elixir of life,” and the career of
a patent medicine man just closed is additional evidence of
the gullibility of the public in this particular. “ Dr.” S. A.
Richmond, an epileptic paranoiac, has for years been manu¬
facturing and selling a remedy for “ fits and nervousness,”
called the “ Samaritan Nervine.” This remedy, probably
originally prescribed for “ Dr.” S. A. Richmond’s own
epilepsy, had an immense sale in the West. That it never
cured u Dr.” Richmond is evident from the fact that he
recently shot Col. J. W. Strong during an attack of epileptic
fury, and has just been acquitted of murder on the ground
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1887.]
195
by Jab. G* Kiernan, M.D.
of insanity. An utterly illiterate epileptic paranoiac, “ Dr.”
Richmond was yet able to realize an immense fortune from
preying on the misfortunes of epileptics, the most gullible
and afflicted of mankind. From the profits of his “ Samaritan
Nervine” he was able to build a magnificent hotel at St.
Joseph, Mo., where unfortunates like himself were treated
under his special supervision. The paranoiac Patterson
founded the Bank of England; the sagacious men of business
associated with him therein soon discovered his twist, and
quietly got rid of him. He devised the Darien scheme, and
nearly ruined half Scotland. The paranoiac Meyers estab¬
lished the Chicago Beehive Bank; by joining a paranoiac
real estate speculation to this bank, he ruined a large
number of the working classes, and did much to engender
the labour riots of 1877.
Other paranoiacs have more directly brought about revo¬
lutions. Marat, Billaud, Lebon, and Carrier were, as
Lombrosa has shown, 15 degenerated lunatics, who, aided
by Burke’s attempts to bring about a “ White Terror,” 16
by Marie Antoinette’s inventively-stupid mendacity, by the
selfish partition schemes of Austria and Prussia, 17 were able
to impose their suspicional delusions on the French people
and produce the undue severities of the “ red ” Reign of
Terror. Most historians and novelists have recognized the
part paranoiacs play in revolutions. Bulwer-Lytton 18
made Edward Ferrier a conspirator against Napoleon the
Little. “ Thoroughly sincere, his father and grandfather
had died in a madhouse.” A Bohemian paranoiac who
believed himself the real heir to all the Talbot estates and
said the working classes should be kept down with dyna¬
mite, was able to impose himself on the Chicago University
Faculty, the Chicago Public Library Officials, and, after his
public trial and escape from an insane-hospital, on the
Harvard University Officials, as an able, promising young
man. Another paranoiac patient of mine had been Surgeon
Dentist to Queen Victoria, a General in the second French
Republic, a leader in an Australian attempt at revolt, and in
London riots, and a candidate for the New York Comptroller-
ship. His mind, perverse from the start, was rendered still
more perverse by the unjust treatment received from court
officials, who malignantly persecuted the word of honour of
Lady Flora Hastings, the poor victim of an ovarian tumour
whom this lunatic as chivalrously defended.
Neuro-degeneracy in the palace has stamped itself on
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196
American Problems in Psychiatry , [July,
history in letters of blood. The crimes of the Caesars were
the outcome of neuro-degeneracy in the Julian and Claudian
families. Claudius, Caligula, and Nero were degenerative
lunatics at once masters of Rome and the world. 19 Richard
II. of England, Henry VI., and James I. were paranoiacs
whose insanity resulted in the “ Wars of the Roses ” and the
first English Revolution. They drew their tainted blood
from the same source as Charles V. of Germany and the
Spanish line descendant from him. 20 To the same taint
the English Church owed its existence, for this taint evinced
itself in the death of most of Catherine’s children in convul¬
sions. Henry VIII., stimulated by his love for Anne Boleyn
and the Tudor dread of a disputed succession, not unnaturally
looked upon this as a judgment on an illegal marriage made
with a brother’s wife. Mary Tudor owed her duplicity,
cruelty, and delusions about childbirth to the Arragon taint.
To the insanity of Charles VI., derived from the same
source. Prance owed the misery from which she was relieved
by the paranoiac Joan of Arc. The same taint led indirectly
to the massacre of St. Bartholomew. The paranoia of George
III. lost England the American Colonies. The taint which
led to all these blood tints of modern history was, like that
of Otto and Ludwig of Bavaria, derived from the Burgundian
family, which ascended the Portuguese throne in 1095. To
it the numerous paranoiacs, congenital criminals, and
imbeciles who have reigned in Europe are due. The
Romanoffs have had a similar taint since the days of Joan
the Terrible, at whose deeds even a barbaric people stood
aghast.
Neuro-degeneracy is hence far-reaching in its conse¬
quences. American and Australasian Anglo-Saxon lands,
upon whose shores are flung the mental wrecks of European
civilization, are brought face to face with the necessity of
preventing the incoming of these as well as the home
manufacture of these and other lunatics. The Arabian-
Night-like prosperity of Cook County has thrown a herculean
task of this kind on it, and its business and social habits
have added to this task.
The first psychiatrical problem before the sociologist is
the prevention of home-made insanity. On the text, “ He
that ruleth his spirit is greater than he who taketli a city/’
Spurgeon might have preached the sermon he once did
against religiosity, as he terms that disturbance of the
emotional balance w T hicli so frequently associates sexuality
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1887.]
197
by Jas. G. Kiebnan, M.D.
and religion. Undue emotionalism is the great cause of most
home-made insanity in Cook County. The thirst for ascen¬
dency swings the mind between the hypersemia of joy and
the ansemia of despair, and breaks down the vaso-motor
balance which results in the curable and incurable psychoses
of the last two classes. Nor is this the only way such
influences produce these psychoses. “ He that maketh haste
to get rich shall fall into a snare/’ and the snare the business
man falls into in the present case is mental destruction,
followed by destruction of fortune, family happiness, and
personal character from insane crimes and misdemeanors.
His wife, broken down by anxiety from financial and
domestic misfortune and resulting privation, often becomes
insane. The employes dependent on the business man are
thrown out of work by his bankruptcy, and they or members
of their families thereby become insane.
The neuro-degenerative psychoses are largely the result of
physical causes. Even crime often has, as the learned
devout Baxter 21 pointed out, a physical basis. These causes
have as yet not produced much effect in Cook County, but it
is none the less necessary to heed Lord Beaconsfield, 23 who
has said that unless modern civilization looked to the
physical aspect of morality it would have the fate of that of
the Greeks of the Lower Empire. Anything which saps the
mental balance of the citizens of the state tends to destroy
that state. “ Liberty without good morals is impossible,”
and good morals are impossible without a well-balanced
mind. Modem civilization i3 actively manufacturing its
own enemies. Mechanical arts crowd the population into
towns; overcrowding creates foul air, which engenders
ennui , resulting in debauchery and alcoholic excess; from
the inter-action of these causes neuro-degenerate beings
result with equally degenerate descendants. Idiots and
imbeciles born from these people are least burdensome to the
community, but the congenital criminal, pauper hysterical,
nymphomaniacal and paranoiac scions of such a stock are
essentially savages bom in the midst of a civilization which
has sharpened their claws for its own destruction.
Cook County, not content with manufacturing these
savages, is importing them in large numbers, and these
importations naturally seek the defective classes in marriage.
The foreign population furnishes thrice its proportion of
criminals, paupers, and lunatics. The somewhat defective
Cook County statistics show that the foreign born insane of
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108 American Problems in Psychiatry , [July,
this class are quadruple the proportion found whence they
come. 23 The degenerative lunatics weighed down by real or
fancied European tyranny flock to American centres of life
and bustle as sea-birds to lighthouse lanterns on a dark,
stormy night. 24 In the rush of Cook County life an active
bustling paranoiac whose insane egotism makes him keen in
business, long passes muster, perhaps never reaches an
insane hospital, but is regarded as an energetic, able man,
one of the leaders of the community. Guiteau’s father, a
paranoiac like the assassin, was regarded as one of three
ablest men of an Illinois town. While the majority of the
children of these people die in infancy, enough survive to sap
the mental stamina of future generations.
The tables on opposite page show the natality of paranoiacs
in the Cook County Insane Hospital.
In consequence of the enormous importation of the insane.
Cook County has suddenly found itself saddled with the
problem of how to provide for these insane. Its citizens
have paid munificently for such provision, but one of the
greatest wrongs has been done the insane and the State.
More than two million dollars (£400,000) has been wasted
during ten years.* This waste has resulted from very obvious
causes. The Cook County Insane Hospital has been, and is,
regarded as a place 25 “ where the vilest politicians and their
female acquaintances are provided for under the pretext
of serving as attendants, and the higher offices have been
filled by drunkards, gamblers, and ex-concert saloon-keepers.
The unfortunate insane have been delivered over to the
tender mercies of the most vile, filthy, and brutal of their
species.” The Cook County insane for decades remained in
the same condition; the other Illinois County insape are
to-day chained, naked, and filthy, in dungeon with only an
opening in the door-top for air, light, and heat, through
which food was pitched as to a dog. 26 The Cook County
insane remained in this state for decades after Conolly had
lived and laboured without remonstrance from the resident
clergyman, member of the State Board of Charities, and
unheeded by the business man wrapt up in financial cares,
but who had paid munificently for their support.
“ Treat the insane man as a patient , and let him see that
you recognize in him a human being, if you would cure and
* For ten years it cost three times as mnch to keep the pauper iosane in
Cook County as in New York, although everything is cheaper in Cook
County . 26
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1887.]
by Jas. G. Kiebnan, M.D
199
Table I.
Civil Condition.
Male.
Female.
Total.
Harried—childless.
12
8
20
„ children born dead .
9
2
11
„ majority died infants .
18
11
29
„ „ survived infancy .
4
5
9
Unmarried .
19
11
30
Total .
62
37
99
Table II.
Children in Family.
No. of
families.
Survived
infancy.
Died in
infancy.
5 ohildren in family...
...
...
...
...
3
7
8
6
ft
tt
it •••
...
2
5
7
8
ft
tt
a •••
7
19
37
9
it
tt
ft •••
8
20
50
10
ft
tt
» ...
11
31 ‘
79
11
tt
ft
tt •••
2
5
17
12
tt
tt
a •••
■■
3
9
13
ft
tt
tt •••
B
2
11
16
ft
tt
tt •••
...
I
3
13
17
rt
ft
tt •••
B
4
13
22
ft
tt
tt •••
m
3
19
Total
.
...
...
38
102
263
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200 American ’Problems in Psychiatry , [July,
not render worse his insanity! Thus might be briefly inter¬
preted the pith of the appeal made by all great teachers of
morbid psychology, against the prejudice, the indolence, and
conservatism of their day.” 27 But no one in Cook County
came forward to make such an appeal. The insane were
only “ pauper cranks.” The insane hospital was needed to
support the friends of politicians and the impecunious scions
of plutocrats, who provided for them at the expense of the
insane. The plutocrat and the “boodle” 28 politician
made common cause, as in the New York Tweed ring, and
the gambler-plutocrat, who rules the county, formed a
natural connecting link. It was cheaper for a financial
magnate to pay a “ boodle ” politician for a place for a
termagant cousin in the insane hospital than to pay her
board. Waste, corruption, and brutality naturally followed.
Dr. Folsom, 29 free from Cook County social and
political ties, free from fear of the gambler-dictator of
county common to the medical, legal, clerical, and journal¬
istic professions, made a rigid investigation, and found
drunken male and female rowdies in charge, who handcuffed
and tossed into dark corners men and women, delicately
brought up, with sensibilities rendered more keen by disease.
Stung by the picture drawn by Dr. Folsom, Dr. Jewell
induced Drs. Brower, Lyman, Chas. Gilman, Smith, and
others of the Chicago Medical Society to join in an in¬
vestigation, which corroborated Dr. Folsom’s results. 30
They found drunken male and female employes dancing
orgies, called amusements, incompetent physicians, drunken
commissioners, poor food, fuel, and clothing. No change
was made for three years despite all efforts, and within a
very short time, maugre the handcuffs, the institution re¬
sumed its old aspect. Within the next three years the same
story was thrice retold. 30
In 1883 Dr. Clevenger was elected special pathologist.
With him a new era in the history of Cook County’s insane
dawned. Attempts at reform in their care came from
within the hospital walls for the first time. Through Dr.
Clevenger, the Chicago Woman’s Club became interested in
the female insane. Through his and their efforts a self-
sacrificing female physician was appointed at the salary paid
the rowdy female attendants. Despite the taunts of the
superintendent, and the consequent discourtesies of his sub¬
ordinates, this lady effected wonderful improvement in the
condition of the female insane. The death-rate fell, under
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201
1887.] by Jas. G. Kiernan, M.D.
her care, eight per cent. Of the scene of her labours she
has drawn the following picture :— 31
From the first I was struck by the lack of system or organization that pre¬
vailed. No histories of cases by the physician in charge were kept; no census,
and very meagre records of any description. The visits of the superintendent
to the wards were few and hasty. In each ward was kept a bottle of whisky
and a bottle of strong sleeping medicine of bromides and chloral, which the
attendants dealt out at their discretion. Many times, on being called to a
patient, I received this history of the case: “ I gave her a drink of whisky and
then a dose of sleeping medicine, but she did not get any better, so I called you.”
It took some time to impress the idea that I preferred to be oalled before the
ever-ready remedies were used. Evidently a physician had been a luxury, and
only oalled as a last resort. I have known of attendants hiring patients to
work for them by giving them whisky and sleeping medicine, which they (the
patients) had come to orave as the opium-eaters their opium. The amount of
this sleeping medicine used on the female wards alone was enormous, as was
also the whisky. It is safe to say that the amount used on the female wards
alone, with less than three hundred patients, was twenty times more than is used
in the entire institution of over fourteen hundred patients at Kankakee, and the
noise at the latter institution is much less than at the Cook County Asylum.
That the attendants, both male and female, helped themselves quite largely
from the ward whisky bottle, which was filled whenever they desired, is beyond
doubt. The real needs of the patients seemed to call for no thought. They had
no bath towels, and the attendants were in the habit of putting the clothing on
the patients without drying the skin. The wards were frequently cold, and the
patients had no winter clothing. Many who would have been benefited by out¬
door exercise did not leave the ward once in six months, because there were no
wraps. No system was adopted with regard to clothing, and no account taken
of what patients brought to the hospital. The bedding was at one time in¬
sufficient.
Restraint was used at the discretion of the attendant; I have seen a patient
jacketed, unable to use her hands, eat her food from her plate like a wild beast.
The food is almost beyond description. Where is the State Institution in which
you will find deaths from scurvy frequent ? Where, but at the Cook County
Asylum, will you find two patients fiercely fighting for a small potato given
only as a Sunday luxury ? Where will you find a hog's head, hair and all,
given to the patients ? I have often picked out the half of a hog's ear with the
hair on it from a dish set before the patient to eat. I have picked out bunches
of hair half as large as my little finger from other patients' food. Dying
patients, if fed at all, were fed on sour milk. The milk, which is so great a
necessity in the treatment of the insane, was almost never fit for use. They had
meat never more than once a day, and often not that. The scurvy alone will
speak for the vegetables; whisky and sleeping medicine seemed to be the only
articles of diet which never failed.
The drug-room was the greater part of the time turned into a saloon. Often
I have had to wait for a prescription, which was needed for an urgent case,
until the druggist had served with beer, port, sherry, or whisky a roomful of
men. I never visited the drug store but with trepidation, and always breathed
more freely when I left its degrading atmosphere.
Mrs. Dr. Lowell, an ex-attendant, adds to this picture a
fitting pendant: " The attendants on the female side of the
house indulged freely in stimulants, and I have on more than
one occasion observed at least three of them under the
influence of liquor. Some of them used in the presence of
the male attendants decidedly coarse language. In every
xxxiii. 14
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202 American Problems in Psychiatry , [July,
ward a bottle of sedative mixture and a bottle of whisky
were kept, and these were administered freely by the
attendants. It was a common remark : ‘ It is no use doing
anything for these cranks ! ’ The physician was called only
as a last resort, and though diarrhoea and scurvy were very
frequent, butlittle attention was paid to the diet; sick
patients were fed with the same food as the others. The
great article of diet was pigs’ heads boiled without being
shaved or cleansed. The meat frequently stank. The
clothing and cleanliness of the patients received but little
attention. For weeks and weeks we were without fine-tooth
combs, and scrubbing brushes were used instead.” Typhoid-
fever patients five days before death were jacketed for
refusing to work on the ground of illness. 33 In con¬
sequence of the practice of entrusting males with keys to
the female wards at least one female patient became
pregnant.
The number of attendants in the Institution were of
necessity insufficient since accommodations are limited.
They are still more numerically reduced by the practice of
allowing every other afternoon off duty; a practice unknown
to other institutions, and productive of neglect of the
patients since the morning is devoted by the attendant to
preparing for the afternoon’s recreation.
Although I had occupied, through examination, the posi¬
tion of assistant physician to the New York City Insane
Hospital during the dying days of the Tweed ring, I was
unprepared for the den in which I found myself when
elected medical superintendent. To aid in destroying the
discipline, there are two drinking-houses, licensed by the
County Board, in the immediate vicinity of the Hospital,
which are places of resort for the employes , and a female
attendant had taken two female patients, at different times,
and treated them there; she is still in the employ of the
Hospital.* The liquors at Dunning were and are kept in the
drug-room, and are dispensed with great freedom to visitors,
officers, and even employes . 83 The Institution was in
much the same condition it had been for years. Drunken¬
ness, scurvy, brutality, starvation, filth and cold 33 were
the portion of the insane. Not a single attendant seemed to
have any idea that the insane were human beings.
* The Institution in 1884 and 1885, with 1,164 patients, used 3863.68 dollars’
worth of liquor (£733); the four State Institutions, with 5,167 patients, in 1884
and 1886, used, 2,167 dollars’ worth (£434).
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m
1887.] by Jas. G, Kiernan, M.D.
Restraint was and is used by the attendants at their own
discretion. In April, 1886, a quiet, hard-working patient
was beaten, jacketed, and starved for forty-eight hours, and
the authorities never found it out until he escaped, when
the “ Daily News ” detailed his misuse for their information.
Men from the slums were and are entrusted with keys to the
female wards, and in January, June, September, and Decem¬
ber, 1885, were detected in partial dishabille therein after
midnight.
Female attendants guilty of neglect, brutality, unseemly
conduct, and denounced for wilful manifest perjury by the
medical members of the State Board of Charities, were and
are still in the employ of the insane hospital. Such is
practically the condition of things to-day.
Nor is it surprising, since the institution is run on a purely
political basis. The warden and superintendent are gang
politicians. The last was an assistant marshal in a low
political procession of 1884. The superintendent, in de¬
fiance of Conolly, avows as a settled principle that he does
not believe in watching employes who have equal rights
with the insane.
Why well-disposed county employes do not expose mis¬
deeds, will be readily understood from the fate which befell
my conscientious first assistant. Dr. Koller. Indignant at
the unseemly conduct of the housekeeper, a rough, brutal
woman, proven to have admitted men at unseemly hours to
her sleeping apartment, he charged her with misconduct
with a commissioner. The grand jury* was packed with
routs to indict him for criminal libel. The court bailiff, an
admirer of the woman, picked the trial jury, and had their
care. The State’s attorney neglected a murder case to
vindicate this woman. By the expenditure of hundreds of
dollars of the State’s money, and by charges which dis¬
graced the bench, Dr. Koller was found guilty; but the
judge, fearful of an appeal, only fined him five dollars (£1)
for an offence punishable by at least a 250 dollar (£50) fine
and six months’ imprisonment. Neither Judge Gary nor his
subordinates exacted this fine until nearly a year after, when
Dr. Koller testified to abuse of the insane.f
♦ The county commissioners choose the grand jury.
t The character of the woman whom the county thus vindicated at such a
cost may be judged from the following extract from the 1886 State Board of
Charities Report:—“ The housekeeper took a patient suffering from some female
disorder out of her ward and set her to scrub in violation of orders; when Dr.
Kieman expostulated with her, she replied, * I do not propose to have anything
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American Problems in Psychiatry , [July,
Although patients had been suffering from a lack of
clothing, this housekeeper and other employes had many of
them at work on quilts and fancy work for their own use.
Anxious to get the patients clothed, I urged them, instead
of doing fancy work, to put their time on sewing and
knitting; 81 but this was forbidden by the commissioners for
reasons which will soon appear. Prior to my advent the
patients had been starved, beaten, and drugged 83 into making
“ fancy work,” which attendants took to the Women's
Exchange and sold for their own benefit. The work of
patients on their own behalf interfered with these per¬
quisites of the attendants, and hence there are now no re¬
strictions on fancy work, which places the patients, as before,
at the mercy of the attendants.
Contractors who for decades supplied filthy and rotten
meat and sour milk, 33 still supply the same.
Nothing better could have been expected from the
humanitarianism of the men who rule the County Board.
Its “ boss,” a man chiefly noted for his biawls in low dens,
taunted the brother of a poor Scandinavian woman who
hanged herself through neglect of one of his appointees,
with his poverty, when he dared to remonstrate against the
neglect which caused his sister’s death.*
Bad as is the provision for the insane in the insanO*
hospital, the provision for them in the gaol, whither they
are sent to await trial for insanity, is still worse. They are
in charge of an a experienced nurse,” who openly avows
brutality as a means of treatment. A medical politician has
their care who has several times been refused membership to
the Chicago Medical Society.
The only bright tints in this dark picture are the arduous
attempts at reform of Drs. Folsom, Jewell, Brower, Lyman,
Clevenger, Koller, and Mrs. Helen S. Shedd, and, brightest
of all, the self-sacrificing labours of Drs. Delia A. Howe and
Harriett C. B. Alexander. Of the labours of Dr. Howe, I
to do with you or your orders.* The whole medical staff united in a request for
her discharge, but it was refused; Commissioner Leyden said that if Dr.
Kiernan continued to insist upon it he would make it hot for him."
* As this case illustrates the discipline of the institution, a citation from the
State Board Report 33 may be permitted:—“ There was a Miss Finerty, who
had been cautioned that a certain patient was not to be left alone in the ward,
but taken out when the rest were; she disobeyed, left her in her room, and while
there she hung herself. In consequence of this suicide, there was an investiga¬
tion by the Committee on Charities, when the warden and Commr. Van Pelt
said that she should be discharged, but Commr. J. J. McCarthy said that she
should not be, and she was not.”
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205
1887.] by Jas. G. Kiernan, M.D.
have already spoken. Great as was her self-sacrifice, that of
Dr. Alexander was, if possible, greater. It was a great
sacrifice for a refined lady to enter the den of coarse males
and females, which the Cook County Insane Hospital was,
and is ; but Dr. Howe had been a missionary in China, and
somewhat inured to such experiences. It was a greater
sacrifice for a woman of the world, from a sense of duty, to
leave refined society, to entail upon her family incon¬
veniences, and to expose herself to the insults of coarse
rowdies, more especially when it is remembered that the
objects for which she was appointed brought her somewhat
in conflict with myself. 35 The picture, however, relieved
by these bright tints, remains very sombre. The institution
is still a den of lazaroni, and more decided action should have
been exercised by the supervisory body, the Illinois States
Board of Charities. The law says that this Board shall
visit these institutions annually, but for two years prior to
November, 1885, no member of the Board had entered the
precincts of the insane hospital, despite the public exposures
of abuses in 1884, made by myself, then medical superinten¬
dent, Drs. Clevenger, Howe, and Koller, then my assistants,
despite a written request for investigation addressed to the
Board by Dr. Clevenger and Secretary Ambler, of the
Chicago Citizens* Association. 84
In 1883, when the insane hospital was a scene of drunken
revelry, brutality, scurvy, and starvation, 83 the Board said :
“ Dr. Spray deserves credit for having entirely dispensed with
the use of restraint.** . . . “ This institution is conducted
in the same manner as the Illinois State Hospitals, and the
same regard is had for cleanliness, ventilation, and the care
and comfort of patients. In most respects this asylum com¬
pares favourably with the State institutions; ” a laudation
which, as its 1886 report 83 demonstrated, was absolutely false.
Despite the publicity of the charges made in 1885, it
required the powerful direct and indirect influence which
the Chicago “ Daily News ** brought to bear on the Governor of
the State, and the Governor’s order to compel it to do its
plain duty, which, it confesses, it was “ reluctant ’* to do.
Even after drunkenness, brutality, starvation, scurvy, had
been proven, it did “ not attribute deliberate and wilful un¬
kindness to any of the County Commissioners, or of the
officers, or employes of the insane hospital.*’ It neglected
to indicate how far what ordinary mortals call brutality must
go to constitute deliberate or wilful unkindness, since
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American Problems in Psychiatry , [July,
dragging sick women out of bed against medical protest,
jacketing typhoid fever patients, slapping and striking them,
kneeling on their stomachs, feeding them on filthy and
rotten badly-cooked meat and sour milk, 83 were not evidences
of deliberate, wilful unkindness. Anything less than the
Seven Stages of Cruelty of Hogarth evidently would not dis¬
turb the Board’s composure.
The law under which the insane are sent to the hospitals
in Illinois disgraces humanity. Family secrets are exposed
to public view; ignorant juries discharge homicidal lunatics,
who murder their friends on their return home. The law
does not protect the sane, since it places in the hands of
venal politicians powers which it denies reputable physicians.
It does not allay the apprehensions of the insane, for as many
of them (demonstrably tried) deny trial as in New York
they deny medical examination for certificates. It does not
protect property, for this question is not investigated, and
the issue of insanity has to be retried in the Probate Court.
The trial is hence only an inquest, and the verdict is subject
to revision by the medical politicians of the insane hospital.
Two of them, ex-porters, just graduated from a Chicago
diploma-mill, recently turned loose as sane a paretic dement,
who had been wasting his estate, in full defiance of the
opinion of two leading alienists, thereby entailing a retrial,
with increased cost to the family, who were subjected to
unkind criticism during the interregnum by the press. It
does not protect the property of the insane in the hospital,
for insane persons in the county insane hospital have signed
orders for money deposited in books for the benefit of un¬
scrupulous people, and to their own loss. It does not pro¬
vide for the protection of the public against the chronic
insane with homicidal tendencies. More than one such
patient has been discharged, and committed fresh assaults.
No lunatic, guilty of murder, assault, or any other crime,
should be discharged except upon a retrial to determine
recovery. No lunatic should be permitted to roam at large
unless someone is legally responsible for him. In such
event the so frequent crimes by “ harmless *’ lunatics would
cease, since that tender spot, the pocket of the lunatic’s
guardian, would suffer. No lunatic having property should
be discharged as recovered from the insane hospital until
the question of his recovery has been retried before the
Probate Court Judge. More money is stolen from lunatics
taken out of hospitals than ever was stolen by the mythical
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207
1887.] by Jas. G. Kiernan, M.D.
method of patting sane men therein. One phase of the
subject is a disgrace to modern civilization. The average
layman looks upon the recovered insane with fear, mistrust,
and suspicion. Many a poor mortal is driven hack into an
insane hospital by the weight of the crime of having once
suffered from a curable insanity. This cruelty is hardly
surprising when it is remembered that among the lower
Irish and Italians insanity is still looked upon as a demon
possession, and from exorcisms certain local clergymen reap
a golden harvest. An Aid Society for discharged patients is
needed in Cook County.* Many a man and woman could
be saved from lifelong insanity thereby. The history of
insanity in Cook County shows:—
First: That the speculative emotional element and its
resulting struggle for precedence should be driven from its
school, academic, business, religious, and political life.
Second: That the social life of the population needs
attention. The sanitary surroundings and social conditions
of the poor should be improved, nor do the sanitary sur¬
roundings of the rich need less attention.
Third: That these improvements, while diminishing in¬
sanity, crime, and drunkenness to a certain degree, just
skim the surface of the evil. Most degenerate lunatics are
imported. Prevention must begin ere the immigrant,
whether of his own accord or &t the mandate of his Govern¬
ment, leaves Europe. No one should be permitted to immi¬
grate to the United States who cannot give a clean bill of
health as to hereditary, nervous, or other disease, crimi¬
nality, pauperism, in himself and his immediate maternal
and paternal ancestry. The Government of the United
States was founded by well-balanced men, but unless
measures of this kind be taken Americans will sink to the
level of the Romans, who cared for nothing but “ bread and
circuses.” Circuses are common enough in our legislative
halls, but are not yet regarded as necessary elements of
government.
Fourth: All laws respecting the insane need revision, and
to secure proper revision the whole question of provision for
the insane requires thorough legislative investigation. More
perfect inspection than that performed by the Illinois
State Board of Charities is needed. All restraint should be
registered (as required by law in other States) in a book
open to public inspection, giving date, reasons, and dura-
* Like the English After-Care Society.
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208
American Problems in Psychiatry, [July,
tion. Restraint should be applied only on prescription
of the physician. When practicable, all restraint should
be abolished.
Fifth : That all county insane should be placed under the
care of the State, since under the existing state of thing3
the insane are maltreated, and their maintenance costs
enormously, since universal experience in the United States
has shown that county care is synonymous with brutality.
Sixth : That strict and frequent supervision of the insane
is absolutely necessary. Mr. Geo. William Curtis has said :
“ The surest defence of every great public interest is the
turning on of the great public light. To every community
as to every individual, with a persistence that cannot be
denied, calling out of the divine heart comes the old ques¬
tion, Where is Abel thy brother ? John Howard heard and
answered. Chiaruggi, Pinel, and Tuke heard and answered.
Gardner Hill, and Conolly heard and answered. Elizabeth
Fry and Dorothea Dix heard and answered. The conscience
and good sense of other communities have heard and
answered. We hear the question, let us take care that we
answer promptly, bravely, wisely.”
1 “ Ill., Mass., New York, Ohio, and Pa. States Board of Charities’ Reports,”
1868-1886 ; “ Anchorage (Ky.) Lunatic Asylum Investigation Report; ” “ New
York Legislative Documents,” 1882-84.
2 Compare Spitzka, “ Race and Insanity,” “ Jour, of Ment. and Nervous
Diseas1880; and Kiernan, “Alienist and Neurologist,” 1886; “Joum.of
Ment. and Nervous Disease,” 1886; “ Neurological Review,” 1886.
3 “ Klin. Ahbandl. fiber die Psych. Krankh.,” 1874. The term was first used
in this connection in English by Spitzka (“ Jour, of Ment. and Nerv. Dis.,”
1878, p. 632).
4 Spitzka, “ New York Medl. Gazette,” May 15th, 1880.
* “ History of England,” “ Remarks on Grandral.”
® Godding, “ Two Hard Cases.”
7 “ Chicago Med. Review,” Vol. iv.
• “ Jour, of Ment. and Nerv. Dis.,” 1883.
9 “ Jour, of Ment. and Nerv. Disease,” 1886.
i® " Boston Med. and Surg. Jour.,” Vol. ii., 1880.
11 “ Alienist and Neurologist,” 1883.
12 “ Amer. Jour, of Nerv. and Psych.” 1883.
13 See also “ Forensic Aspects of Folie & Deux,” “ Alienist and Neurologist,”
1883.
u “ Mental Diseases.”
14 “ L’uomo Deliquente.”
i« “ Letter to the Emigrant Princes.”
17 “ Burke’s Letters to his Son.”
is The Parisians.”
i® “ Suetonius.”
20 “ Macaulay, “ Hist. England ; ” Green, “ Hist. English People ; n Jacoby,
“ Studies in Selection; ” Ireland, “ Blot on the Brain.”
Digitized by L^ooQle
by Jab. G. Kiernan, M.D.
209
1887 .]
" « Sainto’ Best.'’
» “ Lothair.”
n “ Neurological Review,” Vol. i., No. 1.
* 4 Carlyle describes France during the Revolution as having the same
attraction for paranoiacs as the U.S. have permanently (“ French Revolution ”).
15 “ Chicago Med. Journal and Examiner/’ April, 1886.
*• Ibid., Nov., 1885.
** Dr. E. C. Spitzka, “ Cooper Union Address,” Deo., 1879.
,# Macaulay, “ Political Georgies,” 1828:
“ . . . . And boodle's patriot band,
Fresh from the leanness of a plundered land.”
*• 11 Boston Med. and Surg. Journ.,” 1875.
90 “ Chicago Daily Times,” Deo., 1875.
si “ Chicago Med. Jour, and Ex.,” Nov., 1885.
si Ibid.
99 “ Report Dl. State Board of Charities,” Jan. 28th, 1866, p. 6-16.
u Chicago Dailies, Oct. to Deo., 1884; “ Chicago Daily Times,” Oct.
26th, 1884 j “ News,” Nov. 16th, 1884; “ Tribune/’ Nov. 29th, 1884.
54 “ Alienist and Neurologist,” Jan., 1887.
** “Chicago Staats Zeitung,” 1881; “ Daily Times,” 1882-3.
*1 “ Neurological Review,” Vol. i.
Folie du Doute. By P. J. Kovalewsky, Professor of
Psychiatry and Neurology at Karcov.
Every “ psychiater ” knows that “ psychoses ” are divided
into two great groups : primary “ psychosis ” and hereditary
“psychosis.” These two groups differ very much in their
manifestations, in their course, and in their final issue.
Such a classification can therefore be considered as rational,
logical, and satisfactory.
But even with such a division each separate group con¬
stitutes a very complicated whole, embracing a great number
of varieties, hereditary or acquired. It would be interesting
to study the connection existing between these varieties and
their extent. Such a genesis and affinity can only be based
on clinical observations, which, though apparently abun¬
dant, are nevertheless still insufficient.
For the present I limit myself to studying and following up
the genesis of one small branch of “ psychosis ” known by
the name of “delusion of doubt” {folie du doute).
Hereditary “ psychosis,or “ psychosis ” by degeneracy,
we divide into two great groups. The origin of one lies in
modifications in the central nervous system, permanent
organic modifications which admit of macro- or micro-scopic
investigations, and of others resulting from modifications
which in most cases are not accessible to the present methods
of investigation, and are, in consequence, better known
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210
Folie du Doute ,
[July,
under the name of dynamic modifications. To the first
group we apply the denomination idiocy, from which spring
idiotism, cretinism, imbecility (imbecilitas), and frequently
moral insanity. The second group has for its basis the
neurasthenia, which gives rise to an indefinite number of
various kinds of psychosis and neurosis.
Neurasthenia is not in itself psychosis. It is only the soil
from which grow up degenerative psychosis or neurosis. It
forms the background from which we can draw the clinical
picture of every nervous degeneracy.
Indeed, when emotional phenomena prevail in neuras¬
thenia, pathophobia or fits of morbid fear are developed,
mental derangements will predominate, uncontrollable
obsessions (Zwangsvorstellungen, Westphal; GrubeJsuche,
Griesinger) will be developed. Vital senses, when dis¬
organized, produce hypochondria or hypochondriacal lunacy;
when reflex disorders prevail epilepsy is developed; when
emotional (emotif) and vaso-motor derangements prevail,
hysteria shows itself, &c. It is questionable, I think,
whether hysteria and neurasthenia can exist together.
These two kinds of neurosis are certainly very closely con¬
nected. They are sisters. They can exist together, and
they can transfer themselves from one to the other, but
whether one forms part of the other, or whether the two
constitute two distinct illnesses, is a question which remains
to be solved. It is indisputable that neurasthenia is more
common in men, as hysteria is in women, but it is impossible
to assert that it exclusively depends upon the peculiarities in
the organization of the sexes, as we often meet with neuras¬
thenia in women, and hysteria, in all its forms, in men.
Children of psychopathic and neuropathic parents inherit
from them either a decided organic modification of the
central nervous system or only a predisposition of the
central nervous system to psychosis and neurosis. In the
first case they must be classed in the group of idiocy, whilst
iu the second case, neurasthenia or hysteria spring up from
them.
Many neurologists attribute the cause of neurasthenia to
the bad nutrition of the nervous system, from which results
unstableness in its functions, which would seem to show
that this state of the nervous system is very apt to undergo
a transition leading to more serious disorders.
I allow myself a small digression. I do not consider
neurasthenia as purely hereditary, for it may be the con-
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by P. J. Koyalewsky.
211
1887 .]
sequence of drunkenness, syphilis, venereal excesses, in¬
tellectual overwork, an excited life, conditions of social life,
physical exhaustion, traumatism, &c. But, firstly, in a great
majority of cases, these influences may be considered as of an
auxiliary nature in individuals with a hereditary predis¬
position; and, secondly, they appear as the primary and
essential causes in a very small number of cases. We shall
bear in mind only the cases of hereditary neurasthenia.
Neurasthenia is a very common disease. Beard * calls it
the American disease, in consequence of the large number
of people suffering from it in America. But this is not quite
correct, for at the present time we Russians, as regards the
number of neurastheniacs in our country, could not find a
rival anywhere else, and we could, therefore, with more right
call neurasthenia a Russian disease.
Having inherited from their parents an unstable nervous
system, neurastheniacs preserve during their lifetime a pre¬
disposition to serious neurosis and psj'chosis of all kinds.
Fortunately, the largest majority of such individuals under
the influence of favourable conditions of life, or of successful
treatment, remain with the predisposition, but with nothing
worse. The large majority of men continue to live without
falling ill of permanent neurosis and psychosis, and die in
“ a normal condition of mind.” It is clear that in all such
cases the nervous affection remains in a latent state. How¬
ever, although they themselves, in consequence of favour¬
able circumstances, have not suffered from these diseases,
they can transmit them to their progeny, and therein lies
the explanation why neurosis and psychosis can be trans¬
mitted by the grandfathers to their grandchildren.
But in consequence of the unstable state of their nerves
other neurastheniacs cannot support the battle of life, and
they are subject to serious affections.
On such a pathological soil the neurasthenias can develop
themselves, or only the elements of an abnormal state of the
mind, such as uncontrollable obsession (Zwangsvorstel-
lungen), or morbid fear, agoraphobia, claustrophobia,
oieophobia, and, or only, hallucinations, &c.; but sometimes
we meet with neurosis and psychosis completely developed,
such as “ hebephrenia,’ 5 primary insanity, folie du doute, &c.
If we study these two categories of the subsequent mani¬
festations of neurasthenia, namely, the primitive elementary
* Beard, “ Nerreensohneache.”
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Folie du Doute,
212
[July,
disorders, and complicated psychosis, we find that there are
more cases of the former than of the latter.
It is likewise a noteworthy fact that complicated psychosis
and neurosis engendered on neurasthenic soil almost always
go through a stage of elementary disorders, and seem to be
file further development and the completion of these dis¬
orders brought to a state of perfection.
Thus, the case presents itself as follows :—In consequence
of an hereditary taint in a very great number of cases,
instability of the nervous system shows itself, i.e., neuras¬
thenia. This is the first stage of nervous degeneracy of
mankind in the shape of abnormal nervous phenomena.
With most of these neurasthenic patients these patho¬
logical phenomena do not become developed further.
With others these disorders continue to progress, and they
enter the second stage of pathological manifestations: im¬
pulsive ideas, morbid fear, anxieties, prsecordialis, &c.
Thus the second stage of nervous degeneracy consists in the
manifestation of elementary disorders of mental activity on
a neurasthenic soil. The possibility of the development of
pathophobia on neurasthenic soil (in the shape of agora¬
phobia, &c.) has been shown by Beard, Tamburini,* * * § Troit-
sky,f A. A. Takoblew,J and others.
In the great majority of cases this class of patients re¬
cover, but with some the illness progresses and enters into
the third stage of degeneracy—fully developed psychosis and
neurosis, such as primary madness,/oZi€ du doute , &c. Thus
degenerative psychosis constitutes the third or final stage of
degeneracy in general, and before running its course it
almost always goes through the first and second stages.
Such is the general view which we take of degenerative
psychosis. Each of them, until the last stage, pursues a
more or less known course.
For the present we shall limit our task to the study of one
of these morbid states, “ la folie du doute 9 ” which has been
so admirably treated by Professor Legrand du Saulle.§ First
of all, we consider the delusion of doubt as a degenerative
psychosis, and, therefore, as the third stage of nervous
degeneracy, and, according to our opinion, it must be pre¬
ceded by the first stage, neurasthenia, and by the second.
* Tamburini, “ Rivista Sperimentale, di frfeniatria,” 1883.
t Troitsky, “ Russian Medicine,” 1885.
+ A. A. Takovlew, “ Arch. Psych./’ vii, 2.
§ Legrand du Saulle, “ La folie du doute,” 1875.
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pathophobia, la folie du doute itself constituting the third
stage.
We shall not stop to describe neurasthenia, as this morbid
state is known to everyone. It appears in early childhood,
embracing the whole nervous system—the mind, the vital
senses, the organs of sense and motion, anc^ the vegetative
functions. On this background of continually-changing
nervous anomalies, there appear from time to time short
attacks of fear, which have something particular, and have
their own peculiar physiognomy. These phenomena were,
for the first time, carefully described by Westphal * under the
denomination of agoraphobia. Flemming f thinks that this
morbid state was first described in the year 1832, and Horingf
ascribes it to Alexander Balbinus Lombardus, who, in 1512,
observed the vertigo in public places. However, the first
careful clinical description was made by Westphal, and,
amongst French authors, it is Legrand du Saulle§ who has
masterly treated this subject. This state generally occurs
when an agorophobic crosses a place or a street, when he
feels intense fear that he will not be able to accomplish this
act. The respiration becomes short. The throat is seized
as it were by nippers. The heart palpitates, and gets
benumbed. The hands, feet, and the whole body tremble.
The knees bend. The patient is ready to fall. He would
cry, but he is deprived of his voice. He feels as if he was
far away from the whole world; and has an everlasting feel¬
ing of intense horror; and, at the same time, he is per¬
fectly conscious of the absurdity of what he feels. A trifling
circumstance is often sufficient to free the patient from this
dreadful state of fear—the presence of a child, be it even a
year old (Cordes ||), a passing carriage, a stick, an umbrella,
the light of a lantern (Legrand du Saulle). Patients fall
into^this state at the sight of open places, broad streets,
churches, theatres, large rooms, &c.; others when they find
themselves near p,n open window, looking into a square, or
even at the only thought of open places. Considering that
in all these cases the causes of fear were open places, West¬
phal called this disease fear of open places, agoraphobia
(Platzfurcht).
# Westphal, “ Archiv. fiir Psychiatrie und Nervenk./’ Vol. iii., No. 1.
t Flemming, “ Allgem. Zeitsch. f. Psychiatrie/’ Vol. xxix.j No. 2.
I Horing, u Allgem. Zeitsch. f. Psychiatrie, Vol. xxix.
§ Legrand dn Saulle, “ Etude olinique sur la peur des Especee,” 1878.
II Cordes, “ Arch. Psychiatric,” Vol. iii., No. 3.
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However, further clinical observations showed that such
fears manifest themselves not only in the presence of open
spaces, but that there are likewise some neuropates who are
liable to the same fears at the sight of enclosed places, a
closed room, a workshop, &c. Professor Ball* * * § described
this state of morbid fear under the name of claustrophobia,
and Raggi + (Milan) under the name of clitrophobia. This
same pathological state had been already described by Morel,{
one of whose patients could not bear the sight of the rooms
in the lower floor.
As this same kind of fear shows itself in patients at the
sight of open, as well as enclosed places, it would be more
rational to unite these two diseases under one common
denomination. This Beard did, calling them “ topophobia,”
fear of places.
But this is not all. In many cases morbid fear shows
itself under circumstances which have nothing in common
with spaces. Briick relates the case of a clergyman who fell
into a state of terror when his head was uncovered. Whilst
under a tree, or an umbrella, he ceased to be subject to this
state of fear. Cordes’§ patients were subject to the same
fears in crowds. A patient of Krafft-Ebing feared to break
her teeth. I knew the case of a young lady who was in a
state of terror whenever she was in a carriage. She fancied
that her mother and children were under the wheels. The
uncle of this patient is an agoraphobic, her grandmother had
a morbid fear of water, even in a glass. With certain
patients the same fear prevails at the sight of needles, glass,
dirt, &c.
I know a lady who during her pregnancy could not bear
the smell of tobacco, and subsequently the sight of her
husband, whose presence caused her to fall into a state of
prostration and despair, and brought on vomiting. Soon
after she feared water, whilst washing or drinking, and soon
after the mere thought of water brought on fits of fear and
anguish. Subsequently she could not bear the sight of her
own hands. When she saw them suddenly she used to have
fits of agitation, anguish, fear, and despair. Such a state of
things lasted the whole second month of her pregnancy.
* Professor Ball, “ De la Claustrophobic Annal. Medical. Psychol.,” 1879.
t Raggi, “ La Clitrophobie,” “ Gazette des Hopitaux,” 1878, No. 49.
t Morel, “ Du d61ire 6motif. Arch. g£ner de Medecin,” 1866.
§ Cordes, “ Arch. f. Psychiatr. und Nervenk.,” Vol. x., No. 1.
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1887.] by P. J. K!ovalewsky.
A great many other cases of morbid fear have been
described by several authors. According to the circum¬
stances under which these cases of fear were subjected to
observation they received different names. Thus appeared
the denominations of agoraphobia, fear of open spaces;
claustrophobia and clitrophobia, fear of enclosed spaces;
topophobia, fear of space; astrophobia, fear of light¬
ning (Beard); anthopophobia, fear of crowds; mono¬
phobia, fear of solitude; panphobia, fear of everything;
misophobia, fear of dirt (Hammond); vikophobia, fear to
return home (Salemi-Pace); hypsophobia, fear of heights
(Arndt); botophobia, fear of cellars, &c. And until now
some authors are describing various morbid fears, to which
new denominations are given, and will continue endlessly to
be given.
The feeling of fear is natural to man (impulse, unpro-
pitious circumstances), and when there are reasons for it,
has nothing pathological in itself. It may be considered
pathological only when the causes which brought it on are
in disharmony with it.
In the present case, its pathology consists in the fact that
the fits of fear are caused by an absurd and abnormal im¬
pulse, the patient being perfectly conscious of their absurdity.
These phenomena come within the full meaning of im¬
pulsive feelings (Zwangsempfindung). We have already
seen that morbid fear can be produced in different people by
various causes and circumstances, and we should be
obliged to give distinct names for each kind of morbid fear,
but as the number of cases and phenomena in the world is
infinite, we incur the danger of rendering endless the
terminology of morbid fears; and we suggest, therefore, to
bring all these different kinds of morbid fears under one
denomination—pathological fear, or pathophobia.
In some individuals the cause which brings on an attack
of fear continues to be the same throughout their lives;
whilst with others the causes change. I have, for instance,
observed a case * in which the patient had attacks of fever in
open and enclosed places. The aforementioned case of a
lady who feared her husband, water, and her hands, is an
instance of fear brought on by different objects.
I shall quote another case which has come within my own
personal observation. A lady belonging to the aristocracy,
* P. J. Kovalewsky, “ Arch. Psychiatr.” Vol. vi., p. 2.
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Folie du Doute, [July,
very nervous, with psychopathical heredity, had a child. She
had the imprudence to let this child go to her parents, a
considerable distance off. This made her very anxious.
She could neither sleep nor eat well. A fear of dirt made
itself manifest in a short time. She used to wash her hands
constantly. Everything she touched soiled her, and re¬
quired to be cleaned. The skin of her hands began to pain
her, as she used to wash them more than 200 times a day.
The contact of any object, whatever it might be, even her
own body, and the mere thought of touching something im¬
plied the necessity of washing. She soon began to wash her
dresses; first her cotton, and then her silk and velvet
dresses ; the uniforms of her husband, and fur coats. It
became necessary to put her under restraint. However, six
days later the child returned, and she recovered.
We shall mention another case of Dr. Baillarger. A
gentleman on meeting women invariably asked his com¬
panion whether the lady was pretty or not, and, in order to
tranquillize the patient, it was necessary to answer in the
negative. However, on one occasion, when starting for a
long journey, at the time the train left he omitted, on meet¬
ing a lady, to put the usual question. When he was settled
in his place late at night he put the question to his com¬
panion, who had the imprudence to say that he had not
noticed the lady. The dreadful consequences which this
answer produced could only be calmed by returning to Paris
for the specious purpose of ascertaining the fact concerning
the lady.
These cases prove how the phenomena of pathophobia can
become more and more complicated, and pass over into the
third stage of degenerative psychosis—the delusion of doubt
(folie du doute , Legrand du Saulle).
Before describing this third stage I shall point out another
fact which, until lately, stood isolated, but which must be
considered as a link in the chain of stages previously men¬
tioned.
It has long ago been known that in the pathology of
mind there are cases when patients did not move their
hands or feet under the influence of a false idea that their
limbs were made out of wood or glass, and that they would
break them. I know of a case, which came* under my
E ersonal observation, of a patient refusing to work because
is hands were of gold.
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1887.] by P. J. Kovalewsky.
In 1867 Russell Reynolds * published a case of paraplegia
resulting from a sickly fancy or fear of an illness. Analogous
cases were observed by Prof. Erle,+ Prof. Tchiriew,t and
others. It is remarkable that all these patients could move
their paralyzed limbs whilst they were in bed, but were
unable to walk. Charcot § observed similar phenomena in
hysterical subjects, and I noticed them in many persons that
were in a state approaching to hysteria. Dr. Sovetow|| de¬
scribed the case of a patient who could freely move his feet
in bed, could go up and down a staircase, could walk on a
floor (divided into squares), but who fell when he had to
walk over a smooth floor. He was unable to walk from the
fear of falling. Sovetow, with the view of forcing this
patient to walk, had a stick made with a transverse piece
of wood adjusted at the end in the shape of a cross, so that
at every step the patient had to overstep this transversal
piece of wood. By these means the patient was made to
walk.
I had under my personal observation 1) a case of tabes
dorsalis, the cause of which was the fear of falling ill of
this malady. The patient was decidedly neurasthenic from
childhood, and during the last five years had undergone
great misfortunes. His brother-in-law, father of eight
children, died of tabes. The sight of this living corpse
struck so forcibly the imagination of my patient that he
had a constant dread of being seized with the same illness,
the symptoms and development of which were well known
to him by the sad case he had before him, and by the study
of books. He was constantly watching for similar symptoms
in himself. He soon felt pains in the back, and sudden and
violent pains in the extremities, and unsteadiness in the
gait. He could not stand with his eyes closed; pains round
the waist, and disorders of the sphincters. After a careful
examination of the patient, it became evident that the ill¬
ness was of an illusionary character, which had been brought
on by the dread of falling ill. In a month, under the in¬
fluence of an anti-neurasthenic treatment, the patient com¬
pletely recovered.
We believe that these cases can be justly considered as
# Bussell Reynolds, “ Brit. Med. Journ.,” 1867, 6.
t Erie, 11 Ziemseen’e Handbnch Special Pathologic.”
X Prof. Tchiriew, “ Medical Messenger,’’ 1884. (Megucaseckia Brocmnnkr.)
§ Prof. Chaicot, ” Le Progr. Mfcdical,” 1885, and others,
jj S. N. Sovetow, “ Arch. Psychiat.,” Yol. iii., 2.
4 P. J. Kovalewsky, ** Ceutralblatt f. Nervenheilkonde,” 1885.
xxxin. n , 15
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Folic du Doute.
[July,
forming links between pathophobia and folie du doute. It is
possible that we may still be in want of some intermediate
links, but we hope that clinical investigations will soon
complete our knowledge on this point.
The delusion of doubt is not new in science. Cases of
this kind were known to Esquirol.* * * § Falr6t, pere ,f described
them under the name of “folie du doute” and so did, after
him, the French savants, Parchappe, Tr61at, Baillarger,
Falret,^fo, and others.
Something of the kind has likewise been described by
GriesingerJ under the name of “ Griibelsucht,” or “ Frage-
sucht.” But this is not folie du doute in its full meaning;
it only constitutes part of it. The patients, are tortured by
a series of absurd questions. For instance, why has man
one nose and not two ? Why is his hat in his right and not
in his left hand? &c. “ Fragesucht” is frequently observed
in the “ folie du doute” but it does not characterize the
general aspect of this disease.
It is to Legrand du Saulle§ and to Prof. Ball|| that we owe
a complete clinical investigation of this disease.
We shall not give here a full description of this alienation.
We shall limit ourselves to stating that the disease presents
a series of pathophobic phenomena, often accompanied by
uncontrollable obsessions, “ Anxietas prsecordialis,” tic.
(Prof. Charcot).H The characteristic symptoms of this
disease are, according to Ball : (a) The presence of con¬
sciousness (Doyen** is of the same opinion); ( b ) absence of
hallucinations ; and (c) an imperative want of the confirma¬
tion of the patients’ doubts by other persons.
(To be continued.)
* Esquirol, 11 Maladies Men tales.”
t Falret, J., “ De la folie morale,” 1866.
J Griesinger, “ Arch. f. Fsychiatr.,” Yol. i., No. 1.
§ Legrand du Saulle, “ La folie du doute.”
j| Prof. Ball, “ L’Encephale,” 1882, No. 2.
% Prof. Charcot, *• La Semaine M^dicale,” 1886.
** Dr. Doyen, “ L’Encephale,” 1885, No. 4.
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219
The True Theory of Induction . By the Bey. W. G. Davies,
B.D., Rector of Llansantffraed, Abergavenny, late Chap¬
lain of the Joint Counties' Asylum, Abergavenny.
It has been said that recognition will come sooner or later
to the man who can wait. With the gratifying exception of
his long connection with this Journal, the writer cannot say
that this has been his experience. In a work named “ The
Alphabet of Thought," &c., published twenty-five years ago,
was contained what he fully believes, after painstaking sub¬
sequent research, to have been the foreshadowing, at least, of
one of the most important Laws of Thought. The late Dr.
Mansel, Dean of St. Paul’s, was acquainted with the writer’s
views, the work mentioned and the chief contents of this
essay having been submitted to him, and the writer would here
record his gratitude to the late Dean for the unusual courtesy
with which he examined their contents. Since, however, the
writer’s views were strongly opposed to the Dean's, he never
expected from that gentleman anything but adverse criticism.
This fact has,however, completely failed to shake the author’s
confidence in conclusions which for nearly forty years he
has submitted in vain to the most pitiless scepticism he
could bring to bear upon them. Most of Mansel’s strictures,
together with the passages to which they refer, are here
presented to the reader, and also extracts from letters re¬
ceived from the same gentleman bearing on the chief point
herein discussed. Replies to both are given, combined with
the later views at which the author has arrived.
1. That it is of the highest importance to ascertain how
first principles are obtained will readily be acknowledged by
every one who is keenly alive to the influence which ideas
exert upon the advancement of the human race. To describe
the origin of such principles is the object of the following
discussion.
The inconceivableness of the negation is by many held to
be the test of necessary truth. J. S. Mill, however, in his
controversy with Whewell, contends that certain beliefs were
once held to be indubitably true, their negation being in¬
conceivable, which beliefs—for example, that the earth could
not be round, else objects would fall off its surface at the
Antipodes—are now exploded, and, therefore, that such in¬
conceivableness is no criterion of the necessity of a truth.
Herbert Spencer, on the contrary, says:—“ Mean what we
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The True Theory of Induction , [July,
may by the word truth, we have no other choice but to hold
that a belief which is proved by the inconceivableness of its
negation to invariably exist is true.”*
After some controversy on this point between these two
able psychologists, Herbert Spencer, having been brought to
see the variety of meaning which is attached to the term
inconceivableness, defines more clearly the cognitions of
which we cannot entertain the negation, namely, those “of
which the predicates invariably exist along with their sub¬
jects.^ ... “ The discovery that the predicate invariably
exists along with its subject is the discovery that this cog¬
nition is one we are compelled to accept.” This position,
with one modification, Mill accepts. This modification is
thus stated by him :—“ If the invariable existence of the
predicate along with its subject is to be understood in the
most obvious meaning, as an existence in actual Nature, or,
in other words, in our objective or sensational experience, I,
of course, admit that this, once ascertained, compels us to
accept the proposition; but then I do not admit that the
failure of an attempt to conceive the negative proves the
predicate to be always coexistent with the subject in actual
Nature.” Inseparability between the predicate and the sub¬
ject in thought, or to the conceptive faculty, Mill holds,
does not prove a corresponding inseparability in fact or per¬
ception, for the former has often existed, and afterwards
proved erroneous, in more than a few instances.
Now if we seek to know the source from which both J. S.
Mill and Herbert Spencer derive these, our most irresistible
beliefs, we shall find a clue in these forcible words of the
latter:—“ If there be, as Mr. J. S. Mill holds, certain
absolute uniformities in Nature; if these absolute uniformi¬
ties produce, as they must, absolute uniformities in our
experience, and if, as he shows, these absolute uniformities
in our experience disable us from conceiving the negations of
them, then, answering to each absolute uniformity in Nature
which we can cognise, there must exist in us a belief of
which the negation is inconceivable, and which is absolutely
true.”t From this conclusion Mill, however, dissents. “ If,”
says Mill, “ all past experience is in favour of a belief, let
* “ Principles of Psychology.** Introduction.
t As in : A straight line iB the shortest distance between two points.
% The discussion between Mill and Herbert Spencer on this point is ably set
forth in the 7th chapter, Book II., “Of Reasoning”—Mill’s “Logic,” Intest
edition.
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1887.] by the Rev. W. G. Davies, B.D.
this be stated, and the belief openly rested on that ground,
after which the question arises what that fact may be worth
as evidence of its truth ? For uniformity of experience is
evidence in very different degrees. In some cases it is strong
evidence, in others weak, in others it scarcely amounts to
evidence at all. ... In the few cases in which uniformity
of experience does amount to the strongest possible proof\ as
with such propositions as these, ‘ Two straight lines cannot
enclose a space/ ‘ Every event has a cause/ it is not because
their negations are inconceivable, which is not always the
fact, * but because the experience which has been thus
uniform pervades all Nature.” Mill is here alluding specially
to the Law of Causation, the notion of cause being, with
him, the root of the whole theory of Induction; but this
notion he interprets in the same way as Hume does.
Hume, in his essay entitled, “ Of the Idea of Necessary
Connection,” it is well known, holds that every idea must be
derived from an impression, and that in a case of causation
we have no impression of necessary connection between the
consequent and the antecedent. Whence, then, does the
feeling of necessary connection take its rise ? Hume’s
answer is as follows :—“ As this idea ” (necessary connection)
“ arises from a number of similar instances, and not from any
single instance ” (note this), “ it must arise from that circum¬
stance in which the number of instances differ from every
individual instance.” He then points out that customary
connection is the only circumstance in which the former
case differs from the latter, and this, consequently, must be
the sole origin of the feeling of necessary connection. This
doctrine, which, in all essential respects, remains with the
d posteriori school as Hume left it, J. S. Mill endeavours to
fortify against criticism, and to expand to fuller dimensions.
Hume’s famous doctrine let us proceed to discuss. It is
true that in an instance of causation we have no impression
or direct perception of necessary connection; but it does not
follow that we have no indirect perception of the same. On
the contrary, our contention is that we have. J. S. Mill,
believing with Hume and Brown that the feeling of neces¬
sary connection is due to long-continued association, ob¬
serves:—“When we have often seen and thought of two
things together, and have never, in any one instance, either
seen or thought of them separately, there is, by the primary
* This most mean “ not always the fact ” in a certain class of cases, but it is
always the fact in the class of cases here mentioned.
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The True Theory of Induction, [July,
law of association, an increasing difficulty, which, in the end,
may become insuperable , of conceiving the two things apart.”*
According to this view, the belief in necessary connection, so
called, is the result of habitually finding two things together
and never apart. This does, indeed, as in cases of causation,
lead to a very strong expectation of future connection be¬
tween two things, but, as Mill strongly contended, does not
establish necessary connection between one and the other.
In reference to such attacks as were made upon Hume’s
doctrine by Reid, Mill argues as follows :—“ If there be any
meaning which confessedly belongs to the term necessity, it
is unconditionalness. That which is necessary, that which
must be, is that which will be, whatever supposition
we may make in regard to all other things.” To
the same effect he continues:—“ Invariable sequence is
not, therefore, synonymous with causation unless the sequence
besides being invariable is unconditional. There arc
sequences as uniform in past experience as any others what¬
ever, which yet we do not regard as cases of causation, but
as conjunctions, in some sort, accidental. Such, to an
accurate thinker, is that of day and night.”f What Mill
holds, then, is that the belief in so-called necessary truth
springs from the habit of perceiving that connections exist,
notably in causation, which are not only invariable but
unconditional, the way to establish this fact being by the
Method of Difference, “ by which alone,” he says, “ we can
ever, in the way of direct experience, arrive, with certainty,
at causes.”J Thus, then, according to Mill, is that uni¬
formity of experience ascertained which amounts to “ the
strongest possible proof” and which “ pervades all Nature.”
J. S. Mill, in his exposition of Induction, exhibits, to our
mind, two facts which are specially noteworthy, firstly, that
the implicit process of Induction operating in all minds is
forcibly drawing him as closely to the correct method as his
theory, stretched to the utmost, permits, but, secondly, his
theory being only a partially explicit statement of inductive
thought, all he succeeds in accomplishing is to bring his
sailing ship, so to speak, to tack very closely to the wind,
• Mill’s “ Logic,’* People’s Edition, p. 157. This is also the view which
Prof. Huxley, in his Sketch of Hume (“ English Men of Letters ”) takes of this
question. He regards the axiom of causation as “ a purely automatic act of the
mind, which is altogether extra-logical, and would be illogical, if it were not
constantly verified by experience ” (p. 123).
+ “ Logic,” People’s Edition, p. 222.
% Ibid., p. 258.
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1887.] by the Rev. W. G. Davies, B.D.
but no more. It is the steam-ship of fully explicit Induction
alone that can tear along into the mouth of the wind—fully
explicit Induction being that which i3 expressed in a perfectly
formal dress, and accurately sets forth the spontaneous In¬
duction taking place in the mind of every human being. As
a pioneer in exploring the region of Induction, Mill, we
believe, has no equal. But a pioneer cannot do more than
open a way for others to follow.
2.—Having thus opened the question, we proceed to state
our view of the origin of what is called necessary and uni¬
versal truth. After patient research, extending over a period
of nearly forty years, we have arrived at the firm conviction
that necessary truth so-called is obtained by a form of reason¬
ing which may be expressed as follows :—
If it is perceived that this is connected with that , as 4
with 2 + 2.;
And if it is also perceived that this without that cannot
exist, as 4 without 2 + 2;
Then it is mediately perceived that this is necessarily
connected with that 9 namely, 4 with 2 + 2, i.e. t cannot (abso¬
lutely) exist without it.
This form, we call the Canon of Induction, a Law of
Thought constantly in operation, and of a most important
character. It is expressed more briefly in the following
formula:—
This A is b (e.g., 4 = 2 + 2);
Minus this b is minus this A;
Therefore, this A is necessarily (or sine medio) b.
Observe that the Canon is a form of reasoning. We have
in it a positive and a negative premise; for example,
4 = 2 + 2, this is directly perceived; take away the 2 + 2 and
you take away the 4, this is also directly perceived; but it
is by indirect perception, by comparing the above data, that
we get to know the necessary connection existing between 4
and 2 + 2. The Canon, then, seems to be the criterion of
necessary truth. According to it, there is no alternative
save for a connection among facts, whether of the mental or
the physical world, to be proved necessary in character, or
not necessary, that is, contingent.
In reference to this Canon, Mansel puts the following ques¬
tion :—“ How does the conclusion differ from the second pre¬
mise ? What is the difference between cannot exist without ,
and is necessarily connected with ? Can we perceive (empiri¬
cally) cannot? We can only perceive is not . To go from is
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The True Theory of Induction,
224
[Jnly,
not to cannot , or from is to must be requires an a priori intui¬
tion.”
Answer .—The cannot is a perceived or empirical cannot, just
as when one says “ I cannot lift this stone; ” the difference
between cannot exist without in the premise and is necessarily
connected with in the conclusion is this : the former is directly
perceived, the latter indirectly; it is a succinct mode of ex¬
pressing what has been stated in the two direct perceptions
which precede it, the contents of which it summarises. All
reasoning is mediate cognition, and the conclusion of an
argument, if fully, that is, explicitly stated, should clearly
convey this idea. We invite attention to this statement,
because it seems to elucidate the fact that the "conclusion of
the Canon given above means, in explicit language, that this
is so connected with that as not to be able to exist apart
from it.*
It has always been held that a necessary truth is virtually
universal. Now, it appears that the universality of a neces¬
sary truth is inferred from the fact that its contradictory
cannot be thought true. Who can think that 2 + 2 (our
2 + 2) can ever equal 5 ? Let us proceed to explain the
reason of this. If it is proved by Induction according to the
Canon that 4 must equal 2 + 2, then when, by an effort of
conception, we multiply cases of 4 = 2 + 2, if we would not
subvert our principium —a conclusion proved by Induction—
we are compelled to conceive each case as precisely similar to
this, our model. Out of the mould of Victoria sovereigns we
can never believe that spade guineas can ever issue. “ You
say,” remarks our critic, in words, the discussion of which
is calculated to throw some light on this question, “ you
cannot conceive that the fact 2 + 2=4, while thought of as
such , can be also thought of as 2 + 2 = 5. This is perfectly
true, but it is not what I meant. Why cannot I cease to think
of the 4 and begin to think of the 5 ? No one holds that I
can believe two contradictory judgments at one and the same
time , but why, in this case, can I not do it at different times ? ”
My critic admits that 2 + 2=4 while thought of as such,
cannot also be thought of as 2 + 2 = 5, but asks '* why cannot
I cease to think of the 4 and begin to think of the 5 ? ” We
answer, because, on his theory (as, of course, he would con¬
tend), an a priori intuition, and on ours, an induction, would
have to be negatived. No one believes two contradictory
* Hamilton’s postulate, “ That we be allowed to express in language what is
contained in Thought,” here applies.
Digitized by L^ooQle
225
1887.] by the Rev. W. G. Davies, B.D.
judgments at the same time, but why, in this case, our critic
asks, “can I not do it at different times ? ” Because such an
alternative is excluded by the nature of the case; for when at
any time the supposition is made that 2 + 2=5 then will also,
without fail, be the time when we shall think of 2 + 2 = 4
as the only believable judgment. At no time can we suppose
the negation without being confronted by the correct induc¬
tion 2 + 2 must equal 4, for, indeed, that which contradicts
involves that which is contradicted. It seems, then, to be
undeniable that every case of this kind proves to be one of
attempting, at one and the same time, to hold contradictory
judgments, with the result that the inductive judgment is
found to be one of the most irresistible and indestructible of
even speculative or final beliefs. The law here involved we
name the Law of Universalization.
We would here point out a source of ambiguity in the
language of the question with which we have to deal. Any
truth, it has been urged, if it be in reality what it professes
to be, is necessarily true. To say that a truth is contingently
true implies that it may be untrue. This, however, is not
what is commonly understood by a contingent truth. Con¬
tingency is rarely used as a synonym for probability, because
many a so-called contingent truth is true beyond all doubt,
is, indeed, necessarily true. For instance, it is as undeniably
true that a man is smoking while he is doing so, as it is that
a whole is greater than its part, and the former of these we
call a contingent truth. By a necessary truth, then, must be
understood a necessary connection between one thing and
another, and by a contingent truth a connection which is not
necessary. When by inductive reasoning a connection can¬
not be proved to be necessary, it is contingent. Necessity
and contingency are thus related terms, the whole universe
of connections among things, or thoughts, being exhausted
by these two alternatives. There are, therefore, in Nature,
two kinds of uniformity—the one kind is that which rigidly
satisfies the demands of the Inductive Canon, the other that
which fails to do so, and yet to which no exception is known.
Thus, in the induction—a triangle is a trilateral figure;
without being trilateral, it cannot (empirically) be triangular;
therefore, a triangle is necessarily a trilateral figure—we have
the basis of a notion of uniformity, the negation of which,
indeed, cannot be conceived without involving a subversio
principii , i.e., the subversion of an induction admitting only
of the above conclusion. But in the induction—the Atlantic
Digitized by L^ooQle
226
The True Theory of Induction , [July,
Ocean is salt, we can conceive the possibility of its losing its
saltness without ceasing to be an ocean—indeed, we are able
to separate the salt from portions of its volume—so we are
forced to infer that there is only a contingent connection
between the Atlantic and its saltness.
Having now indicated how necessary and universal con¬
nections are known, let us, by way of more clearly elucidating
the position herein maintained, proceed to indicate the rela¬
tion in which it stands to J. S. Mill’s doctrine.
3.—That the general is derived from the particular, we
hold as strongly as J. S. Mill does. When, however, he
contends that necessary connections have not, as a separate
class, any existence, we are compelled to part company with
him. The source and only source of these truths, he con¬
tends, is association, specially controlled by the Method of
Difference. We allow that it is impossible to deny to associa¬
tion much of the force which Mill and others claim for it. But
we must hold that association cannot be thought sufficient to
account for the inconceivableness of the negation of quite
recently ascertained instances of necessary connection, say,
the few first times that a youthful student of geometry
realizes some of the elementary truths of that science. Mill,
when arguing in favour of association as the origin of our
firmest beliefs, makes use of such expressions as these:—
i( Long-established and familiar experience; ” “ old familiar
habits of thought; ” “ when we have often seen and thought
of two things together, and have never in any one instance
either seen or thought of them separately; ” “ in cases in
which the association is still older, more confirmed, and more
familiar; ” “ a sufficient repetition of the process.” Now all
these expressions imply that it is not possible to have the
notion of a necessary connection without much repetition of
experience, and a very considerable lapse of time. But this,
we must think, is not true. For we hold that, from a single
instance of inductive reasoning, a necessary connection can
be inferred; and this can legitimately be extended to a uni¬
versal connection. Even in early youth, long before oft-
repeated and familiar experience can be gained, we feel con¬
fident of many instances of necessary connection. That 2 + 2
must make 4, the youth, by the implicit action of his reasoning
power, very soon feels as certain as he ever will in the course
of years. Now it is here maintained that truths thus known
do not depend on long-continued association for their neces¬
sity, but are known to be necessary connections by Induc-
Digitized by AjOOQle
1887.] ly the Rev. W. G. Davies, B.D.
227
tion, that their necessity is as evident when first inferred as
at any subsequent period ; and that the incapacity for con¬
ceiving the negation of them to be true is not acquired by
habit, association becoming insuperable, but proceeds from
the constitution of the human mind, as much as Judgment
and its expression by a subject, a predicate, and a copula,
proceeds from the same constitution.
Be it known, then, that Induction commences with the
establishment of individual cases of necessary connection.
Inference from a conclusion thus derived to a similar case,
or a number of such cases, involves generalization, but such
inference is not formally valid, unless the remotest possi¬
bility of an exception is most completely excluded, and this
end is not secured, except, as has been described above, by
universalization from one or more instances of necessary
connection. Particulars can only with perfect validity be
derived from particulars, when the latter are instances of
necessary connection inductively proved to be such, and,
therefore, warranting a universal conclusion that embraces
every particular. Thus is the passage from inductive to
deductive logic bridged over.
Having thus paved the way for the examination of J. S.
Mill’s views—more with the object of elucidating our own
by comparing them with his, than of criticising the latter
—let us proceed to inquire where inference commences
in his system. Mill emphatically insists that all inference
is essentially from particulars to particulars without the
intervention of general propositions. It may prove more
satisfactory to acquire these, but they are not indispensable
as part of the reasoning process. Coupling this view with
his violent denial of the existence of such an important
class of connections as the necessary, his inductive system
differs materially from that propounded above. Induction,
according to Mill, is purely and simply generalization from
experience, resulting from the irresistible force of associa¬
tion.
In both the Canon of the Method of Agreement and that
of the Method of Difference—in which, if anywhere, we
ought to find the formulation of the essential points of his
system—J. S. Mill requires two or more instances, but at
least two which agree with or resemble each other. In ex¬
planation of the Method of Difference—the more cogent of
the two Methods—Mill makes the following statement:—
“The two instances which are to be compared with one
Digitized by C^ooQle
228 The True Theory of Induction , [July,
another must be exactly similar in all circumstances, except
the one we are attempting to investigate.”* * * § So there can
be little doubt that similarity is, by him, made the ground of
inference. Indeed, his reiterated declarations that all reason¬
ing is essentially from particulars to particulars, i.e., from
these to their like , admits of no other conclusion. “ In the
strictest induction, equally with the faintest analogy,” he
plainly declares, “ we conclude, because A resembles B in one
or more properties, that it does so in a certain other
property. ”t a It seems, then,” says Jevons, “that the
universal type of the reasoning process wholly turns upon
the pivot of resemblance,” { according to Mill, he here
means; and of himself, the inventor of that ingenious toy
—the Logical Abacus, this is doubly true. But this doctrine,
be it known, seems to us quite erroneous.
4.—Since the Laws of Association have obtained full
recognition, the Law of Contiguity is found to occupy a
leading place among intellectual processes. Under the head
of this law come Differentiation, the Whole of Compre¬
hension, the Singular or the sphere of Things. It is true
that this law never operates apart from the Law of Simi¬
larity, but the latter, as we shall see, has two fields of opera¬
tion, one in advance of the other. The Law of Contiguity,
as such, has but a singular number, whereas the Law of
Similarity has both a singular and a plural number. Now
the theory broached in this essay implies that, fundamen¬
tally, Induction does not involve the comparison of two or
more similar cases, but can be realized in the Whole of Com¬
prehension, in which all thought, all reasoning, is strictly
singular, there being no generalization from this case to that
like case. This latter process is the second step in inductive
reasoning, not the first.
“ It must be acknowledged,” says Reid, “ that the objects
we perceive are individuals. Every object of sense, of
memory, of consciousness, is an individual object.” “ This,”
observes Hamilton, “Boethius has well expressed— Omne
quod est , eo quod est y singulare es£.”§ “As the multitude of
common nouns,” says Cardinal Newman, “ have originally
been singular, it is not surprising that many of them should
so remain still in the apprehension of particular indivi-
* “ Logic,” People’s Edition, p. 256.
t “ Logic,” People’s Edition, p. 365.
X Mill’s “ Philosophy Tested,” “ Contemporary Review," Jan., 1878, p. 263.
§ Hamilton's “ Reid,” p. 389.
Digitized by L^ooQle
229
1887.] by the Kev. W. G. Davies, B.D.
duals .... The terms of a proposition do or do not stand
for things. If they do, they are singular terms, for all
things that are are units.”* To the priority, in the Order
of Evolution, of the singular to its related general know¬
ledge, we have thus drawn special attention, because our
contention is that the first step in Induction is not generali¬
zation from experience, but reasoning solely in the singular
Whole of Comprehension. + We are fully aware that, in
Singular Judgment, as in every other mental process, the
law of Similarity is prominently operative; that is, the
conscious manifestations of the present moment are judged
to be identical with the latest, later, late existence of the
same; an essential condition of all knowing and feeling being
this manifestation of past and present consciousness in one
present picture composed partly of presentation, partly of
representation, partly of perception, partly of memory. But
here take special note, that in analyzing the inductive
process a broad line should be drawn between likeness as
occurring in individual continuity relative to past and
present, and likeness as occurring among a plurality of
individuals. Although the singular can be realized solely
as a continuous thread of similar presentations, yet the fact
must not be overlooked that the general involves two or
more Such singulars or chains of identity. There is, there¬
fore, a higher degree of logical evolution to be detected in
the latter than in the former, namely, that which in
grammar takes the form of the plural number, in logic, of
generalization and classification.
(To be continued.)
* “ An Essay in Aid of a Grammar of Assent,” p. 22.
t See the writer’s latest article in this Journal, “ The Border Land between
Physiology and Psychology: Singular Judgment,” July, 1880.
Digitized by L^ooQle
Y c , u ^ ^
^ Jkw **Vv*J^
c^'^r
[July,
Coca ine in the Treatment of Mental Disorders. Bj Dr. C.
Heimann, of Charlottenburg, Berlin.
Paper read at the 59 th meeting of the Association of German Scientists and
Physicians in the section of Psychiatry and Neurology .
Certain therapeutic effects upon the human organism
ascribed to cocaine,* occasioned me to make use of the drug
in suitable cases of psychosis and psycho-neurosis. Stimulant
action and exhilaration (Euphoria) on the one hand, and on
the other depression of undue sensitiveness, these were the
effects I looked for from the alkaloid. Unfortunately, I
am able to record scarcely a single case of certain and per¬
manent cure following the use of the drug.
In melancholia^ without hallucinations, cocaine was
ordered in doses of 0*01 gramme thrice daily; the dose was
incre ased up t o 0*06 gra mme ( in English we ights gr. -gr. A)
At the~e n d o j^ aj?ortnigiit liie treatment Was obliged to be
abandoned on account of TailiirboFlT^rtth, d ue 16 anorex ia:
the drug had been quite without e ffect on the psychosis .
No s econdary effects were witnessed" with t he exception o f
acceleration of pulse and dilatation of pupi I7 both of which
lasted some 3-4 minutes. The small doses were chosen in
order to avoid the production of hallucinations.
In melancholia with hallucinations cocaine was given in
doses of 0‘2j;rms. (3 grains)~about tli rice daily. again with-
out success^- One of these latter patients suffering from
hypochondriacal delusions, stated that for a very short time
after taking the drug (1-2 minutes) he felt easier. Aft er 14
days, when no advance had been made, but on the contrary,
complete anorexia had superv ened, the drug wa s stop ped.
Another, a young man’ Aylnr ctumT^t hree months that lie had
been in the asylum had^noF spoken a word, and had had to
be fed, though without resistance, and in general was com¬
pletely apathetic, the same in the third week of treatment
became su ddenly the subject of strongly-marked delusions,
began to speak to his fellow-patients, and developed a much
liyelier manner. 'The improvement contiuuediimiJULiiiilJay,
and this in spite of discontinuance of the drug f tha-patient
was in a short time discharged cured. P ossibly in this case
the improvement was accelerated by cocaine.
* Wall6, “Aphoristic Contributions to the subject of Opium Antidotes;”
Aschenbrandt, “ Physiological Action of Cocaine ; ” Hepburn, of New York, “ A
Few Observations on Cocaine Action ; ” Obersteiner, “ Concerning the Internal
Use of Cooaine; ” also Marselli, Buccola, and others.
l ignt tne
t of failur
Digitized by L^ooQle
1887.] Cocaine in the Treatment of Mental Disorders. 231
To a vonng woman, whojfrr a Pfriftfl ftf fijghti mrmtha had
su ffered from melancholia, a nd had made the most serious
attempts at suicide, and resisted being fed with all her
energy, so that the continuous use of the stomach or nasal
tube was necessitated, supplemented or replaced by nutrient
enemata, all other likely methods of treatment having
failed, cocain e w as administered subcutaneously in d oses,.of
0*0 2 grins!' l 1 *- gwflfff ) T The p atient expressed lierselfas feeling
be tter, “so lighi in tlie~~head. n Five minutes from the
injection an acceleration of pulse amounting to 30-40 beats
in the minute occurred, and the patient became very
maniacal. This condition of excitement was taken ad¬
vantage of to administer food in the natural way; this was
done successfully. The excitement lasted for about J to 1
hour, after which the patient relapsed into her former state.
The repetition of the experiment gave the same result on the
second and third days, but after that it failed even with in¬
creasing dose. In the sequence, the patient had to be
watched in order to prevent suicidal attempts, and forced
nutrition was required, but about fourteen days after the
drug had been suspended improvement set in, and pro¬
ceeded ultimately to a comp lete cure; but, as is clear, this was
spontaneous, ancHn no way related to the
To test the valinted innuence of cocaine on the motor
centres, the drug was administered subcutaneously in doses
of 0*2 grms. (3 grains) per diem, to two patients suffering
from katatonia; the drug was continued for several weeks
without The slightest effect.
Finally, even in cases of hypochondriasis, neurasthenia,
and "Eysteria in which T*looked for great success, having
regard* to the exhilarant effects described, even here there
was complete absence of any ob vious or permanent improve¬
ment. The hypochondriacal patient, who hails with*glad¬
ness every new remedy, was soon obliged to complain, and
with justice, or'anorexiar^^The subject of neurasthenia com-
1 *aclH IIM m ore"nf^ weftkn egg, beings "unable to take
0
s ufficient nu triment. I n hysteri caLnatients besides anorexia,
which, by-the-bye, is not to be disregarded, owing to the fre¬
quent coexistence of anaemia, there occurred attacks of
which soon lessened their faith in the. medicine.
?rom these* mj observations* XaarTconstrained to deny to
cocaine a pl acq in the therapy of mental disease..
Concerning the use oi cocaine in the treatment of the
opium habit, I am able only in part to corroborate the
Digitized by Google
232 Cocaine in the Treatment of Mental Disorders , [July,
experience of Erlenmeyer.* On the other hand, my ex¬
perience does not quite accord with that of Smidt.f The
subjects of the combined morphia-cocaine habit received
morphia in rapidly diminishing quantities, whilst the
cocaine was increased till the morphia craving had dis¬
appeared. Then the cocaine was diminished down to zero.
Symptoms due to the withdrawal of the morphia were, on
this plan, observed only during the first few days, and were
only very slight, e.g ., chilliness, sneezing, insignificant
attacks of diarrhoea, which disappeared of themselves. On
the withdrawal of the cocaine, there was no immediate ap¬
pearance of any new symptoms, but a few days later an
insatiable hunger. As to relapse, my experience was that
the morphia-cocaine habit, or the morphia habit simply, was
resumed. I must add that hitherto I have been unable to
determine a permanent advantage from this mode of treat¬
ment ; on the contrary, the use of cocaine during the with¬
drawal of morphia soon manifested its deleterious effects on
the mental state.f
These deleterious effects are of the
After the protracted use of.cocaine :
doses, subcutaneously or by the mouth, also after the use of
coca leaves, the first symptoms to arise were, according to
the statement of the patients, who, for the most part, were
colleagues, a n increased secretion of the sweat and sebaceous
glands, also desquamation. A constant accumulation of
dirt under the nails, probably in consequence of the above,
was observed, and this in spite of frequent cleansing. Com¬
plaint was also made of an itching of the skin, suggesting
the presence of vermin; failing to discover such, the
patients soon become persuaded (hallucinations making their
appearance) that the itching is produced either by an
external invisible power or by organisms which go in and
out of the skin. Larger and smaller insects of variable
colour would then become visible, and in two cases (both
colleagues) these were actually seen under the microscope
(microscopic visual hallucinations!). A third, also a col¬
league, was unable to make this observation since the people
at his lodgings had damaged his microscope of a purpose I
lollowi ng nature :—
n larger or smaller
* “ On Cocaine Craving.*’
t “ On Cocaine Craving and Further Observations on the use of Cocaine in
Morphia Habit.”
J Geissler, “ Instances of Poisoning from CocaineComanos Bey, Cairo, “ The
Effects of Large Doses of Cocaine on the central Nervous System ; ” Heuse and
others.
i - C
Digitized by
b« ^ uCt IvvJ ‘
233
1887.] by Be. C. Heimann.
In fact, the microscope wa^tinusable, owing to extreme dirti¬
ness, such as characterizes the belongings of cocaine eaters
in common with other demoralized beings. Hallucina¬
tions of hearing would now, as a rule, appear, the patients
hearing remarks made about the creatures infesting them.
The perverted sensations, as also the hallucinations of sight
and hearing, become more and more marked. The patients
seek continually for new explanations of their symptoms, and
arrive at the most absurd conclusions. They think they see
holes in the walls and ceilings, they see wires in the air,
which are drawn by invisible power in all directions, and
again these disappear; they are conscious of electric and
hypnotic effects, &c. Hallucinations of taste and smell do
not arise constantly. On the basis of these illusions of the
senses, there gradually arise fixed ideas of insanity which are
in process of time built up into a system. These delusions
appear at first sight to be of the nature of persecution, but on
a more close examination they are found to differ essentially
from the current ideas of persecution. The patients think
they are being followed, it is true, but they do not think that
this is with a view to harm them, but on the contrary that it is
for their own advantage or for that of the world at large.
Thus one patient was under the impression that he was
being constrained to undergo treatment for his morphia
habit. As, however, he objected to interference with
his own freedom on any grounds whatever, he sought to with¬
draw himself. To throw dust in the eyes of his pursuers, he
even presented himself at our asylum and arranged about his
reception. Thereupon, in the dusk, he left the asylum, did not
return home, but passed the night in an hotel. Since, however,
his symptoms did not diminish in the new abode, he fetched
his personal effects from his dwelling, went to the station
and took a ticket. Then, having seen his effects off to their
destination, he drove to another station, and took train in an
opposite direction. Another patient thought he was being
forced into making a grand discovery. He had already de¬
tected the cocaine insects, and having also seen them on the
hands of those with whom he had come in contact, he had thus
discovered the contagious nature of the disease. Patients thus
infected, and himself also, he treated by subcutaneous injec¬
tions of weak salt solution, which effectually disposed of the
insects. A third thought himself pursued by Indians, who
wished to make him marry a rich Bolivian lady. I have
already spoken of the microscope which was out of order
xxxiii. 16
Digitized by L^ooQle
234 Cocaine in the Treatment of Mental Disorders , [July,
and had been purposely damaged by the people of the house in
order that the patient might not distress himself by a clearer
vision of the supposed insects. The same patient travelled
from place to place, thinking himself pursued by the authori¬
ties, who were endeavouring to put him in ward so that his
property, which was being drained by the large expenditure
for cocaine, might be preserved for his children. Patient was
touched by this thoughtfulness on the part of authorities,
but could not bring himself absolutely to sacrifice his own
personal freedom. Another patient discovered that the
people around him broke, bent, and blocked the needles of
his Pravaz syringe, that he might thus be prevented from
administering the drug to himself. It is true they knew well
how much good the injections did him, how much they
strengthened him mentally, how, by virtue of them, he was
enabled to work miraculous cures, but the police had called
upon them to prevent the injection of the drug. Many patients
of his had given him hints by looks and words. He had also
cast out the same, it not being necessary, thank God, for
him to practice. In the end he took down his professional
plate from the door. Asked why the police were pursuing
him, he answered: “ If nowadays a man do not practice and
^ prescribe exactly according to the rules of the art, the authori¬
ties are of opinion that they must protect the public.” That
he might give no ground for offence to the authorities, he
removed his doorplate and gave up his practice.
To be brief, the patients, in the sequence, become more
and more excited, they finally resort to weapons to protect
themselves and to frighten their persecutors, and their con¬
dition may develop into acute mania. The patients are
dangerous to the public, and they are mostly sent by the
authorities to a closed asylum.
The appearance of the cocainists is as follows: The tint
earthy, the pupils widely dilated, the eyes deep-set and show¬
ing circles around them. In their deportment they manifest
increased self-importance, they overrate their own powers,
and furnish frequently excellent examples of the well-known
punning spirit of maniacs, e.g., a colleague, who, on account
of his violence, had to be isolated, asked if it was intended
that he should thus study a new cellular pathology ? !
On discontinuing the cocaine, the patients become quieter,
fresh delusions cease to appear, but the older ones only
disappear very gradually. The patients believe in the reality
of their hallucinations longer than is apparent, since they
Digitized by L^ooQle
1887.] by Be. C. Heimann. 235
soon learn to conceal them. The insane fixed ideas fade in
like manner only gradually.
When these morbid symptoms have quite ceased the patients
do not show any special defect in the spheres of thought and
judgment, and no gaps are apparent in their memory. In
like manner their discursiveness in speech and writing dis¬
appears almost completely.
Nevertheless, especially in cases of prolonged use of the
poison, the cure may have to be regarded as relative only, as
a cure with so-called defects. In the spheres of sensation
and of volition considerable damage has been sustained ? the
patients lie when they open their mouths, they steal on the
first opportunity, and they desire to do that which they are
unable to perform. They are irresolute in their action, and,
should they have begun anything, their activity is of the
shortest duration. In their being they become apathetic,
indifferent to everything, untidy in their belongings, unclean
in their person, in short, they are demoralized.
I have said the cure appears to be one with defect, but
indeed the disease is of too recent a date to permit of a
definitive prognosis. It is possible that the last named
qualities, which are the expression of a diseased mind, should
gradually become effaced. On the other hand, these very
qualities lead the patients again and again to recur to the
poison, for which there is a very decided craving.
Accordingly, we can only say that from our experience the
disease is curable, so long as no permanent psychic defect has
been established. This, again, appears to be dependent on the
size of the doses habitually taken, and still more on the length
of time during which the drug has been persisted in.
The treatment consists in the gradual or sudden with¬
drawal of the drug. I should recommend the former in the
case of morphia-cocainists. I have never observed any
symptoms due to abstinence follow the sudden withdrawal
of the drug.
Now, although the patients, by their demand for cocaine,
reveal at once that they have been taking it, and although
the whole course of the disease, as well as the sum total of
the symptoms above described, is sufficiently characteristic
to strike the difference between it and any other psychosis,
e.g., paranoia hallucinatoria, mania, delirium, and even from
the abstinence-symptoms of the morphia habit, yet, with the
assistance of my friend Dr. Kleimann, of the Royal Poly¬
technic at Charlottenburg, Berlin, I have tested the urine of
these patients.
Digitized by L^ooQle
236 Cocaine in the Treatment of Mental Disorder [July,
With regard to the chemical analysis of the urine in these
cases, it was necessary, in the absence of any literature on the
subject, to first determine whether it was possible to detect
the alkaloid. To solve this, 0*23 grms. of hydrochlorate of
cocaine were added to one litre of normal urine. The acid
urine was then rendered faintly alkaline by the cautious
addition of bicarbonate of soda, and then digested with ether.
In view of the free solubility of the base in ether it was to
be expected that a single extraction with ether would yield
a sufficient quantity of the alkaloid for the purposes of testing.
In point of fact there remained on evaporation of the ether
a not inconsiderable syrupy residue, which, placed on the
tongue, gave a characteristic effect, and, further, when heated
with concentrated sulphuric acid, yielded the characteristic
smell of benzoic acid. Repeated shaking up of the urine
with ether did not increase the amount of extract, and
although in this way the quantity of cocaine obtained
was but a fraction of that used in the first place, yet
the proof was obtained that in the above way small
quantities of cocaine, such as would certainly be present in
the urine of an organism habitually taking cocaine, were
capable of detection, provided, of course, that the cocaine
were excreted as such. The urines of cocainists were now
examined. They were first rendered faintly alkaline, then
shaken up with ether. In this way an emulsion was formed,
which only on prolonged standing separated into an upper,
ethereal layer, and a lower, watery, stratum. The ethereal
extract was evaporated in a watch glass, at the temperature
of the atmosphere (in order to prevent any decomposition),
and gave a slight residue which was bitter to the taste, and
caused numbing of the corresponding portion of the tongue.
The bitter taste is not sufficient evidence, but solely the
numbing of the part, for normal urine treated in the
above fashion yields to the ether small quantities of a bitter
principle.
From numerous experiments made, as above, the con¬
clusion seems justified that of the total quantity of cocaine
consumed, only very small quantities appear in the urine, for
the quantity extracted by the ether sufficed only for the
testing by the tongue, and was always far too small to
permit of chemical tests (formation of benzoic acid by treat*
ment with concentrated sulphuric acid). On the other hand,
the quantities were always large enough to allow of the per¬
formance of an exact physiological test, e.gr., the ethereal
residue was treated with hydrochloric acid, and then, again,
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2S7
1887.] by Dr. C. Heimann.
evaporated. In this way the hydrochlorate of cocaine was
formed, a salt readily soluble in water. The aqueous solu¬
tion dropped into the eye of a rabbit caused complete anaes¬
thesia of the same, so that for 10-15 min. the cornea could be
rather roughly handled without causing the slightest blink¬
ing, whilst the non-anaesthetized eye blinked even at the
approach of an object. This experiment was checked by
using normal urine, and applying its ethereal extract, treated
as above, to the eye.
In conclusion, I must accentuate the following points con¬
cerning cocaine
1. That cocaine acts similarly whether taken internally
or injected beneath the skin;
2. That the coca leaves exert almost the same effect as
the alkaloid.
This statement is based, firstly, on historical data. Coca
played a prominent part in both the social and religious life
of the ancient Peruvians, it being said of the plant that
it stayed hunger, gave new vigour to the fatigued and
exhausted, and caused the unhappy to forget their troubles.
These are the same properties with which we have become
acquainted in the alkaloid itself. We say of cocaine, that it
renders us insensible to hunger and thirst, causes anorexia,
it excites, it exhilarates, &c. Similarly the evil effects of
the use of coca leaves were well known to the inhabitants of
South America, and they stated that the plant was of idolatry
and witchcraft, and only appeared to give strength by the
deception of the Evil One; that it did not possess any real
virtues, and that it spoiled the lives of numbers of Indians,
who, at the best, only escaped with mind and body unhinged.
In like manner we also record of cocaine that it produces,
amongst others, symptoms, not without danger, of a paranoia
hallucinatoria. It seems that the coqueros, like our own
cocainists, are recognizable by their uncertain manner, the
loose skin of earthy tint, the hollow lack-lustre eyes, sur¬
rounded by violet-brown circles, the tremor of the lips, the
style of speech, the suspicious, hesitating, false, crafty
character. Similarly to our cocainists, they are insensible to
hunger and thirst, are often under the influence of delusions,
and, mentally, they not infrequently are degraded to com¬
plete imbecility (an experience which truly darkens consider¬
ably our above-stated prognosis). A case, however, occurring
in my own practice, of the establishment of the above
psychosis by the use of coca leaves, corroborates my
statement. Apart from the actual resemblance of the effect^
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238 Cocaine in the Treatment of Mental Disorders. [July,
of coca leaves and of cocaine, the other substances present
in the leaves, which might be held to be effective, are
in too small quantities to be really credited with observable
effect. Moreover, the method adopted by the Indian in
chewing the leaves proves that it is the alkaloid alone that
he seeks ; he uses, viz., the ashes of plants—caustic lime, in
a word—basic substances whose action will be to set free the
alkaloid.
The third and last point concerns the question whether
the described psychoses result from the use of cocaine alone,
or only when it is conjoined with morphia. I am quite
willing to admit that morphia may beget a certain predis¬
position to our psychosis, but, after all that has been said, in
particular after the last-mentioned proof of the similarity of
effect of coca leaves alone with those of cocaine, there can be
no reason to assume that only the conjunction of the two
poisons will be effectual.
I am unable to conclude without again insisting on the,
at least, doubtful advantages which cocaine offers to us as a
medicine in mental affections. On the other hand, I must
draw attention to the disadvantages which not infrequently
attend the use of the poison.
CLINICAL NOTES AND CASES.
Cases of Masturbation (Masturbatic Insanity ). By E. C.
Spitzka, M.D., of New York.
(Continued from p. 73.)
There are exceptions to the rule that all male masturbators
are shy with regard to the female sex, and at all times. It is
true that the majority are so in the earlier periods of their
vice, and as long as definitive mental disease has not set in.
In some cases where such disease has become established, a
sudden transformation from bashfulness to brazen effrontery,
and from timidity to bold, insulting and lascivious demeanour,
is noticed. These patients exaggerate the characteristic, so
happily drawn by Oliver Goldsmith in “ She Stoops to
Conquer,” of a certain class of men who are heroes before
barmaids and cowards before refined females. In excep¬
tional instances, the masturbatic lunatic is as brutally
indecent to those of a higher as to those of a lower station.
Godding relates a case of this kind in graphic language in
his “ Two Hard Cases.”
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Clinical Notes and Cases.
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1887.]
The picture presented by masturbatic lunatics of advanced
years is, perhaps, as revolting a one as occurs within the
alienist's experience. The common type of whining hypo¬
chondriasis it is not necessary for me to delineate, as cha¬
racteristic cases may be found in the works of Bucknill and
Tuke, Krafft-Ebing, Clouston, and other writers. In the
following case, however, one feature is added which is usually
absent in hypochondriacal paranoia due to masturbation,
namely, a tendency to increased indulgence in the habit in
advanced life.
IV.— Heredity (?); masturbation continued through married life; hy¬
pochondriacal insanity at twenty-seventh year; recovery; outbreak
of selfish hypochondriasis in fifty-second year ; mental and physical
deterioration .
P. B., aged 52 years, married happily, has always been a strict |
man of Business:— A yuo rrger brother is insane since thirty years, and
an older sister committed suicide; a second sister is “ slightly de¬
ranged.” The patient himself had an attack of hypochondriacal
insanity in his twenty-seventh year—attributed, as was also the
disease of his brother, to self-abuse.
Since his twelfth year the patient has masturbated considerably, and
occasionally resumed this practice during his married life. Since
about a year, he has developed a dislike for normal indulgence, and
practised his bad habit daily. This being discovered, through his
brother-in-law, a physician, who was aware of the cause of insanity in
other members of the family, he was placed under supervision in an
orthopaedic establishment l Here it was found that he masturbated
at night, and passed into a sort of frenzy during and after the act, as
well as when prohibited. He was in the habit of boring physicians,
particularly neurological specialists, to whom he had access through
the medium of his brother-in-law, himself eminent in another branch
of the profession. He was also brought to me, and I ordered him to
be transferred to the private retreat at Greenmont, under Dr. Ralph
Parson’s care. Many of the facts of this history were furnished me
by this alienist.
His demeanour was obtrusive, mean, and selfish. He sat out all
my other patients on the morning he called, withdrew to the waiting-
room, under indignant protests, when I represented to him that I
could not keep a physician accompanying patients, who had come a
great distance, waiting any longer, he having already consumed two
hours. He came in repeatedly, and, finally, after I had finished, he
took possession of the field, and as I hurried off* to my much-delayed
lunch, he exclaimed, “ Hurry up, doctor, do not be long ; I have a
great deal to tell you yet. My case is of more importance than any
other yon ever had ; I am the most important man in my family.”
Altogether he was seven hours in my house, of which fully four were
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240
Clinical Notes and Cases.
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occupied by lachrymose and exaggerated accounts of suffering, attri¬
buted, as is usual in such cases, to all sorts of circumstances other than
his vice. A pointed and long continued cross-examination failed to
reveal the nature of these alleged sufferings, but they related to his
bowels, stomach, “ circulation,” “ thoughts,” head-sensations, and
general prostration. Above all, he attributed much of his misery to
his brother-in-law, who, he alleged, had delayed too long to take him
to nervous specialists. Then he declared that those of the latter
whom he had already 6een were swindlers, but again consulted two
of them the following day. On returning to me, he bitterly de¬
nounced them for having given him hypnotics, and to his brother-iu-
law, denounced me for failing to do so. He denied having any pas¬
sage from his bowels, but it was proved that he had had such at least
every other day. He manifested intense hatred to those who con¬
tradicted his claims or revealed their fallacy, and appeared to be
developing a feeble and unsystematized delusion that his brother-in-
law’s neglect was connected with his wife’s aversion, and that the
latter must have exercised some influence calculated to bring on his
bad habits. After his arrival at Greenmont, he had a fit of depres¬
sion, and insisted on going to the city to see his wife, whom he had
accused two days previously of being the cause of his misfortune. At
bed-time he tried to get the attendant to leave the room, and failing
in this, wished to remain in bed while the latter went to breakfast.
He became very much excited after be failed to accomplish his pur¬
pose, reviled the attendant, said he was ignorant, and developed an
intense antipathy to him, so that the latter requested to be relieved of
his disagreeable charge. During the following month he was always
dissatisfied; he complained to the physician about the attendants, and
to the latter about the former. On being requested to specify his
complaints, he was unable to do so, but rejoined that he did not wish
to be in an asylum. It was then suggested that he should go home, to
which he demurred, and on making other propositions to him it was
found that he had no definite aim, and concluded to stay where he
then was. It transpired accidentally that in order to comply with tlie
legal forms, certificates of insanity had been prepared in his case. He
became very indignant, telegraphed to his family to learn if it were
true, and then insisted that they should prove him to be—as they
claimed—his own master, by taking him home. This was complied
with, and there was not one person at the asylum, physician,
patient, attendant, or servant, who did not breathe freer after his
departure. Four days later he reappeared at the institution with
numerous large trunks, but had scarcely entered before he
urged the necessity of consulting another specialist in the city he had
just left. He suffered from nausea and headache, and carried out his
project of seeing the specialist in question, obtained a written guar¬
antee from him, subsequently found in his pockets, that he did not
require asylum treatment, and took the next train to Dr. Parson’s
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1887.]
Clinical Notes and Cases .
241
institution. Here lie claimed to suffer from sleeplessness, not resting
a second all night. But observation showed that he slept from five
to nine hours. Finding that no attention was paid to his statement,
and that the vigilance of the attendants defeated his purpose of ex¬
citing sympathy, he made presents to them, and tried by every
indirect means to get them to report in favour of his theory. When¬
ever in presence of other patients or visitors he moaned and cried as
if in great distress. Finally, after all his complaints had been shown
by convicting evidence to be without material foundation—except as
far a6 spinal irritation was concerned—he discovered that the expen¬
diture involved in his stay at an asylum was too great, and returned
home. During his stay he showed no regard for the other patients,
but pursued the phantom of his own creation in a selfish way, dis¬
regarding the feelings and privileges of others. On one such occasion
he rushed into the room of a debilitated and bed-ridden patient to
deliver a harangue against one of the attendants, full of mean
insinuations and hypocritical diatribe. He subsequently developed
an irritable condition, marked by flushed cheeks, myosis, and great
absent-mindedness. Thus he went about from one physician to
another until he became, as I learned from one of them, bed-ridden
at times, and at the last report was supposed to be afflicted with
some organic affection of the brain, without focal symptoms, which
is being treated in a German sanitarium.
The history of this patient is well supplemented by that
of the convict Graves, whose execution at Newark offered
me an opportunity of studying the morbid changes occurring
in a person who had been addicted to onanism over sixty
years.
James Graves was bom in England in 1818, and came to this
country in 1825. He became a wool-corder, and during his younger
years composed a sort of autobiography, which indicates that he had
been an onanist from his earliest years. The main part of its con¬
tents relates to that practice, of which he speaks with cynical coolness.
The following are fair specimens of confessions of shyness before
females, and general timidity, while in addition some egoistical exair
tation is discoverable. V v<>a/ *
“ The next day i sent her a valentine, i wrot on it these lines o dear o me—
what can the matter be—the matter is i want a wife—in fact i am tired of a
single life, in a few days i took her to exebition, i may here remark that
my scxuel desires was so great and i thought so much about giting maried, that
i did not sleep much nights, as a consequence i begun to git nervous, so that
the night i took my girl to exebition i nervous and dejected. ... At part¬
ing i made bold to kiss her but i think i made a poor job of it i was so nervous
i did not half kiss her. ... At this place i was called a very likely and en-
genuous man and the best corder they ever had, and I had better health than i
ever had scince i was a man. i also menedged my help to a charm bouth girls
and men. 9 pounds of flesh as i walked up and down my room with an easy
and plesent and stern manner i thought i that i was the nepolion of cor -
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242
Clinical Notes and Cases.
ders* ... if i saw a man and woman walking together it would nearly set me
cryeing. ... so i paid my bill at the tavern and went to bed as i was to start
at 3 o’clock in the morning i felt very nervous and figitty as i Thought in was
in danger of being taken up as a rober, but i went out in my stockings and did
not create any alarm i do not think that a rober ever felt as nervous in robing
a hous as i did in going honestly out of that tavern. . . . i tryed to find out
whare the-houses of the city ware, i had heard that there was some but i
did not mix in the company of young men enough to get introduced to one of
them, my habits were to soletary, and i was to timed, this was much agrivated
bg mg high sense of honor , and justice and mg disgiust of the meanness and
perfidg of the inhuman race as a whole
Graves + was a little of everything, a poor joiner, an indifferent
tinker, and a worse machinist. After failing in several lines of
invention he settled down as a pump maker. Down to the time of
his death he was in ill-health, dyspeptic, and melancholy. About
two years before his death he again evolved a project, of a musical
character. He intended to hire a hall to play the violin in, and
actually went about the streets playing that instrument—of which
he had but slight if any knowledge—his face the while being covered
by a mask, which he wore because he was afraid to show it. He carried
his head in a peculiar sidelong way, and appeared to be continually
muttering to himself, working his mouth as if chewing his tongue. He
was, from his singular appearance, known as “ Monkey Graves ” or
“ Crazy Graves,and persecuted by the children of the neighbour¬
hood, one of whom he deliberately shot and killed in retaliation,
saying that he had “ fully counted the costs of his undertaking.” He
was permitted to testify in his own behalf, with the usual result of
convincing a jury unprepared to recognize any other form of insanity
tlian that found in novels, that he was perfectly sane. He showed
considerable defect of memory, a tendency to wander away from the
subject, and a silly demeanour. 1 examined him about a year after the
trial. In his bent attitude the height of the patient was less than
five feet, originally it probably had been five feet two inches. His
weight was between eighty and ninety pounds. The skull was propor¬
tionally large, and there was not a vestige of hair on any part of his
scalp or face, and his pupils were unequally myotic. His vision was
very weak, the colour sense uncertain, his expression vacant, and com¬
plexion sickly. Two large scars, one on the forehead and a second
over the mastoid region, indicated the sites of previous carbuncles.
On compelling him to walk across the room, he shuffled along, in
evident pain, moaning constantly. I suspected a hemi-contracture, but
owing to the patient’s feeble-mindedness and general prostration
was unable to obtain any satisfactory evidences of this or of paresis.
* See “ Proceedings of the Society of Medical Jnrisprudence and State
Medicine,’* Vol. ii., pp. 15-20 ; reprinted from the “Am. Journal of Neurology
and Psychiatry.”
f He made some inventions, which were exhibited before the Society of
Medical Jurisprudence, which be had tried to introduce to notice by means of
doggerel poetry reproduced in the paper referred to.
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1887.]
Clinical Notes and Cases .
243
The impairment of his memory-was profound. But as his history was
known for seven years back, in which he had presented no signs of
acute disease or seizures, and had never mentioned such, and, further¬
more, his motor peculiarites had been noticed to develop gradually, it is
reasonable to assume that he cannot have had any apoplectiform
attacks. He had had visual phantasms, indicated by his daily repeated
expression “ And still the sparks fly upward.” He was irritable under
examination. The nurse reported him to be unclean, but constant
attention restored his control. He had glycosuria, and consequent
frequent and profuse micturition. After his execution I found a
remarkable diminution of the relative area of the cauda equina and
lumbar spinal cord, without any structural lesion disconnected from
his age. The weight of the brain was 41^ ounces, while proportion¬
ately to the skull-capacity as measured, it should have been at least
53. There was both internal and external hydrocephalus. The sulci*
gaped widely, there were large pockets of tbe arachnoid between the *
gyri, which were filled with serum ; there was an enormous amount of
this in the general expanse of the arachnoid, six ounces being
collected, as well as in the dilated ventricles. The posterior horn of
the left lateral ventricle was so much dilated that the occipital lobe
was reduced to a mere bag, and a cicatricial induration of brain sub¬
stance, of almost cartilaginous hardness, surrounding a greenish dis¬
coloured softened area of the white substance underlying the inner
end of the left calcarine fissure, was found. The cortex here was
wasted and indurated. A similar spot was symmetrically situated on
the right side, also a third one of the diameter of centimetres in
the supra-capsular part of the white substance of the left frontal lobe.
All the tissues of the brain, particularly the pons and oblongata, were
unusually firm, there was intense pigmentation of the larger ganglion
cells (senile), and evidences of pigmentary disintegration of the vagus
and auditory as well as the facitd nuclei. A large number of small
cysts were situated in the cortex. The patient was in his seventieth
year, but neither his symptoms nor the lesions found correspond to
those of ordinary senile dementia. Another singular feature is the
comparative latency of large destructive lesions in the brain, a feature
not infrequently found in dements, who do not seem to react, as pre¬
viously normal persons do, to coarse brain-affections.
The results of masturbation as far as they invol ve disturb¬
ances of the spinal and cerebral centres, are usually regarded
as of a functional character. The older physicians were more
inclined than the moderns to regard organic wasting of the
cord or brain as a possible result. Aside from the positive
findings in the above case, and the corroborative symptoms
observed in others which did not reach the autopsy table,
there are a number of facts which indicate the necessity of a
renewed examination of the subject. These are the presence
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244
Clinical Notes and Cases.
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in excessive masturbators, particularly in those who in
addition to their voluntary losses suffer from involuntary
ones, of symptoms not ordinarily found in purely sympto-
I matic states. Among these the following are the most
important found in the histories of 219 cases of nervous dis¬
order based on self-abuse :—
1 .—Sudden electric-like shocks . These occurred in two
cases during the uigasiii, the latter being provoked by the
patient while standing. In one case the patient fell down
powerless, and two weeks elapsed before he regained his
normal power of walking. The knee-jerks were at first com¬
pletely abolished, and returned with the motor power.
Analogous, though less intense phenomena occur when
coitus is arrested by withdrawal.
2 .—Paresis of the lower ex tremities. The physical results
are~particTTlailjr localized ilTThe lower extremities. Many
masturbators are weak in walking. In 1 of 17 females, and
in 23 of 202 males, this weakness reached the degree of a
paraparesis. It was noticed that it increased with increased
excesses, to improve when they were suspended. That it is not
a part of general weakness is shown by the fact that neither
in man nor the lower animals are the anterior extremities in¬
volved to such an extent, or in the same way. Pfisterer, in his
annual report of veterinary matters at Rastatt, reports the
case of a stud foal, aged two years, suffering from paralysis
of the hind-limbs brought on by onanism, and radically cured
by castration, which was rendered necessary as all other
means tried to check the vice failed.*
3. — Exag geration^ abolitmn^Jind asymmetry o f fy*
Among 202 males the knee-jerk was found exaggeratedmtT,
abolished in 3 (aged respectively 29, 33, and 41 years), and
in 2 diminished on the left side alone. In two of the cases of
abolition the phenomenon returned after about a year’s
treatment of coexistent spermatorrhoea. In all of them there
had been rheumatoid and fulgurating pains, which in the two
cases where the knee-jerk was least marked on the left side,
were most marked on that side. The same distribution of
the associated parsesthesias was noticed.f
A>--^Atq xia. . A feeling of unsteadiness and swaying is
usually found in those cases where the lower extremities are
* “ Thierarztliche Mittheil ungen,*’ August, 1884.
t The case of acute loss of the knee-jerk is not classified herewith. The dis¬
appearance as well as the return of the jerk was noted to be marked by a stage
in which it was excessive enough, but halting, as it were, in the “ go-back.”
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Clinical Notes and Cases .
245
1887.]
weak, and is probably due to the weakness. In one case,
however, a marked tabic gait was found, the limbs were
thrown about violently, interfering so as to throw the patient
off his balance.* The knee-jerks were exaggerated, and the
superficial reflexes diminished. No other signs pointing to
organic disease were found. For two years the patient
improved in all the respects mentioned, but was lost sight of
in 1884.
5. — Bladde r-symptoms. Both the bladder and rectum were
tfre~seat oFintense boring pain—compared in two cases to the
forcing of a wedge t or of flatus through a gut—in three
patients, one of whom had abolished, one exaggerated, and
one normal knee-jerks. None of these patients had other
indications of organic disease. Difficulty of retaining the
urine and impaired expulsive power J are recorded in 32
male cases.
6. — Retina . Asthenopia was found in all masturbators,
male" and female, who had passed the fortieth year and
continued the habit beyond that time. In two cases I
recorded concentric limitation of the visual field; in one
this was limited to the colour sense, in the other confirmed by
Mittendorf; the visual fields, with the exception of a minute
central area, were entirely amblyopic. The optic nerve was
pale, but showed no signs of atrophy or other disease. The
patient’s age was twenty-seven.§
7. — Pupils . In young onanists the pupils are usually
d ilated and very mobile ; but in those who have gone very
far in their excesses there is often myosis. This is often the
case in irritable dementia. || ThTTpipillary reactions are
* This was first observed in the 15th year, and had slowly increased to the
3oth, the period of the examination.
f Ibave been unable to find a reference to two cases described, either in
1869, 1870, or 1871, of young men who had been extreme onanists, and suffered
from the same pain. A fibroid growth was found in the cerebellum of one of
them, but whether it was regarded as an accidental coincidence or not I have
forgotten.
t According to Dr. H. G. Lyttle, a genito-urinary specialist, stricture is
developed in some onanists, so that we cannot be positive in our interpretation
of their bladder-symptoms.
§ A. Schiele, “ Archiv fiir Augenbeilkunde,” xvi., p. 145, believes that
asthenopia, as well as consequent limitation of the visual field, may be due to
exhaustion of the gray matter in the occipital lobes aB a result of functional as
well as of organic disease. It iB noteworthy that in Graves a symmetrical
lesion should have been found in this very district.
0 The palpebral aperture often becomes narrow, the brows overhang in con¬
nection with the habitual corrugation of the eye-brows, and the tout-ensemble
is not unlike the expression of a vioious baboon, a resemblance heightened in
some by pouting lips and a sparse irregular growth of hair on the chin.
/
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246
Clinical Notes and Cases.
[July,
usually normal, rarely sluggish, and were undemonstrable
only in the case of Graves, which is not included in the
tables. Inequality was noted in eight cases, in three being
quite marked.
8. — Glycosuria. Sugar occurred in the urine in varying
quantities in IT"out of 202 males. Remarkably often I
found an unusually low specific gravity coexisting, and this
in cases where the presence of sugar was easily demonstrable
and in large quantities. The supposed characteristic signs
of diabetes are usually absent; thirst, bulimia, rapid
emaciation, and other general indications of this disorder,
were present in but one case, and even here the diabetes
appears to have been a temporary condition, as, notwith¬
standing the patient’s return to an ordinary diet after a
year’s treatment, sugar has not reappeared. In the case of
Graves, not included in this computation, there was a history
of repeated attacks of furunculosis in connection with
glycosuria.
9. — Other symptoms on the part of the cranial nerves.— In
three out of 29 subjects of the masturbatory neurosis under
the age of fourteen, all males, I found d eviation of_th e
t ongue to the left, and the left pupil narrower! Inivvoof
these cases the evidence of theTiunil)' attendant showed that
the inequality of the pupils was acquired.
10. — Tr ophic disor ders . In one case, that of a youth,
aged eighteen, a herp etic p atch following a peculiar drawing
sensation in the left supraorbital distribution, together with
ansesthesia of that side of the face, was observed after every
excess. On several occasions this patient experienced a
sensation like the report of a pistol, accompanied by a sense
of “being overwhelmed” previous to the artificial orgasm.
In an earlier case, where a similar subjective sound was ex¬
perienced under like circumstances, it was followed by
left-sided choreic twitching, and the skin and hair changed
colour on that side.* Burr mentions a lightning-stroke
sensation, followed by severe dorsal pain in one case. It
was one of the paranoiac type, in which similar subjective
sensations are by no means rare.
The above symptoms indicate the presence in a small
* Kiernan describes the same patient in two papers on trophic disturbances,
“ Journal of Nervous and Mental Diseases,” 1878, and 44 Alienist and Neu¬
rologist/' Vol. vii., p, 474, as one of hebephrenia, and inclines to attribute the
trophic changes to a deep abscess, which might have involved the sympathetic.
The pistol-shot sensation in the head which the patient complained of occurred
while he was indulging in his unnatural practice.
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Clinical Notes and Cases .
247
1887.]
proportion of excessive onanists, sane and insane, of a condi¬
tion which is on the border-line between organic and
symptomatic (functional) nervous disease. Their presence
should render us cautious in following the routine practice
of treating all the onanist's complaints as necessarily
hypochondriacal or imaginary. It has a bad effect—one
ruinous to the moral management of the patient—when he
discovers by exact and convincing evidence that the
physician does not discriminate between his real sufferings
and his apprehensions. On the other hand, the removal of
any one of his causes of complaint often inaugurates a rapid
progress to improvement in other respects. This has been
frequently illustrated in my experience in the favourable eflFect
of an initial large dose of the bromides in those cases where
there is a tickling or running sensation in the urethra or a
rubbing sensation on the glans. Imperative conceptions
and hypochondriacal fears have been rapidly and favourably
influenced after its disappearance, and relapsed on its return
b 7 some mysterious morbid association. I may mention
here that I regard these peripheral sensations as one of the
indications justifying the exceptional use of the bromides
in these patients. As a general thing they have no good
effects.
Among the commoner subjective symptoms of the
masturbatory neurosis is occipital headache . A dull and
tired feeling is noticed, especially after rising; and this is
apt to be associated with the sensation of a ti ght J aand
a round the head^ w hich may seem to the patient to pulsate.
Asthe day progresses, thedulness and heavy or clogged feel¬
ing disappears, while the head-pressure is liable to become
aggravated at any time by mental exertion. In some the
ache or pulsating pain in the nucho-occipital region is
greatly aggravated by a repetition of the vice or by coitus.
The majority of masturbators, b^come^ hy and n e rv o us, a ne b
d evelop morbid fears, o r at least an exaggeration of those
fears to which men and boys are liable. Thus they become
greatlv alarmed in a railroad train as it shoots a curve, in a
steamboat as the steam is let off; or they are anxious in
passing high buildings, particularly when scaffoldings are
erected on them. They fear dogs, and are afraid of this or
that “ rough customer ” hitting them. One of these
patients crossed over regularly to the other side of the
street because he dreaded that he might be caught in the
whirling belt of machinery in a closed building, and his
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Clinical Notes and Cases .
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agony finally became so great that he selected another
street—though at some loss of time—to pass through. In
those who discontinue the habit at this time, the morbid
timidity may continue through life, growing fainter with
advancing years, and may remain the only residue of
damage done the nervous system. In others, some one or
several topics of fear or of morbid brooding tyrannize the
mind as imperative conceptions. Of eighty-nine classified
male cases of imperative conceptions, only eleven had not
been confirmed masturbators. In some instances the de¬
velopment of an imperative conception from a morbid fear
is very clearly shown. Thus a patient had the vague fear of
dogs generally from his eighteenth to his twenty-ninth year.
About this time the “ New York Herald ” contained terrify¬
ing announcements about hydrophobia. A dog passed the
patient while he was thinking over this matter, and, as
usual, he diverged from his path to give him a wide berth.
' But the dog having passed over the line which the patient
would otherwise have taken, he began to speculate that
some froth must have struck a certain part of his trousers
and penetrated to the skin. He could, like all sufferers
from such distressing conceptions, reason himself out of the
belief *, but was unable to rid himself of the speculation on
this topic. And the morbid concentration of his mind
became fixed by the development of a congested spot on his
right tibial region, which flushed up when his thoughts
were most intense, nearly disappeared when they were
otherwise engaged, and ultimately led to pigmentation of
the affected area. This and other varieties of the foliedu
doute avec dilire du toucher, usually manifesting themselves
in dread of venereal contagion, appear as frequently to be
based on masturbation in males, as imperative conceptions,
folie du doute , and morbid impulses in the female are found
associated with those uterine disorders which are accom¬
panied by weakening discharges. They are of importance,
in so far as they furnish a groundwork for the development
of delusions in paranoiac onanists.
Timidity and the development of morbid fears are par¬
ticularly marked in cases complicated by spermatorrhoea.
This condition appears to be by itself competent to produce
these symptoms. A healthy, broad-shouldered frontiers¬
man from Texas, aged thirty-eight, who, as overseer of a
large cattle-range, had been almost constantly on horseback
during the day, became afflicted with both diurnal and
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Clinical Notes and Cases.
249
1887.]
nocturnal seminal losses—aggravated by sexual excesses.
His words were: “ Before nothing could startle me, but now
I am as nervous as a lady.”
An instructive case, illustrating developing morbid
timidity, with ensuing fnlie du doute r is related by Hoster-
mann. The youth, after committing excesses in this direc¬
tion, became very shy and nervous, exceedingly scrupulous
as to hurting the feelings of others. This was manifested
more especially in regard to conventionalities ; thus he was
morbidly particular as to not having his hands in his
pockets. Finally, he could not be induced to shake hands
with ladies ; and in his toilet assumed the most unusual and
constrained positions in order to avoid touching his genitals,
or bringing them in contact with anything his hands might
touch. He was continually examining himself to see if he
were properly buttoned up. He became excessively re¬
ligious, and it was possible to detect in his countenance,
while engaged in religious devotions, that he fought down
thoughts of a different character. He developed that
common form of imperative conceptions which manifests
itself in a repeated examination of the premises, to see if
they are not on fire, and if the doors are properly locked.*
In the following series of cases there were certain compli¬
cations present which modified the psychosis. But the
fundamental character of the patient’s mental state appears
to have been determined by the vice of onanism.
V .—No hereditary taint; two attacks of inflammatory rheumatism at
8 and 14 / onanism from fifteenth to nineteenth year ; imperfectly
cyclical alienation.
P. H., aged 20, student in a Catholic seminary, no ancestral taint,
examined June 28th, 1884. He has a sodden countenance, and sits
still in a corner, looking distrustfully and timidly at his interlocutor.
He is greatly depressed, his hands are cold, and the capillary circula¬
tion imperfect. Two years ago it was found advisable to submit him
to asylum treatment, but at that time the father’s means did not
permit of this being done in any other than a pauper asylum. Here
his condition became rapidly worse, both physically and mentally, and
his memory, which had been somewhat impaired before admission,
was said to have been almost abolished by the time of his removal.
He was placed under tonic regimen by the physicians of his native
*“ Allgemeine Zeitschrift fur Psychiatric, 11 Vol. xli, Heft. 1, p. 26-27. Wille,
in his paper on “ Imperative Conceptions” (“Archiv fiir Psychiatric,” xii.), states
that of seven males suffering from them, four were onanists; of nine females
bat one was so addicted.
XXXIII.
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250
Clinical Notes and Cases .
place, and improved in health. He now answers questions with some
reluctance, and after a great deal of suasion responsively and correctly.
( Masturbation one e per diem for the past four years is acknowledged.
He has had two attacks of acute articular rheumatism at the ages of
eight and fourteen, and Dr Seneca Powell, who referred the patient to
me, says that a very distinct mitral murmur could be made out a year
ago. At present there is an accentuation of the second sound at the
apex.
As a boy he was quarrelsome among those of his age, but at
home so remarkably subdued and quiet that his father thought
him fitted for the priesthood, and—although a labouring man —
he devoted all his energies to the one aim of his existence: that of
giving bis son that education which would fit him for saying “ a
mass for his father’s soul.’* This expectation, I need not add, is not
destined to realization, and the father’s despair and disappointment
constituted one of the saddest of the numerous minor tragedies in
which a consulting alienist’s experience is so rich.
S The patient continued under my treatment, which consisted in re¬
strictive watching, the administration of cannabis indica during the
spells of worst depression, of warm sitz-baths in the evening, and a
^regulation of the somatic functions generally, including a tonic regi-
\jnen and phosphates for four months, during which time he rapidly
improved, so that by August 3rd he presented a normal condition.
Previously it bad been observed by himself and by others that he
would awake in a bewildered state in the morning, and become clearer
as the day advanced, so that in a day, where morning would find him
confused, amnesic, and dazed, he would be bright, active, and intelli-
( gent in the evening. The relief of his nocturnal emissions, which the
warm sitz-baths (before retiring) and atropine gave, was probably the
cause of his increasing clearness in the morning. His complexion,
which had been disfigured by acne, cleared up, tbe puffiness disap¬
peared, the hands became warm and moist, instead of being, as previ¬
ously, cold and bluish. At times they would become hot. On tbe
first of September he was entirely normal, physically and mentally,
and then did not report for nearly two months, when (Oct. 20th) he
was brought to me in a typical state of incipient mania. His physical
condition was excellent; his speech, which was very emphatic, was
accompanied by active gesticulations. It lacked but little, and he
would have pounded his statements into his auditors’ heads with his
fists. His loud and boisterous assertions related chiefly to the credit
which he claimed was due to him for having the ability to con¬
trol his bad habits, and for controlling them. “ There are few would
have done it ” were his last words as he left me on his road to the
asylum. Dr. Wm. Hardy, since deceased, informed me that at the
pavilion of Belle Vue he broke out in a genuine maniacal attack,
reiterating the above statements at intervals, and passing into expan¬
sive delirium before he left his charge. He was egotistical, and
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Clinical Notes and Cases.
251
emphatically announced himself as " a good boy.” The case was
then lost sight of.
In the next case we have an impure type to deal with.
The case is one modified by the coexistence of a fundamen¬
tal neurosis developing on the basis of spinal irritation, all,
however, due to early masturbation. This history, like some
of the preceding, teaches that the views of those who believe
that the accomplishment of coitus does away with all ills
provoked by self-abuse is erroneous. It may modify, but
rarely cures.
VI.— Neurotic heredity; masturbation practised very early and exces¬
sively; cerebrospinal irritation and exhaustion with spermatorrhoea ;
marriage ; sexual excesses ; systematized delusions of persecution;
sexvxil perversion.
Albert L. L., aged 27 years, a lawyer and stenographer by occupa¬
tion, examined June 13th, 1884. His father, the only member of the
family presenting a neurotic history, is said to have had an attack of
trance of a death-like character and lasting more than eleven days.
His brother, one of the then leading neurologists of Germany, happened
to have crossed the Atlantic to visit him at this time, and is said to
have either pronounced life extinct or about to become extinct ; but
recovery ensued, and he is to-day in fair health. He had also, prior
to his trance, passed through the Civil War with a good record.
The patient had a peculiarly conceited and at the same time shy
expression of countenance. His face was flushed, and the temperature
of his head appeared (objectively) raised. His cranium was far
inferior to that of other members of his family, and narrow as well as
retreating in the frontal region. During the summers of 1882 and
1883 he complained of a feeling of pressure and burning in the
occiput, which sometimes recurs. During April, 1883, he consulted
the distinguished ophthalmologist Knapp for a burning sensation in the
eyes, which was attributed by the latter to overwork. At this time
he also suffered from trembling, which was apparently relieved by
medication.
In his early youth this unfortunate person had been demoralized by a
servant-girl, and his mother stated that he had complained of sharp
pains through both hips in his seventh year. From his seventh to I
his eleventh year he masturbated daily. He remembers having been ’
ashamed of this practice. After his twelfth year voluptuous imagery (
was indulged in at night, then masturbation—at least as a voluntary
act—ceased ; but he had from three to seven seminal emissions on 1
most nights, and at least one on the others. At this time he clan- 1
destinely consulted a physician. Another medical adviser removed a
phimosis in the patient’s eighteenth year. Shortly after, a woman
who frequented the house—of whom it was well established afterwards
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252
Clinical Notes and Cases.
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that she had a husband living in Germany—worked on his sexual
weaknesses with the result of accomplishing a secret marriage. His
imagination was kept at the highest strain by licentious books when
his natural resources failed him. He claimed that he became divorced
from her in secret, the cause being jealousy on her part; she accused
him of having relations with her lady friends, and would put them to
the proof wheu they asserted their innocence by requesting them to
look into the patient’s eyes while she observed both parties. At
other times she urged her husband to excite their passions. From
the father’s account, it is evident that this woman was an unbalanced,
if not actually insane, nymphomaniac. The marriage, as well as
the informal li divorce,” were successfully kept from the parents’
knowledge for years ; and the witnesses of certain transactions above
alluded to had not even suspected that the two were man and wife.
Five years ago he married again ; in the interval of two years between
the divorce and second nuptial transaction he had relations with pro¬
stitutes on about twenty occasions. He claims that such relations, in
contradistinction to those with his legitimate partners, were revolting
to him. He descants at length about the purity and dignity of his
present wife. He has indulged in what—with his weakened sexual
organs, imperfect erections, and continuing seminal emissions—must
be regarded as marital excesses for the first year of the second
married life.
The special occasion which led to my opinion being asked was that
the patient had acted strangely, not venturing into the street, becoming
very restless, and complaining of being followed. He stated that he
had had an undefinable feeling of being shadowed by persons unknown
for over a year. Three weeks previously he had accompanied his wife
to Astoria, and suspecting that certain persons on the ferry-boat were
watching him, he returned by way of Greenpoint Ferry—distant some
miles—and still found the Bame persons on the boat. This convinced
him that he was the object of a pursuit. A few days later, while
amusing himself with his canary birds, he noticed some grown-up girls
and women watching him. That same afternoon he identified one of
these women in a horse-car, who was dancing a baby up and down in
the seat directly opposite his. He claimed that this was done to
attract his attention : she had seen how kind he was to his canaries,
expected him to become interested in the child, then entrap him into
a flirtation, compromise him, and thus cause his arrest.
As he had been for several years engaged as clerk in the publishing
department of a prominent firm of medical booksellers, and was—like
most of his class—an omnivorous reader, I asked him if he had ever
read of people who imagined themselves the victims of a conspiracy.
He instantly brightened up, and said that he knew very well to what
I alluded ; he recognized that the insane entertained such beliefs, and
based them on similar impressions to his own ; but he had committed
an act which was punishable, and justified his being pursued by the
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Clinical Notes and Cases .
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1887.]
officers of the law. He then proceeded to relate an immoral occur¬
rence, as to whose reality I might have remained in doubt had not con¬
firmatory evidence shown that it must have occurred nearly as the
patient related it. About a year ago, and up to May 25th of this
year, when he claims it subsided, he developed an “ impulse ” to
question young girls, between the ages of thirteen and fifteen, in a
disgusting manner. He claims that he did not do this from erotic
motives, but merely to make “ physiognomical studies.” He states
that he put such questions to thirteen or fourteen groups of girls in
the Central Park, and that, with one exception, they turned away or
ran from him. Of one instance and all its abhorrent details he speaks
with cynical coolness. He claims that, in public conveyances, he
frequently corresponded with women by rubbing his knees together,
on which they would respond by the same motion.
Complaints had been made of such a person as the patient, and
alluded to in the public prints. About the same time a detective had
shot a man who had been followed to a letter-box, into which he had
been in the habit of throwing blackmailing letters, after attempting
to abduct a young girl. All these facts served to strengthen the
patient's delusion. When I asked him why, if the detectives were
assured of his identity, they did not arrest him at once, he said “ The
parenta of some of those girls may be so wealthy that they could
easily afford to pay a high figure to run me down and prolong my
agony. They want cumulative evidence, and the longer the detectives
can keep it up, the heavier will be their bills.” The patient manifests
no real shame or contrition, though he claims to feel remorse at the
prospect of a “ low life 99 and “ public disgrace.” He is, however,
much afraid for himself. Some weeks ago he thought of suicide to
escape his fate, but abandoned it, for the reason that, as the detec¬
tives had already tracked him, they would expose him after death.
Yet he was an atheist. He added, u I then saw no other refuge than
to make myself insane, so as to become irresponsible.” On asking
him whether he was, in his own opinion, insane, he indignantly re¬
pudiated that notion. He was, during the four days I had him under
observation, exceedingly mobile in his emotions—at one moment
hilarious, at another deeply depressed. It was impossible to induce
him to attend to his favourite canaries, except after nightfall. He
presented the typical signs of spinal irritation, and there was a
certain degree of dulness of the memory noticeable on repeated and
prolonged examination, which appeared to relate equally to remote as
to recent eveuts. I strongly urged the patient's commitment to an
asylum. His relatives, liowevef, claiming ihat my compelling him to
analyze the basis of his belief in persecution had led to his abandon¬
ment of the latter, took him to the Catskill Mountains. There he
wrote lengthy statements ot his case, which were submitted to me.
They were hypochondriacal and exaggerated in tone. He was then
taken to another part of the country, his spinal irritation increased,
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Clinical Notes and Cases .
[July*
he again had voluptuous imagery, and, finally, became excited, and
was reported to me inofficially as restrained in an institution eleven
months ago. Since that time I have obtained no further details of
his history.
It had been noted that for years this patient had not perspired, and
Russian baths had been used in vain to bring on the cutaneous secre¬
tions. Under the treatment instituted—probably a mere coincidence
—they became normal again. At this time it was observed that with
every attack of occipital headache, his “ neck would swell,” and this
measurably so. As in most patients of this class, constipation was
a feature greatly complained of, and a headache was the never failing
signal of an accumulation in the colon.
fTo be continued).
A Case of Imbecility with Choreoid Movements. By Fletcher
Beach, M.B., M.R.C.P., Medical Superintendent Darenth
Asylum.
(With Illustrations.)
F. P., aged 17, was admitted May 17th, 1875, with the following
history :—Parents healthy, temperate, not connected by consan¬
guinity. His maternal grandfather and a cousin on the mother’s side
are paralyzed. He is the eldest of six children, of whom two are dead,
one succumbing from scarlet fever, the other soon after birth. The
rest are healthy. His mental condition is said to have been good up
to the age of ten years, when, during a fight with a boy, he was struck
with a key in the face. Disease of the jaw followed, and on recovery
he was noticed not to be so bright, having been a good scholar before.
Twelve months afterwards he was knocked down and became insen¬
sible, and some months after he fell and struck the back of his head.
He has been getting gradually duller. Four years ago he had an
epileptic fit, affecting both sides of the body. He was taken to the
Hospital for Epilepsy and Paralysis, and, while there, had two fits.
He became excitable and tried to stab a patient, and his removal
became necessary. After he was taken out of the hospital he became
quiet for a time, but the excitability reappeared. He was taken to
the Hampstead Asylum, and subsequently removed to the one at
Clapton.
The following was his condition on admission
He is well nourished, of a dark complexion. Head symmetrical,
and of fair size ; circumference 22 inches, transverse diameter _ 14 *
inches, antero-posterior 14^ iuphes. Width of forehead 4^ inches.
No sign of rickets, syphilis, or scrofula. He is good-natured, obedient,
and obliging; somewhat talkative. Mental capacity fair. His
powers of observation, imitation, attention, and memory are good for
an imbecile.
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Clinical Notes and Cases.
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1887 .]
After admission he had at times epileptic fits, which at first did not
prodace any loss of power on either side. Eleven months before his
death he bad a number of very severe ones, and, on recovery, the left
side of the body was found to be weaker than the right. There was
no spasm, and gradually the left arm and leg gained power. Three
months afterwards another series of epileptic fits supervened, leaving
him again with loss of power on the left side, the arm being more
affected than the leg. The loss of power in the left side remained,
and a month afterwards continuous spasm of the left hand and arm
was noticed.
The following description was taken at the time :—As he sits in a
chair he bolds the tremulous left hand in the right. On nncrossing
them, and letting the left hand and arm hang by his side, the whole
arm is seen to be continually in action, and the hand is undergoing
rather quick spasmodic movements. The thumb is extended and the
fingers flexed, the fore and middle ones completely into the palm, the
ring and little ones to a less extent. This is the usual position, but
the position of the fingers changes, and the ring finger is at times less
flexed. He can extend his arm and hand in front of him, and when he
does so the movements increase. The fibres of the flexors of the
fingers, of the biceps, triceps, and some of the scapular muscles can be
felt twitching, and the scapula, arm, forearm, and fingers are con¬
stantly moving. Sometimes the triceps pulls the arm backwards ; at
other times the biceps pulls it forwards. The movements are not
attended with pain, cease during: sleep, and are not increased by atten¬
tion being directed to them. The hand is not pronated, abducted, or
adducted, but hangs by the side of the body in a straight position.
When he attempts to take hold of an object the hand is brought for¬
wards with the fingers extended, and the fore and middle ones widely
separated, but they soon become spasmodically clenched. They go
round the object, but cannot at first get close to it; after repeated
trials they do so, and then, by an effort of the will, he opens the hand,
though only for a moment, and grasps the object with a clutch. He
has a fair amount of power in the left hand and arm, and can grasp
my hand and pull me towards him. There is, however, considerable
loss of power, when compared with the opposite (unaffected) side.
All the toes, but especially the third and fourth, of the left foot now
and then twitch, but to a much less extent than the hand. When he
attempts to use his hand the great toe is drawn upwards and the
other toes flexed into the sole, as is seen in cases of athetosis. The
movements of the hand do not increase when he walks. There is a
good deal of power in the left leg, but not so much as in the right.
He walks as steadily with his eyes shut as when they are open. His
speech is fairly clear, and has not been altered by the epileptic seizures.
His tongue is tremulous when he puts it out, and very often, while
doing so, his head is drawn backwards and directed upwards. It does
not move at any other time. There are no movements of the face.
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256 Clinical Notes and Cases . [July,
Sensation is diminished on the affected side, and the limbs measure
less in circumference. A measurement, taken at the same points on
both arms, shows the left arm to be one inch and the forearm half an
inch less than the right. There is no shortening. Shortly before
death he experienced another attack of epileptic convulsions, and a
semi-conscious 6tate followed. He took no notice of what was going
on around him, but would answer “ Yes, sir,” and “ No,” in answer
to questions spoken in a loud voice. He lay in bed with his legs ex¬
tended rigidly, and his arms and hands stretched out on either side of
him. The movements before described ceased. At the end of
the week he became quite unconscious, passed urine and faeces under
him, and died.
Autopsy, thirty-six hours after death. The body was well nourished,
rigor mortis persistent ; the thumb of the right hand was clenched in
the palm. The cranium was symmetrical, the calvaria thicker than
normal. The dura-mater was congested, easily removed ; it was not
adherent to the cranium or cerebrum. The subarachnoid fluid was
turbid and in excess; the vessels running over the surface of the
brain were congested, and the pia-mater injected ; there was no
thickening or opacity of the membranes. A little fluid drained away
on removing the brain, which weighed three pounds and half an
ounce, from the cranial cavity. The convolutions were normal in size,
with the exception of those in the parietal and temporo-sphenoidal
regions. In the former position they were slightly , in the latter veil/
coarse in character, z.e., not highly developed, island of Eeil very
evident. On applying gentle pressure with the fingers the brain was
found to be firm in consistence, the parietal regions more resistant
than normal, and the occipital convolutions firm and hard, those on
the right side being a little harder than the left. On slicing through
the brain a little excess of fluid was found in the ventricles. The
white matter presented “ puncta vasculosa ” in excess, and was, so to
say, “ greyish ” in character. In the region of the first temporo-
sphenoidal convolution, and of the inferior parietal lobule on both
sides, on a level with the middle part of the lateral ventricles, the white
matter appeared fibrous. The same appearance was noticed in the
white matter of the occipital convolutions on the same level.
Excellent microscopical sections of the affected parts of the brain
were made for me by my friend Dr. Palmer, of the Lincoln County
Asylum. On examining them with No. 7 Hartnack the chief changes
noticed were : 1, great increase in the number of the vessels; 2, dis¬
tension of many of these vessels ; 3, extensive infiltration of the tissue
with leucocytes, especially in the perivascular sheaths of the vessels.
These changes were seen especially in the grey matter of the right
inferior parietal lobule and first temporo-sphenoidal convolution, more
particularly where the angular gyrus joins the temporo-sphenoidal.
Examination of this part showed great infiltration of the grey matter,
and, to a less extent, of the white matter, with leucocytes. These bodies
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r
T
TO ILLUSTRATE DR. FLETCHER BEACH’S CASE OF IMBECILITY
WITH CHOREOID MOVEMENTS.
Fig. 1 . —Vessel containing blood corpuscules. The wider portion contains
so-called “ pressure lines ” (stained pink) probably due to the blood
pressure. The narrower end of the vessel is surrounded by a large
nnmber of leucocytes.
Fig. 2.—Large collection of leucocytes round a vessel which is nearly obscured.
Below is a smaller collection round another vessel.
Fig. 3.—Accumulation of cells in perivascular sheath. To the left is an
aggregation of cells forming a “ miliary abscess.”
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1887.]
Clinical Notes and Cases .
257
were present in the perivascular sheaths of all the vessels, in some
places forming a single layer, in others many layers, being often in
such quantity as to compress the vessel they ‘surrounded. Generally
they were rounded, but, where subjected to pressure, they assumed an
oval or angular appearance. In several places the vessels were much
distended and their sheaths filled with leucocytes, while further on the
walls were absolutely crammed with these bodies, exerting pressure on
the vessel and reducing its lumen considerably. In some places the
leucocytes had escaped into the surrounding tissue. Here and there
they were collected into dense masses, forming so-called “ miliary
abscesses.” Very often the leucocytes were in such numbers as to
entirely obscure the vessel, so that its course and distribution could
only be seen by the direction taken by them. Many of the vessels
contained clot, and, in a few cases, mixed with it, were rounded bodies
which stained with carmine, showing their recent character. In some
of the vessels the blood-corpuscles had undergone a granular change,
and in two sections the clot appeared dark in the centre, the surround¬
ing portions shading off gradually. In one vessel the clot presented
curved pressure-lines, described by Dr. Gowers as being due to
exposure to pressure by the blood current. In some places there
appeared to be an excess of fibrous tissue around the vessels. The
white matter showed many leucocytes and an increase in the number
of the vessels, but otherwise no change. The grey matter of the left
inferior parietal lobule and first temporo-sphenoidal convolution, and
that of the left occipital convolution, showed excess of leucocytes, but
no great excess of vessels. A few of these presented perivascular
sheaths filled with leucocytes. The nerve-cells of the third layer
presented in many sections a clear space at the basal end, caused
apparently by shrinking of the protoplasm, which stained readily,
showing that there was no degeneration. Many of the cells had no
processes, and others had only one at the apex. These appearances
in the cells, I believe, are due to the mode of preparation, as they are
not seen in frozen sections. In order to be certain as to the amount
of change present I examined the sections of the brain of this patient
side by side with others obtained from the brain of a man killed by an
accident.
Some particulars of the foregoing case were given in the
“ British Medical Journal ” a few years ago. I have now
described the symptoms present during life, and the ap¬
pearances found after death, including the microscopical
appearances, with greater detail, and the drawings ac¬
companying the paper are published for the first time. I
formerly regarded the case as one of athetosis, but subsequent
reflection has led me to look upon it as a post-hemiplegic dis¬
order of movement, allied to those described by Dr. Gowers
in his paper published in the “ Medico-Chirurgical Trans-
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258
Clinical Notes and Cases.
[July,
actions in 1876,” Yol. lix., page 271. The movements of
the hand and foot in the cases described by Dr. Hammond,
who first gave the name “ athetosis ” to the disease, were
slow and continuous, did not cease during sleep, and were
unaccompanied by paralysis. In the case which I have
related the movements were rather quick , ceased during
sleep, and did not present themselves until paresis appeared.
I do not lay much stress upon the last two symptoms, but
the movements were quite different from those described by
Dr. Hammond, and many other muscles than those of the
hand and foot were affected. Dr. Gowers states that the
essential difference between athetosis and the mobile spasm
seen in partially paralyzed limbs is that in the latter there is
a fixed spasm superadded to the mobile spasm. There was
fixed spasm of the fingers in this case, which resembles, in
many particulars, Case 12 in the paper of Dr. Gowers before
referred to, except that in my case the movements are less
severe, and there was no fixed spasm of the arm and forearm,
but only of the fingers of the hand.
There were some special characters peculiar to this case.
Among these may be mentioned presence of considerable
voluntary power, although the movements were interfered
with by the spasm, the affection of the arm being greater
than that of the leg, an increase in the movements when an
attempt was made at voluntary action, the drawing back¬
wards and upwards of the head when the tongue was put
out, and cessation of the movements shortly before death, no
doubt due to exhaustion of the nerve-centres from the
violence of the epileptic convulsions which he at that time
experienced. The symptoms were quite different from those
present in chorea.
What is the pathology of this affection ? “ The symptoms,”
as Dr. Gowers says, u point clearly to damage to the grey
matter of the brain, to local perverted nutrition of nerve-
cells, in consequence of which they overact, either spon¬
taneously or on the stimulus of a volitional impulse, which is,
by their overaction, perverted or irregularly distributed.”
Now, in this case, great congestion of the grey matter of
the brain was present, evidenced by the microscopical ap¬
pearances. The vessels are seen distended with blood-
corpuscles, and the perivascular sheaths crammed with
leucocytes, which are present in such numbers as often to
obscure the vessels and the nerve-cells as well. That these
appearances are pathological I have no doubt, as the mode
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Clinical Notes and Cases.
259
1887.]
of death was not asphyxial, and they were not observed in
the brain of the man killed by an accident. It is therefore
quite possible that the nerve-cells in this case have overacted
from perverted nutrition, due to excessive supply of blood,
and hence the spasms. Although I did not examine the
ascending frontal and parietal convolutions, yet there is no
reason to doubt that the changes described were present in
them. Appearances similar to those I have mentioned were
seen in the medulla from a case of hydrophobia, and were
described by Dr. Gowers at the Pathological Society, and to
a less degree in the cord from a case of tetanus, which Dr.
Ross brought before the same society. Although it is quite
open to an objector to say that these changes are secondary
to irritation of the nerve-elements, I have an equal right to
hold the opinion that the vascular changes arc the primary
lesion. The youth of the patient would no doubt cause the
nerve-elements more readily to receive permanent damage.
On Catalepsy , with Cases. Treatment hy High Temperature and
Galvanism to Head. By Alex. Robertson, M.D.,
Physician to the Royal Infirmary and City Parochial
Asylum, Glasgow.
Catalepsy is one of the most striking of the great group of
functional disorders of the nervous system. In this country
it is a rare disease, except in lunatic asylums, where, at least
in a modified form, it is by no means uncommon. Among
the recorded cases a considerable proportion occurred in
women of a hysterical disposition. It has, however, been
observed in many other conditions. Thus in some indi¬
viduals it has been associated with gross organic lesions of
the brain, such as tumours and softening; but these may be
regarded as accidental coincidences, and not as essential to
the disease. Malaria would seem to have been the agent in
its production in a number of instances, this opinion being
supported by the fact that the patients recovered under the
use of quinine and other remedies with similar properties.
A curious case is recorded by Vogt of an Alpine village near
Wurzburg, in which half of the population, both males and
females, suffered from this disease. He states that the in¬
habitants had been much given to intermarriage, and that
generally they are, or at least were—for his account was
published in 1863—a small and deformed race. The seizures
/
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260
Clinical Notes and Cases.
[July,
were of short duration, not generally lasting longer than
five minutes. They were preceded by a chill, which was
soon followed by a strange sensation in the arms and legs.
Then the sufferers became deadly pale, while their limbs got
stiff, and continued in the position they were in when the
attack commenced.
It is stated by Vogt that in these cases the intellect and
senses were normal. In this respect they differ materially
from general experience, as it is usual for the mental powers,
as well as the various forms of sensation, to be in complete,
or at least partial, abeyance.
Observers are generally agreed that the muscular rigidity
is quite independent of the will. Thus EJandfield Jones, in
his work on “ Functional Nervous Disorders,” after review¬
ing the group of cases recorded by the eminent alienist
physician, M. Lasegue, remarks, “ In such cases it must be
admitted there is a permanent tension or contraction of the
muscles independent of the will, and unattended by fatigue,
which, were it even felt, would show itself by relaxation.”
This is certainly the usual impression, but the following
cases throw doubt on the soundness of this conclusion, so
far as it applies to those occurring in association with
mental disturbance. The variety of mental disorder which
it accompanies is melancholia, and, so far as my experience
goes, the form known as melancholy with stupor. Three or
four years ago I showed a young woman to my class of
students in the asylum who suffered from a resistive form
of melancholy with a degree of stupor. When her arms
were stretched out and put into any position, they remained
there, until they slowly fell, seemingly after the muscles
were exhausted. The lower extremities were not affected in
the same way, nor other parts of her body. This plasticity of
the arms was observed during some weeks, and then
gradually passed away. She is still insane, and in the
asylum. It will be observed how limited the disease was in
this instance. Many cases of partial catalepsy, resembling
this one, are on record; and in them, as well as in my patient,
consciousness was not altogether in abeyance.
The patient to whose case I shall specially refer was first
under the care of Dr. Wood'Smith, in the Glasgow Royal
Infirmary, who showed him to a meeting of the Medico-
Chirurgical Society in 1883. Ultimately he came under my
charge in the Town’s Hospital. While in the infirmary Dr.
Smith was good enough to allow me to examine the patient.
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Clinical Notes and Cases .
261
and afterwards sent me a full report of his medical history
up to the time of his leaving that institution. Some other
details were obtained from his relatives. From these sources
I have drawn out an abstract of the case, which I shall
submit before relating the after history. Besides the
interest wrhich attaches to the question of volition, there
are some practical points in the treatment to which attention
will be directed.
J. Kelly, age 23, labourer in a chemical work, was admitted into
the Royal Infirmary on 11th January, 1883, in a state of uncon¬
sciousness, which had set in on the previous day. It was stated
that up to this illness he had been a healthy man, and particularly
that he had never previously suffered from disease of the nervous
system. His family-history was pretty good, except that a
maternal uncle had been insane. Though not a habitual drunkard,
it had been his habit for years to get drunk occasionally. For
some weeks before the occurrence of the seizure there had been a
noteworthy change in his mental condition and habits, as in the
evenings he had become a regular attendant of religious meetings,
and at home had been singing hymns and reading the Bible—all
which were very different from his previous mode of life. During
the week just before his admission he had been taciturn, doing
things mechanically, and his eyes had a strange expression. Still,
he had been going to his work. On the morning of the 8th
January, however, while at his employment, he suddenly began to
stare vacantly at his fellow-workmen, and would not speak. He
was sent home, and was able to walk thither alone. In the
course of that forenoon he had become apparently unconscious,
and his limbs were stiff, retaining any position in which
they were placed. This seizure did not last more than ten
minutes, the rigidity passed away, and he was able to walk home
from a medical man’s residence, where the attack occurred. On
the 9th he had returned to the singing of hymns, and said that
God was showing him his sins (I would direct special attention to
this fact in relation to his mental condition when he emerged from
the cataleptic state). Again, however, on the 10th his limbs
became stiff, but at the same time plastic, and his eyes were
fixed. This was his state on admission into the hospital. It was
then also noted that the pupils were dilated, but sensitive to a
bright light ; he swallowed well; respirations were 24 per
minute; axillary temperature was 98°‘4. His limbs were found
to retain any position in which they were placed. When his aims
were fully extended and raised perpendicularly above his head they
remained so for fully ten minutes ; his lower extremities, and also
his head, and neck, and trunk, could likewise be moulded into posi¬
tion in the same way; the muscles being in a state of plastic
rigidity. In the course of the next few days repeated examinations
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262
Clinical Notes and Cases .
[July,
showed that there was general anaesthesia, for on pinching or
pricking him anywhere, both on trunk and extremities, with
needles and pins, there was no indication of sensation. Nor was
there any sign of feeling on the passage of the full current from a
40-cell Leclanch6 battery. A deep thrust of a pin produced no
response, and there was no oozing of blood at the point of inser¬
tion. The interrupted current produced vigorous contractions of
the muscles of the extremities. Both superficial and deep reflexes
were in abeyance. He w r as able to swallow well. Though in the
state described, when supported on both sides, he was able to walk
up and down the ward ; and on the 15th, when ordered, he walked
a few steps alone. Yet his rigidity soon returned. Thus, on the
14th, after a walk in the ward, he became stiff, and while so was
placed with his heels resting on one chair and the back of his head
on another, the chairs being apart from each other. He maintained
this position about minutes. On the 16th, and for four or five
days afterwards, the rigidity of the limbs did not last above a
minute at a time when they w’ere put into position. Altogether,
at this time, his symptons had abated considerably; he was even
able to take his food himself, and attend to his bodily wants occa¬
sionally. From this time his temperature was normal, except
between the 13th and 16th January, when it rose to about 100°F.
Dr. F. Fergus examined the eyes with the ophthalmoscope, and he
reported that there were no important morbid conditions ; he par¬
ticularly notes that there was no anaemia of the fundus. During
his further stay in the infirmary his condition became less satisfac¬
tory, and he was discharged on the 16th February, after thirty-six
days’ residence. The principal medicines administered were, first,
potassium bromide, and afterwards the tinctures of valerian and
assafoetida. My examination of the patient was made on the third
day after his admission into the infirmary. The note that I then
took states that his arms retained the outstretched and unsup¬
ported position in which I placed them for twelve minutes, and
then they slowly fell to the bed; the legs did not remain in situ
so long as the arms. I pricked him with a needle at eight
different points of his extremities, but there was no appearance or
expression of feeling, and none of the points bled. When dis¬
charged from the infirmary he immediately came under my care in
the Town’s Hospital. For the first four days after his removal he
obstinately refused food, and had to be fed by the stomach-pump.
He kept his teeth firmly clenched, and I required to use the
nasal tube. When mastered by this means he cried out bitterly.
The waxy flexibility (fleanbilitas cerea), as the cataleptic condition
has been called, continued. It was observed that the rigidity of the
muscles was by no means great; they dM not seem firmer when
the limbs were extended than they would be had the extension
been effected by voluntary action. His pulse was 70, and of fair
volume. His skin felt warm and moist; the temperature was
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1887.]
Clinical Notes and Cases .
263
abonfc a degree above the normal. He was cleanly in his habits,
using the chamber utensil voluntarily. He also now took his food
himself. Sensibility of skin was often tested in various ways, but
there was never the least indication of its presence, whatever the
test. His lips had generally a dusky colour. There was no disease
of heart, or lungs, or kidneys. The treatment up to the 28th
April, besides careful attention to the improvement of his strength
and condition and the regulation of his bowels, consisted in the
application of two fly blisters to the shaven scalp. There was,
however, no improvement in his condition, nor much apparent
change for some weeks after admission. It was then determined
to try the effect of the stimulus of heat to the head. Accordingly,
on the 28th April, the water-cap * was applied to the head, and
water at 104° was circulated through it for two hours. At the
beginning of the application the pulse was 84 and the axillary
temperature 99°; at its close the temperature was 101° and pulse
108. That afternoon and next morning he showed more mental
activity. From that date till 11th May, a period of 14 days, this
treatment was continued. The temperature of the water was
higher than at first, ranging from 108° to 120° Fahr.; on the 10th
and 11th May it was 120°. On each occasion I noted the axillary
temperature and the pulse immediately before each application
and at its close. On an average there was 1° F. of an increase on
the removal of the apparatus, and the pulse was twelve beats
higher. From the 11th to the 14th May the water was circulated
at 116° or 118° for two hours each day, and was then gradually
lowered to cold—about 50° F. The latter was continued for about
an hour. On the 14th I recorded that “the expression of his
countenance for some days has been much more intelligent than
before this treatment was commenced. He follows with his eyes
the movements of anyone beside him. When asked to sit up and
take his meals he does so at once. On seeing the thermometer he
withdrew his arm to admit it into the armpit, and brought the arm to
his side when requested.” His limbs still showed the same waxy
flexibility as before, without distinct rigidity. The circulation of
hot and cold water in the way described was continued daily till
1st June, the increase of axillary temperature being less than with
the hot water alone. At that date the entry in the note-book is:
* This iB one of a number of apparatus which were designed by the writer
about seventeen yearB ago for the purpose of applying heat and cold at
graduated temperatures to different parts of the body. They inclnde, besides
the water-cap, a spinal bag (which has been of great use in the treatment of
various diseases of the spinal cord), a chest and abdominal bag, a uterine bag,
and a throat bag. A description of them, particularly of the chest one, was
published in a serial paper in the 44 British Medical Journal ” for November and
December, 1871, and in the “Glasgow Medical Journal” previously. I have
added this note to prevent possible misapprehension, as there are now other
apparatus, metallio as well as India-rubber, in use, constructed on the 6ame
principle, bnt all of them have been introduced since the period referred to.
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264 Clinical Notes and Cases . [July,
“ Mental condition much improved; now asks questions and
answers them correctly; puts off and on his clothes himself;
played a game at draughts with me fairly well.” I tested the
sensibility of the general surface, and it seemed greatly improved,
though impressions were slow in transmission. On asking him if
he felt me pinching him, answered “Yes.” Even though so much
improved generally he still maintained the attitudes in which his
limbs were placed. On the 4th June I asked him why he kept
up his hand in that way, namely, stretched out, and his forefinger
pointing upwards. He replied, “ It is the Lord.” On being asked
if he meant God, he said “ Yes,” but would say no more. I pricked
his arm at six different points, three of which bled freely, showing
that the circulation was much more active than at the early part
of his illness. On the 13th June, there being no further change,
the water-cap was discontinued, and the continuous current was
ordered to be passed from neck to head, first on one side and then
on the other; the positive pole was placed over the cervical
sympathetic, and the negative was moved slowly along one side of
the head. On the 4th July the positive pole was put into a basin
of salt and water along with his feetr, the negative being moved
over both sides of his head alternately as before. From five to ten
cells of a Leclanche’s battery were in use, and the current was
passed for five minutes on each side of the head daily. On 25th
July his mind is noted to be much more active. I then subjected
him to a careful examination, and have noted a long series of ques¬
tions and answers. I shall quote the part relating to his visit to
the meeting of the Medico-Chirurgical Society in the Faculty Hall.
Question : Do you remember being taken to any place out of the
infirmary P Answer: I was taken to a place like a hotel with my
father. Question: Did they give you anything ? Answer: He
(meaning his father) took the tea and cake ; they forced a little on
me. Question : Did they do anything else to you ? Answer:
They took me into a large room with a big table, where there were
a number of dressed gentlemen. They passed me round the room,
and a pin was put into my hand, but I did not feel it much. I
cannot say how that should be. They set me leaning back on a
chair, and put my arms and my legs up. I tried to keep up as well as
I could. Question : What happened after that ? Answer: After
I left the room where there were so many gentlemen they offered
me brandy. I took some of the brandy, but it w*as forced on me.
I was afraid they were going to do something to me.—From this
time there was no further indication of catalepsy, sensation wa s
fully restored, and his mind continued active. He was, how r ever,
found to entertain delusions about God speaking to him by audible
voice, this delusion having been manifested at the outset of his
illness. He was also occasionally troublesome, and threatened
violence to the nurse. It w r as therefore deemed advisable to
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1887.]
Clinical Notes and Cases .
265
transfer him to an asylum, and he was accordingly sent to
Woodilee, under the charge of Dr. Blair, on 17th August, 1883.
Dr. Blair’s letter contains the after-history. It is dated
2nd June, 1886, and is to the effect that Kelly was then in
the asylum, and had been so on three previous occasions
since he was sent there from the Town’s hospital. Twice he
was dismissed recovered, but on the third time only relieved.
There had not been the least approach to the cataleptic
state. He was, however, supposed to have had more than
one epileptic fit. His inability to continue well when out of
the asylum Dr. Blair ascribes to drinking-bouts.
In briefly reviewing this case I remark that sensation was
much more deeply involved than the power of motion. The
various forms of sensibility were, at least, very greatly
impaired, if not entirely in abeyance, whereas there was no
clear evidence of motor defect. The muscles responded per¬
fectly to the faradic stimulus, and there was no paralysis.
The cutaneous circulation was obviously very sluggish, and
the question suggests itself—Was the circulation in internal
organs, and particularly the brain, in a similar state P If so
we have here at least one cause for serious disturbance of
the cerebral functions. But the further question arises—
Why should the circulatory system be in that condition?
Was there any deeper cause in action ? When this patient
was shown to the Medico-Chirurgical Society, in the course
of the after-discussion I expressed the opinion that, should he
emerge from his then state, it would probably be found that
he had been labouring under some overpowering delusion,
and also that he was not altogether unconscious of what was
passing around him. His statements, which I have quoted,
show that this opinion was well founded. A profound delu¬
sion appears to have occupied his mind throughout his
illness. It would almost seem that this morbid idea, or
rather, that the pathological condition of the cerebral tissue,
of which the idea was the expression, had so tyrannized over
him as to absorb the nerve-force and exhaust the nerve-cells
of the part of the brain which is associated with psychical
action, as well as the cells of the highest sensory centres.
The sympathetic system was also involved, if we may draw
that inference from the languid circulation, and this would
tend to maintain the prevailing inertia through the nervous
system generally. With respect to treatment, it was sought
to stimulate the brain, and thus rouse the patient from his
xxxiii. 18
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266 Clinical Notes and Cases . [July,
long protracted torpidity of mind and body. The high
temperature applied to his head, ranging from 112° to 118°
Fahr., seemed to effect this; at least there was no distinct
indication of improvement till this measure was used. After
a time it was thought that the stimulating effect would be
more decided by alternating heat and cold, and the result
was apparently a further progress. At a still later stage of
the case these modes of treatment were laid aside, and
stimulation of a different kind, namely, by galvanism, was
employed; this, too, acted beneficially. It was certainly
disappointing that complete recovery did not then occur.
The remaining disorder was purely mental, which, as men¬
tioned by Dr. Blair, waB entirely removed in Woodilee
Asylum. That gentleman is also of opinion that our patient
might have continued well had it not been for his intem¬
perate habits. If the impression on Dr. Blair's mind, that
Kelly has now become epileptic, be correct, support is given
to the view that catalepsy and epilepsy are allied in nature,
but, on the other hand, it is possible that the latter—the
epilepsy—may have been induced by his excesses in alcohol.
In the description I have given of the state of his limbs
when extended during the cataleptic condition it was stated
that the degree of firmness or rigidity of the muscles did not,
in my opinion, exceed that which is present in the same
positions maintained by voluntary effort in health; and if we
may credit his statement when he had partially recovered,
the attitudes in which his limbs were placed by myself and
others were retained there by volitional acts till the muscles
were exhausted. He said distinctly, “ I tried to keep up as
well as I could. ,, My impression is the same respecting the
girl to whose case I have referred. Her muscles were not
more firmly contracted than was necessary to maintain the
position of the limbs. She, also, probably acted under
delusion.
As alreadv mentioned, the records of published cases of
catalepsy all state that there was muscular rigidity of the
limbs, and in some this was undoubtedly a marked feature.
The descriptions also leave the impression on the mind in
reading them that these contractions were involuntary. Still
there is much need of fresh observation with special re¬
ference to this point. It may be that the muscular contrac¬
tions are really maintained by the will in an abnormal state.
Assuming, however, that the recorded observations are cor¬
rect, then there would seem to be an essential difference
Digitized by Google
Clinical Notes and Cases.
267
1887.]
between the muscular condition in my cases, as well as pro¬
bably in the great majority of those that are associated with
the same forms of mental disorder, and that which is pre¬
sent in catalepsy of other origin.
If it be contended that the absence of volition in any form
is essential to the existence of true catalepsy, then it may be
fairly questioned if cases occurring among the insane have
any proper title to be so regarded—at least such cases as are
here recorded—and the writer considers that in all pro¬
bability other cases have not generally any better claim.
Should it ultimately be determined that genuine catalepsy
in this sense does exist, then a cataleptoid group should be
recognized, in which the will is not altogether in abeyance,
and most of the insane cataleptics would find their correct
place in this category. It is, of course, clear that the will
in this, the apparently completely or partially voluntary
class of cases, is not really free, but is subjugated by the
morbid thought. In its turn the unhealthy ideation is the
result of the serious disturbance of cerebral function, which
in the sphere of sensation is manifested by ansesthesia, and
in vaso-motor action by the torpid circulation in the smaller
blood-vessels.
A Case of Prolonged Sleep. By J. Keser, M.D., F.R.C.S.,
Surgeon to the French Hospital, London.
Cases of prolonged sleep and hystero-epilepsy being of
comparatively rare occurrence in England, it may be worth
while to record one which came under my care in March
last. ,
The patient, Chauffat, aged 38, belongs to a family in which tuber¬
cular and nervous affections haye been frequently observed. His
grandfather had a nephew who committed suicide; his grandmother
died of phthisis ; the father, who was addicted to drink and had had
epileptiform attacks when 49 years old, died of tubercular laryngitis
eight years later. The mother died of phthisis in her forty-seventh
year. She was a passionate woman, subject to violent headaches and
to paroxysms of nervous excitement. Chauffat is the eldest of eight
children. His only brother died of croup when three years old ; one
of his sisters died of phthisis at the age of 26 ; another had repeated
attacks of sleep, which lasted from one to six days, and were accom¬
panied by cataleptiform phenomena ; she also died of phthisis in her
twenty-fourth year. The third sister had a fever after a premature
confinement; the fourth had a severe attack of typhoid fever, after
Digitized by C^ooQle
268 Clinical Notes and Cases .
I which one leg became shorter than the other ; she limps a little, but
1 there is no atrophy of the limb. The fifth sister has a situation as
\ cook in Switzerland ; her son has been rickety, but he is now in good
\ health. The sixth (youngest) sister is ansemic, and of a weak consti-
\ tution. It is not necessary to do more than note in the patient's
family the coexistence of phthisical and nervous affections, which has
been observed in so many other instances.
Chauffat was bom at Gy (near Geneva), and, when twenty years
old, he enlisted in the Foreign Legion of the French Army, where he
remained for two years. During the Franco-German war he had an
attack of p leuri sy, and received a wound on the left frontal protuber¬
ance, whichTTKwever, does not seem to have been serious. Later on,
a g un-shot wound of the left elbow necessitated tha amputation
arm~m the~uppcr "third. Chauffat left the army and wentTo
Switzerland, anththeiTToAlgiers, where he appears to have had a
seri ous disappointment in lo ve. In October, 1873, he had an attack
of fever and delirium, which lasted six days. The temperature went
up to l(f7°-5, and there were other serious symptoms, such as extreme
restlessness and carphology. Two medical men diagnosed an acute
meningitis, but after the sixth day there was a steady improvement,
and two weeks later the patient had entirely recovered. Shortly
after, however, he was seized, after a drive in an open carriage, with
r igors and severe cephalalgi a. He fell unconscious on the floor, and
had a violent attack of convulsions, which Wgs~foB owcd by co ma and
de lirium. He recovered graduaHyTbut in 1875, on his way to Algeria,
he hadlfnother fit of a similar kind, which lasted only a few hours.
In Algeria he had small-pox, and, later on, an attack of ague,
which obliged him to leave^The country. He came back to Switzer¬
land, and afterwards went to Germany as a commercial traveller.
While at Balingen, in January, 1880, he went to bed one evening as
usual, and remained fast asleep for forty hours. When he woke up he
was paralyzed on the left side, and quite dumb. He went to Geneva,
where he was treated in the hospital, and then left for Lyons,
apparently in good health. During the summer of the year 1881
he often felt pains in the head, and on September sixth, without
any previous warning, he fell unconscious on his bed, where he was
found by his friends, who took him to the Hotel Dieu. He was
treated there as a case of tumour of the brain, and woke up hemi¬
plegic and quite dumb, as at Balingen. Several other attacks of a
similar nature occurred at Valence and in Switzerland, and Chauffat
then decided to go to Paris in order to consult Professor Charcot.
He was admitted into the Salpetriere in October, 1885, but left
- shortly after. He fell asle_ejL one day, without any special cause, in
an hotel, and remained unconscious for 130 hours, but when he woke
up there was neither paralysis nor dumbness. During another attack
of sleep he was robbed of a sum of money, and he then decided J*>
come to England,'thinking that he might earn some money by ex-
[July,
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Clinical Notes and Cases.
269
1887.]
hibiting himself as a fasting man, as he had on one occasion lived
without food for 16 flays! "
Jie arrived in London on Ma rch 2ft rd. find the next evening h e
went tp n. cluij witn tne intention of making some acquaintances witn
people who might have helped him to execute his plans ; but things
turned out otherwise than he expected; t he strong En glish drinks
upset him. and while he was muddled he was robbed ofhi s^mgpfty ^nd
wfoyji. _ On Mardh 25tfl f lU ituiam e d in b e d tliO whule Tlaj without
having anything To eat or dnnkj On the following day hebocanae
quite unconscious^japd on March 27th I wassailed in to see him. A
card was found in his pocket, on which The patient asked to be taken
back to the Salpetriere if found asleep. This, of course, helped to clear
up the diagnosis, and I wrote to Profes sor Charcot, asking him to
give me some details about Chauffat! ITake Tins' occasion to express
to the highly-esteemed Professor of the Salpetriere and to _Dr.
Babinski my best thanks for their valuable information. In thei r
opinio n, an d in the opinion of those who have taken the trouble to
examine Chauffat carefully, the diagnosis is that of liystero-epilepsy, )
with occasiona l attacks of prolongecl sleep^pbntit must he admitted I
that, had nothing whatever~b*een known of the patient’s previous
history, other diseases might have been thought of as possible. As a
matter of fact, Chauffat has been repeatedly treated abroad for cerebral
haemorrhage, cerebral anaemia, acute meningitis, and tumour of the
brain.
I found the patient a strong, health y-lookin g man, lying on his bed
in a small* rest&UKHlb Ih Greek Sireet, Soho. He appeared to be
s leeping sound ly, and did not make any movement when called or
touched gently; a tap with the finger on any part of t he body was
followed, after an Interval oi about halFa second^bja^ sudden shaking
oT the whole hody^which lasted for about two seconds.. The colour
of the face was natural, and the general appearance was that of
ordinary sleep; the breathing was quiet, regular, of normal frequency
and rhythm; pulse 84, soft; temperature 98 0, 5 at 5 p.m. (in the
mouth). A careful examination of the chest and abdomen revealed
nothing abnormal, except a cons iderable distension of the bladder,
which had to be emptied by ' the catheter; it contained about two
pTnfTof dark-coloured urine. When the skin was pricked with a pin
the same shaki ng of the w hole body occurred .as after a tap withTKe
finger, buf there was no expression of pain on the patient’s face, and
a mere trace of blood showed itself in the small wound. I tried
to put some water into the mouth with a spoon, but it was nqt
swall owed. I then opened the right eye with the finger and threw^a
ray or right Into it by means of a concave mirror^in order to examine
th^mpil. The"globe was turned upwards and inwards, but after two
or three seconds the eye began to move, and the pupil became visible ;
jFreacted to light as usual for about half a minute, and then remained
dilated ; the left eye opened spontaneously, and both remained open.
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Clinical Notes and Cases.
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They soon began to follow the movements of the mirror, and as the
patient seemed to be partly awake he was placed in the sitting
posture, supported by cushions, and I made hi m swa llow about an
ojince of wine and water, which was on the table. Every movement
oi deglutition was followed by a general tremor oTthe body. I sent
someone downstairs to fetch some milk, but before I had time to give
, it, the patient closed his eyes, and I was unable to rouse him again,
On March 28th I examined the patient again, and made him
1 swallow some milk and heaf-tea. The "patellar, cremfiSterfc7“and
plantar reflexes were normal on both sides, afid'Thefe was no ankle
clonus, fclignt friction oi the skin, especially acrb&s ihe 6h£st,
produced a well-marked t ache cerebrate , which persisted for a long
time afterwards. When the eyes were c losed th ere was complete
flaccidity of the, lpgg, but aApr tbopatipnt had been" partly
roused by means of the mirror limbs^ renvained for an almost in¬
definite time in the position in which they were placed. The condi¬
tion of TtTFTrniSCleE'wasTi^ ; if, for example, the arm
was placed very gently in the perpendicular position, it remained
motionless, but there was no rigidity of the muscles, and a stroke
with the hand did not cause it to fall down. If, on the contrary, the
arm was firmly grasped by the hand and lifted up suddenly, the
muscles became rigid and the rigidity could be increased by rubbing,
but then a gentle stroke with the band produced a complete relaxation
of the muscles, and the arm fell down on the bed. The same result
could be obtained by simply blowing on the arm or by passing the
hand over the patient’s eyes from above downwards.
(jn AfW h 29th the patient made some spontaneous movements
with the arm; during the night he spoke of thieveSj and repeated
several times the numberT3JL9 j 8-; some words were pronounced quite
distinctly, generally, however, there was a good deal of stammering.
The pulse, temperature, and respiration were normal, and the patient
t ook s ome milk or beef-tea every two hours^.the urine ha d to be
drawn off as on the first 4&y. —
Oja March 30th Chauffat was examined by several medical men,
and amongst others by Mr. Brudenell Carter,* who fo und contractio n
of the vessels of the fundus. During the afternoon the patient was
restless, and began to speak again in an incoherent and almost unin¬
telligible manneryHe“ dccasionally^mtyfed his arm, but he never
answered or~seemed to understand any question. When the arm was
stretched and the fist clenched, the patient’s face took an expression
of anger ; it was also noticed that a movement of the limbs or face
performed passively once or twice was continued automatically and
with great rapidity for an almost indefinite time, when the eyes were
open ; closure of the eyes was followed by a gradual cessation of the
automatic movements. I tried, but without success, to induce the
patient to perform various movements by suggestion. It should be
* See memorandum by Mr. Carter at the end of this case.—[E ds.]
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1887.]
stated that daring the above rapid movements of particular muscles
there were no signs of effort in the patient. His facial muscles re¬
mained as placid as before. In the fi vftning r Dr. Da JKattflzille
ascertain ed that the electrical r ftftfttinna of mna/>W WArA normal ;
prolonged faradizationof the facial nerve produced a persistent con¬
traction in the corresponding muscles; faradization of the septum of
the nose gave rise to signs of uneasiness, the patient moving his head
away, but without opening his eyes. He then had a well-marked
epileptiform seizure with violent tremor of the whole body, pleuros-
thotonus and clonic spasms, which were followed by rigidity of the
extremities.
On March 31s t T the pa tien t had an enema, b ut it remained jrithoBt
effect; about 300 grammes of u rine were drawn off with f-ftfl ;
li quid food was given every two hours.
The foHo wing day (ApriLlst}* I succeeded for the first time in in¬
ducing the patient to pass water, hy suggestion : he was also able to
sit up almost without h§lp.On April 2nd he began to anawnr aim pi a
questions In writing, and to walk abouf the room when supported on
both sidesj^it was n oticed that the lef tlegWas very weak, andJhatThe
patient was unable to stand alo ne; was quite speechless, but c&Jlld.
write wiflinnt. Whan asked if he was asleep, he wrote
that he had not slepFTor several days, and that he was not hungry but
very thirsty ; when told to write something which was either absurd
or untrue, he did so, but with very evident signs of displeasure ; he
signed his name in his usual hand. Having been asked to write
Charcot’s name, he did so, forming the letters as he did when writing
any other word, but when he was told to sign “ Charcot,” he imitated
Charcot’s signature in a very striking manner. I then ordered him to
write a letter to Charcot, and he at once set to work; he began by
excusing himself for having left the Salpetri&re so suddenly, and went
on to say that “ this fatal sleep always played him tricks; ” that he
had gone to sleep on a bench, and had been robbed of all his money,
&c.; he signed this letter—“ Chauflfat, Paris, le 13 Mars, 1887.” It
was ascertained later on that he had really left the Salpetriere without
permission, and that he had written a letter of apology to Professor
Charcot, but that the letter had never been sent. On the following
days, whenever he was told to write to Charcot, he began the same
letter.
On Ap ril .3 rd, in the evening, Chauflfat could be made to open his
eyes by passing the hand before the face from below upwards several
times ; a single movement in the reverse direction sent him to sleep
again. Patient ate three oysters and drank some white wine.
On April 5th lie recognized Qharcors phOtcrgraptl , , — which was
shown to him by Dr. A. Garrod; he answered reafdly'most questions
by writing, but was unable to make a choice; when, for example, he
was asked if he would like to have some claret, he answered no ;
when asked if he desired to drink some white wine, he wrote yes ; but
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[July,
whenever I asked him which wine he liked best, the answer was
always—“ I do not know.”
On April 6th the patient was more easily roused than before, and
made sorri^Tspontaneous movements with tne lips ; on the following
day it was noticed that the automatic movements were less easily
.^•induced, and less persistent.
yf On A pril 8th, when the landlord entered Chauffat’s room in the
morning, he found him apparently asleep, but when he tapped him on
the shoulder and asked him if he was still sleeping, he at once opened
his eyes, sat up in bed, and s howed by signs that h e wished to wri te n
I arrived shortly after, and found the patient wide awake, but nearly
paralyzejd piitke }eft side, a nd quite unable to speak. The right eye
was slightly congested In answer t6 my questions, Chauffat wrote
that he had a headache and felt very drowsy ; he had no appetite,
but felt thirsty. He was soon after remoy^.d. to the French Hospital,
where he rapi(]Ix„uupxoe influence of galvanism anuTnux
vomica ; at ihe endgf,. xuweek-Lavras Abla ta..walk alone, and witl^ut..
article, but the aphonia was still .cppgplpt^..
During his 1«S dq y« nf slopp, P!lmnffnt.’R temperature had always
been normal, but tne pulse and respiration had varied a good deal;
the pulse was soft, regular, and the number of the beats oscillated in
an irregular manner between 68 and 100 ; respiration 18 to 24.
The quantity of urine passed or drawn off daily varied between 50
grammes on the second day and 1,600 grammes on April 6th; the
average was about a pint. The urine has been examined for me by
Mr. Woodland, who has sent me two reports on which the following
table is based :—
Date.
Reaction.
Spec. Gravity.
s
t-l
p
Uric Acid %
Hippuric Acid %
Chlorides %
ao
£
a
■a
to
o
£
Albumen.
Sugar.
April 1.
Very acid
1029
413
0-481
0-431
0-01
0-21
none
trace
April 3.
Acid
1026
1*26
0-3-1
0*216
In small pro¬
portion.
trace
trace
April 5.
Acid
1028
1-002
0-312
0-221
none
traoe
During his sleep the patient had two motions, one on the 81st of
March, and one on April 3rd ; the first was abundant, oT aTTirown
colour; the second was small in quantity and of greyish colour.
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1887.]
Clinical Notes and Cases .
278
The sensibility of the skin was frequently tested while the patient
was asleep, and also afterwards. There was a partial loss of annaa-
t ion on the left sic fa pf • on the leg, beTween the knee and
ankle, the anaesthesia was almost complete. Careful examination
revealed the existence of four patche s where the sensibility was either
normal or exaggerated; one of these patches was situated in front of
the left external malleolus, and had an oval shape; the second
occupied the front and back of the left knee ; the third was found in
the left inguinal region ; and the fourth on the extremity of the
stump. The shape of the three last patches was irregular, but always
the same on repeated examinations.
Although both eyes are apparently normal, the patient sees better
with the right than with the left, and the same difference is found in
regard to his hearing. The taste is almost completely abolished on
both sides of the tongue. There is a marked anaesthesia of the
pharynx, which makes the examination of the larynx very easy.
The vocal cords present their usual appearance, and move freely
when the patient breathes ; when he tries to speak, they remain quite
flaccid and separated by an interval of 2 or 3 millimetres, 60 that the
patient is unable to produce a sound. According to Professor Char¬
cot, this dumbness is likely to last some time, and the patient will
stammer when he begins to speak again.*
I have not much to say about the treatment of this case, as I con¬
sidered that the best plan was to feed“an'd“ wait. The retinal vessels
being contracted, it was thought that nitrite of amyl might produce
some favourable effect, but this expectation was not realized, although
a rather large quantity was given to the patient to inhale. There was
a well marked congestion of the face, but no 6ign of returning
consciousness.
Editorial Note .
To the foregoing report by Dr. Keser, we append the
memorandum by Mr. E. Brudenell Carter, referred to at
p. 270.
“ While Chauffat was in a state of profound unconscious¬
ness, I twice examined his eyes with the ophthalmoscope,
and once again when he had so far recovered as to be able
to write replies to questions. In consequence of the
difficulty of giving any definite direction to his eyes, I was
unable, on the two first occasions, to obtain a satisfactory
view of the optic discs, but I saw the general surface of the
* After this notice had been written, the patient recovered the use of his
voice. On May 9th, during the application of the galvanic current to the
sides of the neck, he was able to utter an inarticulate sound. The next evening
he suddenly began to speak in a peculiar squeaky voice, but without stammer,
ing.
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274
Clinical Notes and Cases.
[July,
retinae very well, and noted an entire absence of any morbid
appearance, together with a state of the vessels which I
should best describe negatively as the reverse of distension.
On the third occasion I examined both discs minutely, and
came to the conclusion that an apparent slight turbidity of
the nerve tissue was physiological, and due to its being
somewhat massed together towards the inner side of the
scleral foramen.
“ Dr. Tuke asks me to append to this note a mention of a
case of catalepsy, which I saw more than forty years ago.
The patient was a young woman, employed as a farm ser¬
vant, who had a stormy interview with a man of her own
class, by whom she was pregnant, and who refused to marry
her. On returning home she was attacked by convulsions
of great violence, which lasted for about two hours, and
then passed into catalepsy, with well-marked flexibility
cerea . She was left about midnight, and woke up the next
morning as well as usual, except for fatigue and stiffness.
She had a severe instrumental labour, but never showed any
more tendency to convulsion or other nervous disorder.”
We are indebted to an article by Dr. Edgar B6rillon in the
April number of the “Bevue de l’Hypnotisme” for the
following references to cases of prolonged sleep, d propos of
the report by himself of a case of lethargy in a woman.
Dr. B^rillon borrows them from a work by Dr. Semelaigne,
Superintendent of the Maison de Sante of St. James, at
Neuilly. His work is entitled a Du Sommeil pathologique
chez les ali6n6s,” Paris, 1885. See also “ Annales m6dico-
psychologiques,” Janvier, 1885. He himself reports a case
which he had observed from 1875 to 1883, in which there
had been altogether, in the course of eight years, 1,698 days
of pathological sleep. The last crisis of sleep had pasted 15
months, and during the whole of this time he was fed only
by means of the (esophageal tube. After the death of this
patient, on the 19th of June, 1883, an examination was
made, and at the close of a report made to the Medico-
Psychological Society of Paris, Dr. Semelaigne collected to¬
gether 80 cases presenting similar phenomena. From these
80 instances Dr. Berillon extracts only the principal:—
Dr. Burette observed in 1713, at la Charity a carpenter who
slept for six months. ' During this time he was fed with spoonfuls of
broth and of wine introduced every day between the teeth.
In a case reported by Franck the sleep lasted 18 months. Nourish¬
ment was administered to the patient in the same manner. Legrand
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Clinical Notes and Cases.
275
1887.]
da S&ulle had under his observation at the Bicetre, a sleeper whom he
found on September 9th, 1868, during his ronnd, in the attitude of a
man plunged into a state of profound sleep. This patient remained in
almost the same condition until his death, which took place in April,
1869. He was nourished by means of the tube.
In another case reported by the same physician, a man, eighty
years of age, slept from April 3rd to October 1st, 1867.
From this pathological sleep he never awoke. As in the preceding
case he was fed by the tube.
In 1868 Dr. Foville had under his observation a man at Charenton
who remained in a condition of absolute immobility for about nine
weeks.
In 1707, Homberg read at the Academy of Sciences a report of an
extraordinary instance of lethargy. The man was called “ the sleeper
of Holland,” and his sleep was prolonged for six months, without any
interruption, during which he evinced no sign of voluntary movement,
or of feeling. (Not reported in the work of M. Semelaigne.)
In the foregoing observations there are points of difference between
them and that of Mdlle. B. (reported by M. B4rillon) ; but there is a
second group of facts which more nearly resembles it, in the 6ense that
they are manifestly dependent upon hysteria. Thus, Sandras cites the
case of a young hysteric, who had several complete attacks of lethargy.
These attacks ,only lasted a few days, but the description of her 6tate
during the lethargy recalls that of Mdlle. B. exactly. As with this
latter case, liquid placed upon the back of the tongue was swallowed
without effort. Louyer-Villermer has placed on record a similar case
of hysterical lethargy which lasted about a week.
In the same group of hysterical lethargies, it is necessary to include
the patient of Louvain, known under the name of La Marmotte de
Flandre , who was seized every day, from the morning until the
evening, with an attack of complete lethargy. We may add that
similar cases of more or less limited duration have been observed by
Briquet, Charcot, Delasiauve, &c. Quite recently, in the service of M.
Jules Voisin, we have seen a patient, called Eudoxie R., remain
during several months, at the end of a nervous crisis, in a state of
complete immobility and insensibility. The report of this patient,
who in many respects resembled cases of lethargy, will be found in the
“ Iconographie Photographique de la Salpetriere,” de MM. Bourne-
ville et Regnard.
This patient has been described by M. Charcot in several masterly
lectures, and she is one of the subjects which have aided him in recon¬
structing the complete natural history of these peculiar cases of pro¬
longed sleep.
We have found also in the “ Bibliotheque Nationale ” some facts
of the same description, old cases, but, nevertheless, very carefully
studied. Among these, we may cite that of a young hysterical girl,
published by M. De Beauchene, physician to the King. This patient
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276
Clinical Notes and Cases .
[July,
for five years was attacked with lethargic sleep, for periods lasting
from eight to ten days ; and of which one lasted even seventeen days.
The patient during this period had no excretions. She took food
only when awake. Another case, not less conscientiously observed,
is that published by M. Dionis, surgeon to the Dauphiness. Elizabeth
Devigne, aged 25, living with her mother in the Faubourg-Saint-
Germain, was attacked on May 26, 1709, with an extraordinary
malady, which was looked upon as catalepsy. . . . The physicians
who came to sec the patient went away convinced that there was no
imposture ; but no one was able to formulate a plausible theory.
. . . The Lieutenant-General of Police had her placed in one of the
religious hospitals, where she was placed under the care of Drs.
Ombert, Morian, and Geoffroy. They found that in the hospital,
under their eyes, the patient had the same attacks of catalepsy.
Ultimately, the patient greatly improved.— [Eds.]
OCCASIONAL NOTES OF THE QUARTER.
Lunacy Acts Amendment Bill.
The Medico-Psychological Association has not been idle
in considering the clauses of this oft-introduced Bill, and
in bringing its defects and actually mischievous enactments
under the notice of the Lord Chancellor. The Parlia¬
mentary Committee has repeatedly met, and it has stated the
grounds of objection in the form of a circular. It was
thought only fair to the members of the Association, and
likely to be productive of benefit to the Committee itself, to
submit this statement to the quarterly meeting of the
Association. As will be seen from the report of this
meeting under “Notes and News,” the result was a lively
and practical debate on the Bill. Experienced men in and
out of asylums agreed in regretting the troublesome inter¬
ference with the prompt admission of private patients into
institutions for the insane. A curious omission in the clause
referring to urgency certificates was pointed out by the
Chairman, in his appropriate opening remarks.
Strong protests were made against the worse than useless
checks put upon the care and treatment of single patients.
That they should be visited only once a year is, no doubt,
a great defect; but we fail to understand why the Bill
should rush from this extreme of neglect to that of so great
an interference with the system that it would become
practically unavailable, much to the detriment of the
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1887.]
277
Occasional Notes of the Quarter.
patients, who will be driven by this Bill, should it become
law, into out-of-the-way nooks and corners of England,
or expatriated to Belgium or Trance, or no one knows
where. Dr. Eingrose Atkins forcibly pointed out the ab¬
surdity and inconvenience of excluding medical men on
committees of registered hospitals from signing the cer¬
tificates of patients should they happen to be admitted into
those institutions. Indeed, the more the Bill is looked at
in the light of this and some other causes, the more it shows
the want of practical acquaintance with lunacy among those
who have been engaged in drawing up this elaborate Bill.
One of our judges once made the pertinent and sarcastic
remark that it might be supposed from the character of
some of our Lunacy Acts that they had been drafted by
lunatics themselves !
Dr. Murray Lindsay, than whom no one is better informed
on the question of pensions, brought out the main points,
upon which he has always insisted. The difficulty, however,
remains as to the scale upon which pensions should be
reckoned, it being felt by some that if the present rate of a
maximum of two-thirds of the salary and emoluments could
be depended upon as certain, it would be undesirable to
propose any change beyond (1) the addition of seven years to
the term of service, (2) the inclusion of the previous service
of a superintendent in another county, should such be
the fact, and (3) the right of appeal to the Home Secretary
if there should be a disagreement between committees of
asylums or Quarter Sessions on the one hand, and superin¬
tendents on the other, in regard to the amount of pension.
Much may be done by the influence brought to bear upon
Members of Parliament by the members of this Association.
We hope that now the definite points of objection to the
Bill have been clearly put forward by the Association, no
legitimate means will be omitted in exercising this influence
in bringing about amendments in Committee in the House
of Commons.
Some of the objections to the Bill are so well stated by
Dr. Needham, in his recent Annual Eeport, that we cannot
do better than add them to the foregoing remarks:—
As the same, or a slightly altered, Bill will probably be again
introduced, I venture to draw attention to two clauses especially, which
appear to be in a high degree objectionable, seeing that they have
reference to institutions such as this, which were established by volun¬
tary effort for philanthropic purposes, the whole of whose resources
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278
Occasional Notes of the Quarter . [July,
are devoted to the comfort and recovery of the patients, and which are
managed by Committees of independent gentlemen, such as form the
Committees of County Asylums, who derive no pecuniary or other
benefit from their connection with them.
Clause 8, sub-section 3, provides that no person shall he received as
a lunatic in a hospital under an order on the application of a member
of the Managing Committee of the Hospital. This provision seems
both unnecessary and unfair to those who, associated with these
institutions solely for philanthropic purposes, devote much time and
trouble to their management, and who, approving of their constitu¬
tion, and having an intimate knowledge of their character and
arrangements, would naturally be desirous of selecting them, in case
of need, in preference to other classes of asylums in whose constitu¬
tion they might not have so much confidence.*
Clause 53, in its present form, is considered to be peculiarly objec¬
tionable.
While admitting the propriety of some provision whereby the
Commissioners in Lunacy can enforce compliance with their reason¬
able requirements, there is probably no precedent for such extensive
powers, practically without appeal, being given by an Act of Parlia¬
ment to any department over large public institutions which, for
many years, have been fulfilling a great public requirement, and
which, as the reports of the Commissioners in Lunacy bear witness,
have been conducted with efficiency and success.
It must also be noticed that, in this clause especially, a responsi¬
bility, under severe penalties, is thrown upon the Superintendent of
the Hospital, which he, as the paid servant of the Committee, could
have no possible power of discharging except by their permission.
The objectionable character of this clause would be greatly diminished
if it were so varied as to give power to the Secretary of State to take
independent action against the Hospital, in the event of the reason¬
able requirements of the Commissioners not being complied with, and
upon their representation ; right of appeal to Parliament, or to some
practical body, being, at the same time, conferred upon the hospital
authorities.
A Theistic Monomaniac^ Suicide .
A book full of interest and of ghastly instruction might be
compiled from newspaper cuttings of extraordinary suicides.
Of these few would be more startling than one recently re¬
ported at Kemerton near Tewkesbury. The head gardener to
a Mrs. Holland, named Adams, aged 40, was found burnt to
a cinder in the root-house. The under-gardener had known
him for two years, and having been informed that he was
* In our opinion the same objection applies to the restriction on signing a
medical certificate.—[E ds].
Digitized by Google
279
1887.] Occasional Notes of the Quarter .
missing one Monday morning, made search for him, and, in
doing so, had his attention drawn to smoke issuing from
the root-house in the garden. There, after extinguishing
the fire with assistance, the remains of the deceased were
found, although they could not be identified. A can used
for petroleum, a flask with brandy in it, and a small benzo¬
line lamp were also there. What remained of the body was
lying face downwards on the fire of burning wood.
The root-house spoken of in his evidence is an excavation with a
brick roof, used for keeping roots, &c., in winter time. In the floor
was a square hole six feet by five feet, and about a foot deep. The
hole is filled with charred wood and a few logs partly burned, all
quite greasy with the melted flesh of the unfortunate man. The heat
of the flames must have been very great, for the door-posts were half
burnt away, as also was the ivy overhanging the doorway. Of the
deceased nothing was left but blackened bones, chiefly the backbone
and thighbones in one piece, and several small pieces of bone. Of the
flesh nothing whatever remained, except a piece of the heart. Even
the skull was unrecognizable.
A hole had been dug in the floor of the house, and the wood
must have been carefully laid in it. This witness had seen
him in his usual health on the previous Sunday, and he had
never given any indication of his not being in his right mind.
The unfortunate man’s mother, Mrs. Adams, stated that
he got up on the Monday at 4 o’clock, and had said on the
previous Saturday that if the weather continued the same he
would have to get up early to go to the vinery. He always
came back to breakfast about 8 o’clock. When he was
missing, search was made for him at the mother’s request,
with the result already stated.
Then comes the explanation of the suicide in the form of
letters placed in his writing-desk on the Monday morning,
one being addressed to his mother and the otner to Mr.
Eeuben Smith.
The latter is as follows (the former being identical with the
exception that it was addressed to his mother as “ recipient
for the whole jury of women ”):—
" My dear Sir,—I make you the recipient of this charge to the
whole jury of men, and you will find a true verdict upon it according
to the evidence set before you.
“ God has commanded me to burn my body ; I have done so in the
root-house in the kitchen garden as a protest against Christianity.
To pronounce sentence upon it in the following terms:—
“ That it is high treason against the majesty of God.
11 A libel upon His works.
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u And a degradation of the reason of man and woman.
“ The Lord is the whole spiritual power of man.
4< The Spirit the whole spiritual power of woman.
u And have no claim to equality with God.
“ Absalom and Christ are the same persons.
“ Make your prayers direct to God.
“ God, who is judge of all, hath judged me.
“ With the permission of God I shall return again in about three
months, more or less, newly recreated.
“ My wife as my helpmeet will accompany me.
“ We shall be fully endowed with the prerogative of God’s Com¬
mission.
“ Our duties then will be to rearrange the machinery of Govern¬
ment, to rewrite the Bible, leaving out the transgressions of man and
woman, chronology, history, deeds of prowess, and other objectionable
matter, and honour the pure and valuable precepts only.
“ Woman will be redeemed from the original curse passed upon her
body, and will have a separate government to manage her own affairs.
“ I have been content to address God as my master.
“ You will do well to reduce yourselves to subjects, and to consider
that you are the sons and daughters of man and woman only.
“ Your loyal and faithful friend and servant,
“ Samuel A. Adams.”
The mother stated that she had never seen anything
peculiar about her son's behaviour; he was the same as any¬
one else in manner or conversation. It turned out, however,
from her evidence that Adams was confined 15 years ago in
the Lancaster Asylum. He had lost his wife in May, 1886,
and this made him melancholy for some time. He had no
children. After his wife died his mother came to live with
him. When she last saw him alive on the Sunday night
about 10 o'clock, he seemed quite happy and jocular; better
than she had seen him for a long time. This remark shows
that the symptoms of mental disorder following his wife's
death had in reality never quite departed.
The coroner pointed out to the jury that they must take
into consideration the fact that Adams had been confined in
a lunatic asylum. He thought the letters proved that he was
of unsound mind. There was nothing to show that the
fumes of the oil suffocated him; but the position of the body
indicated that he had laid himself down upon the fire.
The jury immediately returned a verdict that the deceased
committed suicide while in a state of unsound mind.
We have thought it well to place this case on record. A
theist, he was a religious monomaniac. He had heard a
voice commanding him to do the deadly act, and it is quite
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consistent with the mother's evidence that he was happy and
jocular. Granting the premises, his conduct was but natural.
He was proud of being thus employed by God himself. He
expected to return to earth in about three months, recreated,
and his wife would accompany him as his helpmeet, both of
them endowed with extraordinary powers. Had he com¬
mitted a murder, and written no letters, the evidence of the
under-gardener and of the mother would have left the im¬
pression on the minds of a jury that he was a responsible
being, and the judge would have laid down the law, with
characteristic emphasis, that unless the jury were satisfied
that he did not know the nature and quality of the act which
he had committed, they must find him guilty.
In regard to the letters themselves, it may be said that,
while affording ample proof of insanity in Adams, in Eng¬
land, in the year of grace 1887, they would not have neces¬
sarily been so in all other persons, in every country and in
every age. A Mahdi might arise to-morrow in the Soudan,
who might write a letter to the same effect, and immolate
himself for what, to him, would be a great cause, and the
carrying out of a Divinely-appointed commission, and yet
possess a brain entirely free from any pathological changes.
On the other hand, a case like this of Adams is an illustration
of what some religious fanatics may really have been in all
ages and countries. They are yet far from having disappeared
from the face of the earth.
The Houghton Tragedy .
The event described in the following paragraph in the
daily papers, is decidedly unusual, and as such seems worthy
of being placed on record. It has reference to the death of
McCann, the murderer of a miner on New Tear’s Eve last.
The Houghton Tragedy.—The Death op McCann.—
On Saturday morning, an inquest was held in the Chief
Warder’s office in Durham Gaol, before Mr. John Graham,
coroner, on the body of John McCann (31), miner, who, as
already stated, died in the prison infirmary on the previous
day.—Chief Warder Proctor identified the body as that of
John McCann, who was admitted to the gaol on the 15th
January last, on the charge of the wilful murder of John
Dixon, miner, at Houghton-le-Spring on New Tear’s Eve.
He was tried before Mr. Justice Day on the 26th January,
xxxiii. x 19
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Occasional Notes of the Quarter. [July,
was found guilty, and sentenced to death. Subsequently, he
was reprieved, and the death sentence was commuted to one
of penal servitude for life. McCann was a native of Lanark¬
shire. In regard to the circumstances of his death, the
first symptoms of mania exhibited themselves about ten days
previously. At first he was quiet, but more acute symptoms
quickly developed themselves, and on the Saturday previous
he was placed in the infirmary, where every attention was
paid to him by Dr. Treadwell, the prison surgeon. He
gradually got worse and refused food. On the Wednesday
he was so violent that he broke a large square of glass, and
he had to be put into a “ straight " waistcoat, and liquid food
was pumped into him. He never recovered, and died at a
quarter past nine on Friday morning from acute mania.—Dr.
Treadwell corroborated the chief warder's evidence and said
the mania was of a religious kind. He made a post-mortem
examination of his head that morning, but found nothing
unusual, and that there were no indications that McCann had
been an intemperate man.—Mr. Robertson (a juryman) said
the evidence at the trial of McCann bore out that statement.
—After some further conversation, the jury returned a verdict
in accordance with the medical evidence.
PART II-REVIEWS.
The Life and Work of the Seventh Earl of Shaftesbury , K.O .
By Edwin Hodder. Three Vols. Cassell and Company,
London, Paris, New York, and Melbourne. 1887.
It is a striking proof of the many-sidedness of Lord
Shaftesbury's labours, that while the work he performed in
relation to the insane presents itself to those interested in
their care and treatment as the great work of his life, it is
found to constitute but a fraction after all of the multi¬
tudinous services he rendered to humanity. One of his peers
paid a tribute in the “ Times " after his death to his memory,
but omitted any reference to his action in regard to lunacy
legislation. This circumstance we mention merely to em¬
phasize the truth we have above stated, and which accords
with the fact that a very large proportion of the contents of
the biography before us is devoted to other paths of service
in the interests of mankind than that which led him to
pursue a course of beneficent action justly endearing his name
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to those who have at heart the welfare of the disordered in
mind.
It may be said at once that the task of writing Lord
Shaftesbury’s Memoir has fallen, happily, upon the right
shoulders, for Mr. Hodder gives just so much as, and no
more than, is requisite for the clear understanding of the
diary and letters which he introduces into the biography.
He is also discriminative in his appreciation of the Earl's
character, and does not nauseate the reader, as so many
biographers do, by a continual repetition of eulogistic
epithets. Great credit is due to him for clearly stating (and
to the members of the family for permitting it) the unhappy
circumstances connected with the influence of his father and
mother, as without such a statement Lord Shaftesbury's
character would have been imperfectly understood. The
wretched school-life which young Ashley endured formed
also an important element in the formation of his character.
Parental harshness and scholastic sufferings left a trace of
sadness upon his features, the cause of which was not guessed
by a large number of those with whom he came in contact in
after life. Hand ignarus mail, miseris succurrere disco must
have been a line often in his thoughts, and no doubt prompted
many a kindly act to suffering children.
The third chapter opens with a short sketch of the condi¬
tion of the insane in former times and of the Acts of Parlia¬
ment passed on their behalf. The success of the York
Retreat, and the cruel treatment pursued at the old Lunatic
Hospital in that city, are stated to have been the circum¬
stances which led to the well-known changes which took
place in public opinion, and as a consequence in legislation.
The Select Committee of the House of Commons, which took
evidence in 181^ an( l 1815, followed, and a Bill passed the
House of Commons which required the periodical inspection
of asylums by magistrates, and the appointment of eight
Lunacy Commissioners; but the House of Lords at that
period contained within its walls only fourteen peers who
cared for the humane treatment of the insane. When an
Act did pass both Houses of Parliament, in 1819, entitled
“ For the Better Care of Pauper Lunatics," the clauses were
only permissive. Lord Ashley entered first upon the move¬
ment with which his name is now so honourably associated,
in the year 1828, when he seconded the motion of Mr.
Gordon for leave to bring in “ A Bill to Amend the Law for
the Regulation of Lunatic Asylums." A quotation is made
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from Hansard that “ his lordship spoke in so low a tone that
he was nearly inaudible in the gallery.” In his diary he
wrote:—
Feb. 20th, 1828. Last night I ventured to speak, and, God be
praised, I did not utterly disgrace myself, though the exhibition
was far from glorious; hut the subject was upon lunatic asylums,
a mere matter of plain business, and requiring simplicity alone,
with common-sense. Gordon had requested me to second his
motion; having sat on the Committee, and having, felt unusual
sympathy for those whom the Bill is intended to protect, I did not
decline, more especially as I had heard that, from certain circum¬
stances, my support in this affair would render some small service
to the cause. And so, by God’s blessing, my first effort has been
for the advancement of human happiness. (Vol. i., p. 97.)
Lord Bathurst wrote (Feb. 20, 1828):—
Peel said that if your speech had been uttered with as loud a
voice as that of Lord Morpeth, everybody would have said it was
an excellent speech. It is now your own fault if you do not go on.
I could not help writing this, as I know you to he mighty sensitive,
and may, therefore, take it into your head that there had befen a
failure, which I can assure you is not the case.
The Bill passed July 15th, 1828. Power was transferred
from the College of Physicians, which had only too clearly
failed to do its duty, to fifteen Metropolitan Commissioners.
Two medical certificates were required for private patients
before admission into an asylum. Lord Ashley was one of
the Commissioners, and in the following year he was
appointed Chairman of the Board. As is well known, he
occupied the post of Chairman of this Board, and that which
succeeded it under a subsequent Act, for the rest of his life
—fifty-six years ; and during this time his attention to the
duties of the office was exemplary in the extreme, for the
multiplicity of his engagements in other departments never
led him to neglect his first love.
As Lord Ashley was born in the year 1801 (at 24, Gros-
venor Square), he was in his 27th year when he took the
first step in the promotion of lunacy reform.
Under date October 3, 1838, Lord Shaftesbury writes:—
Gave a decision to-day, along with colleagues, in the Com¬
mission in Lunacy (upon a division of 6 to 4, the first division that
has taken place since the institution of the body, now 10 years
ago), that one It. P. should be set at liberty. It is an unpleasant
and responsible office either to detain or discharge a patient; in
the first case, you hazard the commission of cruelty to the prisoner;
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in the second, to his friends or the public. We can lay down no
fixed rules for decision; we must take our course according to
doctors* prescriptions, pro re natd. In the instance before us, R. P.
had been seized only a few days when we proceeded to inquire into
his alleged insanity and the grounds of his detention. A more
heartless ruffian, one more low in mind and coarse in language,
though a man of talent and education, never entered the walls of a
prison or a mad-house. The opposite party, however, could not
prove against him one single act of personal violence ; his words,
his manner, his feelings, were awfully wicked ; but had never, as
yet (although their charge extended over several years), broken
out into action. In fact, a decision on our part that he was
rightfully detained would have authorized the incarceration in a
Bedlam of seven-tenths of the human race who have ever been
excited to violence of speech and gesture. Three days’ sitting—
myself Chairman—of five hours each, and all “gratis!” (Yol.
i., p. 234.)
The next reference to lunacy in these volumes occurs in
Chapter XII. of Yol. ii. It was in 1842 that Lord Somerset
brought in a Bill u To extend the Metropolitan System of
Inspection to the Provinces, and to appoint Barristers as
Inspecting Commissioners, who should devote themselves
exclusively to the Service.” This was supported by Lord
Ashley.
Lord Shaftesbury observes, in reference to the Lunacy
Bill ofl 842:—
March 18th. Spoke again last night on the Lunacy Bill.
I seemed myself to do it without force or point, and with difficulty;
half left unsaid, and the other half said ill. This is humbling and
despairing, because I plough not in hope. How can I look to success
in the great measures I propose if I am so weak in the smaller ?
The House mil despise schemes so brought forward. Am I
working in the truth and for the truth ? This doubt often arises
now, and yet, what is my guide if I am not ? (Yol. i., p. 411.)
* The Act was added to the Statute Book July, 1842.
Under date November 9th, 1842, Lord Shaftesbury makes
the following entry in his journal:—
Have been to London to transact business in Lunacy. This
is a mighty subject, and one on which authority and power could be
extensively and beneficially exercised. How often do I exclaim,
for this and many other purposes:
0, Thou, my thoughts inspire,
Who touched Isaiahs hallowed lips with fire.
But God’s strength is made perfect in man’s weakness.” (Yol. i.,
p. 439.)
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The remarkable Report on the condition of asylums in
England and Wales, presented to Parliament in 1844,
formed the basis upon which to proceed to a thorough
reform of both public and private institutions for the insane,
vulgarly called “ madhouses/ 5 The following entry in Lord
Ashley’s diary is of interest:—
July 2nd, 1844. Finished, at last, report of the Commission in
Lunacy. Good thing over. Sat for many days in review. God
prosper it. It contains much for the alleviation of physical and
moral suffering. (Yol. ii., p. 61).
On the 28rd of this month Lord Ashley moved for an
Address to the Crown, praying Her Majesty to take into her
consideration this Report of the Metropolitan Commissioners
in Lunacy. In his speech, after giving a graphic description
of the abuses which require reform, he said:—
To correct these evils there was no remedy but the multiplica¬
tion of county asylums; and if advice and example failed, they
ought to appeal to the assistance of the law to compel the con¬
struction of an adequate number of asylums over the whole
country. (Yol. ii., p. 64.)
We quote the following passage from Lord Ashley’s
diary:—
July 24, 1844. Last night motion on Lunacy. Obtained indul¬
gent hearing. The speech did its work so far as to obtain a recog¬
nition from the Secretary of State that legislation was necessary,
and should be taken up in my sense of it. Sheil made a neat
allusion, by way of compliment, to my great-grandfather’s work.
He added, too: “ The noble Lord’s speaking is a sursum corda
kind of eloquence.” This is the most agreeable language of praise
I have ever received; it is the very style I have aimed at.
July 25. My friend, the “ Times,” in character, as usual,
charges ipe with weakness. How can I be otherwise, not having
in the House even a bulrush to rest upon ? “No politician ! No
statesman! ” I never aspired to that character; if I did I should not
be such a fool as to attack every interest and one half of mankind,
and only on the behalf of classes whose united influences would not
obtain for me 50 votes in the County of Dorset or the Borough of
Manchester. “Rides but one hobby at a time ! ” Of course; a man
who cannot afford to keep a groom, if he be rich enough to have
two horses, must ride them alternately. I have no aid of any
kind, no coadjutor, no secretary, no one to begin and leave me to
finish, or finish what I begin ; everything must be done by myself,
or it will not be done at all. (Yol. ii., p. 67).
Under date November 18th, of the same year. Lord Ashley
records in his journal his visit to the Peckham Asylum :—
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Long affair—six hours. What a lesson! How small the
interval—a hair’s breadth—between reason and madness. A
sight, too, to stir apprehension in one’s own mind. I am visiting in
authority to-day. I may be visited by authority to-morrow. God
be praised that there are any visitations at all; time was when
6uch care was unknown. What an awful condition, that of a
lunatic! His words are generally disbelieved, and his most in¬
nocent peculiarities perverted; it is most natural it should be so :
we know him to be insane; at least, we are told that he is so; and
we place ourselves on our guard—that is, we give to every word,
look, gesture, a value and meaning which oftentimes it cannot
bear, and which it never would bear in ordinary life. Thus, we
too readily get him in, and too sluggishly get him out; and yet
what a destiny! (Yol. ii., p. 77).
The following passage from his diary must not be
omitted:—
Nov. 9th, 1844. Sittings renewed in Lunacy. What a scene of
horrors ! If such be the condition of things under all our inspec¬
tion, law, public opinion, and the whole apparatus of “ philan¬
thropy ” (what a sad word!), what must it have been formerly, and
what would it be again, in a state of pure principle of non¬
interference ?
On the 21st of the same month Lord Ashley writes :—
Graham has asked me to undertake the Lunacy Bill, promising to
treat it as a Government measure. Prodigious work f but cannot
refuse to lighten the burden on a Minister’s shoulders. Agreed,
on condition of full Government support in every respect. Oh, that
I might prosper and do something for those desolate and oppressed
creatures!
We must now pass on to the year 1845, in the spring of
which year he visits the Surrey County Asylum, in regard to
which he makes the following entry in his journal:—
A noble establishment and admirably conducted. A sight to
make a man, who cares a fig for his fellows, jump for joy, and give
thanks to God. Surely we are on the advance to better things.
Compare this with the state of lunatics fifteen years ago; and
what a change ! We see it all around, but do we go fast enough ?
Is not the cup being filled more rapidly by our iniquities than
emptied by our obedience ? Oh, that I might be permitted by
God’s grace to introduce and carry my measures for the benefit
and protection of this helpless race! (Vol. ii., p. 108.)
May 7th. Cannot get in my Lunacy Bills. Graham is not
ready. Session is slipping away. The labour and hopes for years
will be lost. “ All these things,” said old Jacob, “ are against me.”
God grant, for 1 commit all to Him, that I may be alike persuaded
of the contrary ! (Ibid.)
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At last, on the 6th of June, Lord Ashley introduced
those Lunacy Bills •which have become so well known
as the main code upon which those engaged in Lunacy
have to depend; the first being “ For the Regula¬
tion of Lunatic Asylums,” and the second being entitled
“ For the Better Care and Treatment of Lunatics in England
and Wales.” Lord Ashley’s speeches on this occasion
possessed all the good qualities for which his addresses were
distinguished—directness, lucidity, common sense, warm
appeals to the human feeling of his audience, and a very
effective choice of words. He sketched the leading principles
of the Bills, including the appointment of a permanent Board
of Commissioners, the obligation on the part of counties to
provide asylums for insane paupers, and the protection of
single patients. He did not fail to pay a tribute of praise to
those who in Paris (Pinel) and in York (Tuke) had intro¬
duced a better system, and in England paved the way for
reform and the interference of the Legislature in the interests
of the insane.
In passing it may be observed that Lord Ashley enter¬
tained the idea, from which, strange to say, he never seemed
to free himself, that the mentally deranged were “ under the
marked visitation of a wise though inscrutable Providence,”
a proposition which might seem calculated to paralyze any
attempt to relieve them from a malady inflicted upon them
for some special end. But Lord Ashley was not always
logical, and happily he followed his benevolent feelings, which
safely conducted him to the practical line of action which he
so earnestly pursued. Had he lived in the seventeenth
instead of the nineteenth century, he would probably have
believed in witches, and have found himself in a painful
dilemma between the impulses of his kindly nature and the
stern requirements of his belief in the sin of witchcraft.
After Lord Ashley’s Bills had passed, he makes the follow¬
ing entry in his diary :—
June 7th, 1845. I must enter an expression of humble, hearty,
and unceasing thanks to Almighty God for my great success in the
introduction of the Lunacy Bills yesterday evening. Sir J. Graham
seconded the proposition in a very kind and fervid speech, and
announced the full support of the Government.
June 30th. Never have I suffered more anxiety than on these
Lunacy Bills. I dream every night, and pass in my visions every
clause, and confuse the whole in one great mass. It is very trying
—perpetual objections, perpetual correspondence, perpetual doubt,
and yet there are good feelings exhibited. Nevertheless, at this
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late period of the session, one obstinate, ill-disposed, and stupid
man may impede our entire progress.
July 22nd. Have toiled through obstruction, insult, delay,
desertion, to the third reading, and have been detained all this
day by Mr. Duncombe on clause by clause of the Bill, as he has a
right to do on this stage. What a time I have passed ! Every
hour of every day engaged in this Bill and its collateral troubles!
Not a moment to myself for thought or comfort. Have had a
violent attack, brought on by labour and anxiety.
July 30th. Both Bills passed Committee in the Lords, and they
are now quite safe. Most humbly and heartily do I thank God
for my success.
(To be continued.)
Diseases of the Nervous System. By W. R. Gowers, M.D.,
F.R.C.P. J. and A. Churchill, 1886. Vol. I.
(Second Notice.)
In a first notice of this work we dealt with diseases of the
nerves. We have thus to consider the remaining and larger
part of the volume, which treats of diseases of the spinal
cord.
The anatomy of the cord is described at some length, but
care is taken to exclude details which are without obvious
practical bearing; a number of excellent wood-cuts illustrate
the chapter. On p. 116 the whole motor path, from the
cortex of the brain to the muscles, is set forth in a diagram,
according to which this same path is to be divided into an
upper or “ cerebro-spinal ” segment, and a lower or “ spino-
muscular ” segment; each segment consisting of a ganglion
cell, a nerve fibre, and the terminal expansion of the fibre.
One might add, and an end organ; the spinal ganglion cell
playing this part to the upper segment, while the muscle-
fibre represents it in the lower. We feel that the author
says truly when he states that such a representation “ con¬
duces to clearer ideas of many phenomena of disease.”
The functions of the spinal cord come next for considera¬
tion. On pp. 128-130 the more important movements, i.e.,
grouped muscular actions, are set down in relation to their
representation in the spinal cord. This is a piece of anatomy
and physiology which complements the teaching in an
earlier part of the work as to the representation of those
same movements in the motor fibres of the anterior nerve
roots. The general truth underlying these details is
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given in the statement on p. 128, “ That most movements
and muscles ai*e represented in vertical tracts, and the whole
anterior grey matter at any one nerve segment contains cells
that are concerned with different movements. An extensive
lesion of small vertical extent may thus weaken many move¬
ments, but abolish none.”
The paths of sensory conduction follow on p. 130, et seq .;
alas, they are still painfully intricate.
On p. 142 is a very useful table “ showing the approximate
relation to the spinal nerves of the various motor, sensory,
and reflex functions of the spinal cord.” This table is of
special value for purposes of reference.
The symptoms of disease of the spinal cord are contained
in a very interesting chapter. In relation to this subject we
find, on p. 144, the statement that the nutritional stability
of the axis-cylinder becomes less, the greater the distance
from the parent cell, and “ that it is least in the terminal
ramification of each segment.” (The segments here referred
to are the above-mentioned cerebro-spinal and spino-mus-
cular.) So far so good, but we fear that the tempting
suggestion which follows, viz., “ that this may be the reason
why curara acts chiefly on the intra-muscular nerves,” is too
good to be true. More likely, we think, is it that chemico-
physical affinities will be needed to explain the strange
selections of given tissues by drugs which pharmacology
presents us with.
This chapter abounds in facts which are so put as to be
most available for the student of clinical medicine, whilst, at
the same time, the author endeavours, where possible, to
make these facts intelligible, by suggesting a possible or
probable explanation, e.jr., the more ready impairment of the
conduction of tactile impressions, as compared with those of
pain, is suggested as resulting from the less energy of the
former. On the value of pain as a diagnostic symptom of
spinal disease, the student is warned of the many abdominal
and neuralgic affections which may counterfeit it; but—and
this refers specially to the group of excentric pains—we are
told that “in all cases-persistent rheumatic pains in the
limbs should suggest the possibility of spinal disease, and
watch should be kept for such symptoms as loss of local
power, or alterations in reflex action.” On reflex action
attention is drawn in a foot-note, p. 149, to the analogy
between the effects of degeneration of the two segments of
the motor tract; the over-action of the muscle reflex centres
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resulting from disease of the cerebro-spinal segment being
likened to the increased irritability of the muscular fibres
•which results from degeneration of the motor nerve-endings
of the lower segment. On page 150 we find the statement
that “ the muscular state on which myotatic irritability
depends ... is probably identical with physiological tone”
From this, by an easy mental process, we pass to the further
statement that the increased irritability of the spinal-reflex
centres, which marks itself by a tendency to tonic extensor
spasm, “ is probably an excessive and morbid degree of the
normal tone.” We quote the above few instances as examples
of the endeavour, everywhere apparent, of the author to
bring home to his readers the facts of pathology, to make
them really his by explanation, by analogy, and by reference
to the more familiar facts of physiology. We must repeat
that throughout Dr. Gowers orders his teaching with a view
to bedside application.
Pathological diagnosis forms a concluding section to this
general and introductory portion of the work.
Space does not permit us to do more than mention the
remainder of the work, though this forms the chief part.
Individual criticism of the several chapters would be very
instructive to the critic, but since choice had to be made it
appeared to us more profitable to consider the ground-plan
of the structure rather than the details.
Among the list of chapters, and grouped along with the
idiopathic forms of atrophy and hypertrophy, we find that
most curious disease described by Thomsen, and bearing his
name. In considering the pathology of this disease, the
author is loth to attribute the symptoms solely to abnormal
condition of the muscular tissues—this being the more
generally accepted theory, and he dwells on the intimate
functional relationship which exists between motor cell and
muscular fibre. Some rare cases of the arising of the disease
in adult life, also the influence of emotion upon the muscular
rigidity, speak in favour of a nervous element in the patho¬
logy.
We trust that the few points we have been able to accen¬
tuate in this short notice of a most admirable work may
serve to induce others to study it. The old proverb, Quot
homines , tot sententice , will, we think, here suffer loss, for
however numerous the readers of Dr. Gowers’ work should
prove, we are convinced they will be of one mind as to its
worth.
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Observations on the Spinal Cord in the Insane . By R. S.
Stewart, M.D., C.M. Edinburgh. 1886.
The author has made this the subject of his thesis for the
M.D. of Glasgow University, and has investigated the condi¬
tion of the spinal cord in twenty cases of insanity. Each
case is fully recorded, and we have a detailed account of the
microscopical appearances of the spinal cord, and in many
cases also of the brain after death. The cases selected
were: Five of general paralysis ; six of dementia; four of
melancholia; four of imbecility with epilepsy; and one of
imbecility without epilepsy.
In the clinical histories the frequency and serious nature
of the bedsores is to be regretted, but beyond that nothing
very unusual or striking is recorded.
With the microscope Dr. Stewart found vascular changes
in the central grey substance of the cord in sixteen cases,
but the most constant changes found were atrophy and
degeneration in the nerve cells; pigmentary changes being
especially frequent. He failed, however, to find in any of the
cases either hypertrophy, multiplication of nuclei, or vacuoia-
tion of the nerve-cells such as would meet the descriptions of
Charcot, and in two cases only did he find a condition at all
approaching sclerous atrophy.
In conclusion, the author ventures to state his belief that
changes in the spinal nerve-cells are constant features in
almost all, if not all, cases of insanity of some duration.
With regard to spinal lesions in general paralysis, he adopts
the views of Westphal and Schultze, that the degeneration
of the lateral columns is, with few exceptions, a primary
development; also that the atrophy, pigmentary, and fatty
degenerations of the nerve-cells of the grey substance is a
primary affection in the majority of cases, and he does not
admit the explanation that they depend upon muscular inac¬
tion or confinement to bed, since in some of the cases there
was a continual motor excitement and restlessness till death.
This paper, although evidently the result of a great deal of
labour and care, yet fails to teach us much or to advance the
state of our present knowledge.
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293
Influence of the Sympathetic on Disease. By Long Fox, M.D.
Smith, Elder, and Co., 15, Waterloo Place, London.
1886.
This volume is an extension of the line of thought ex¬
pressed by the author in the Bradshaw Lecture, delivered at
the College of Physicians, in 1882, and, on account of the
large number of observations and facts it contains, necessarily
furnishes us with a wealth of material for farther thought
and study.
The first few chapters are devoted to Anatomy and
Physiology alone, and although the descriptions are not by
any means exhaustive, yet there is sufficient for reference
in reading the later chapters. The author next discusses the
General Pathology of the Sympathetic, then proceeding to
the Special Pathology, he considers at length the effects of
pressure upon the Cervical Sympathetic, and the probable
relationships of Myosis, Mydriasis, Glaucoma, &c. To each
of the following morbid conditions a separate chapter is
devoted: Exophthalmic Goitre; Headache ; Hemicrania;
Insomnia; Epilepsy; Spinal Cord Lesions—Progressive
Musctdar Atrophy, Tabes Dorsalis, Sunstroke, Hemiplegia,
Lesions of Nerves, General Paralysis; Ephidrosis, Angina
Pectoris; Hepatic Neuralgia; Diabetes Mellitus; Visceral
Neuroses; Neurasthenia ; Pigmentation, Diabetes Insipidus,
Nephralgia; Neuroses of the Extremities, Symmetrical
Gangrene ; Myxcedema and Scleroderma.
The author has not attributed to the Sympathetic System
undue influence in the causation of these various conditions,
but rather has endeavoured to attack the subject from all
directions in an unbiassed manner, giving us as the result an
interesting volume from which much can be learnt.
On Aphasia; being a Contribution to the subject of the Dissolution
of Speech from Cerebral Disease. By James Boss, M.D.,
LL.D.Aberd., Fellow of the Royal College of Physicians
of London, and Senior Assistant Physician to the Man¬
chester Royal Infirmary. London: J. and A. Churchill,
11, New Burlington Street. 1887.
This brochure is for the most part a reprint of papers
which recently appeared in the “ Medical Chronicle.” It does
not pretend to be a systematic essay, or an exhaustive
monograph. The most important part of the treatise con-
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sists of a discussion of Dr. Broadbent’s views, from which Dr.
Boss, in some particulars, strongly dissents. He discovers, or
thinks he discovers, a serious “ tendency to break up the
human mind into numerous faculties, with their correspond¬
ing cortical centres.” We should not be doing justice to the
author if we attempted to give an abstract of his theory of
Aphasia in a short notice. We must, therefore, refer the
reader to the book itself, which contains in a small compass
the records of interesting and typical cases of Motor and
Sensory Aphasia. A section is devoted to the Morbid
Anatomy of Aphasia, in which the nature and the localiza¬
tion of the lesion are described, while another section is
devoted to Morbid Physiology, in which Aphemia and Motor
Agraphia are considered, as well as the Aphasia of Recollec¬
tion, Psychical Blindness, Psychical Deafness, Paraphasia,
Paragraphia, Paralexia. The remaining portion of the book
comprises a statement of the theories of Aphasia, enunciated
by Kussmaul, Charcot, and Lichtheim. Several diagrams
help to make the writer’s observations more readily under¬
stood. We commend this, the most recent contribution to
the literature of Aphasia, to our readers, whether in or out
of Asylums.
A Text Book of Pathological Anatomy and Pathogenesis. By
Ernest Ziegler, Professor of Pathological Anatomy in
the University of Tubingen. Translated and edited by
Donald MacAlister, M.A., M.D., M.K.C.P., Fellow and
Medical Lecturer of St. John s College, and Physician
to Addenbrooke’s Hospital, Cambridge. Second
edition. Three Vols. 1885-7. Macmillan and Co.,
London.
The concluding volume of Ziegler’s “ Pathological
Anatomy,” as translated and edited by Dr. Donald Mac-
Alister, of Cambridge, has now appeared. We hope to
review the entire work in the next number of the Journal;
meanwhile we must say that welcome as these volumes are
to us, they do not comprehend the whole of Ziegler’s Text
Book. The part not included treats of the morbid anatomy
of the eye, the ear, the bone-joints, also the organs of sex.
We trust Dr. MacAlister will take it as a compliment that
we regret the omission of these subjects.
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295
Our Temperaments: their Study and their Teaching . A
popular outline . By Alexander Stewart, F.R.C.S.
With illustrations. London: Crosby, Lockwood, and
Co. 1887.
In forming an estimate of this book, it must be con¬
tinually borne in mind that it only professes to be a popular
outline. If, instead of this, it be criticised as a scientific
treatise, the medical reader will be disappointed.
An ingenious attempt is made to group the forms of faces
under such classes as the square, the tapering, the oval (long
and broad), the semi-oval, the oblong, and the melancholic
face. Interesting illustrations are given from Lodge’s His¬
torical Portraits, and no doubt these forms may be made to
comprise the various outlines of the human face. Whether,
however, they are associated with a distinct mental charac¬
teristic is a much more difficult question. That facial forms
mean something, and that the temperaments, when rightly
understood, are correlated with very different tendencies of
mind, may be allowed, but we fear we are yet far from the
sanguine conclusion of the author that all will become
familiar with their temperaments and their associated
mental qualities, and that they will not only find guidance
in forecasting the action of those they may have to deal
with, but make themselves and others happier by greater
tolerance of the different ways of those who differ from them
in temperament (p. 389). Notwithstanding this hesitation,
we commend Mr. Stewart’s work as one containing much
interesting information on a subject in regard to which
medical psychologists ought to be well informed. What¬
ever can be brought together bearing upon the relation
between the features and the character is valuable.
The Healing Art; or. Chapters upon Medicine, Diseases , Reme -
dies, and Physicians , Historical , Biographical, and Descrip¬
tive. Two Yols. London: Ward and Downey. 1887.
The anonymous author of this work has exercised not a
little industry in its preparation, for it is a history of medicine
from the time of Hippocrates to our own times. It will be
found a very useful compilation, and medical men will do
well to procure it for reference, even if their busy lives do
not allow them to read it from cover to cover.
The information given respecting the apothecaries may be
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taken as an illustration of the interesting matter which the
work contains. In the 14th century they were incorporated
with grocers. In 1543 the Act 34 & 35 Hen. VIII., c. 8,
which was intended as a remedy for the ignorance and greed
of London surgeons, tolerates and protects the irregular
practitioners afterwards known as apothecaries. It sets forth
that the aforesaid surgeons had “ sued, troubled, and vexed
divers honest persons, as well men as women, whom God had
endued with the knowledge of the nature, kind, and opera¬
tion of certain herbs, roots, and waters, and the using and
ministering of them to such as had been pained with custom¬
able diseases, as women’s breasts being sore, a pin and the
web in the eye, uncomes of hands, burnings, scaldings, sore
mouths, the stone, strangury, saucelim, and morphew, and
such other like diseases ; and yet the said persons have not
taken anything for their pains or cunning, but have ministered
the same to poor people only, for neighbourhood and God's
sake, and of pity and charity," and therefore it ordains “ that
at all time from henceforth it shall be lawful to every
person being the King’s subject, having knowledge and ex¬
perience of the nature of herbs, roots, and waters, or of the
operation of the same by speculation or practice, within any
part of the realm of England, or within any other the King's
dominions, to practice, use and minister in and to any out¬
ward sore, uncome, wound, apostemation, outward swelling,
or disease, any herb or herbs, ointments, baths, pultess, and
emplaisters, according to their cunning, experience, and
knowledge, in any of the diseases, sores and maladies before-
said, and all other like to the same, or drinks for the stone,
strangury, or agues, without suit, vexation, trouble, penalty,
or loss of their goods " (p. 71.)
The apothecary did not, however, attain a high position
socially. He was not more than a druggist. The regulations
laid down by William Bulleyn* for his guidance are given
by the author, and are of great interest. Among them are the
following: The apothecary must first serve God, foresee the
end, be cleanly, and pity the poor. His place of dwelling
and shop must be cleanly, to please the senses withal. His
garden must be at hand with plenty of herbs, seeds, and
roots. He must read Dioscorides. He must have his
mortars, stills, pots, filters, glasses, boxes, clean and sweet.
* Born in the Isle of Ely early in the sixteenth century, and belonged to the
game family as Anne Boleyn. He died in 1576, and was buried in St. Giles’,
Cripplegate, London.
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He must have two places in his shop—one most clean for
the physic, and the baser place for the chirurgic stuff. He
is neither to decrease or diminish the physician’s prescrip¬
tion ; he is neither to buy or sell rotten drugs ; he must be
able to open well a vein, for to help pleurisy. He is to
meddle only in his vocation, and to remember that his office
is only to be the physician’s cook. Lastly, he is to remember
his end, and the judgment of God (p. 72-3).
James I. granted a charter in 1608 by which “all and
singular the Freemen of the Mystery of Grocers and Apothe¬
caries of the City of London ” were constituted a body cor¬
porate and politic, by the name of “ Warden and Commonalty
of the Mystery of Grocers of the City of London.” -Nine
years afterwards another Royal Charter was issued, forming
the apothecaries into a distinct company under the control
of the College of Physicians. We need not follow the sub¬
sequent rise and prosperity of the Apothecaries’ Company.
If its days are now numbered, it has served a good purpose
during its long career.
We have said enough to indicate the kind of information
which can be gleaned from this work, the concluding
chapter of which contains biographical notes of eminent
contemporary practitioners, including Sir Henry Acland, Sir
William Bowman, Sir George Burrows, Sir Andrew Clark,
Sir Dominic John Corrigan, Mr. Erichsen, Sir William
Gull, Sir William Jetiner, Sir Joseph Lister, Sir James
Paget, Sir Henry Thompson, Sir Spencer Wells, and others.
In conclusion, we may say that the author of these volumes
has no occasion to conceal his name, as he has succeeded in
producing a very useful and interesting work.
Oedenktage der Psychiairie und Hirer Hulfsdisciplinen in alien
Ldndem. Yon Dr. Heinrich Laehb. Berlin, 1886.
English alienists who have visited Germany are well
acquainted with Dr. Laehrs useful work on German asylums,
the first edition of which was published about thirty-five
years ago. From the same author proceeds the small book
whose title appears above. The compiler has with infinite
pains ascertained the dates of the most, and, indeed, in some
instances the least, important events in the history of insti¬
tutions for the care and treatment of the insane in various
countries of the world. It constitutes a sort of almanack
xxxiii. 20
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for the medical psychologist, arranged according to the
months of the year. Thus, under January 1st, we find
recorded the opening of St. Luke’s Hospitalin 1787, the
opening of the Sieburg Asylum under Dr. Jacobi in 1825
(being the first asylum in Germany whose director was a
physician), the opening of the Pennsylvania Hospital of the
Insane in Philadelphia under Dr. Kirkbride in 1841, and the
opening of the Lancaster County Asylum, Prestwich, in
1851, &c., &c.
Although we think it would have been more interesting to
have arranged these occurrences under the year instead of
the month, so as to have made the latter of secondary import¬
ance to the former, the reader will find a mass of useful
information collected together in a small compass. An English
alienist has no occasion to complain of the omission of
references to the movements of the insane and important
events connected with British asylums. It would be a pity
if the commendable industry of Dr. Laehr should not be
rewarded by the extensive use of his compendium. It has
already reached its second edition.
Monomanie sans Delire: An Examination of the Irresistible
Criminal Impulse Theory . By A. Wood Renton, M.A.,
LL.B., of Gray’s Inn, and of the Oxford Circuit,
Barrister-at-law. Edinburgh: T. and T. Clark. 1886.
To begin with the end rather than the beginning, we may
state the conclusions at which the author thinks himself
justified in arriving, and that really hang upon the vexed
question of so-called moral insanity, which, judging from the
title page, one might suppose Mr. Benton to confound with
an irresistible criminal impulse. He maintains, then, that
to prove the existence of moral insanity as an irresistible
impulse to do some act known to be contrary to morality or
law, cases must be adduced in which the following elements
combine, viz., an unlawful impulse, protracted resistance,
perfect intellectual soundness, and involuntary gratification
(p. 76). Certain cases which have been published in England
and on the Continent, as also in America, are subjected to
rigorous analysis, and are disposed of with triumphant
success in the opinion of the writer. That there have been
“ unskilful advocacy ” and “ ill-assorted evidence ” brought
to bear upon moral insanity must be admitted. As, however,
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1887.] .
the doctrine of moral insanity is still held, in spite of the
unskilfulnegs of its advocates, by men like Maudsley and
Clonston, there would appear to be something fundamentally
true to nature, or rather disease, in the contention that there
are a considerable number of most important cases in which
the emotions or feelings are so deranged as to render a
person thus affected irresponsible for his acts, although it
may be impossible to detect that definite lesion of the
intellect which the legal mind considers so essential to the
definition of insanity. Of this the author is unconvinced,
and one might say that he “ loses himself in countless
masses of adjustments,” and ends in the “ sceptical destruc¬
tive slough ” of which Carlyle speaks. Granting all that
may be fairly advanced against the illogical, non-lucid, and
slip-shod writing that has too often marked the productions
of the advocates of Monomanie sans D6lire, we should sup¬
pose that the majority of thinking men (lawyers excepted)
would think it more probable that the mental physicians
referred to would be right in their judgment, based as that
judgment is upon actual clinical experience, than even
Mr. Renton. We say this with all respect, as with like
respect, we think the latter has mistaken his vocation in
entering upon the discussion of this profoundly interesting
but very difficult problem. The real truth will remain,
although many of the reports of cases of moral insanity may
be made to look ridiculous and improbable by the hair¬
splitting ingenuity of gentlemen at the bar. However, we
do not complain that the weak points in the evidence should
be exposed. All we contend for is that the clever attacks of
the lawyers should not be allowed to destroy the substantial
truth which lies at the bottom of the doctrine of moral
insanity, by whatever name it may be called and however
much it may be abused, in common with every other truth in
medicine and morals. When Mr. Renton next enters the
lists in an attack upon a position which is supported by so
considerable a number of practical and experienced men, we
should recommend him to study with care the cases recorded,
not only by a past generation, but in modern treatises on
insanity, including the pages of this Journal, although pro¬
bably nothing but the actual knowledge of patients would
carry conviction to his mind. We hope to meet the author
on a future occasion, treating of subjects within his own
special range of experience. Ne suior , &c.
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[July,
Lemons sur les Maladies du Systbme Nerveux faites a la
Salpetriere. Par J. M. Charcot. Tome Trisi&me.
Paris, 1887.
Les D&moniaques dans Vart. Par J. M. Charcot et Paul
Richer. Avec 67 figures intercalates dans le Texte.
We regret that we cannot do more in this number of the
Journal than bring under the notice of our readers the fresh
contributions to medical science whose titles stand at the
head of this notice—the latter of the two having the joint
names of Charcot and Richer, They deserve an extended
notice, and we rejoice that M. Charcot has found time to
continue his former work “ On the Diseases of the Nervous
System,” and to add others to his list of contributions. He
has his calumniators, no doubt, both in France and England,
but when the history of the progress of neurology conies to
be written at a future day the Professor at the Salpetri&re
will stand out in bold and dignified relief, while his petty
foes and critics will be forgotten. In our next number we
shall return to these admirable writings.
Handbook of Practical Botany for the Botanical Laboratory
and Private Student. By E. Strasburoer, author of
“ Zellbildung und Zelltheilund,” etc., etc. Edited from
the German by Professor Hillhouse, M.A., F.L.S.
London : Swan Sonnenschein, Lowrey, and Co.
An Elementary Text Book of British Fungi, Illustrated . By
William Delisle Hat, F.R.G.S., author of “ Brighter
Britain,” etc., etc. London: Swan Sonnenschein,
Lowrey, and Co.
What have botany or fungi to do with psychological
medicine or mental science? some of our readers may be
disposed to ask. In truth we often find it difficult to know
where to draw the line, and we are conscious that we may
expose ourselves to the charge of inconsistency in accepting
some works for review and declining others. For example,
we have before us a little book on the “ Athanasian Creed,”
anonymous, but generally supposed to be written by a retired
medical superintendent, esteemed for the work he performed
in past days. Coming from such a source, it commands
our respect and tempts us to give the author a friendly hand¬
shake. We hold, however, that while some may maintain
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301
that theology has as much to do with mental science as
botany, there are sufficient reasons to debar us from review¬
ing a distinctly theological work, while we bring under the
notice of our readers a botanical treatise. We might, indeed,
have cited the incidental references scattered throughout
the book to hereditary transmission, and to the relation
between organization and thought; but we should not find it
easy to separate these from the body of the work without
injustice to the author. We, therefore, adopt the position of
non po88umuSy as regards works of this nature, and proceed to
the notice of those at the head of this review.
Although, then, not directly connected with medical
psychology, works of this description ought to find readers
among those engaged in this department of medicine. They
contain a large amount of information, systematically and
carefully prepared. A special description is given in the
first volume, at the head of this notice, of the methods of
studying bacteria. Simple directions will be found for the
practical examination of these organisms. Minute instruc¬
tions are given for microscopical investigations, as also in
regard to the best method of culture. In short, this work
is an elaborate, detailed and practical treatise, and is con¬
scientiously prepared. It is accompanied, moreover, by a
number of illustrations.
The work on “ The British Fungi ”—not very correctly
called a “ Text Book ”—which contains a large number of
plates (not all original*), deserves a certain amount of,
although a qualified, commendation, and in spite of its faults
cannot fail to be useful to medical men. The writer says,
and we can well believe him, that he has never had the
privilege of meeting with anyone versed in rliycology from
whom he could derive instruction. It is really surprising that
the subject of British poisonous fungi should have been so
much overlooked. In the tenth chapter Mr. Hay gives as
perfect a list as he is able of toxic fungi. His comments
are often lively and original, in striking contrast to the
orthodox dulness and dryness of modern botanical works,
which remind one of the happy definition of pea soup, that
it distends the stomach without improving the mind. Thus,
of one species of Agaricus, the Destroying Angel, the
writer’s comment is as follows :— te Angelically beautiful and
demoniacally poisonous, it reminds me of a bride in white
satin and lace ” (we hope the simile does not go on all fours).
“ A perfect specimen I once lit upon in the shade of a dark
* It should have been stated what plates are copied from other works.
/
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[July,
shrubbery, illuminated by a straggling ray of sunshine
through which a red admiral butterfly fluttered down
upon it, afforded me an artistic feast.” Again, of
Agaricus Lacrymabundus of the crocodile, the comment
runs—“It is bowed with the weight of its guilt.” The
esculent and economic uses of the fungi are strongly insisted
upon, and an amazing amount of ignorance would be dis¬
pelled were this work widely circulated among the public.
It would seem that “prejudiced Britons ” are in a condition
of much greater ignorance than the French and Germans.
“ The recognition of the common esculents is easy enough
to learn, once the mind has grappled the idea of discrimina¬
tion. On the Continent children are taught to recognize
those kinds of fungi locally appreciated, and they will select
such a species with which they have become familiar un¬
hesitatingly from amid a thousand others. Surely English
children are as quick as those of the Black Forest or
Lorraine.” The author adds: “ Little as English people
know about esculent fungi, that little is illumination com¬
pared with all they know on the subject of * Fungus Poisons/
In that field there is almost total darkness.” A study of
Mr. Hay's work is certainly calculated to diminish some, at
least, of this darkness, notwithstanding many blemishes
which disfigure it, and it might be criticised at length did
our space allow.
L’EncSphale. Structure et description iconographique Saa
Cerveau , du Cervelet et du Bulbe. Par E. Gavoy, M6decin
principal de Parm6e. Avec Atlas de 59 planches en
glyptographie. Preface de M. le Professeur Yulpian.
Paris Libraire, J. B. Bailliere et Fils, 19, Rue Haute-
feuiiie. 1886.
This fs an atlas of the human brain, giving a complete
representation of the cerebrum in the three chief planes, viz.,
frontal (lateral-vertical), sagittal (antero-posterior and ver¬
tical), and horizontal. The sections are made only a short
distance apart, and in this way a very complete series of
pictures is obtained of the brain in the various planes. The
plates are drawn by hand to the natural size, from the sec¬
tions, and are reproduced by the glyptographie method.
The drawings are most beautifully executed, and the minutest
details are figured.
Accompanying the atlas is a full explanatory text describ¬
ing the different sections.
1887.]
Reviews.
308
It is stated in the text that the sections have been pre¬
pared by a method which brings out the various parts more
clearly, but unfortunately the method employed is not de¬
scribed. Certainly the fibres are brought out much more
sharply than they appear when a section is made in the fresh
brain or after hardening in bichlorate of potash.
A similar atlas has been previously brought out by Prof.
Dalton (America). There is this distinction, however, that
the sections of the brain have been photographed in place of
being drawn, so that while the fibres are not reproduced so
vividly, the plates are necessarily more accurate so far as they
go. There are some parts of the text with which we are not
fully in accord, more especially as regards the omission of
any reference to the direct pyramidal tract—the fibres of
which go direct from the motor area of the cortex, through
the internal capsule to the pons and medulla without joining
the basal ganglia; and we would take exception to the
description of the minute anatomy of the fibres of the cere¬
bellum.
The atlas, at the same time, is a work which will be very
valuable for reference in elucidating the complicated ar¬
rangement of the interior parts of the brain, and particularly
the intricate regions about the basal ganglia. The author
is to be congratulated on a production which must have
entailed a vast amount of labour.
Professor Vulpian, since deceased, prefaces the work in
terms of high commendation. B.
The Life of Percy Bysshe Shelley . By Edwabd Dowden,
LL.D. Two Yols. Kegan Paul, Trench, and Co.,
London. 1887.
(Continued from p. 126.)
Our notice of this work left off at the point when Shelley
was unable to find sufficiently impassioned terms to describe
his admiration of Miss Hitchener.
A reconciliation now took place between Shelley and his
own and his wife's father, one practical consequence being
that the allowance for the young couple was made £400 per
annum.
Shelley, who when at Oxford had conceived a great admira¬
tion for the author of “ Political Justice,” now fell completely
under Godwin's influence. He wrote a letter to him in which
he desired an interview with one whom he had been accus-
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tomed to regard as “ a luminary too dazzling for the darkness
which surrounds him.” Tn this letter he says : —
I am married to a woman whose views are similar to my own. To
you, as the regulator and former of my mind, I must ever look with
real respect and veneration.
Shelley now threw bis enthusiasm into the Irish questions
of the day, especially Catholic emancipation. Leaving Kes¬
wick, where lie and his wife had resided since quitting York,
they proceeded to Dublin. As his biographer says —
Of Irish parties and internal politics Shelley knew but little. He
was not the first or last of his countrymen who fancied that by a pro¬
menade in Ireland he could restore order from the chaos (p. 241).
We need not discuss the pamphlets which Shelley issued in
order to bring about the regeneration of Ireland, but he
exhibited at this period considerable ability and unquestion¬
able sincerity, although everyone would admit with Shelley’s
biographer that —
Practical men of action, like Scully and O’Connell, could have little
in common with a boy-dreamer, who supposed that he had mastered
Irish politics in a week, and whose chief thoughts and hopes were
centred in a vaporous millennium of equality and freedom, resplendent
and remote as a sunset palace in the western sky (p. 245).
Godwin remonstrated with the course his young disciple
was pursuing in Ireland, and thus proceeds:—
He that would benefit mankind on a comprehensive scale, by chang¬
ing the principles and elements of society, must learn the hard lesson,
to put off self, and to contribute, by a quiet but incessant activity like
a rill of water, to irrigate and fertilize the intellectual soil. Shelley,
you are preparing a scene of blood ! (p. 263.).
Shelley withdrew his condemned publication from circula¬
tion and left Dublin. He was blamed by Godwin for
“ running from one extreme to another.” This, in truth,
was precisely what a temperament like Shelley’s was certain
to do.
Now Shelley is a resident in Nantgwillt, in Wales. Here
Harriet became very ill, and Shelley was troubled with some
legal difficulties. Injurious reports were circulated in regard
to Miss Hitchener and her admirer, who indignantly wrote to
his uncle, Captain Pilfold, and to her father, Mr. Hitchener.
Writing to the latter Shelley says: “Take care, sir; you
may destroy her by disease, but her mind is free —that you
cannot hurt. . . . When next I hear from you I hope that
time will have liberalized your sentiments” (p. 276). This
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was quite the Shelley style of writing to his elders. All that
the kind Captain Pilfold was sure of was that his nephew was
“ very much attached ” to Eliza Hitchener.
Next we find Shelley and Harriet residing in lodgings at
Lynmouth, one room being assigned, in anticipation, to the
angelic Miss Hitchener, who, after her arrival, was engrossed
in helping Shelley in his writings, and in reading his Irish
manuscripts. Dr. Dowden thinks that this period was the
happiest in Shelley's early life. “His love for Harriet was
ardent and un marred by fleck or flaw. In his relations with
Miss Hitchener he had not yet passed from enthusiasm to
disillusion ” (p. 283). It is interesting to note here that
when in Dublin, Shelley had written : “ I either am, or fancy
myself, something of a poet.” And everything now tended
in his surroundings and in his domestic happiness to favour
his marvellous poetical genius.
It may be mentioned here that Shelley's opinions in
regard to marriage were confirmed by the reading of a work
by Sir James Lawrence. It “ convinced him, if any doubts
yet remained, that marriage is essentially an evil” (p. 286),
To him Shelley, having then been in the bonds of matrimony
for a year, addressed a letter, in which he says: “ Love
seems inclined to stay in the prison." To Harriet he
addressed birthday lines, which show that on August 1,
1812, he had no cause for regarding the alliance as
uncongenial:—
Ever as now, with love and virtue’s glow,
May thy unwithering soul not cease to burn,
Still may thine heart with those pure thoughts o’erflow,
Which force from mine such quick and warm return.
And in other lines he thus apostrophises the Harriet whom
he then adored and called his “ second-self” :—
0, thou most dear,
’Tis an assurance that this Earth is Heaven,
And Heaven the flower of that untainted seed
Which springeth here beneath such love as ours.
Harriet 1 let death all mortal ties dissolve,
But ours shall not be mortal! The cold hand
Of Time may chill the love of earthly minds
Half-frozen now. The frigid intercourse
Of common souls lives but a summer’s day;
It dies where it arose, upon this earth.
But ours ! Oh 1 ’tis the stretch of fancy’s hope
To portray its continuance as now,
Warm, tranquil, spirit-healing. . . .
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Shelley then speaks of Harriet’s “ woman-sweetness,” the
fire which throbs in her “enthusiast heart,” and of “the
dear love that binds our souls in soft communion,” and he
is assured that they can never “ dare to cut the unrelaxing
nerve that knits our love to Virtue ” 2 —
Can those eyes,
Beaming with mildest radiance on my heart
To purify its purity, e'er bend
To soothe its vice or consecrate its fears ?
Never, thou second self!
The poet ends his beautiful lines to Harriet with —
Virtue and Love ! unbending Fortitude,
Freedom, Devotedness, and Purity!
That life my spirit consecrates to you* (p. 288).
Nor was this fondness for Harriet a mere poetical expres¬
sion. Writing to Hogg subsequently (Feb. 7, 1813), he
says 2 “ When I come home to Harriet I am the happiest of
the happy” (p. 320).
To Fanny Godwin (daughter of Mary Wollstonecraft and
Imlay) Shelley writes of Harriet: “ The ease and simplicity
of her habits, the unassuming plainness of her address, the
uncalculated connection of her thought and speech, have
ever formed, in my eyes, her greatest charms; and none of
these are compatible with fashionable life, or the attempted
assumption of its vulgar and noisy eclat ” (rather later date.)
Shelley’s visit to London in October, 1812, with his wife,
sister-in-law, and Miss Hitchener, was an important incident,
inasmuch as he met Godwin in person for the first time.
Everything, in Shelley’s eyes, was admirable. Godwin was
an infallible mentor and profound philosopher, while Mrs.
Godwin was “ chiefly distinguished by a sweet resoluteness
and magnanimity of soul.” Godwin’s daughter, Mary Woll¬
stonecraft, was now fifteen, and it is probable, although not
certain that Shelley met her at that time.
Shelley’s admiration for Elizabeth Hitchener now vanished,
she who as “the chosen partner of Shelley’s spirit in its
higher strivings and aspirations ” (Dowden) had naturally
caused Harriet much unhappiness by coming between her
and Shelley.f
* In the MS. book from which this is taken it is followed by the beantifol
sonnet to Harriet, Aug. 1,1812.
t Mrs. John Williams writes (Vol. i., p. 321) that Shelley’s taking Miss
Hitchener into his honse brought to it “ confusion and anarchy ” in addition to
the poverty.
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Dr. Dowden speaks here with unusual directness:
“ Certainly Harriet was stung by expressions which implied
that the girl-wife must take up a humbler position of service
towards Percy than that held by the elect sister of his soul.”
What with Miss Hitchener’s natural acceptance of the posi¬
tion accorded her, and the extravagant terms of admiration
expressed for “ the chosen partner of Shelley’s spirit,” poor
Harriet may well have begun to doubt whether she was any
longer her husband's “ second-self.”
When Shelley ceased to admire the Surrey schoolmistress
he went from one extreme to the other, and “ Portia” was now
regarded with disgust. Shelley offered to make her some
compensation for having induced her to give up her school
and live in his family, but it is not clear that she accepted
it. “ The Brown Demon, as we call our late tormentor and
schoolmistress, must receive her stipend. I pay it with a
heavy heart and an unwilling hand; but it must be so. . . .
What would Hell be were such a woman in Heaven ! ”
(Shelley to Hogg, Dec. 3, 1812, p. 313). The terms in which
this former idol is described in this letter form one of the
innumerable examples of fickle change of opinion on Shelley's
part in regard to his heroes and heroines.
A brief reference may here be made to an alleged attack
made on Shelley during the night of February 26th, 1813,
while residing at a small house (Tanyrallt) at Tremadoc,
North Wales. Many supposed that this was a delusion of
Shelley's brain, although the narration of the occurrence by
Harriet at the time was very circumstantial. Peacock wrote,
after making inquiries on the spot, that the evidence appeared
conclusive that the whole series of operations took place
from within, and not from without (p. 354). Again, Mr. J no.
Williams, a neighbour, who was sent for, and found Shelley
sadly excited, believed that there was no attempt whatever
at burglary, but that the whole affair was the product of
Shelley's heated imagination. He said * that Shelley
M Fancied he had seen a man’s face on the drawing room window;
he took his pistol and shot the glass to shivers, and then bounced out
on the grass, and there he saw leaning against a tree the ghost, or, as
he said, the devil; and to show Mr. Williams what he had seen, he
took his pen and ink and sketched the figure on the screen, where it
is at this moment, showing plainly that his mind was astray. . . .
* What follows in inverted commas is from a statement made by Mrs.
John Williams long afterwards (1860), as to her husband’s opinion of the
Shelley ghost (see Yol. i., p. 354).
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When I add that Mr. Shelley set fire to the wood to burn the ap¬
parition, you may suppose it was not all right with him.”
Leeson, who was his supposed assailant, was a real man
who had charged Shelley with sedition. In after-life Shelley
appears to have dreaded being pursued by the same person,
who, on his part, asserted that Shelley invented the story in
order to escape from his creditors, which seems a very far¬
fetched and improbable explanation. It is certainly remark¬
able, and favours the theory of delusion (or invention) that
Harriet used to be angry whenever Leeson was named. She
said Shelley wanted to frighten her, and that for long she
was frightened, but that Mr. Peacock had told her it was
untrue (p. 355).
Soon after this period Shelley wrote to his father from
London, proposing reconciliation. Shelley was not one to
say to his father what he did not really feel, and it is, there¬
fore, of some importance to record that he frankly acknow¬
ledges that the intercourse between himself and his father
was forfeited by his own “ follies; ” (p. 3t>5). He adds: “I hope
the time is approaching when we shall consider each other
as father and son with more confidence than ever, and that
I shall be no longer a cause of disunion to the happiness of
my family.” We must admit, with Dr. Dowden, that Shelley
had been “ a trying, intractable son.” Unfortunately, his
father still required him to disavow his sentiments on re¬
ligion, which, of course, Shelley could not do with truthful¬
ness. That old Mr. Shelley meant well, and had just cause
for bitter disappointment in the course his son had pursued,
is not denied. But wrong as Shelley’s former disobedience
was, it would have been an act of hypocrisy to have con¬
sented to profess beliefs which he did not hold, as his father
is said to have wished him to do.
Shelley at this period was a vegetarian. He rarely took
beer, spirits never. Tea was his favourite beverage. At
one time he took freely of laudanum. His dress was
neglected, as became a philosopher and poet. His throat
was generally bare. In the street he felt obliged to wear a
hat, “ but in fields or gardens his little round head,” says
Hogg, “had no other covering than his long, wild, ragged
locks” (p. 372).
Shelley informed Cornelia Turner that he dreaded the
visions that pursued him when alone at night. Iu 1813,
The strange delusion afflicted him that he was attacked by
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elephantiasis; he had travelled in a mail coach with a fat old lady,
whose legs, the reverse of slender, had horribly fascinated Shelley’s gaze
and imagination. She most be a victim of that cruel disease which
changes the human skin into an elephant’s hide ; the disease must he
contagious, and he himself could not now escape from its invasion.
u One day, at Mr. Newton’s house in Chester street, as he was sitting
in an armchair,” writes Madam Gataves, “ talking to my father and
mother, he suddenly slipped down on the ground, twisting about like
an eel. ‘What is the matter V cried my mother. In his impressive
tone, Shelley answered, 1 1 have the elephantiasis 9 ” (p. 373).
Shelley consulted a doctor, and in the course of a few
weeks his hypochondriacal delusion vanished. * He was by
no means a stranger to mirth, and sometimes told a good
story, “ shrieking with paroxysms of the wildest laughter.”
Hogg, from whom we quote, represents him as carried away
irresistibly by this laughter, which rose to a “ fiendish
peal” on the most inopportune occasions.
Shelley now becomes a father. Ianthe was bom in the
summer of 1813. Although, according to Hogg, the child
did not appear to afford any gratification to Shelley, we are
assured by Peacock that he was extremely fond of it; and
this is confirmed by the sonnet he addressed to it, in which
he expresses his love to it for its “ own sweet sake,” although
still more for its mother’s; for it is—
Dearest when most thy tender traits express
The image of thy mother’s loveliness.
In reference to this period, Hogg records that Shelley
Took strange caprices, unfounded frights and dislikes, vain ap¬
prehensions, and panic terrors, and, therefore, he absented himself
from formal and sacred engagements. He was unconscious and
oblivious of times, places, persons, and seasons; and, falling into
some poetic vision, some day-dream, he quickly and completely forgot
all that he had repeatedly and solemnly promised ; or he ran away
after some object of imaginary urgency and importance, which
suddenly came into his head, setting off in vain pursuit of it, he
knew not whither (p. 377).
It is pleasant to find that about this time a friendly meet¬
ing took place between Mr. Timothy Shelley and his son,
who had not been in receipt of more than £200 a year, and
was in gieat want of money. Indeed, his arrest for debt
was only prevented by his father’s interference, without the
son being aware of it. His mother and sisters gave repeated
proofs of their attachment to Shelley, and appear to have
been friendly with Harriet.
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Shelley was re-married in London, he being now of age.
The author of “ Political Justice ” had modified his own
views in regard to the legal form of marriage, and he ac¬
companied Shelley to Doctors’ Commons to obtain a license.
Two days later, March 24, 1814, Shelley and Harriet were
re-married in St. George’s Church, Hanover Square.
(To be continued.)
PART III.—PSYCHOLOGICAL RETROSPECT.
Asylum Reports , 1886.
Very little is necessary in the form of introduction to our notice of
the Reports. The same features appear year by year; some reports
are too long, others far too short. The majority, however, indicate a
determination on the part of medical superintendents to keep their
buildings and arrangements up to the times, and, so far as can be
judged by the criticism of the Lunacy Commissioners, most of them
succeed.
It may have been noticed that during the past year or two the
Commissioners have made special inquiries about the exercising of
the patients beyond the airing courts. This official pressure, if it
may be so called, appears to be doing good, though there is still
sadly too much room for improvement.
The cost of maintenance of pauper lunatics continues to fall, and
there seems to be a fierce competition as to which asylum is to occupy
the place of most questionable distinction as being the most econo¬
mically managed in the country. We hope we may be excused when
we say that in our opinion this struggle is a most foolish one. There
are so many improvements in asylum management retarded by the
disinclination of the public to pay for them that the present is an ex¬
ceptionally favourable time for their introduction. If with little
exception the medical staff of our asylums requires to be increased, the
same may be more strongly said regarding the number of nurses and
attendants, and in all, the hours on duty urgently call for diminution.
None of these really necessary improvements can be carried out
without money. “ Few attendants ” means neglect and restraint.
Barnwood House , Gloucester .—This hospital continues to prosper
abundantly, as indeed it richly deserves to do. Some of Dr. Need¬
ham’s excellent observations will be found under u Occasional Notes
of the Quarter.*’
Birmingham. Wtnson Green .—Relative to employment, Dr. Whit-
combe remarks:—
A recent visit to the asylums at Berlin and Vienna impressed upon me the
advantages possessed by them over the majority of our English asylums in
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their excellent provision for a variety of employments. In the blook for idiots
at Berlin this was especially noticeable, resulting, I was informed, in the
discharge of 80 per cent, of that class as being competent to earn their own
living.* Whilst at Vienna a system prevails of giving a small monetary re¬
muneration to patients for their work, the manufactured articles being sold
and proving a financial success.
There is truth in Dr. Whitcombe’s criticism, but there is very little
chance of a real advance in asylum management in England so long
as the foolish efforts to reduce the cost of maintenance continue. We
repeat that the first step in the improvement of English asylums is to
largely increase the staff of attendants.
Birmingham. Rubery Hill .—Judging from the extract from the
Lunacy Commissioners’ report, this asylum is in a most efficient
condition, and we would suggest that in future the whole report, with
that for Winson Green, should be published in full.
Bristol .—Extensive additions, at an estimated cost of £65,676,
have been begun. These consist of four projecting blocks, and are
arranged for the accommodation of 240 patients.
The following paragraph from Dr. Thompson’s report may be
interesting for more reasons than one :—
Though this document is addressed to a Committee of “ laymen,” I hope it
is read by some of the medical officers of other asylums. It will not therefore
be ont of place, perhaps, to say something of some of the means used for
treating the patients medicinally. I should say at onoe, then, that chloral,
bromide of potassium, and cannabis indica—those dreadful destroyers of nerve
function—are not used in this asylnm. Bnt during the year a new weapon has
been added to our armoury, which promises to be of great service in the treat¬
ment of acute, chronic, and recurrent mania. I refer to the hydrobromate of
hyoscine. Given in doses of from *^jth to ^\jth of a grain by the mouth or in¬
jected beneath the skin, the effect, especially on the latter class of cases, is
simply marvellous. Where the tendency of such persons (a very common one)
is to destroy their clothing and property generally, the new drug most
peremptorily puts a stop to it. Bnt the hyoscine should on no account be
given to an epileptic, as that condition known as the status epileptious is at
once induced in a dangerous degree. I find that small doses of aconite and
antimony, together or alone, are of great service in the treatment of the ordi¬
nary morose epileptic. The fits are reduced in number, and the temper and
manners and intelligence are improved all round. The calabar-bean is still
used in the early stages of general paralysis, and, I think, with beneficial
effect; but our trouble is, that we do not get such cases early enough to expect
benefit to follow upon any mode of treatment; and until medical men outside
asylums are trained to recognize this disease in its earliest stage, our tables of
causes of death will present a large proportion of the deaths in asylums as
being due to this sad disease. Sometimes jaborandi takes the place of the
calabar-bean, and with about the same result—a general improvement of the
patient if given early enough.
To criticise the preceding statements would be to go over the whole
field of therapeutics as applied to mental cases. If we may express
* Supposing this extraordinary statement to be a misprint, we communicated
with Dr. Whitcombe, but find such is not the case. It is obvious that either
the ‘‘ idiots ’’ are not what we call by that name, or an incorrect statement was
inadvertently made to Dr. Whitcombe.— [Eds.]
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312 Psychological Retrospect . [July,
an opinion, it would be that we scarcely agree with anything Dr.
Thompson has said.
Berkshire , $c. —The Visitors pay a warm tribute to the worth and
ability of the late medical superintendent, Dr. Gilland.
The alterations in the sanitary arrangements are now complete.
A considerable accumulation of patients has occurred during the year.
Although this report extends to 79 pages, it does not include the
result of the annual inspection of the asylum by the Commissioners.
The new superintendent, Mr. J. Harrington Douty, would do well to
remedy this omission in future.
Broadmoor (1885).—This contains the last report by Dr. Orange,
whose retirement we have already noticed with sincere regret. As is
well known, he is succeeded by Dr. Nicolson, who will doubtless
maintain the reputation of this great asylum.
The medical staff has been strengthened by the addition of another
junior officer. There is nothing calling for special notice, except,
perhaps, the heating of some of the blocks by hot water. Dr. Orange
gives a detailed account of the arrangements connected therewith ;
they appear to be most satisfactory, and would doubtless repay in¬
spection.
Cambridgeshire , $c. —At last the Commissioners have compelled
the Visitors to consider the enlargement of the asylum. The cost is
roughly estimated at £16,000.
Whilst the report by the Visitors is distressingly minute in detail,
that by the Medical Superintendent is quite as minute in size. The
former contains some information, however worthless ; the latter,
none at all.
The Visitors recommended a retiring allowance to an attendant of
17s. per week ; the Quarter Sessions declined to confirm it; whilst
these embodiments of wisdom wrangled over it, “ the beggar died.”
£20 to the widow to defray the funeral expenses cannot atone for
the previous cruel meanness of Quarter Sessions.
Carmarthen .—The new chapel makes satisfactory progress towards
completion. Dr. Hearder states that this work has included the
quarrying of more than 2,000 tons of stone, and its removal by boat to
a landing place four miles from the quarry ; all this has been done by
the patients and the ordinary staff, with the assistance of one paid
labourer. This is exceedingly creditable to all concerned.
Tbe number of admissions has been lower than for any year since 1877.
This would be a matter for sincere thankfulness if it could be regarded as a
result of decrease in the freqnenoy of attacks of insanity ; but, unfortunately,
we have no corroborative evidence to snpport such a theory. The number of
chargeable lunatics does not diminish. In this district the proportion of
lunatics in the asylum is still under 50 per cent, of the total number charge¬
able ; while for the whole of England and Wales tbe proportion under treat¬
ment is above 67 per cent. The admissions to asylums throughout the country
during the year are in the ratio of 5 to each 10,000 of the population; in this
asylum the ratio was last year only 5 to each 22,000 of the population; in other
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words, our admissions for the past year, if equal to the average of the rest of
the country, would have been 140 instead of 65. This disparity between the
ratio of admissions to this and to other asylums becomes even more strongly
marked when we have ascertained the proportion of the chargeable insane to
the general population in this and in other districts; for we find that in the
whole of England and Wales there are 26 chargeable lunatios to each 10,000
of the population; while in the counties of Carmarthen, Cardigan, and Pem¬
broke, the proportion is 88 to each 10,000.
We doubt whether this diminution in admissions of pauper patients
is due, as Dr. Hearder supposes, to the fear entertained by medical
men of legal proceedings following on the signing of lunacy certifi¬
cates.
Cornwall .—It would appear that the new accommodation is being
rapidly filled up by chronic cases from workhouses. The epileptic and
more actively suicidal patients are now under continuous supervision
at night.
Crichton Royal Institution .—The number of pauper patients has
been kept down by the discharge of all who were fit to reside out of
the asylum, and most of those discharged unrecovered were boarded
out in private dwellings. This policy has been steadily pursued for
the last few years, with the result that the number of pauper patients
belonging to the district has fallen from 302 to 239.
Concerning general paralysis Dr. Rutherford says —
For some years I have observed what seems to be a change in the duration of
this disease. Ten or fifteen years ago from two to three years was considered
the limit of life in men after its symptoms were decidedly pronounced. At
present there are several men, undoubted general paralytics, who have been ill
upwards of four years, and are yet in good physical condition. The less rapid
course of the disease may be due to improved methods of treatment and nursing,
or perhaps to its having been brought on by slighter causes than in those we
were accustomed to see long ago ; if so, this would account for the increase in
the numbers of such cases. Another feature in the nature of the admissions now,
as compared with ten years ago, is the small number of cases of acute mania,
and the large number of those of mental depression or melancholia.
It is satisfactory to learn that gentlemen in increasing numbers
engage in garden work, which is limited to four hours per day.
Extensive structural alterations are still in progress.
No report by the trustees is given ; neither is the entry made by
the Commissioner at his semi-annual visit. These we cannot but think
should be published. They refer to a public institution and are of
general interest.
Cumberland and Westmoreland .—The official report on the con¬
dition of this asylum is most favourable.
Concerning the visiting of the patients by their friends, Dr. Camp¬
bell says :—
It is a distinct hardship when asylums are built in such remote districts that
the patients are deprived of visits from their relatives. I am more and more
convinced, as my experience extends, of the value of visits from relatives in
many cases of insanity. To be left without the sight of a relative or friend,
without a cheering word from home, in an asylum among strangers, is enough
xxzin. 21
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314 Psychological Retrospect . [July*
to make a desponding patient more desponding; a patient tending to dementia
more ready to lose interest in all mundane matters. I strongly advise frequent
visits to such cases, as I believe they will benefit by them; and I also advise
such friends as oan afford it to send occasionally the special local paper which
interested their relative; for even though our supply is a good one, patients
prise getting a paper for themselves.
If all the patients’ friends were discreet, no doubt they would be
welcomed by the officers of an asylum much more heartily than has been
the case hitherto. It cannot be denied that they occasionally work
irretrievable mischief.
Denbigh .—It is to be regretted that the Visitors delay providing
accommodation which is evidently required. They prefer to send
patients to other asylums
Bather than recommend a large outlay in additional buildings in these de¬
pressed times, and with a possible change in the government and arrangement
of asylums in prospect under a County Government Bill.
The Commissioners point out that the staff of attendants is nume¬
rically weak. Other defects, chiefly structural, and others due to
overcrowding, are pointed out. As the rate of maintenance is at the
dangerously low figure of 7s. per week, it would not be amiss to in¬
crease the cost by carrying out the suggestions made by the Commis¬
sioners.
Mr. Cox seems to be doing what he can to increase the useful em¬
ployment of the patients, and has placed an attendant in charge of the
newly instituted upholsterer’s shop.
Derby .—Dr. Lindsay brings under the notice of his visitors some
paragraphs from the Report of 1882, relating to the Capitation Grant
and how it might be spent more wisely than at present. He has got
hold of an excellent subject, and should not drop it.
Three of the admissions were found not insane, and were returned to
the workhouses from which they had been sent.
The mortality is again high, and the deaths from phthisis are exces¬
sive. In 8 of the 15 deaths from that disease it probably existed on
admission.
A photographic apparatus has been purchased, and is used by the
assistant medical officer, who takes the photographs of the patients for
insertion in the Case Book, so as to facilitate the better illustration
of the cases. This ought to be done in all asylums.
Devon .—A sum of £4,000 has been granted to provide sleeping
accommodation for 85 female patients, and for the erection of a dining-
hall to seat 400.
An observation dormitory for epileptic and suicidal patients has at
last been provided.
A marked falling-off in the number of admissions in the last two years,
causes Dr. Saunders to remark that the fact is noteworthy, but not
easily accounted for. Although in the present uncertain and transitional
state of the Lunacy Laws, both magistrates and medical men are reluc¬
tant in some cases to make the necessary orders and certificates for
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admission to the asylum, the movement of population in agricultural
districts must be a more important factor, as the tendency is for a
certain proportion of the rural population to remove to urban dis¬
tricts or to emigrate.
The absence of the Commissioners’ report is to be regretted.
Dublin. Richmond Distnct Lunatic Asylum .—The report of the
medical superintendent of this asylum is, to our thinking, one of the
most important events in the Irish lunacy world. When any asylum
has been governed for many years by one man, however good, the
chances are that when a change comes, many necessary improve¬
ments are needed. Men stand still much more than medical science
does. What was good enough 30 years ago will not now be tolerated.
In looking over the report we are struck with the amount of much-
needed sanitary reform which Dr. Norman has to carry out, and unless
he is ably supported by his committee, it will be a hard matter to get
all things in order before the visit of the Medical Association to Dublin
this year. The state of water, of the drains, and of the general health,
as represented by dysentery and diarrhoea, is alarming, and if cholera
happened to visit Ireland, it would be hard to say where the disaster
might end. We believe Dr. Conolly Norman knows fully his respon¬
sibility, and will not shrink from his duty, which is to persist in
pointing out the grave dangers to which his patients are exposed till
they are removed. It is intolerable for a conscientious superintendent
to think that patients suffering from mental disorder may come in for
cure, but may be injured or killed by the evils pf the establishment
where they seek health.
Dundee .—We regret to find that this Royal Asylum continues to
struggle against severe financial embarrassment, though the directors
express a hope of speedy relief in this direction.
The following paragraph from Dr. Rorie’s report holds out the hope
that yet another asylum may be utilized for the teaching of psycho¬
logical medicine:—
The oh&racter of the institution is, however, affected in another way. The
pauper patients allowed to remain in the asylym chiefly belong to the epileptic
and paralytic class, and those whose physical condition requires special atten.
tion. When this is kept in view, and the large increase in the numbers ad¬
mitted, it will be seen that the Institution is becoming year by year more and
more a hospital for the curative treatment of the insane, and for the treatment
of persons suffering from paralysis, epilepsy, and other allied nervous diseases,
and year by year less a place for the detention of the insane for the safety
of the publio; and this purely medical aspect of the question is one
that ought to be kept prominently in view, the more especially as the
establishment of medical classes in connection with the University College
seems to be meeting with greater and increasing approval on the part of the
community generally. Indeed, the question how far the Institution even at
present might not be, to a certain extent, a means of medical education, is
worthy of consideration. Thus, by establishing one or more clinical clerkships,
and throwing them open to advanced medical students from any of the Univer¬
sities or Medical Schools as might be desirous of acquiring a practical acquain¬
tance with the treatment of the insane, a satisfactory commencement would be
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Psychological Retrospect.
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made in this direction at scarcely any cost to the Institution, or, at least, a
cost which would be more than compensated for by the additional assistance
that would be in this manner rendered in the individual treatment of the
patients and in pathological investigation and research. The opportunities
available in this direction have long appeared to me to be too little taken
advantage of, and it is with satisfaction that I can now report the accomplish¬
ment of what has been a long cherished desire on my part—the establishment of
a thorough and systematic pathological examination in all cases where per¬
mission can be obtained. In connection with this department, the foundation
of a pathological museum has now been laid, which already is interesting, and
in after years will, no doubt, prove of greater value.
Fife and Kinross .—This asylum has now been occupied twenty
years. Dr. Turnbull has prepared some statistics for this period, and
we make the following extract from his remarks :—
It may be interesting to note the amount of pauper lunacy at the beginning
and the end of the period. On the first of January, 1866, a few months before the
opening of the asylum, the number of registered pauper lunatics belonging to
l4fe was 261, and to Kinross 16. At 1st January, 1886, the corresponding
figures were 452 and 23. Taking the general population of the district as repre¬
sented at these two dates by the numbers given in the census for 1861 and 1881
respectively, the population of Fife in 1866 was in round numbers 155,000, and
of Kinross 8,000; while in 1886 the population is 172,000 and 6,000. In Fife
the general population has increased during the 20 years by nearly 11 percent.;
but the number of pauper lunatics has increased 80 per cent In Kinross the
general population has decreased by 25 per cent; the number of pauper lunatics
has increased 43 per cent. Taking the proportion of pauper lunatics per 100,000
of the general population, we find that in Fife the number was 162 in 1866
and 263 in 1886, and that in Kinross the number was 200 in 1866 and 379 in
1886. The amount of pauper lunacy has thus increased in a much greater
ratio than the general population. As has already been pointed out more
than once, this does not necessarily indicate that insanity occurs more fre¬
quently now-a-days than it did 20 years ago. The influences which lead to an
increase in the proportion of pauper lunacy, independently of any increase in
the real amount of insanity, have been referred to in previous reports, and need
not now be mentioned again.
Turning to the disposal of the patients, it appears that at 1st January, 1866,
of the total 267 pauper lunatics of Fife and Kinross, 208, or 76 per cent., were
in public establishments (that is, asylums or licensed wards of workhouses), and
64, or 24 per cent., were under private care. At 1st January, 1886, of a total
number of 475 pauper lunatics in the two counties, 365 (77 per cent.) were in
public establishments, and 110 (23 per cent.) under private care. There is thus
only a slight variation in the mode of disposal of the patients at the two dates.
For the whole of Scotland, the proportion at present of pauper lunatics placed
in public establishments is 78 per cent., and under private care 22 per cent.
All suicidal patients are now under continuous supervision at night.
This very necessary part of asylum work might with great advantage
be introduced in other Scotch asylums.
Glamorgan .—The auxiliary asylum is nearly ready for occupation.
At their visit, the Commissioners indicated several serious structural
defects in this building.
Dr. Pringle again directs attention to the large proportion of
melancholiacs in the cases admitted.
Gloucester. —Mr. Craddock’s report is a record of much work
accomplished. We can find room for the following paragraph only.
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Asylum Reports.
It is interesting from a legal point of view, and relates to a topic
never before discussed, so far as we know.
The existence of overlapping Unions, i.e., Unions extending into more than
one county, was, during the year, the cause of considerable correspondence
between your Superintendent, the Commissioners in Lunacy, and the Clerk of
the Peace, and of discussion by your Committee. A patient was sent here from
the Shipston-on-Stone workhouse, which is situated in Worcestershire. Pre¬
vious to his admission into the workhouse, he had been resident in that portion
of the Shipston-on-Stone Union whioh is situated in Gloucestershire. The
question raised was whether a Justice of the Peace for Gloucestershire had
jurisdiction to send a patient here whose settlement was in Gloucestershire, but
who at the time the order was made was actually resident in Worcestershire.
A case for opinion was submitted by your direction to the Clerk of the Peace,
and this gentleman held that the order for the patient's admission was good,
and that, under the Act 30 and 31 Vic., c. 106, s. 27, “ A Gloucestershire magis¬
trate acting judicially within the area of the Union would be acting within his
jurisdiction by force of the Statute. 1 ’ This definite opinion has, it is hoped, set
a much-disputed question at rest, and will form a useful precedent for guidance
should such a case occur again.
Oovan .—A limited outbreak of erysipelas occurred, ending fatally
in one case. Mr. Watson, the medical officer, reports that “ steps
were taken to discover, if possible, and remedy any sanitary defects
which might account for the disease. This, it is to be hoped, will
prove successful; but inasmuch as the causes of erysipelas are not
certainly known, it would be rash to predict its permanent disappear¬
ance.” There is one chief cause of erysipelas which should not be
overlooked, especially as it exists in this asylum. We refer to over¬
crowding. One of the Visiting Commissioners reports : “The diffi¬
culties attending the management of the asylum are much increased
by the fact that the population is considerably in excess of that which
it was designed to accommodate, leading to a disproportion between
the day-room and the dormitory accommodation, and an insufficiency
of hospital accommodation.” Here is a sanitary defect, obvious and
easily removed.
At last an epileptic has been suffocated in a Scotch asylum. And
so an additional night-attendant has been engaged. It has frequently
struck us as remarkable that the manner in which the night-atten¬
dants perform their duties in Scotch asylums is scarcely ever the
subject of official observation. Except as relating to the number of
wet beds, about which night-attendants may tell any number of lies,
their work escapes criticism. So far as we know, it is quite exceptional
to check them by tell-tale clocks. If so, this is not as it should be.
Glasgow District .—In reproducing the following paragraph from
Dr. Clark’s report, we must say that we do not quite agree with his
views. It will surely be admitted that a wet and dirty case is not a
suitable inmate of an overcrowded house. The patient cannot be
attended to by a woman who has a husband and perhaps five or six
children to work for. Neither is it desirable, nay, most unreasonable,
that a whole household should be inconvenienced, and, as we have seen,
made miserable, by a dirty, evil-smelling, foul-talking old man. Cer-
y
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Psychological Retrospect.
[Jaly,
tainly such a case might be cared for in a workhouse, but if he does
at last gravitate to an asylum, why should he be so unwelcome ?
The admissions were of (an) unusually hapless character, the proportion of
incurable and dying cases being above the average. Many patients came to ua
who in the hospital wards of English workhouses would find their appropriate
place, shattered in body, and mentally helpless, because of their physical help¬
lessness ; but, if these cases are cases of lunacy, every old man or woman who
has a stroke of paralysis is a lunatic, for no rigid line of distinction can be
drawn between the one and the other. They are not raving lunatics ; they are
neither homicidal, suicidal, dangerous, nor destructive ; they are no more offen¬
sive to decency than any other paralytio who, by his helplessness, requires the
cleansing offices of a nurse from time to time. They may wander in their talk v
but it is a quite inoffensive delirium, and they may be childish or have lost
memory, but these are nothing strange in an hospital ward. It does not take
long to exhaust the affection of their relatives; because from paralysis they are
“ wet and dirty,” the hospital will not have them, and they are not good enough
for the poorhouse ; but “ wet and dirty,” though it never appears in the medical
certificate, is the reason for their removal to an asylum. Nervous diseases are
very much on the increase, and if they are to be confounded with lunacy in the
ratio of their increase, the structural character of asylums must undergo
extensive alteration, and their limits be considerably increased.
If the welfare of a patient be the chief consideration, we have no
hesitation in saying that any senile or paralytic dement will be much
better cared for and nursed under Dr. Clark’s care than in any Scotch
workhouse, or boarded out.
Glasgow Royal Asylum .—A youth labouring under acute mania
developed signfe of scarlet fever three days after admission. The
disease did not spread, but the need of a detached hospital was
demonstrated, and is under consideration.
Hants .—Nearly all the drains have been taken up and relaid ; and
the whole sanitary condition of the buildings, old and new, is receiving
attention. This work is being carried out under the superintendence
of Mr. Rogers Field, at a cost of about £3,000. The water supply is
not beyond suspicion. The reports by chemical experts as to its
character are certainly most surprisingly at variance.
Two blocks of cottages for attendants, in all 12 houses, have been
provided.
Dr. Worthington’s report is largely devoted to the consideration of
the water supply, and the other questions connected with the origin
of typhoid.
Although it may be necessary in an official report to mention such
unimportant events as the birth of children, we cannot see why the
mothers’ names should be given in full. Surely this has been done
in error, as it is self-evident that such announcements must be dis¬
tressing to the patients and their relatives.
A useful report by the County Surveyor on the sanitary condition
of the buildings, the disposal of the sewage, &c., is given.
Hereford .—Here also sanitary improvements have been in hand. A
new main sewer has been laid, which has been disconnected from all
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Asylum Reports .
the branch drains, and from the ventilating pipes around the asylum
buildings. The branch drains have in several parts been relaid and
ventilated.
We reproduce the following paragraphs from Dr. Chapman's
report:—
The appeal made to the Unions at the beginning of the year to moderate the
influx of “ workhouse eases ” seems to me to have been a complete failure; the
admissions are certainly seven less than the average of the previous ten years,
but the cases I miss from among them are not these “ workhouse cases/’ but the
more manageable of the recent and curable oases that ought certainly to have
been sent to the asylum. Whether their absence is a curious coincidence, or
whether such cases have been retained at home or in Unions, as an answer to
our appeal, I do not know, but if they have been, then our appeal has not only
been a failure, but a very unfortunate one.
Beferring to the unfavourable nature of the cases under treatment,
he says :—
The number of persons confined to bed constantly increases; those who are
only able to get up for a portion of the day increases in a greater ratio. Those
in bed all day exceed 30 on most days. A census taken one morning lately
showed 64 patients (out of 400) in bed at breakfast time, and 24 who had to be
fed. The patients of wet and dirty habits are no less than 119, and those
partially so 45, leaving only 237 out of 401 of clean and decent habits. Twenty
years ago a score would have been a fair proportion of patients of dirty habits
in this number.
Dr. Chapman gives a valuable table, showing the character of his
cases since 1872. As usual, his report is of much interest.
Holloway Sanatorium. —This first report is not very encouraging to
amateurs in asylum construction. We sympathise with Dr. Philipps
in his work ; it will be no easy task to arrange this magnificent but
defective building for the special purpose for which it was built.
This report makes it quite evident that so far as time has permitted,
he has made great progress in all the branches of administrative and
structural work. It is disappointing to see an advertisement in
which the institution is described as for " patients of the upper
classes only.” If such is the case, and we are bound to believe the
statement, we do not hesitate to say that Holloway’s is a great
Charity wasted, for Mr. Holloway's original intention or plan was to
provide for private patients just above the pauper class— none over
21s. a week. Now the class he intended to benefit is expressly ex¬
cluded. Endless structural alterations are or have been required, and
a great charity is nullified. “ But yet the pity of it, Iago 1 *' What
unspeakable good might have been done with that money on the lines
of the first intention 1 We are almost tempted to say that the taste
of the pill though silvered is scarcely disguised, and that there are
not a few il dead flies which cause the ointment of the ” worthy donor
" to send forth a stinking savour.” We do not refer to the imperfect
drainage only.
We specially commend the arrangement mentioned in the following
paragraph from Dr. Philippe’s report:—
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320 Psychological Retrospect . [July*
Encouraged by the great suooess which has been obtained by Mr. Bayley, the
Medical Superintendent of St. Andrew’s Hospital, Northampton, in getting the
gentlemen patients to engage in manual labour, to the improvement of their
physical and mental condition, an attempt has been made to introduce a similar
system here. About 18 gentlemen have worked in the grounds, and about 12
have assisted in the lighter house.work. The advantage all round has been
great; grumbling and quarrels among the gentlemen have been infrequent,
while the general health has improved. On the ladies 1 siie, such good results
have not been obtained; but still, a great deal of needlework has been done,
and some housework; and few of those who are mentally capable have been
altogether idle.
Hull .—This new asylum appears to be rapidly getting into full
working order. The cases admitted here appear to be most un¬
favourable. Dr. Merson reports that of 95 admissions, 22 were
general paralytics, 16 were epileptics, imbeciles, or subjects of some
form of brain disease, and many others were cases of long standing
mental disease. Only 32 of the whole number were considered at all
likely to recover. And yet we go on talking about the great things
we could do, if we bad separate asylums for recent cases 1
The mortality continues high.
One cause of this excessive mortality is the great prevalence of general paralysis
among the patients admitted here, and it may not be without interest to compare
this asylum with others in respect to the occurrence of this disease. The Com¬
missioners in Lunacy, in their yearly reports, have for some years past given
tables showing the proportion of cases suffering from general paralysis to the entire
number of admissions in all county and borough asylums. From these tables
I find that for the last three years published, the proportion of cases of general
paralysis to the entire admissions in county and borough asylums was 8’3 per
cent. During the corresponding three years the proportion in this asylum was
16*7, or more than double, while during the year just closed it has been 23 per
cent.
Isle of Man .—Dr. Richardson mentions in his report that a
family, consisting of husband, wife, and daughter, was sent to the
asylum on one day. As they were suffering from the milder forms of
insanity an attempt was made to have the old married couple boarded
out, so that they might be able to spend the remainder of their days
together, free from that monastic discipline which seems to have be¬
come a necessary part of the arrangements of every asylum.
Ipswich .—One of the serious disadvantages of the boarding-out
system is noticed by Dr. Chevallier in the following paragraph :—
For the first time, I believe, in the history of this asylum, a birth took place
within its walls, the mother being a patient whose friends had removed her into
private lodgings, and had not sufficiently watched over and protected her during
her absence of several months.
{To be continued.)
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321
PART IV.—NOTES AND NEWS.
THE MEDICO-PSYCHOLOGICAL ASSOCIATION.
The Quarterly Meeting of the Medico-Psychological Association was held at
Bethlem Hospital, on May 17th. In the absence, at first, of the President,
Dr. Savage, the chair was occupied by Dr. Rayner. There were also present:
—Drs. Ringrose Atkins, S. H. Agar, R. Baker, D. Bower, P. E. Campbell,
C. Clapham, E. East, W. M. Harmer, C. K. Hitchcock, H. G. Hill, Murray
Lindsay, A. MaoLean, G. Mickley, A. Newington, H. Hayes Newington, J. H.
Paul, Evan Powell, Walter Pearce, G. H. Savage, H. Sutherland, D. Hack
Tuke, A. R. Urquhart, S. W. D. Williams, T. Outterson Wood, H. F. Winslow,
F. J. Wright, &c.
The following gentleman was elected a member of the Association, viz.:—
Alfred Miller, M.B., and B.Ch. (Dub.), Senior Assistant Medical Officer,
Hatton Asylum, Warwick.
Dr. Bo web said that he wished to enlist the interest of the members of the
Association in the case of a young man, aged 22, who for the past four or five
years had been subject to epilepsy, but was at present engaged with an ac¬
countant, with whom he had been nearly four years. The yoong man’s father
had once been proprietor of a private asylum, and might, perhaps, some years
ago, have been a member of the Medico-Psychological Association. The father,
having another son afflicted with the same disease, and being himself in weak
health, was anxious to get the young man into an asylum or hospital to assist
the steward, and do desk-work and book-keeping, giving his services for his
board and the care he might occasionally need. Dr. Bower added that he
should be pleased to receive any communication on behalf of the person
referred to.
The Ohaibman said that, in bringing before the meeting a memorandum
containing the observations and suggestions of the Parliamentary Committee
of the Association on the Lunacy Acts Amendment Bill, he thought it right to
refer to some observations made by the Lord Chancellor in introducing the Bill
into the House of Lords. Certain of these observations were very remarkable
and striking, as throwing a considerable amount of light upon the way in which
the question was viewed by the Lord Chancellor. The quotations were taken
from Hansard. The first of his lordship’s observations to which he wished to
draw attention was that in which it was stated that “ Every person accused of
Lunaoy should have the right to be brought before a Judicial Tribunal.” Now,
inasmuch as upon such an important occasion his lordship would probably
weigh well his words, this could only mean that he regarded insanity as a
crime ; hence the provision found afterwards in the Bill. Further on were the
words, “ The examination which medical men were supposed (he used the word
deliberately) to make before signing certificates.” That, if it meant anything
at all, implied a deliberate insinuation against medical men in regard to the
manner in which they discharged their duties. If it did not mean that
definitely, it meant a vague slur cast on the profession such as a barrister might
use in special pleading, and was entirely unworthy of the position occupied by
the Lord Chancellor. Another statement was, “ He could not understand why
a magistrate should not be competent to decide the question of insanity with as
judicial a mind as a medical man.” Here, again, the original idea was followed
out, that insanity was a question of criminality, and not one of disease or dis¬
order. If the reasoning were logical, the Lord Chancellor would not, after such
an assertion, make it necessary for medical men to sign certificates. In that
view of the case anyone might do so. If the legal mind was as capable of
deciding the question of lunacy as the medical mind, one was certainly
astonished that so many lunatics were received into asylums after being tried
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[July,
by magistrates and judges and sentenced as criminals, whereas it was clear
that at the time they were judged they were insane.
A Memorandum* of the Parliamentary Committee was then read, the
Chairman remarking that it was proposed to bring the views of the Associa¬
tion before as many members of the House of Commons as possible; and that
as about fifty of the members of the Lower House were members of Asylum
Committees, it was to be hoped that the superintendents of the asylums to
which they were attached as committee-men would use their best interests in
attaining this object.
Dr. Rinorosb Atkins said that in Ireland one of the methods by which
lunatics were sent to asylums—viz., that under the provisions of the Dangerous
Lunatics Act, 30 and 31 Viet., c. 119—was in spirit somewhat similar to what
was about to be introduced into England. The effect of the Act mentioned
was to cause lunatics to be regarded as criminals, and in Ireland its abuse was
very great; and it was to be regretted if the wrong idea should bo perpetuated
by the proposed English Bill. Under the Dangerous Lunatics (Ireland) Act,
patients might be taken to petty sessions nnd subjected to indignity, being re¬
moved thence to asylums by the Royal Irish Constabulary, after committal by
magistrates. The asylum-superintendent could not discharge them until they
had been certified as having actually recovered. His own experience was that
people, from ignorance and other causes, were very prone to get their friends
put into asylums under that form of procedure, sometimes inducing them to
break glass or assault persons in order to bring them within the Act. It
seemed wrong and cruel to have a person afflicted with disease made the subject
of magisterial inquiry. It was quite right, of course, to have safeguards; but
it was not right that a patieut should be placed in an asylum only when it had
been proved by magisterial inquiry that it should be done. It appeared by the
Bill that the lunatic was to be informed that he was to be made the subject of
inquiry. This would, probably, do much harm. Patients should certainly not
be irritated by being told this. The Lord Chancellor's expression, “ accused”
should never have been used. It threw a slur upon insanity. One of the
most unjust clauses in the Bill was section 28. He thought it should be pressed
upon Parliament that it was a great injustice that medical men should be
unable to receive patients (with a few exceptions). All other classes of persons
would still be able to do so. The mode of treatment in question might be the best
kind in early cases. It did not matter to Irish practitioners, as the Bill would
not apply to Ireland ; but to them it seemed as though there was a kind of fear
in England that every maD was trying to get his neighbour into an asylum.
The clause in the Bill which prohibited medical men who happened, by virtue
of social position, to be connected with a Board of Governors of a hospital,
from signing a medical certificate for a patient admitted there, was absurd. A
medical man was as trustworthy a man as any other in the world, and he ought
to have a perfect right to certify, unfettered by this restriction.
The Chairman referred to one remarkable omission which appeared to have
escaped notice. In the memorandum on the Bill it was stated that “ In urgent
cases (Section four) a patient may be confined upon an order by a relative, ac¬
companied by one medical certificate ; but in that case a petition for an order
must be presented to a county-court judge, stipendiary magistrate , or justice
within seven days” There was no provision in the Act itself whereby this
proceeding would necessarily follow. He also mentioned that the Parliamentary
Committee of the Association had met some eight or nine times, and had made
several communications to the Lord Chancellor while the Bill was passing
through the House of Lords.
Dr. Outterson Wood pointed out that, in dealing with cases of urgency, there
would be required three medical certificates, and. in addition, a fee to the Petty
Sessional Clerk, which would weigh heavily in poorer cases.
* This Memorandum (“ Observations,” &c.) will be found at the end of the
Journal.—[E db.]
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Notes and News,
823
Dr. Urquhart said that the matter of Clerk’s fee had been one of great
grievance in Scotland. In one county the charges payable amounted to 5s. for
a private patient, and 2s. 6d. for a pauper patient, but in another place it was
double that amount, and elsewhere higher still. The Bill did not fix any scale
of fee, and he thought it important that in the case of parochial patients or of
the poor private patients some limit should be put on these charges. He would
like to know whether the observations and suggestions of the Parliamentary
Committee were put forward to-day for the approval of the meeting.
The Chairman replied that they were put forward only for discussion. The
memorandum was only a proof 60 far as they had got. The Committee would be
glad to consider any further suggestions made by members.
Dr. Urquhart said that two years ago he had moved “ That the Commis¬
sioners or Inspectors of Lunacy in England, Scotland, and Ireland, shall have
powers of removal of patients on trial, or for the benefit of their health, through¬
out the three countries. That the English Commissioners may grant writings
under their seal to this effect, that shall be valid for Scotland and Ireland, and
similarly with the Scotch and Irish Lunacy Boards.” He noticed that there was
no mention whatever of this in the preseut memorandum.
The Chairman said that he remembered that it was urged upon the Lord
Chancellor in 1885, and without success.
Dr. Urquhart said it was very important, if the Commissioners were to have
power to recapture patients escaping over the border, that they should also have
power to gtant leave of absence for the corresponding distance. He should like
to see this added to the memorandum.
Dr. Murray Lindsay said he thought they were greatly indebted to the Par¬
liamentary Committee for the trouble they had taken in regard to the Bill. With
respect to the magisterial authority, he had a very strong opinion, and be quite
concurred in the remarks of the Committee thereon. One of the main objects of
all lunacy legislation should be to render the early treatment of insanity as easy
as possible. It seemed to him that some of the proposals in the Lunaoy Bill
would have a tendency in an opposite direction. He noticed, moreover, that it
was proposed to abolish the order of a clergyman and relieving officer, restrict¬
ing it to that of a magistrate. Theoretically, and for the sake of uniformity,
this may be right enough, but considering the matter from a practical point of
view, in some districts of the county of Derby, at all events, its operation would
be attended with great hardship, not only hindering proceedings and delaying
the removal of the lunatic to the asylum, but causing the relieving officers much
inconvenience and the guardians additional expense. So far as his own ex.
perience went, he could not say that he had seen any disadvantage in orders
being signed by a clergyman and relieving officer. Theoretically, it might be
well to have magisterial authority in all cases, and to make no exception, but he
would repeat that he had not found disadvantage in the other method. In
connection with this matter, there is another practical difficulty deserving con¬
sideration, for some magistrates even now are reluctant to sign lunacy orders,
occasionally refusing, and under the new Lunacy Bill, when passed, this difficulty
will probably be increased. One relieving officer had told him that he had been
to three magistrates, at some distance apart, before he succeeded in getting the
order signed, one magistrate having positively declined to sign any lunacy orders
at all. Another relieving officer had said that he might have to drive twelve
miles to get the necessary signature, and his guardians would grumble at the
expense. He would much rather see the Bill start on the assumption of embody¬
ing the Scotch plan. Why not adopt the Scotch plan ? The real essence of the
Scotch plan had been ignored. Why not make the magistrate's action merely
ministerial as in Scotland ? The whole thing worked well in Scotland, the
sheriff signed the order without seeing the patient, and this plan seemed to
satisfy both the public and the lunatic. He was strongly of opinion that the
action of the Justice should be simply ministerial. With regard to idiots, he
had received a communication from Dr. Ireland, one of the best authorities on
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[July,
idiocy, suggesting that a clause should be inserted in the Bill making it pro¬
hibitory to send idiotio and imbecile ohildren to asylums for adults. Under the
Idiots Act of 1886, the guardians have the power to send pauper idiots as imbe¬
ciles to special institutions, and are entitled to receive the benefit of the Capita*
tion Grant of 4s. Although, with Dr. Ireland, they might like to see it made
compulsory, it was very doubtful whether they could succeed in getting such a
clause introduced into the Bill under existing circumstances. As regards super¬
annuation, it was apparent that this question stood on a very unsatisfactory
basis, and something ought oertainly to be done to render their position more
stable. Referring to the recommendation of the Committee with regard to
continuous service^ that service in different counties should reckon towards
pension, he suggested that it would be well to make sure that this provision
should apply to boroughs as well as counties. He was glad to see that the
Committee were endeavouring to secure the privilege of added service t a privi¬
lege which existed in the civil service, and to bring about the addition of seven
years, after a certain period, to the service of medical superintendents. He also
considered it to be a most useful and very necessary recommendation, the sug¬
gested power of appeal to the Some Secretary in the case of refusal or reduction
of pension. The necessity for this had recently been illustrated by several cases.
One was that of the Superintendent of the Dorset County Asylum, who was
recommended by the Committee of Visitors for a pension of £600 per annum
after thirty-two years 1 service. At Quarter Sessions this amount was reduced to
£450 per annum, being a reduction of 25 per cent.! In this case the Committee
of Visitors, who knew well the value of their medical officers services, had
decided to award him the maximum amount, viz., two-thirds, to which they con¬
sidered he was justly entitled. At the Cambridgeshire Asylum there had been a
very hard case. An attendant there became affected with general paralysis, and
was removed to Northampton County Asylum, where the surplus Cambridge¬
shire lunatics are temporarily taken care of. The Committee of Visitors
recommended that he should be granted a pension of 17s. per week, being
the maximum two-thirds. He was forty-three years of age, and had served
a few weeks short of fifteen years. There was opposition to this proposal
at the Quarter Sessions ; a correspondence took place between the Clerk to the
Visitors and the Clerk of the Peace, but in the meantime the poor man died.
His body was brought from Northampton for burial at his own place in
Cambridgeshire, and the Committee of Visitors made a grant of £20 to his
widow. It is worthy of note that another officer at the same asylum, suffering
from the same form of mental malady seven years previously, was granted a
pension by the Quarter Sessions for seven years' service, just half the length of
service of the poor man referred to. The third case he should mention was a
very striking case. It was that of the Superintendent of the Linooln County
Asylum, who was recommended for a pension of £600 per annum, being nearly
two-thirds. His pension has to pass the trying ordeal of three Quarter Sessions, of
Lindsey, Kesteven, and Holland, and three Town Councils, of Lincoln, Stam¬
ford, and Grantham, the latter Corporation having dissented from the proposal
to grant the pension. Several Lincolnshire Boards of Guardians are protesting
against the proposed pension, and clamouring for a reduction of the amount.
He has served thirty-nine years, and is seventy years of age. In regard to super¬
annuation, everything was indefinite, there being no certainty or fixed system.
He (Dr. Lindsay) had, unfortunately perhaps, had as much experience in re.
commending pensions as any Superintendent in the same length of time,
having had to make seventeen recommendations for pensions during a period
of fifteen years. There had, in addition, been three granted before his time.
But of all these, in his opinion, the maximum, two-thirds, bad been granted in one
case only, and that was in the case of the chaplain, a non-resident, officer, who
was vicar of a neighbouring parish three or four miles distant, and visited the
asylum about twice a week.
The Chairman referred to a plan which had been passed in one of the
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counties of granting pensions for limited periods, and also to a case in which
superannuation had been granted for ten years’ service.
Dr. Murray Lindsay remarked that this showed all the greater necessity
for something definite. There was power, which was frequently exercised,
under the Lunacy Acts to pension after short service on account of ill-health,
as was done at one county asylum where the officer, who was known to be
affected with general paralysis, was granted a pension after seven years’ service,
“ for twelve years, should he live so long.” It is unnecessary to add that he did
not live so long, but died in a year or two afterwards. At two other county
asylums pensions of one-sixth and under one-third of the total value of office
were granted to two attendants for nine and thirteen years’ service. But so
long as the superannuation system is merely permissive, and each county can
have its own plan within the Acts, the anomalies, already too numerous, will
not only continue, but in all probability increase. In addition to these pensions,
at least thirty-six pensions for short periods of service, varying from 7 to 14
years, have been granted to officers and attendants in 15 county and 2 borough
asylums. This should suffice to settle the question of power to grant short
service pensions. It is the practical application or exercise of this power that is
variable, uncertain, and anomalous, as in the case of the poor man at Cambridge
Asylum already referred to.
Dr. Ubquhart said that he hoped that the question of superannuation
would be urged strongly. In Scotland there had been some clamour about it
lately. The Act was drawn out providing for pensions, but, by an accident of
the draftsman, the words *' district or parochial asylums ” had been omitted, so
that those asylums stood in an anomalous position. In 1877, or thereabouts, a
deputation waited upon the Lord Advocate, which was very cordially received,
and an absolute promise was made that on the very first possible occasion a
clause should be inserted securing pensions to officers and servants of district
and parochial asylums of Scotland. No opportunity occurred till the other day,
when the Government found it necessary to bring in a Bill granting powers to
the Board of Lunacy in Scotland to sub-divide districts. They thought it would
then be a good time to reorganize their forces to accomplish what they wanted,
and they accordingly met together in Edinburgh and drew up a memorial,
showing that whilst superannuation powers existed in regard to similar institu¬
tions in England, there was nothing of the sort in Scotland. In their investi¬
gation of the subject, they found that within the last few years—for it was, of
course, only within the last few years that the effects of long service would have
come into operation—there had been a great many cases of evasion of the law
on the part of the magistrates governing the asylums. In one case a matron
had been continued as matron whilst there was no longer residence in the
asylum. At another asylum, a medical superintendent who had fallen into ill-
health, and had served a long time, was made consulting physician, with a
salary of £600 per annum. However satisfactory these arrangements may
have been to the persons who were the recipients of such misguided charity,
they were not satisfactory to those who were placed in the position of having
to resign their appointments without getting anything. Their memorial upon
the subject had been duly sent in, but, unfortunately, the Marquis of Lothian
did not see his way to inserting a clause in the Bill. He, therefore, thought
that the Association should take some very active steps in the matter of pensions,
and at the same time not forget Scotland.
Dr. Outtebson Wood, quoting Sub-section 4 of Clause 28, said that he
thought that the Commissioners should be required to visit single patients in
unlicensed houses at least twice in every year, or that in any case some provision
should be made for other visitation. There were several paragraphs providing
for recapture in case of escape from England into Scotland or Ireland, or vice
vered, but there was nothing to cover escape to the Isle of Man, which island,
from some northern portions of the United Kingdom, was very easy of access.
Dr. S. W. D. Williams said that he could not endorse the words of the
JT
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[July,
memorandum, that “ the statutory question * whether any near relative has been
afflicted with insanity ’ is looked upon as unnecessarily inquisitorial, and cannot
be defended on the ground of scientific interest/' He thought the question was
of very great scientific interest.
Dr. Hac;k Tuke agreed with Dr. Williams, and said that he had strongly
upheld in the Committee the attempt made by the Government to obtain this
information in the statement, and was disappointed to fiud that the general
feeling of the Committee was against it. He did not see what the Association
had to do with the penalties the friends of the patient might incur by not giving
correct information.
Mr Hayks Newington said that as he was responsible for the objection to
that information being specified on the statement he would like to explain the
grounds of the objection. Perhaps the words of the memorandum were too
strong. Of course they were all scientifically interested in having information
of this sort, but the fact was that it was a tremendous farce for anyone to have
to answer that query as a statutory inquiry to start with, considering that any
malfeasance would be a statutory crime and punishable. It was a question
whether the patient’s friends would not be sufficiently frightened by the inters
vention of the magistrate without having such an inquiry as this to meet. The
question of its scientific interest was brought up in the Committee, and was
answered in this way: That the returns already supplied to the Lunacy Com¬
missioners, at their request, sufficiently answered the inquiry. He had given it
as bis experience (and he believed most of the Committee agreed with him)
that if they were to deal with an answer to such a question in an admission
paper they would be dealing with a mass of lies. A person who would be abso¬
lutely truthful on any other subject would, without a blush, tell a lie upon the
subject of insanity in his family. They had therefore considered it important,
in the interests of science, that the matter should not be answered straight off,
but at the end of the year, when they would be better able to judge and give a
well-formed opinion in their returns to the Commissioners.
Dr. S. W. D. Williams said that his exception to the Committee’s objection
was taken on the score of the words used—that it could not “ be defended on
the ground of scientific interest.” Perhaps the sentence might be improved.
Dr. Savage said he thought it would be best merely to say that the statutory
question referred to was “ unnecessarily inquisitorial.” He had felt in the
Committee its immense importance, but it would be inquisitorial if the friends
had to state this in the first instance on the statutory document, in the same
way as it would be inquisitorial if they were required to make a statement as to
intemperance or syphilis.
The Chairman, referring to Dr. Murray Lindsay’s remarks respecting
pensions, said that it should be borne in mind that where the emoluments of
resident officers were taken into consideration in fixing superannuation allow¬
ance, the value put upon such emoluments was generally considerably below
what the cost would be to officers living outside.
In the course of further discussion on the subject of pensions it was suggested
that, in view of pensions being apportioned among different counties, some
uniform rate of superannuation would be desirable. Dr. WILLIAMS pointed out
that all the arguments were in favour of making the pensions chargeable to some
central fund, a proposal which Dr. Savage reminded the meeting was brought
forward some years ago by Dr. Lockhart Robertson. Dr. Rayner advocated
the principle of “ deferred pay.”
Dr. Hack Tuke said he thought that members of the Association might do
a good deal through Members of Parliament. He was surprised that more had
not been said in medical papers on the subject of the proposed check upon
patients being received into the houses of medical men. He believed that the
late Lord Chancellor, in introducing this clause, entertained the idea that none
but medical men took patients, and unless Members of Parliament were pro¬
perly informed in regard to the whole subject, it was to be feared that the only
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327
result of their pointing out the distinction which had been drawn between
medical men and other classes of persons, would be that no one at all would be
permitted to take patients without the restrictions indicated.
Dr. Agar said that with a view to carrying out Dr. Hack Tuke’s desire that
members of the Association should use their efforts with members of the House
of Commons, he would suggest that a copy of the Memorandum of the Parlia¬
mentary Committee should be posted to each member of the Association.
Dr. Outtkrson Wood supported this proposal, which was agreed to; Dr.
Tuke intimating that copies of the Memorandum would be furnished quite dis¬
tinct from the Journal.
Dr. Agar then said that he had heard that afternoon of the difficulty which
existed in regard to patients in England going to Scotland or Ireland. This
seemed very hard, for, supposing the case of a patient coming originally from
Ireland or Scotland, and becoming sufficiently recovered to go home on leave, he
did not see how the medical superintendent would have the right to send him.
Dr. R. Baker said that it was evident that great difficulty was felt in regard
to patients travelling. It was to be hoped that any extension of power which
might be given in this direction to the Commissioners in Lunacy, would also be
conferred upon the committees of persons in hospitals to whom the sanction of
the Lunacy Commissioners did not apply, and who, being generally of the
wealthier class, were more likely to travel than other classes of patients.
Dr Outtebson Wood said it was to be noted that the recapture of patients
in Ireland or Scotland was to be carried out under the seal of the Commis¬
sioners in Lunacy. This was a very important step for the Commissioners to
initiate—to allow anybody to go into a country where the law was entirely different,
and administered in a different way. It would be a very difficult thing to make
any arrangement about, but if power was to be granted under the Bill as to re¬
capture in this way, he did not see why similar power should not be given to enable
patients to be sent to a neighbouring country for their benefit. On a recent
occasion, he had arranged for Dr. Savage to take one of his patients for a time,
and the Lunacy Commissioners in London strongly objected to it. In Scotland
there was no difficulty at all in this respect, although, of course, it was illegal
at the present moment. In regard to removing patients from one country to
another at the instance of their friends, he cited an instance in which the
curator bonis, or committee, of the estate of a lady under the charge of the
Court of Session in Scotland wished to take the patient from England into
Scotland, and yet it was possible for her friends to spirit her away, and he
did not think her whereabouts had been yet ascertained. To convey a patient
from England into Scotland, it was necessary to proceed under the English law
till the border was passed, and then to proceed by the Scotch law—the whole
business being most complicated. At the present time, a Chancery patient
could not be recaptured in Scotland. On the border being crossed, the patient
was legally free. The case was similar with Scotch patients going to England.
Dr. Baker said he thought it very desirable that the clause should be ex¬
tended in the way indicated by Dr. Wood. It would be a great pity to have it
limited.
Mr. Evan Powell suggested that a clause should be introduced into the Bill
inflicting a penalty on friends of patients for conniving at escape from an asylum.
He was in the habit of allowing patients to visit their friends a good deal,
especially when the cases became convalescent, or when they were chronic
cases. On a recent occasion, a mother asked to be allowed to have her daughter
out for a day. This was granted, and on the next morning he received a bundle
of clothing, with a polite note from the mother, stating that the daughter had
been sent to Birmingham for change of air, and that the mother did not think
it necessary for her to come back to the asylum. If any asylum-official had
thus acted there would have been liability to penalty, and he threw out for the
consideration of the Parliamentary Committee the suggestion whether persons
other than asylum-officials should not be also thus liable. Many present would
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[July,
remember the ease of Elliot at the Banning Heath Asylum. He would also
like to know whether the term “county asylum” would include “borough
asylum/’
The Chairman said that it would be well for this latter point to be made
quite clear. It was to be sincerely hoped that every member of the Association
would endeavour to press upon individual Members of Parliament the recom¬
mendations now made, so that when the Bill came forward for consideration in
the House of Commons there might be an adequate number of supporters of
their views in that House.
SUGGESTIONS FOR ASYLUM PENSION8.
Dr. R. H. W. Wickham, Medical Superintendent of the Borough Asylum,
Newcastle-on-Tyne, has forwarded us the following for publication.— [Eds.]
1 . —Pensions should be obligatory.
2. —Asylum officers to be retired at 60, and at such less age as they may desire,
or as may seem to the Committee of Visitors necessary, always provided that,
except in the case of infirmity directly caused by the service, no officer should
be eligible for a pension who is not both 40 years of age and who has not served
for ten years in the asylum.
3. —The pension at 60 years of age and after 20 years of service, both inclu¬
sive, to be two-thirds of salary and all allowances.
4. —One-fortieth of the two-thirds to be deducted for each year below the
age of 60.
5. —One-sixtieth of the two-thirds to be deducted for each year below the 20
years period of service.
6 . —The pension to be chargeable, as at present, on the county or borough
rates. To charge it on the Treasury Grant would be practically charging It to
maintenance, and would introduce a new element into the discussion.
Examples.
1.—Superintendent: Salary, Ac., £1,100. Aged 46. Service 18 years.
£ s. d. 60 years—46 years=16 or $$ age.
Two-thirdaof £1,100... 733 6 8 20 years—18 years=2 or ^ servioe.
Deduct. 299 8 10 U of £733 6s 8d=£276 0 0
' & of £733 6s 8d=» 24 8 10
Pension due .£433 17 10 ' Total deduction ... £299 8 10
2.—Nurse: Salary, Ac., £69. Age 61. Service 13 years.
£ s. d. , 60 years—61 years=9 years or age.
Two-thirds of £69 . 46 0 0 20 years—13 years—7 years or & servioe.
Deduct. 16 14 4 * of £46 - £10 7 0
' A of £46 - 6 7 4
Pension due.£80 6 8 ' Total deduction ... £16 14 4
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1887.]
Notes and News .
329
SCOTTISH MEETING.
A Special Meeting of the Medico-Psychological Association was held in the
Edinburgh Hotel, Edinburgh, on the 1st April, 1887.
Dr. Clouston was called to the chair, the other members present being Dr.
Aitken (Inverness), Dr. Blair (Lenzie), Dr. R. W. K. Cameron (Midlothian), Dr.
C. M. Campbell (Murthly), Dr. Eeay (Mavisbank), Dr. Watson (Govan), and
Dr. Urquhart, Secretary.
The Secbetaby stated that he had called the meeting in consequence of the
general agreement amongst the Scottish members that a Pension Clause should
be inserted in the Bill dealing with lunacy districts in Scotland, shortly to be
introduced by Government. He then read letters from the members of the
Association who had made suggestions in reference to this matter; and, after
discussion, the meeting adjourned to the Chambers of the General Board of
Lunacy, where Dr. (Houston briefly indicated the views of the Association. Dr.
Arthur Mitchell, C.B., on behalf of the Commissioners, assured the Association
of the sympathy of the Board, and stated that the Board had already recom¬
mended the introduction of such a clause.
Dr. Clouston having thanked the Board for their courtesy, and having
expressed, on behalf of the meeting, their satisfaction with the action of the
Board, the members of the Association returned to the Edinburgh Hotel and
drafted the following memorial:—
44 Unto the Most Noble the Mabquib of Lothian, K.T., Her Majesty’s
Secbetaby of State fob Scotland.
44 The Memorial of the Chief Medical Officers of the Scottish Royal , Dis¬
trict, and Parochial Asylums for the Insane , as representing all
the Officials of the Institutions under their care ,
14 Humbly Showeth,
44 1. That provision has been made by the Legislature for granting Superannua¬
tion Allowances to the Officers and Servants of the County and Borough Asylums
in England and of the District Asylums in Ireland.
44 II. That by the Act 29* and 30° Yict. Cap. 51, Seot. XXV., the Directors of
the Chartered Asylums in Scotland were also empowered to grant similar
Superannuation Allowances.
44 III. That there is no such provision for the same classes of Officials in the
District and Parochial Asylums of Scotland, however long or meritorious their
services may have been, or however much they may be incapacitated by injury,
accident, or otherwise.
44 IV. That this is a manifest injustice to Scotland and to such Scottish
Officials. It is directly calculated to impair the efficient working of these
Asylums, and has been found to draw away their staff to more favoured Insti¬
tutions.
44 V. That the cure and welfare of the Insane being, as in your Lordship’s
opinion, the main point at issue, it iB necessary to attract efficient and energetic
Officials in the prime of life to a service which is in many ways repellent and
arduous; and it is equally necessary that due facilities should be given for
their retirement from active service when their full power of work has become
exhausted.
44 VI. That those principles have been found in practice so necessary for the
efficiency of Asylums, and the injustice of the present want of statutory pro¬
visions for carrying them out so glaring, that, in many of these Institutions,
District and Parochial Boards have hitherto, without objection on the part of
the ratepayers, continued the emoluments of those Officers on retirement after
long periods of service, or in consequence of ill health.
i4 VII.—That the promised introduction by her Majesty’s Government of a
Bill relating to Lunacy Districts in Scotland seems to afford a favourable op-
xxxiii. 22
S'
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portunity for the rectifying of this injustice to Scottish District and Parochial
Asylum Officers and Servants, as compared with the Officers and Servants of
English and Irish Asylums, and of Scottish Royal Asylums.
“ Your Memorialists therefore humbly pray your Lordship to introduce into
the promised Bill such a clause as will remedy the omission of which they com¬
plain.”
The. Secretary was instructed to have the Memorial printed and signed by
the chief medical officers of the Scottish Asylums. The following signatures
were appended in due course :—
Thomas Aitken, M.D.,
Medical Superintendent, Inverness District Asylum.
R. Blair, M.D.,
Medical Superintendent, Barony Parochial Asylum.
John Cameron, M.D.,
Medical Superintendent, Argyll and Bute District Asylum.
R. W. D. Cameron, M.D.,
Medical Superintendent, Midlothiau and Peebles District Asylum.
C. M. Campbell, M.D.,
Medical Superintendent, Perth District Asylum.
A. Campbell Clark, M.B.,
Medical Superintendent, Glasgow District Asylum.
T. S. Clouston, M.D.,
Physician-Superintendent, Royal Edinburgh Asylum.
D. Fraser, M.D.,
Medical Officer, Riccartsbar Parochial Asylum, Paisley.
Thomas Graham, M.D.,
Medical Superintendent, Abbey Parochial Asylum, Paisley.
S. Grierson, M.R.C.S.,
Consulting Physician, Roxburgh District Asylum.
J. C. Howden, M.D.,
Physician-Superintendent, Montrose Royal Asylum.
Robert Jamieson, M.D.,
Consulting Physician, Aberdeen Royal Asylum.
J. Carlyle Johnstone, M.B.,
Medical Superintendent, Roxburgh, Berwick, and Selkirk District
Asylum.
W. C. M’Intosh, M.D.,
Consulting Physician, Perth District Asylum.
J. Maclaren, F.R.C.S.,
Medical Superintendent, Stirling District Asylum.
A. J. Manson, M.D.,
Physician to the Banff District Asylum.
W. Reid, M.D.,
Physician-Superintendent, Aberdeen Royal Asylum.
Alexander Robertson, M.D.,
Physician to the City of Glasgow Parochial Asylum.
James Rorie, M.D.,
Physician-Superintendent, Dundee Royal Asylum.
James Rutherford, M.D.,
Physician-Superintendent, Crichton Royal Institution, Dumfries.
J. B. Ronaldson, M.D.,
Medical Officer, Haddington District Asylum.
James Ross, M.D.,
Medical Officer, Elgin District Asylum.
Charles Holland Skae, M.D.,
Medical Superintendent, Ayr District Asylum.
A. R. Turnbull, M.B.,
Medical Superintendent, Fife and Kinross District Asylum.
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1887 .]
A. R. Ubquhart, M.D.,
Physician-Superintendent, James Murray’s Royal Asylum, Perth.
James Wallace, M.D.,
Physician to the Greenock Parochial Asylum.
W. R. Watson, L.R.C.S., L.R.C.P.,
Medical Superintendent, Govan Parochial Asylum.
David Yellowlees, M.D.,
Physician-Superintendent, Glasgow Royal Asylum.
The memorial was Bent to the Marquis of Lothian, and copies to the Lord
Advocate and the Solicitor-General.
The following is the reply of the Marquis of Lothian
“ Dover House, Whitehall, S.W.,
“3rd May, 1887.
“ Dear Sir, — I am desired by Lord Lothian to acknowledge receipt of the
Memorial of the Chief Medical Officers of the Scottish Royal, Parochial, and
District Asylums for the Insane on the subject of Superannuation Allowances.
“ His Lordship, while feeling that there is probably much justice in the
demand for Superannuation Allowances put forward by the Officers of Scottish
Asylums, cannot hold out any hope of the subject being dealt with in the Bill
dealing with Lunacy Districts now before Parliament.
“Iam,
“ Yours faithfully,
“John Blackburn.
“ A. R. Urquhart, Esq., M.D
It was thereafter agreed, in addition to what might be done by private efforts,
that Drs. Clouston, Aitken, and Watson should be empowered to act on behalf
of the memorialists as might seem expedient to them.
MRS. LOWE’S APPEAL TO THE HOUSE OF LORDS.
The case of Lowe (the appellant') * and Fox (the respondent) is one of too
much importance in its legal aspect to be allowed to pass without placing on
record the grounds on which final judgment was given by the Lord Chancellor,
and Lords Watson, FitzGerald, Herschell, and Macnaughten.
The Lord Chancellor (Halsbury), after complimenting Mrs. Lowe on the great
ability and propriety with which she had argued her appeal, and stating her to
be in full possession of her faculties—thus exercising that power of diagnosis in
insanity which the present Lord Chancellor believes to be as satisfactorily per¬
formed by a legal as by a medical man—proceeded to give it as his opinion that
it was impossible to deal with the order upon a patient received into an asylum
without taking all its parts and its contents together, and judging of them as a
whole. He held that Mrs. Lowe had dissociated the various parts of which it
was composed, and dissected it as if one such part had no relation to or depen¬
dence upon another. Much turned upon the answer to the question “ Whether
the first attack ? ” The answer was “ For the last 20 years has been subject to
what is termed hysteria.’* The Lord Chancellor admitted that, taken by itself,
the question had “ reference to that which alone the keeper of the house has
to consider, namely, the state of her mind.” But an answer, “ Yes” or “ No,”
would be inadequate and misleading. Hence the above reply merely gave the
important information that she had suffered from hysteria for 20 years, but by
no means alleged that she had been insane during this period. Again, in reply
to the question, “ Age on first attack ? ” the answer was given “ 30.” The
* We are indebted to the shorthand notes of Messrs. Cherer, Bennett, and Davis, 38, Lincoln's Inn
Fields, lor tie summary of this appeal to the House of Lords, which took place January 31st, 1887.
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Notes and News.
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Lord Chancellor admitted that, taken alone, the natural conclusion from it
would be that it meant the first attack of insanity. On the principle, however,
of interpreting one question and answer by others, no one could doubt that the
age on first attack, namely 30, had reference to the attack of hysteria from
which she had been suffering 20 years.
It is not necessary to give the observations of the Lord Chancellor on the
other answers to the statutory questions, further than to quote the passage upon
which he says: “ It seems to me that no one with a knowledge of the facts, as
we are now possessed of them, could have answered those questions with a more
apparently scrupulous regard to giving the whole state of the facts/*
On the point whether an alteration alleged to have been made in the order
deprived it of any validity, the Lord Chancellor admitted that, if a material
part of it were altered, so that the document no longer spoke the language
which it did speak when it was originally received, the document was vitiated.
But in all the cases which Mrs. Lowe quoted it might be clearly perceived that
materiality was an essential condition to make the instrument void. In the
statement upon which Mrs. Lowe was received into Burlington House, there
were only the words “ for hysteria ** added to the sentence “ during this period
of 20 years has been constantly under treatment.**
Lastly, on the question—whether Mr. Lowe*s written direction, that Mrs.
Lowe should be discharged—complied with, the conditions of the Lunacy Acts,
the Lord Chancellor observed: “ That point appears to me to be beyond all
doubt.** The letter in question was so worded that it left a certain discretion to
the person receiving it. Then “ the question is,** said the Lord Chancellor,
“ whether the person who acted in pursuance of that discretion, and fulfilled
strictly the authority which he got, namely, to exercise a discretion to retain
the lady for the period of a fortnight, disobeyed an order within the language
of the statute. My lords, it seems to me that it is impossible to maintain for
one moment that he did, and I am, therefore, of opinion, and so move your
lordships, that the judgment of the Court of Appeal should be affirmed, and
that this appeal should be dismissed with costs.’*
The other law lords concurred in the views expressed by the Lord Chancellor.
We congratulate the Drs. Fox on the result of Mrs. Lowe’s appeal.
PHARMACEUTIC AND THERAPEUTIC MEMORANDA*
We would draw attention to the many admirable preparations which Messrs.
• Burroughs and Welcome, Snow Hill, London, have introduced. Few things are
more surprising than the change which has taken place during the last few
years in the art of preparing medicines in a way which makes them palatable
and even tempting to the most fastidious taste. There are the neat and dainty
tabloids used in hypodermic injection, and there are the beautifully prepared
pills which offer so striking a contrast to the repulsive boluses of former
days. Again, there are the convenient cases of selected drugs which the
practitioner can carry about with him. We have been more especially struck
with the carefully contrived case of antidotes to poisons. This has been for
a long time past a desideratum, and we can confidently recommend it to
practitioners and physicians, but especially to those engaged in the department
of mental medicine, for whom the possession of such a selection of remedies at
hand in emergencies cannot fail to be a great help. The case contains not only
bottles of remedies required for prompt exhibition, but tabloids for hypo¬
dermic injections. There is also a stomach tube which can be used as a
syphon for emptying the stomach of its contents. A gag should be provided.
The price of this case is moderate (£3), and ought to be procured by asylum
men and by physicians specially engaged in the treatment of the insane*
* We purpose giving under this head, from time to time, short memoranda of important
drugs, &c.— [Eds. J
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Notes and News ,
338
THE EAME8 MEMORIAL FUND.
Dr. Courtenay begs to acknowledge the receipt of the following sums to the
Eames Memorial Fund :—
£ 8. d.
Drs. Charles and Bonville Fox .5 5 0
Dr. W. Orange, C.B.5 5 0
Medico-Psychological Association...10 0 0 (omitted.)
The following is a letter from Mrs. Eames:—
2, Dyke Parade, Cork.
Dear Dr. Courtenay, —Will you kindly convey to the members of the
Psychological Association my sincere thanks for their very liberal contribution
of £245 19s. 6d. to the memory of my dear husband, and believe me
Your greatly obliged,
Helen Eames.
March 14th, 1887.
SYDNEY UNIVERSITY.
Psychological Medicine has been made a compulsory subject at the
University of Sydney at the Examinations for the degrees of M.B. and M.D.
Attendance at Lectures and Hospital Praotioe is insisted on, and a Lecturer on
Psychological Medicine has been appointed, Dr. Manning being the first
ocoupant of the chair. This is an excellent beginning.
Correspondence .
A VISIT TO ASYLUMS IN PARIS.
To the Editors of “ The Journal of Mental Science.”
Gentlemen, —The following notes of a visit to the two chief and typical
asylums of France, both of them situated in Paris, may be interesting to some.
I thankfally acknowledge the kindness and courtesy of my friend, Dr Larroque,
one of the internes at Charenton, both during my visit and also since. The
Asylum of Ste. Anne, for acute cases, is at thejsouthern boundary of Paris, near
Gentilly; that at Charenton is north of the Seine, outside the fortifications, and
close to the park of Vinoennes. Charenton, for the less acute oases, is the
National Asylum of France; it is destined by the State to be the model
establishment for the insane throughout the country; it is erected upon a
raised plateau, and is sheltered from the north by the woods of Vincennes. The
situation commands a most extensive and beautiful landscape along the Seine
Valley, and from a sanitary point of view, it leaves nothing to be desired.
Charenton dates from a very remote period; it has several times been pulled
down and rebuilt. Previous to 1830 it belonged to and was governed by the
brotherhood of St. Jean de Dieu, and ranked, I believe, as a monastery; the
treatment of mental disease being undertaken by the monks themselves. In
1830, the time of the great Revolution, when Louis Phillippe became King, and
civic improvements were resumed at a vast outlay, it became the property of
the State, was reconstructed with pure white limestone (resembling our Portland
stone), and has remained so up to the present time. It has a strikingly clean
Digitized by L^ooQle
334
Notes and News.
[July,
and bright appearance. It was here that the great Esquirol, Calmeil, and other
great teachers practised; among the internes are also the names of Bayle,
Trousseau, Legrand du Saulle, &c. There is a most complete medical library,
including, as his own gift, all the valuable books of Esquirol himself. The
building is surrounded by extensive gardens and woods, affording work for the
male patients, recreation and diversion for the females. Corresponding to the
divisions or sections on either side are well-planned airing courts, made pleasant
with fountains and flower beds. Within the asylum everything is the picture
of cleanliness; the beautifully waxed parquet floor, against which some of ua
cry out, does not appear to increase the casualties; whilst the dainty dimity
canopy over the beds adds much to the brightness of the dormitories for the
quieter patients. The beds are for the most part arranged in single rooms—
although accommodation for servants and nurses adjoining the patient’s own
room is also provided— comfortably furnished and well-arranged suites of
apartments, to admit of this, being supplied at higher rates of payments.
Drawing-rooms arranged with chaste bric-il-brac are a marked feature on the
women’s side; readings and entertainments in these rooms help to pass the
time pleasantly during the winter evenings. Carefully-planned, commodious
workrooms, linen rooms, and wardrobes also exist where the industrious
females find employment. Light is plentiful in this asylum, and ventilation is
good. The atmosphere is kept at an even temperature during the winter
months by means of heated coils passing through the building. I was greatly
struck with the complete methods of hydro-therapeutics in vogue; Turkish,
Roman, and medicated baths, packs, douches, &c., being fitted on each side. I
have not seen the equal in any English asylum. Ought this so to be ?
The lay management of the asylum is entrusted to a director or governor,
who is responsible to the Ministre de l’lnterieur (or Home Secretary), by whom
the appointment is made. The director resides in the establishment, and in the
present instance is an old private secretary of the late Gambetta; he is relieved
in the management by a nnmerous staff, to whom the work is mostly delegated.
His post is by no means onerous, the selection being possibly more a reward
for past political services than adaptation for the post; still, he is highly
respected and esteemed by the medical staff. There is, in addition, a Com¬
mittee of Management, consisting of honorary members, selected by the
Ministre de l’lnterieur from members of the Courts of Justice, the State
Councils, the Court of Repeal, and other judicial Courts in Paris. This Com¬
mittee appoint one of their number every year to act as provisional administrator
of property belonging to those who for the time being are deprived from
managing their own affairs.
The medical staff consists of two resident physicians, supported by two
assistant medical officers or internes , the latter being selected after a competitive
examination, and holding the post for three years; there is also a consulting
surgeon of high repute, who assists and performs operations, and who is non¬
resident. A dispenser is also attached to the asylum.
Dr. Christian and Dr. Ritti are respectively responsible for the male and
female department; both are well known in Paris for work in the specialty.
A morning visit is made by the medical officers together, each for their respec¬
tive departments, the internes making an additional evening visit at the hour of
dinner. A resident chaplain conducts daily services according to the rites of
the Romish Church; all the patients are encouraged to attend, the selection
being generally made upon the authority of the medical officers, who are
empowered to act with responsibility and unrestrained freedom in all that
concerns the welfare of the patients. The salary is not so high as that paid to
English superintendents, but they have more freedom, as a rule, being allowed
to hold honorary appointments in addition to consultations.
The number of the attendants and servants amounts approximately to 190,
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1887.]
Notes and News ,
335
varying according to the requirements of private patients, who may each have
two or more according to payment. The establishment is divided into sections
or wards; at the head of each section is a charge attendant, who has the
supervision of the others, each charge being responsible for his section. Among
the women, religious sisters fulfil the duties of charge or head attendant; they
are devoted, refined, and fairly educated, and appear to give every satisfaction.
The office corresponding to our matron’s is filled by two ladies of the Augustine
Sisterhood; the more responsible being called the Sister Superior; together
they have the general supervision of the female department under the doctors,
whose confidence they seemed to me fully to possess; their close interest and
sympathy with the afflicted greatly impressed me. There are eight sections on
the male side, including the infirmary; the female side comprised twelve sec¬
tions, including an infirmary.
Admission into Charenton is obtained in two ways: either by the order of
the Prefect of Police, with or without a medical certificate, or through a
petition signed by the nearest relative, together with a proof of the identity of
the person making application, as well as of the patient himself; both these
certificates to be accompanied by the ordinary medical certificate giving
reasons for admission, and bearing a date of less than fifteen days. The
medical man signing the certificate must be unconnected with the asylum, and
not in any way related to or interested in the patient to be admitted. Extensive
libraries, containing the daily papers, serials, and other journals are a feature
on both sides of the establishment. With regard to the patients, the number
at Charenton is about 600; a little more than half being females, the women
preponderating, as in most asylums. They are, unfortunately, classified,
primarily, according to payments, and into three divisions, varying from £50 to
£200 per annum (although 20 beds are secured for free cases); the higher
rates include separate apartments, board, wages, and attention of private
servants. The diet, although abundant, good, und daintily served to all, is
more varied and recherche for those providing increased payments; wine in all
cases takes the place of our beer; it was light and refreshing, and appeared
very suitable for the women. The patients, for the most part, are derived
from the middle and artisan classes, being kept by the contribution of their
friends or guardians, although artists, actors and actresses, military and naval
officers, are in many cases supported by State subsidies. The age varies accord¬
ing to the average scale of those in English asylums. Many patients at
Charenton, certainly the greater number, suffer from chronic forms of mental
disease. The women, as is their wont, were more noisy, clamorous, and
turbulent; some were in restraint, strong camisoles being used, and the
patients strapped in chairs, arranged in a row, exhausting themselves into a
state of quietude, in this situation, by screams and shouts. I did not see this
method adopted on the male side, or elsewhere, and was assured that it was
an uncommon practice, and very rarely used. Considering the number of
attendants and nurses at disposal, the necessity for such treatment should be
exceptional. There were very few in bed of either sex, those unable to get up
being generally paralyzed, or otherwise feeble. Food was artificially adminis¬
tered through the mouth in a large number of cases; light red wine and
peptonized preparations being added to the usual fluid nourishment in each
case, artificial feeding being an essentially gentle, and particularly facile
operation in the hands of Dr. Larroque, one of the internes. I met Beveral
British patients in the asylum; all were anxious to return, one Irishman being
full of ardent promises for the benefit of his native land as a return for his
liberty ; he was reproached with being a dangerous patient, but respectful and
plausible complacency was all that I saw. Alas, how the race may be misjudged
even nearer home ! Although kind and gentle treatment was so marked here,
I could not leave my incarcerated countryman without a pang of remorse.
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836
Notes and News.
[July,
The asylum of Ste. Anne, for the accommodation of abont 600 oases, is a very
different institution compared with its predecessor. It is less impressive from
without, and there is less dignity, ease, and luxury within. No paying patients
are received here; it is free for all, being supported by the Department of the
Seine, entirely depending for its income upon State aid. It is more a hospital
for the cure than a receptacle for the care of the insane. I have reason to
believe that the asylum is the outcome of an important Commission held in
Paris in 1864 to inquire into the state of the great hospitals for the insane in
that city. M. Lelut was closely examined before that Commission, and oertain
propositions having been fully discussed, they were adopted by the oonstruo-
tion of Ste. Anne. The most important of these provided that there should be
erected a central asylum, situated in Paris, for the reception of all formB of
insanity—more especially acute and recent cases j that this accommodation
should be combined with clinical instruction; that there should be a special
block instituted (as annexe to the central asylum) for the admission of patients,
and in which the admissions might be carefully examined, and their distribution
afterwards determined; also that there should be erected special asylums for
the care and treatment of epileptics and idiots. Clinical instruction is well
carried out here under professors from the Paris Faculty of Medicine. I had
the privilege of attending the clinic of Professor Ball, who is almost as well
known in England as in Paris, having about equal claims upon the two
countries, being English by birth and French by adoption ; he was spoken of in
Paris as a great French physician and orator. I can quite believe it. Among
other physicians who teach here are Drs. Magnan, Dagonet, and Bouchereau,
all well known for their works in psychology and nervous diseases. The
appointments of the physicians and internes are made in a precisely similar
manner to those at Charenton. Dr. Magnan, whose clinic I also had the honour
and privilege to attend, resides in the asylum, and every morning was occupied
in a special section (resembling very much our out-patient hospital depart¬
ment), examining reputed lunatics, who are sent here from a central bureau,
or by orders from the Prefecture of the Seine, with or without a medical
certificate. After examination they are kept under observation for a time,
being discharged if not insane, or if the certificates be faulty, without being
committed to the registers of the asylum, and officially admitted. When the
diagnosis and prognosis are made, they are detained until recovery, if acute;
or drafted into special asylums outside the capital for the reception of the more
chronic class, such as Yaucluse, Ville Vraz, and Burge. The patients are all
recruited from the poorer classes, and being all acute, possess by far the
greatest interest for the scientific student. The staff is large; the wards are
small, affording greater individualization, a point greatly emphasized in
Clouston’s plan of a model asylum for acute cases; the wards are certainly
not cheerful, being lighted from cramped airing courts. The oontrast with
Charenton was very marked, but I saw no camisoles, and no personal restraint;
the padded rooms were in use for such patients as generally occupy them in
English asylums, I mean those where prejudice does not run high. For the most
part the occupants were exhausted from mania, melancholia, and general
paralysis. Many noisy ones were exercising in the airing courts, which were
small, depressing, and very confining. There were many in bed, with various
bodily disorders of a serious nature. I saw several children of the imbecile
class in one part of the building, arranged as a nursery; an attempt to entertain
and educate them was in vogue, after the manner of our asylum at Earlswood,
although I admit with a staff much less keen and imposing. Among the insane
generally it is easy to discover how largely racial peculiarities enter into the
mental constitution ; it was interesting to find, even here, the graceful polite¬
ness which is inborn, the glimmer of native chivalry, and that sensitive
emotional nature, which, in the outside world, either bubbles over in un¬
restrained expressions of feeling, or, moderated, throws the Gaul so soon and
Digitized by L^ooQle
Notes and News.
337
1887.]
bo completely into rapport with others. I trust, however, that I have not
wearied my readers with uninteresting details of a visit which afforded me
most keen enjoyment, and which helped to seal the bond of friendship. It is
one thing to see, another to desoribe.*
Yours truly,
Robert Jones, M.D.
Perth, 6th June, 1887.
To the Editors of “The Journal op Menjal Science/’
Gentlemen, —With reference to Dr. Campbell Clark’s letter in the April
number of the Journal (p. 167), I beg to state that the substance of his reply
was given with perfect correctness in the number for January (p. 624). I now
enclose the shorthand writer’s verbatim report. At page 100 it runs :—
“ As to its affecting the power of the superintendent, he thought that Dr.
Maclean had answered that very well. He would supplement that by saying that
it would be a good thing if superintendents in that respect were a little more
hampered. He thought there was a good deal of arbitrariness on the part of
superintendents in dealing with attendants, and it would make superintendents
less hasty in sending attendants away, and lead them to do to others as they
would wish others to do to them. If that were followed out they would be
better treated.”
Of course Dr. Campbell Clark has every right to correct what he said on the
spur of the moment, but he has no right to impugn the accuracy of the reporter
and myself.
It would be interesting to know what Superintendents are still included in Dr.
Campbell Clark’s condemnation, and what their views are regarding the evictions
referred to.
I am, yours truly,
A. R. Urquhart, M.D.
Hon. Secretary for Scotland.
Obituary .
WILLIAM CHAPMAN BEGLEY, M.D., F.R.C.P.
With deep regret we have to record the death of Dr. W. C. Begley, which
took place at his residence, 26, St. Peter Square, Hammersmith, on Easter
Monday, 11th April. He was in his 85th year, and had been in failing health
for some time. His remains were interred in Highgate Cemetery on 18th April,
after a very impressive ceremony at the church in St. Peter Square, which he
used to attend. He took his B.A. degree in 1826, M.A. in 1840, and M.D. in
1851, all at Trinity College, Dublin. He obtained the diploma of M.R.C.S.Eng.
in 1830, and in 1872 he was elected a Fellow of the Royal College of Physicians
of London, the Membership of which College he obtained in 1859.
He was engaged in private practice at Glossup, in Derbyshire, and subse¬
quently, in 1838, he was appointed house surgeon to the male department of
Hanwell Asylum, which post he held, under the direction of the successive
resident physicians, Sir William Ellis, Dr. Millingen, and Dr. Conolly, for 14
* We should be very glad if other travellers in search of the asylumesque would forward us
rimilar letters, even if not so well written as Dr. Jones’s excellent coniributton.~[EDs.].
Digitized by L^ooQle
338
Notes and News.
[July,
years, up to 1852, when he was promoted to the office of medical superintendent
of the male department on the resignation of Dr. Conolly. His service, there¬
fore, as medical officer at Hanwell Asylum extended over the lengthened period
of 34 years.
Dr. Begley had a well-stored, cultured mind, he was a good classic, very fond
of Greek, a man of noble character, sterling, upright, warm-hearted, full of
charity and benevolence, ever ready to assist the needy or those who required
his aid, dispensing his charity in a quiet, unostentatious way, hating display,
never letting the left hand know what the right hand doeth. He was modest,
unassuming, and of a retiring disposition, slow to make friends, but when once
his friendship was gained, he proved himself a true friend in every sense of the
word. The true nobleness of his character and his generous disposition were
known to comparatively few men. The writer had the great privilege of his
intimate friendship for many years, during which he learned to appreciate his
worth and to entertain for him a feeling of the most profound respect. He
became a Governor of Bethlem Royal Hospital for the opportunity it afforded
of enabling him to do good, for he was never weary in well-doing.
During his lengthened service at Hanwell he worked hard for the good of the
poor afflicted creatures placed under his care, showing a manly spirit of sturdy
independence in making suggestions and asserting his opinions, even to the risk
of occasionally incurring the opposition or displeasure of the Committee.
Indeed, it is very questionable whether any medical officer at Hanwell has ever
done more for the benefit of the patients and the staff than Dr. Begley. Such
was his spirit that if he thought he was right he acted accordingly, and feared
no one.
Of all the men connected with the treatment of the insane, Dr. Begley
appeared to have the highest appreciation of the labours of Sir William Ellis,
who did so much to promote their occupation, and whose labours were duly
acknowledged and favourably commented on by Dr. Conolly in his Hanwell
reports.
Dr. Begley assisted Dr. Conolly in his lectures delivered at Hanwell, and did
much to maintain and increase the reputation of that well-known institution.
In the Report of Hanwell Asylum for 1872, the Committee refer to Dr.
Begley’s “desire to retire from the appointment of medical superintendent of
the male department, which he had filled with so much credit and advantage to
the patients for more than 34 years; and they recorded their appreciation of his
professional merits and unremitting devotion to his duties and the interests of
the asylum in a resolution, and by awarding him the highest retiring annuity
which it was in their power to recommend.”
In respect of pensions, the Hanwell Committee are deserving of all praise,
and show an example worthy of being followed, for they have always been
considerate, just, and liberal towards their staff in the matter of super¬
annuation.
The following is copy of resolution referred to above :—
Resolution of Committee of Visitors upon Dr. Begley’s Retirement .
At a Meeting of the Committee of Visitors, duly appointed for the purposes
of the Middlesex Pauper Lunatic Asylum, held at Hanwell on the 4th day of
April, 1872 :
Resolved unanimously—“ That this Committee receive with great regret the
resignation of Dr. Begley, and desire to express their high opinion of the
manner in which he has performed the arduous duties as Medical Superin¬
tendent during the long period of 34 years, of his unvaried kindness to the
patients, and the deep interest which he has evinced in the welfare of the
Asylum; and that this be communicated to Dr. Begley, together with the
assurance that the Committee will not fail to give their cordial support to his
claim for a good service pension, ,,
Dr. Begley leaves behind him a widow to mourn his loss, a lady who shared
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1887 .]
Notes and News .
339
his kindly, charitable, benevolent spirit, and who was truly his helpmate
through life.
On his memorial card these very appropriate words appear, “ Blessed is the
man that provideth for the sick and needy; the Lord shall deliver him in the
time of trouble.”
“ Now the labourer’s task is o’er.”
J. M. L.
DR. JEWELL, OF CHICAGp.
Those who had the pleasure of Dr. Jewell’s acquaintance could not fail to
recognize his originality of character, his ability, enthusiasm for work, fearless
pursuit of truth, and the charm of his character. We deplore his loss, and
append the following appreciative notice of him in Dr. Sach’s “ Journal of
Nervous and Mental Diseases: ”—
“ We are pained to announce the death of Dr. James Stewart Jewell, of
Chicago, on April 18th, after a lingering and complicated illness. During the
past year or more, numerous evidences of Dr. Jewell’s poor health reached his
New York friends and acquaintances, but none expected so early an end to a
bright career. Dr. Jewell was born September 8th, 1837, at Galena, Ill. He
took his degree at the Chicago Medical College in 1860, and two years later
began his practice in Chicago, in which he continued until the time of his
death. From 1864 to 1869, he held a position as professor of anatomy in his
college, and since 1872 has filled the chair of Nervous and Mental Diseases.
In 1874, Dr. Jewell founded this Journal, and, in the face of many discouraging
conditions, continued it until a few years ago. Through the efforts of its
founder, the ‘ Journal ’ soon obtained an enviable reputation among journals on
neurology. Looking back upon past numbers, we find that Dr. Jewell performed
his editorial duties in the most painstaking fashion. Innumerable reviews,
signed and unsigned, were written by him, and many excellent original articles
appeared in the ‘Journal’ from his pen. Dr. Jewell had the satisfaction of
seeing his ‘ Journal ’ a pronounced success, and although it had passed out of
his hands, he retained a lively interest in its welfare up to his dying day. In
1886, Dr. Jewell founded another journal, the ‘ Neurological Review.* The
plan and design of the new journal were both good, but the editor’s health was
not equal to the task he undertook, and that journal had to be abandoned after
three numbers had appeared.
“ Dr. Jewell rendered many valuable services to American neurology, and
helped to place this special department upon an equal footing with other great
specialities. He was one of the early members and organizers of the American
Neurological Association. In practice Dr. Jewell was eminently successful,
and deservedly popular among patients and physicians.
“ Dr. Jewell possessed great enthusiasm for his special subject, and was at all
times well abreast of the latest advances in the science. Free from feelings of
personal envy, he was ever happy to prove to others his recognition of the good
work they were doing. We mourn the loss of an earnest student, a generous
friend, and an honest critic.”—“ Journal of Nervous and Mental Diseases,”
New York, May, 1887.
DR. KIRKMAN.
At the ripe old age of 93, the former medical superintendent of the Suffolk
County Asylum at Melton died at Brighton, April 3,1887. For the long period
of forty-five years he held this post, and was much esteemed by all who knew
him. He retired eleven years ago on a pension of £600 per annum. He was
a warm advocate of the non-restraint system.
Digitized by L^ooQle
340 Notes and News. [July,
He occupied the Presidential ohair of the Association in 1862, and in the
oourse of his address observed :—
“ I am old enough to remember the origin of this Association, existing at first
only in a small volunteer band, urged on by the energetic labours of Dr. Hitch.
I can revert in pleasing recollection to its more organized arrangements, and
its augmented numbers from our meeting at Oxford (with the liberal encourage¬
ment of Mr. Ley) ; and in marking its progressive growth, from the days of
its peripatetic youth, widening its area before it deepened its roots into 4 a
local habitation and a name/ I cannot but congratulate every officer and every
member on the influence that the Association now exerts, and the rank that it
holds among the nations.?
At one period Dr. Kirkman was President of the East Anglican Branch of
the British Medical Association.
Another generation of mental physicians is growing up who do not remember
Dr. Kirkman. By those who are passing away, and were acquainted with him,
he will be remembered with esteem, and the honest practical work he per¬
formed in asylum-life will be duly appreciated.
Appointments.
Anderson, W. A., M.B., C.M.Ed., appointed Assist. Med. Officer to Kent
County Lunatic Asylum, vice W. F. Menzies, M.B., C.M.Ed., resigned.
Christie, J. W. S., M.D., appointed Med. Superintendent to the Stafford
County Asylum.
Shaw, Harold, B.A., M.B., M.C.Cantab., appointed Assist. Med. Officer to
the Gloucester County Asylum.
Taylor, Alfred Everley, L.B.C.P. & S.Edin., L.S.A.Lond., appointed
Sen. Res. Med. Officer to the County Asylum, Stafford.
Turner, A., M.B., C.M.Edin., appointed Assist. Med. Officer to the Dorset
County Asylum.
Williams, Lionel, M.R.C.S., L.S.A., appointed Assist. House Surgeon to
the York County Asylum.
White, Ernest H., M.B.Lond,, MJLC.P.Lond., M.R.C.S.Eng., L.S.A.Lond.,
A.K.C., appointed Res. Med. Supt. of the City of London Asylum.
Wreford, John, M.R.C.S., L.R.C.P., appointed Res. Clinical Assist, to the
Birmingham Borough Asylum.
Several Original Articles and Reviews have been crowded out this Quarter.
Digitized by t^ooole
1887.]
Notes and News <
341
MEDICO-PSYCHOLOGICAL ASSOCIATION.
HONOUR8 EXAMINATION (GASKELL PRIZE), July, 1887.
The Examination will be held at Bethlem Royal Hospital on the 29th and
30th July, 1887.
Candidates must have passed an examination for the Certificate in Psycho¬
logical Medicine in the United Kingdom, must have attained the age of twenty-
three, and must have been qualified medical officers in one or more asylums
for at least two years. Candidates will be examined in—1. Healthy and Morbid
Histology of the Brain and Spinal Cord. 2. Clinical Cases with Commentaries.
3. Psychology, including the Senses, Intellect, Emotions, and Volition. 4.
Written Examination, including questions on the Diagnosis, Prognosis,
Pathology, and Treatment of Mental Diseases, and their Medico-legal delations.
Candidates intending to present themselves for examination are requested to
give Fourteen Days* Notice to Dr. H. RAYNER, Hanwell, W.
A Pass Examination for the Certificate of Efficiency in Psychological Medicine
will be held at Bethlem Hospital, London, on the 25th and 26th July, and in
Edinburgh on the 16th and 17th July.
H. RAYNER,
2To». Sec.
25th May, 1887. Hanwell, W.
MEDICO-PSYCHOLOGICAL ASSOCIATION.
ANNUAL MEETING, 1887.
The Annual Meeting will be held at the Medical Society’s Rooms, Chandos
Street, W., on Wednesday, July 27, 1887, under the Presidency of Frederick
Needham, M.D.
Council Meet at 10.30 a.m
General Meeting at 11.
Afternoon Meeting at 2 p.m.
The Agenda will be forwarded to Members of the Association by the Hon.
Secretary, Dr. Rayner, Hanwell.
Digitized by A^ooQle
342
Notes and News.
MEDICO-PSYCHOLOGICAL ASSOCIATION.
CONDITIONS AND REGULATIONS RESPECT ING THF. EXAMINAT ION
— F OR TH E CERTIFICATE IN PS YCITOLOGICAT7M EDICINE .
I. Ca ndidates mus t be at least 21 yea rs of age .
II. They must produce a Certificate of having resided in an asylum (affording
sufficient opportunity for the study of mental disorders) as Clinical Clerk or Assistant
Medical Officer for at least three months, or of having attended a course of Lectures
on Insanity and the practice of an asylum (where there is clinical teaching) for a
like period, or they shall give such proofs of experience in Lunacy as shall in the
opinion of the President be sufficient.
III. They must be Registered under the Medical Act (1858) before the Certifi¬
cate is actually bestowed.
IV. The Examination to be held twice a year, at such times as shall be most
convenient, in London, Scotland, and Ireland.
V. The Examination to be written and oral, including the actual examination
of insane patients.
VI. The fee for the Examination to be fixed at £3 3s., to be paid to the
Treasurer, for any expenditure incurred, including the Examiners* Fees.
VII. Candidates failing in the Examination, to be allowed to present themselves
again at the next and subsequent Examinations on payment of a fee of £1 Is.
VIII. The Certificate awarded to the successful candidates to be entitled
“Certificate in Psychological Medicine of the Medico-Psychological Association
of Great Britain and Ireland.’*
IX. Candidates intending to present themselves for Examination to give Four¬
teen Days* Notice in writing to either the General Secretary of the Association, the
Secretary for Scotland, or the Secretary for Ireland, according as they desire to be
examined in London, Edinburgh, or Dublin.
X. The Examiners shall be two in number for England and Wales, for Scot¬
land, and for Ireland.
XI. They shall be appointed annually by the Council of the Association from
Members of the Association. They shall not hold office for more than two years
in succession.
XII. Form of Certificate to which the Seal of the Association is to be affixed:
The Medico-Psychological Association op Great Britain and
Ireland.
Examination for the Ctrtificate in Psychological Medicine .
This is to certify that Mr. has satisfied the Examiners as to
his knowledge of the subjects of the Examination.
Dated
N.B.—Candidates intending to present themselves for Examination are re¬
quested to give notice thereof Fourteen Days prior to Examination—
In England, to Dr. Rayner, Hanwell.
In Scotland, to Dr. Urquhart, Murray’s Asylum, Perth.
In Ireland, to Dr. Courtenay, Limerick.
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VoL mm , Vo. 143. (New Series, No. 107.)
THE JOURNAL OF MENTAL SCIENCE, OCTOBER, 1887.
[Published by authority of the Medico*Psychological Association .]
CONTENTS.
PAOB
PART I.—ORIGINAL ARTICLES*
Frederick Needham, M.D.—Presidential Address, delivered at the Annual
Meeting of the Medico-Psychological Association, held at the London
Medical Society’s Booms, Chandos Street, W., July 27,1887. . . 348
Lloyd Francis, M.D.—Outdoor Work as a Remedial Agent in Insanity. . 864
A. Campbell Clark, M.D.—^Etiology, Pathology, and Treatment of Puerperal
Insanity. ......... 872
Oscar Woods, M.B.—Our Laws and Our Staff. ..... 879
Joseph Wlglesworth, M.D.—On the Use of Galvanism in the Treatment of
Certain Forms of Insanity. ...... 385
Cllnioal Notes and Cases.—Cases of Masturbation (Masturbatic Insanity); by
E. C. Spitzka, M.D.—A Case of Epilepsy ; by W. J. Dodds, M.D. 895—405
Occasional NoteB of the Quarter.—Lunacy Acts Amendment Bill.—Irish
Lunacy Law.—Examination and Prizes in Psychological, Medicine. 406—408
PART II.—REVIEWS.
The Life of Percy Bysshe Shelley; by Edward Dowden, LL.D.—The Life
and Work of the Seventh Earl of Shaftesbury, K.G.; by Edwin Hoddeb.
—Magnetisme et Hypnotisme; expose des ph£nom&nes observes pendant
le sommeil nerveux provoquA Par Dr. A. Cullkrre. —The Health of
Nations: A Review of the Works of Edwin Chadwick, with a Bio¬
graphical Dissertation; by Benjamin Ward Richardson, M.D.—Before
Trial: What should be done by Client, Solicitor, and Counsel, from a
Barrister’s point of view ; together with a Treatise on the Defence of
Insanity; by Richard Harris, Barrister-at-Law.—The Defence of
Insanity in Criminal Cases; being an Essay by Lancelot Fielding
Everest, LL.D.—Anatomy of the Brain and Spinal Cord; by J. Ryland
Whitaker.— A Text Book of Pathological Anatomy and Pathogenesis;
by Prof. Ernest Ziegler. —The Curability of Insanity and the Indi¬
vidualized Treatment of the Insane; by John S. Butler, M.D.—
Elements of Physiological Psychology: A Treatise on the Activities and
Nature of the Mind from the Physical and Experimental point of view;
by George T. Ladd, M.D.—Three Lectures on the Anatomy of Move¬
ment : A Treatise on the Action of Nerve Centres and Modes of Growth;
by Francis Warner, M.D.—Nervous Diseases and their Diagnosis: A
Treatise upon the Phenomena produced by Diseases of the Nervous
8ystem, with especial reference to the recognition of their Causes; by
H. C. Wood, LL.D. ...... 409--431
PART III.—PSYCHOLOGICAL RETROSPECT.
1. Scandinavian Retrospect; by Miss White. .... 482
2. French Retrospect; by D. Hack Turk, M.D. . . . .438
3. German Retrospect; by W. W, Ireland, M.D. . . . .443
4. English Retrospect (Asylum Reports). ..... 448
PART IV.—NOTES AND NEWS.
Forty-sixth Annual Meeting of the Medico-Psychological Association of Great
Britain and Ireland, held at the Medical Society’s Rooms, London.—
British Medical Association: Dublin Meeting, August, 1887.—Inaugura¬
tion of the Statue of Guisiain.—Obituary of Miss Dix (with Portrait).—
Certificate of Efficiency in Psychological Medicine.—Sir Arthur Mitchell.
—Appointments.—Index Medico-Paychologicus.—List of Members,
Ac. ........ 456—482
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The Journal of Mental Science .
Original Papers, Correspondence, &c., to be sent direct to Dr. Hack Tukk,
Lyndon Lodge, Hanwell, W. (Town address, 63, Welbeck Street, W.)
English books for review, pamphlets, exchange journals, &c., to be sent
by book-post to the care of the publishers of the Journal, Messrs. J. and A.
Churchill, New Burlington Street.
Authors of Original Papers {including “ Cases 9 *) receive 25 reprints of their
articles . Should they wish for additional Reprints they can have them on
application to the Printer of the Journal, H. Wolff, Lewes, at a fixed charge.
The copies of The Journal of Mental Science are regularly sent by Book-post
( prepaid ) to the Ordinary and Honorary Members of the Association, and the
Editors will be glad to be informed of any irregularity in their receipt or
overcharge in the Postage.
The following are the EXCHANGE JOURNALS .—
Zeitschrift fiir Psychiatric; Archiv fur Psychiatric und Nervenkrank-
heiten; Centralblatt fiir Nerrenheilkvnde, Psychiatric , und gericktliche
Psychopathologie ; Der Irrenfreund; Neurologisches Centralblatt; Revue des
Sciences Midicales en France et a VEtranger; Annales Medico-Psychologiques ;
Archives de Nevrologie; Le Progres Medical; Revue Philosophique dc la
France et de V fat ranger, dirigie par Tk. Ribot; Revue Scientiftque de la
France et de VEtranger; VEnciphale; Annales et Bulletin de la SociHl de
Midecine de Gand; Bulletin de la Sociitl de Midecine Montale de
Belgique; Russian Archives of Psychiatry and Neurology; Archivio
Italiano per le Malattie Nervose e per le Alienazioni Mentali; Archivio di
psichiatria, scienze penali ed antropologia criminals i Direttori , Lombroso
et Garofalo; Rivista Clinica di Bologna , diretta dal Professore Luigi
Concato e redatta dal Bottore Ercole Galvani; Rivista Sperimentale di
Freniatria e di Medicina Legale , diretta dal Dr . A . Tamburini; Archives
Ital. de Biologic; Psychiatrische Bladen ; The American Journal of
Insanity; The Journal of Nervous and Mental Disease; The Quarterly
Journal of Inebriety , Hartford , Conn.; The Alienist and Neurologist , St.
Louis, Misso.; Medico-Legal Journal; The American Journal of the Medical
Sciences ; The Dublin Journal of Medical Science; The Edinburgh Medical
Journal; The Lancet; The Practitioner; The Journal of Physiology; The
Journal of the Anthropological Society ; The British Medical Journal; The
London Medical Record; The Asclepiad ; Reports of the Psychical Research
Society ; Brain; Mind; The Canada Medical and Surgical Journal;
Polybiblion ; The Index Medicus ; Revista Argentina ; Revue de VHypnotisms ;
Bulletins de la SociSte de Psychologic Physiologique; Science (New York) ;
Journal de Medicine de Bordeaux ; The Sphynx ; The Hospital .
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THE JOURNAL OF MENTAL SCIENCE.
[Published by Authority of the Medico-Psychological Association]
No. 143. ne ^ 0 s io R 7 ! es ’ OCTOBEK, 1887. Yol. XXXIII.
PART 1.—ORIGINAL ARTICLES.
Presidential Address , delivered at the Annual Meeting of the
Medico-Psychological Association , held at the London
Medical Society’s Rooms , Chandos Street , W., July 27,
1887. By Frederick Needham, M.D., Medical Super¬
intendent of Barnwood House, Hospital for the Insane,
Gloucester.
Gentlemen, —In occupying the position to which you
have done me the honour to elect me, I beg to thank you
sincerely for having conferred that honour upon me, and to
assure you that it has my warmest appreciation.
A position which has been held by men like my pre¬
decessors, whose names are among the most distinguished in
our department of medical science, is one which may be
occupied by anyone with pride and satisfaction. But I can¬
not fail to be conscious that in conferring this office upon
me you have sought, through me, to pay a mark of high re¬
spect to registered hospitals, and especially to those members
of our specialty who are practising in the provinces.
In giving an address, which is the first duty of the Presi¬
dent, those who have preceded me have discharged that
official duty with a variety as to subject which has followed
the course of their special studies, or been the result of the
selection of circumstances. The high character of these ad¬
dresses, and the wide extent of ground which has been covered
by them, render the task increasingly difficult with each re¬
currence of the occasion which calls for them. It is almost
impossible to say what is new. It is most difficult to repeat
in varied language that which has frequently been better
said by more able persons. One’s only hope is in reliance
upon the # forbearance and kindly feeling of an audience
which is not unduly expectant or harshly critical, and in this
hope I appear before you to-day, while I endeavour to tread
xxxiii. 23
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344
Presidential Address }
[Oct.,
in the footsteps of some of my predecessors, to the extent
of passing in brief review those events of the year which
have been connected with our specialty, and cannot, there¬
fore, be entirely devoid of interest to any of us.
Since our last annual meeting we have had to deplore the
thinning of our ranks by the death of several of our honorary
and ordinary members.
Of the former we have, in Dr. Naime, lost a friend whom
we older superintendents especially, regarded, and had reason
to regard, with much respect and affection, as having, during
his long term of office, discharged his duties as a Commis¬
sioner in Lunacy not only with great efficiency, but with the
utmost consideration for those who were subject to his
official supervision. A lecturer on medicine and physician
to a large Metropolitan hospital, he did not commence his
career as a Commissioner with the advantages which result
from extensive practical experience in the management of
asylums and the special treatment of the insane. But his
kindliness of heart, refined feeling, good common-sense, and
educated tact soon made him one of the most efficient and
deservedly-popular Commissioners. This he continued to be
during the long term of his official service of nearly 30 years.
Another honorary member of our Association, whose
name was a power across the Atlantic, has also joined the
majority since our last annual meeting. I refer to Dr. John
Gray, the distinguished superintendent of the New York
State Hospital for the Insane.
A man of strong intelligence, of distinct individuality, of
vigorous, active mind, and very definite opinions, not always
in accordance with those which are usually received or con¬
sidered orthodox, he could not fail to be a power, or to leave
a gap when his place knew him no more. His death appeared
to be the ultimate result of an injury inflicted upon him by
a patient, and adds one to the line of those who have so
died within recent time.
From among our ordinary members death has taken three
distinguished asylum superintendents—Dr. Lalor, Dr.
Gilland, and Dr. Kirkman.
In Dr. Lalor the profession, in Ireland especially, has lost
a valuable member, whose services at the Dublin asylum had
shed a lustre upon Irish lunacy administration which will
last far beyond his time. He was at once an originator and
an enthusiast, an accomplished physician and an able
administrator, a genial, high-spirited gentleman, whose
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by Frederick Needham, M.D.
345
1887.]
qualities of heart and brain gained the confidence and
secured the affection of all with whom he was brought into
official relation, and although his work has been taken up
by an able successor, and he had previously resigned active
work, his loss is one which will be severely felt wherever his
influence had impressed itself.
Dr. Gilland died in what should have been the prime of
life, worn out by incessant work overacting on a sensitive
and anxious organization. His death points a moral which
those who are engaged in the arduous and responsible duties
of our specialty cannot too earnestly take to heart, that a
man’s best work is sustained only by adequate relaxation,
and that to neglect the latter is as certainly to stop the pro¬
duction of the former at its source.
Dr. Kirkman’s death has removed an ancient landmark of
our department of medicine. He had attained to almost
a patriarchal age, and had retired from the active practice
of his profession for some years. But he retained his ap¬
pointment as superintendent of the Suffolk asylum until he
was 82 years of age. He was well known as one of the
earliest adopters of the non-restraint system, and he held the
office of President of this Association so far back as when
it was known as the Association of Medical Officers of
Asylums and Hospitals for the Insane.
In reviewing the events of the year one of them stands
out in strong relief, as promising to impress it with a dis¬
tinctive, if not an altogether pleasing, character.
I refer, of course, to the progress of the new Lunacy Bill,
which has passed through all its stages in the House of
Lords, and made some way in the House of Commons.
As this Bill, for what is euphemistically called the amend¬
ment of the Lunacy Acts, if passed, as it probably will be,
will effect very important changes in the relation of the
medical profession generally to the public, and in that of
ourselves to the patients under our care, I may, perhaps, be
excused if I venture, somewhat at length, to review its chief
provisions, and offer such criticisms as have occurred to me.
This Bill, the progeny of a long series of generative efforts,
appears to have excited a singularly small amount of interest
among more than a very limited section of the public and in
the profession whose interests will be chiefly affected by it.
The reason is not far to seek. The general public knows
but little of the legal relations of lunacy, and cares less.
Its practical incidence has to be met when it occurs; but
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346
Presidential Address,
[Oct.,
this necessity having passed away it prefers to bury the
whole subject out of sight, and let the future take care of
itself. As to the medical profession, its rank and file would
probably have been willing to accept a much more generally
objectionable measure in order to secure the protection
which is supposed to be conferred by clauses of the Bill,
against the malicious persecution from which so many of
them have been made to suffer.
But for this feeling, many of the leading provisions of the
Bill would, in all probability, have been subjected to keen
criticism and determined opposition; for it is a Bill manu¬
factured by lawyers, who do not seem to have recognized or
remembered that the condition to which it relates is a con¬
dition of actual physical disease, and neither an accident nor
a crime, and that those who should be helped and not hindered
in their treatment of it are not banditti attacking a helpless
foe, but physicians anxious only to pursue their legitimate
calling in peace, and under that protection which every
citizen of the State has a right to claim from it.
Those who made the Bill have filled it with curious
anomalies, but this one idea seems to have been constantly
kept in view—that in the diagnosis of morbid states of mind
the non-medical class has, in its ignorance, a better claim to
public confidence than those who have devoted the trained
intelligence of their lives to the discrimination of such
diseased conditions.
That an indignity of this kind can be offered to the
medical profession is no doubt due to the fact that there is
among us no effective powtr of combination.
We have no legitimate trades-union, no common cohesion
which would make us conceal or sink our differences while
we present a bold and an unbroken front to the enemy.
What would be the course of the legal profession if grave
questions of law were to be submitted to the members of
other professions for their elucidation and settlement 9 Here
is a fact with a difference. *The recent Bill for the amend¬
ment of the law relating to the transfer of land, because it
affected the interests of the legal profession, was handed over
to the Incorporated Law Society for criticism and suggestions.
I have not heard that the Lunacy Bill Las been submitted
to any body representing the medical profession for a similar
purpose.
The basis of this Bill has been stated to be principally
the recommendations of the Select Committee of 1877, but
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1887.] by Frederick Needham, M.D. 847
in many essential particulars it travels far beyond, and in
others it departs widely from them. The principle of the
Scotch procedure has been said to have been adopted
with somewhat fuller elaboration of detail, but in the
machinery which regulates that procedure are initial condi¬
tions which cannot be reproduced in any English Lunacy
Bill. The Scotch Sheriffs and Sheriff substitutes, who are
skilled lawyers of standing at the Bar, have no analogues
in the English magistrates, who become so, not necessarily
because of their legal knowledge or judicial minds, but because
they are respectable citizens, with decided political sym¬
pathies, or, in many cases, good business capacity.
The primary and fundamental principle of the Bill is that
in future no private patient shall be deprived of his liberty,
either for his own benefit or the good of society, by an order
under the hand of a friend or relative and the certificates of
two medical men, but that in every county and borough
there shall be made a selection of justices, to whom petitions,
supported by medical evidence, shall be presented. They are
to consider the medical evidence of lunacy, and, if they think
fit, personally examine the patient. They are also empowered
to take evidence upon oath, and summon persons to give it.
They may use the services of the Clerk to their Petty
Sessional Division, and the petitioner is to pay his fees.
Patients may be confined under an urgency order made by
a relative, or even friend, accompanied by one medical certi¬
ficate, but this order will only remain in force for seven days,
before the expiration of which the petition to the judge or
magistrate, accompanied by the two medical certificates pre¬
viously referred to, must have been presented if the patient
is to remain in confinement; but the medical certificate
given with the urgency order must not be under the hand of
either of the medical men who give those which accompany
the petition.
The objections to these provisions are, I think, obvious.
Upon the magistrate is conferred the power, not of satis¬
fying himself as to the bonafides and respectability of the
medical certificants, and that the necessary legal requirements
have been complied with, as in Scotland, but to decide as to
the sufficiency of the medical facts adduced as evidence of
insanity. This duty has, up to this time, been in the skilled
and experienced hands of the Commissioners in Lunacy. By
the new Bill the magistrate will decide questions of medical
fact which, under ordinary circumstances, he will be unable
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348 Presidential Address , [Oct.,
to understand or assess at their legitimate value; while
upon the Commissioners, whose wide experience especially
qualifies them to estimate such facts at their proper value,
will devolve the duty of seeing that the necessary legal forms
have been complied with, a matter as to which the most
ignorant of magistrates would have required no lengthened,
education.
Moreover, the clerk’s fee, and that of the third certificant
will, in numbers of instances, make a very material addition
to the charges which, under ordinary circumstances with
persons of small means, are already sufficiently difficult to
meet.
But if these objections are well-founded, what must be
thought of the publicity and exposure which will be implied
in the personal visit of the magistrates, of whom the ‘ f fools,”
if there are any, “ will rush in where the angels would fear
to tread.”
Who is to pay the fees and recompense for the incon¬
venience and sacrifice of time of the busy practitioners whom
they may summon from the four corners of the kingdom to
give evidence as to the questions of medical fact which they
are unable to comprehend ?
It may be urged that these are powers which will not be
exercised; but who can answer for this, for “ Are they not
in the bond P ”
Personally, I have no doubt that all our effort should be
directed to the modification and alteration of these provi¬
sions as a distinct invasion of our rights as a scientific pro¬
fession, and as inflicting an injury upon the public, who have
hitherto, in the main, trusted us.
It may be that this public insists upon the magisterial
intervention in the interests of what, by a misnomer, is called
the liberty of the subject; but, at any rate, such intervention
ought surely to be ministerial only. Physicians alone should
still be suffered to do physicians’ work, and disease be
diagnosed and treated by the only persons who can have,
even presumably, the requisite knowledge for doing it with
any degree of efficiency.
I am aware that, although the general interest which has
been aroused by this Bill has been singularly small, deter¬
mined and persevering efforts have been, and will be, made
to increase its stringency, and still further give it the
character of a Prisons’ Bill. A body of persons, calling them¬
selves the “ National Association for the Defence of Personal
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1887.]
349
by Frederick Needham, M.D.
Rights,” have addressed to Parliament a memorial, setting
forth at length the absolute right of every supposed lunatic
to trial by jury, with the utmost possible publicity; that
privation of liberty should alone be consequent upon the
commission of some act or neglect, which in a sane state
would be regarded as a legal offence; and that safety and not
treatment should be the test of all imprisonment.
Under the pressure, perhaps, of opinions such as these, an
endeavour was made in recent revisions of the Bill to make
the magisterial intervention more real and personal, and, as
a compromise, it was agreed in the House of Lords that,
where the patient had not been seen by a magistrate prior
to reception, he should be informed that he had a right to
be so seen by some magistrate other than the one upon
whose order his commitment had been made.
It is true that a safeguard has been introduced side by side
with this provision that the superintendent of the asylum,
or the medical attendant of the single patient, might certify
that the exercise of the right would be prejudicial, and
further proceedings then be stopped at this stage.
If medical men choose to take this responsibility gene¬
rally, no harm will result, but the position will be in¬
vidious, and it is curiously suggestive when contrasted
with that in which the Bill places them in some of its other
clauses.
The protection given to medical men and others in the
discharge of their duties under the Bill will, I greatly fear,
in practice be found to be somewhat illusory, for there is no
finality in the clauses. Good faith and reasonable care are
incapable of mathematical definition, and even in courts of
law and among judges there might be differences of opinion
as to which arguments would require to be heard upon these
points in cases even in which no mala fides was intended,
and as reasonable care was exercised as was possible under
the circumstances.
It would, undoubtedly, have been more satisfactory, as it
would only have been reasonable, to have had some provision
whereby security for costs was to be given before even the
initiatory proceedings of an action could be entered on. An
attempt was made to obtain this concession, but without
success, although it would be difficult to oppose it upon any
valid ground.
Unless the clauses, as at present drafted, have the effect
which is hoped for from them, or some efficient alternative is
*
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350 Presidential Address, [Oct.,
adopted, the public will shortly have to deplore one unfor¬
tunate result of the Bill. It is not probable that the best
or average members of the medical profession will be content
to continue the discharge of public functions, for which they
receive neither honour nor due emolument, unless they are
at least protected against vexatious litigation, which, even in
the unlikely event of not costing them money, involves
them in worry and loss of time. The men best qualified,
therefore, would sooner or later cease to certify.
There are in the Bill numerous provisions as to visitation,
reports, and other matters, many of which have been shown
by experience to be neither necessary nor desirable. Those
clauses which provide for reports at fixed intervals, failing
which the authority for detention will cease, will involve a
serious addition to the duties of the superintendents of the
larger asylums, unless they are made formally and in a
wholesale manner, when they will be useless.
But there is one clause of which I have been hitherto
unable to see either the need or any justification.
It is to the effect that no person who is not temporarily
insane only, or suffering from senile insanity, or desirous
of voluntarily submitting to care and treatment, may be
received into the house of a medical man as a single patient, -
except upon a special order by the Lord Chancellor, or a
Judge of tho Supreme Court; in other words, unless he be a
Chancery patient. I must confess my entire inability to
understand the reason for this enactment. It would have
been intelligible if it had provided that no patient should
be received into houses other than those of medical men,
but in its present form it seems to widen and extend the
basis of the system by which any person of limited means
and education may farm a lunatic.
Its chief incidence will be upon medical men in general
practice, and upon the public which desires to avoid sending
its insane relatives to asylums ; but it will also deprive us of
an excellent method of treatment in certain cases, and it is
another indignity to the medical profession.
The clauses which relate to the letters of patients, although
based to some extent upon the recommendations of the
Select Committee of 1877, are likely, if passed, to be pro¬
ductive of considerable confusion and inconvenience.
None of us require to be reminded of the letter-writing
mania which affects so many of our patients, and the pro¬
posed new regulations cannot fail to intensify and aggravate
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1.887.]
by Frederick Needham, M.D.
851
the propensity far beyond its present limits. For not only is
every letter written by private patients to be forwarded to
the Lord Chancellor, the Judges, Secretaries of State,
Masters, Visitors in Lunacy, Commissioners, Committees,
and individual members thereof, relatives and friends, but
in every asylum, hospital, and licensed house are to be
exhibited at all times printed notices; conspicuously setting
forth the rights of private patients both to have their letters
so forwarded, and to demand personal private interviews
with Commissioners and visitors on the occasion of any
visit. There can, 1 think, be no doubt in the mind of any¬
one who has had practical experience in an asylum of the
unwisdom of such provisions in the interests of the patients
themselves. The alternative is obvious. You cannot make
men honest by Act of Parliament. You certainly cannot
make them more honest by constantly suspecting them and
telling them that you do so. Therefore use every precaution
to guard against the confinement of patients who are not
insane; have them regularly and carefully inspected; pro¬
vide that asylums are founded upon a proper basis; and
that their management is entrusted only to persons who are
believed to be efficient, trustworthy, and honourable: but
do not publicly degrade the officers of those asylums in the
eyes of their patients, who by the very nature of their
disease are suspicious, by practically publishing that they are
the victims of an adverse combination which would, if it
dared, deprive them of all their civil rights.
Why, these notices will act, in numerous cases, where
rest and quiet are needed as the first elements of cure, as
constant provocatives, disturbing all the nice and pleasant
relations which ought to, and at present so frequently do,
exist between the patients and those who have charge of
them.
By what arrangement can the Commissioners possibly
deal fairly with the shower of letters which will daily
descend upon their office? My patients annually write more
than 9,000 letters, of which three-fourths are forwarded, and
the remainder detained, giving an average to each patient of
close upon 59 a year. Multiply these by the total number
of private patients under care, and the absurdity of the new
departure becomes at once apparent.
It is pleasant to turn from this part of the Bill to those
sections of it which have reference to the care of patients’
property, and the treatment of the licensed houses. The
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352 Presidential Address , [Oct.,
latter have met with fair and liberal treatment in the
revised editions of the Bill, such as they could scarcely have
dared to hope for in its earlier stages. The prophet who
came to curse remained almost altogether to bless, and I
cannot say that, in my judgment, substantial justice has
not been done. The licensed houses had done much for the
treatment of certain classes of the insane. They had met a
great public need. Most of them had been well and liberally
conducted. Some of them were exceptionally good, even
when compared with the best class of asylums anywhere.
They were as free from legitimate suspicion as others, and
I have no doubt that their retention will be a distinct ad¬
vantage to the community. With such competition as will
be introduced the worst will die out, and the best will still
remain to compete with each other and with the best of the
hospitals, to the mutual advantage of them all. I am
naturally a strong believer in the hospital system, and
should like to see its wide extension, but I hold that for a
certain class of patients the high-class private asylums, the
proprietors of which study the whims and unnecessary re¬
quirements of the friends of patients, offer advantages which
no hospital has any right to be able to afford.
It is, I think, greatly to be regretted that the resources of
the hospitals have not been more generously assisted by the
public, but that they have had to rely chiefly upon the sur¬
plus income derived from the more ample payments of the
rich for the means to render assistance to the less affluent
among their patients. This is so even in the most recent
addition to their number, and it is greatly to be deplored.
The hospitals have, I think, received more than their due
recognition and less than justice entitled them to in the new
Bill. The clauses relating to them seem to have been
framed with the object of bringing them under, perhaps,
more strict legal control than almost any other class of
institution. And yet they are said to have been almost uni¬
formly well-conducted, and their extension formed one of the
strongest recommendations of the Select Committee of 1877.
Great, and, I think, very just, exception has been taken to
the clauses which place in the hands of the Commissioners
in Lunacy the power of summary closure of hospitals. It is
a power which could scarcely be practically exercised when
the character and position of these institutions are con¬
sidered, and the discretion and good judgment of the present
Board of Commissioners might very safely be trusted with
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1887.] by Frederick Needham, M.D.
even such exceptional powers. But one cannot foresee
what the remote future may bring forth, and I can con¬
ceive it to be not impossible that, at some time or other, the
retention of this clause in its present form might enable a
great act of injustice to be done. If this clause is requisite
at all, it should, I think, be modified to this extent at least,
that the power of closure should be transferred to the Secre¬
tary of State, to be exercised by him upon the representa¬
tion of the Commissioners, but only after careful separate
inquiry by himself.
The unfortunate Superintendent should no longer be made
the scapegoat upon whose back are loaded all the sins con¬
templated in these clauses and in the Bill generally, for he
is only the servant of his committee, to do, or suffer to be
done, that which they decree.
Excellent provisions in the Bill secure the right to retake
escaped patients in any of the three divisions of the
kingdom. They remove what has long been an absurd
anomaly, and, it is to be hoped, are the beginning of many
similar changes, which will sweep away complications and
absurdities which have long deformed the Statute book.
But it is greatly to be regretted that the main principles of
the Bill will entirely destroy any prospect of certificates
granted in Scotland or Ireland being available in England,
and vice-versd —a matter which is in the highest degree
desirable.
The greatly extended scope of the new Lunacy Bill will, I
should think, necessitate some considerable addition to the
inspectorial and clerical staff of the Commissioners’ Office.
To meet this, the Bill provides for an amalgamation of the
Masters in Lunacy and their staff, with the Visitors in
Lunacy and their staff, and the Commissioners in Lunacy and
theirs. Whether this arrangement would work satisfactorily
remains to be seen, but it is certainly a new departure for a
proportion of the cost of such amalgamation to be charged
to the fund derived from a percentage of the incomes of
Chancery patients, whose contributions have hitherto been
devoted to defray the expenses of their exclusive visitation
and the management of their estates.
Such are the most important features of a Bill which pro¬
mises to become law within a reasonable period, and which
will certainly, for good or ill, effect important changes in the
legal relations of insane persons and their custodians.
In the modification of this Bill and its improvement by
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354 Presidential Address , [Oct,,
the removal of many ill-considered and objectionable clauses,
the Parliamentary Committee of this Association has done
excellent service, and it is to be hoped that their influence
with regard to it is not yet exhausted.
There is still one more measure looming in the not very
far distant future which also promises to materially affect
the position of county asylums, their officials, and their
inmates. I refer to the Bill which is promised by the pre¬
sent Government for local government in counties. Every¬
thing, I think, points to a somewhat drastic Act, which will
materially modify the position of county asylums, unless
they can, by any means, be excluded from its operation.
It is clearly of the first importance that their external
government should be conducted by intelligent and educated
persons, that good salaries should be continued in order to
secure and retain the services of the best men as superinten¬
dents, and that while due economy should prevail, so as to
lighten as far as possible the burden upon the rates, economy
should not be the only, or the chief, consideration. I consider
that the present competition in public asylums for a reduction
of the rates to the lowest possible point is simply disastrous
from the point of view of the cure and comfort of the patients,
and the future of the asylums and their officials.
The comparatively limited experiences of our own country,
and the more extended experience of other countries, does not
give one an unqualified belief in the wisdom or the public spirit
of Democracies. Evidences exist, even under our present
system of limited county government, of the absence in too
many instances of these qualities in those who are respon¬
sible for the administration of our public local charitable
institutions, and I do not think that County Boards, with
their constitution what I fear it will be, are likely to intro¬
duce an improved or a more liberal system.
This is, I think, obvious from facts which are within our
knowledge and recent experience.
The committees of county asylums at present consist
generally of gentlemen of position, who have both a large
personal interest in securing an economical administration
of county finance, and an enlarged appreciation of what
constitutes true economy. They know that present parsi¬
mony may imply a large future expenditure, and that what
may be called the fringe of expenditure is especially valuable.
They are told and believe that the decoration and furniture
of rooms, and the provision of suitable amusements, have a
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distinct moral influence in the cure of insanity. But they
are not absolutely essential, like so much beef or so much
bread and milk, and is it to be expected from what is seen
and known of the typical guardian, the guardian not of the
poor but of the rates, that he will be willing to continue an
expenditure in respect of them when he is unable accurately
to weigh or measure the advantages to his pocket which are
to accrue from them 9
So, also, with reference to the salaries and pensions of the
superior officers. The present committees, with some un¬
fortunate exceptions, to which I shall have occasion further
to allude, know that ability and efficiency are qualities
having a distinct money value, and that they are deserving
of recognition, even from a selfish standpoint, at the hands
of those who use and profit by them.
Will this be the case with those who, adopting trade
union principles, place everyone on a common platform of so
much work so much remuneration, without regard to the
nature of the work or the ability of the worker 9 It is well
known that the estimation in which brain services rendered
by officials to the guardian class are held by them is ex¬
pressed in the formula: 44 We can get plenty of men to do
the work for less money.” Apply this to the office of medical
superintendent, and you have the disgust and discourage¬
ment of the individual, and the ultimate narrowing of the
area from which a selection may be made.
The wear and tear of asylum work is undoubtedly great,
and it needs the inducement of a liberal salary and pension
to secure the devotion of the best men to the service.
Will County Boards be likely to recognize these claims, and
continue these inducements? The answer to this question
is, I think, involved in the reply to the following:—Will
County Boards consist chiefly ot such men as administer the
present county government, or will the guardian and farmer
class predominate 9
Personally I have no doubt upon the subject, or that the
policy of these Boards will be the guardian policy, intensified
by the existence, if they still continue, of the hard times
and the consequent pressure of every small expenditure.
The Superintendent of the Gloucester Asylum broke down
from ill-health in 1883, after nineteen years of service. His
salary and allowances were calculated at £1,100 a year, and
a pension of £550 was proposed. All the guardian instinct
of the county was immediately aroused, meetings were held,
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356 Presidential Address, [Oct,,
and opinions were expressed which, in combination, afforded
a very full and fair statement of the prevalent views upon
the subject. Here are some of them : “ A direct stand
must be made against these extravagancies. I never could
understand why officers of public bodies (in many cases
already overpaid) are entitled to, or should be led to expect,
pensions.” “ Does anyone suppose that under a representa¬
tive County Board this grant would have been made? I
answer emphatically, No.” u I, for one, entirely disagree
with the superannuation principle. The opinion of the
ratepayers is that there should be no pensions whatever.”
All this was in 1883. In 1887 similar proceedings have
occurred.
The Dorset Asylum Committee, who had been well and
faithfully served by their superintendent for the long period
of thirty-two years, recommended that, on his retirement,
he should receive a pension of £600 a year, or two-thirds of
his salary and allowances. An agitation was immediately
started by Boards of Guardians throughout the county, with
the disappointing, but perhaps not unexpected, result that
Quarter Sessions rejected the committee’s proposal by a
majority of three to one, the statements being made that
“ no man had a right to any pension whatever,” that “ an
officer was not to receive a large pension because he had
done his duty,” and that “the ratepayers were opposed to
giving pensions at all.”
Again, at the Norfolk Asylum, a pension of the same
amount was proposed for the superintendent, after twenty-
five years’ service, by the committee, who alone could estimate
the value of his services, and although the pension was
ultimately secured, it was only after the most degrading
discussions and agitation had prevailed throughout the
county.
Very much the same course was followed with reference to
a pension of £400 to the Superintendent of the Berks Asylum,
after seventeen years’ service and his retirement from ill-
health, the result of overwork, and the same process is being
repeated at the Lincolnshire Asylum, after an honourable
service by the superintendent of thirty-nine years.
It is at least gratifying to know that in Hampshire the
Justices have given their late superintendent a pension of
£800 a year, and that at the City of London Asylum a pen¬
sion of the same amount has been granted to Dr. Jepson.
But the facts quoted, and the consideration of the relation
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357
by Frederick Needham, M.D.
of county asylums to County Boards, suggest the great desir¬
ability of energetic and combined action being directed to the
procuring of such amendments in the new Lunacy Bill as
shall secure to the principal officers of asylums the right to
reasonable pensions in respect of services rendered, not
only in any particular county or borough asylum, but
in any number of asylums in that county or elsewhere—
the basis of such claim being that the salaries are never
so large, even under the most liberal committees, as to
enable men, during the period in which they can efficiently
discharge their arduous and responsible duties, to save
sufficient wherewithal to provide an adequate fund for their
own superannuation, and that the holding of an appoint¬
ment does not, as does general practice, secure a vested
interest which can be turned into money upon the cessation
of active work.
From the first introduction into either House of Parlia¬
ment of a Local Government Bill every force which can be
brought to bear should be focussed in opposition to the
clauses which will provide, if the claims already loudly made
are conceded, for the handing over of the county asylums to
the tender mercies of the County Boards.
Unless this can be done, and done successfully, I fear that
evil times are in store for those institutions, for there is
ample evidence to show, especially from the experience of
the Colonies, that wherever the representative, that is the
democratic, principle is newly in operation, those public
officials whose work is chiefly subjective and mental have
but little sympathy to hope for from the rude intelligence
which can only estimate the money-value of physical labour
and the capacity to raise foot-pounds.
An important Act has been added to the Statute Book
during the past year in the u Idiots Act of 1886.”
It provides for the registration of hospitals, institutions,
and licensed houses, and for the subsequent reception into
them of idiots and imbeciles upon an order under the hand
of the parent or guardian and the certificate of one medical
man.
The Act is very short, consisting of only 16 sections, but
it effects a very important and useful change in the legal
status of the persons to whom it refers, and will, no doubt,
greatly facilitate the proper care and treatment of the
imbecile class, which is so great a desideratum.
I have thus endeavoured, but at greater length than I had
/
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Presidential Address ,
[Oct,,
intended, to bring to your notice the various proposals which
have been, or are now, under discussion with reference to the
legal relations of the insane.
They indicate that, although the public concern in any
particular Bill or form of proposal may be small, there is a
growing interest generally in the questions which are con¬
nected with the subject of insanity. If no other evidence
of this existed it might be found in the rapid increase,
within recent years, of literature having as its foundation
the phenomena of insanity in some form or other. “ Called
Back” was only one of a long series of novels which would
come under this category.
That this general interest has been shared in an ex¬
aggerated degree by a section of the public, whose restless
activity and energy alone give it strength, which is impatient
of authority in any form, and rides to death the hobby of
respect for the liberty, that is the license, of the subject, is
a misfortune which every well-wisher of the lunatic has
greatly to regret.
But all this points one moral, to which it behoves us to
give practical expression. Upon us devolves the treatment
of the disease insanity, and the working of the laws within
which its treatment must be regulated.
We should, therefore, agree upon definite principles, avoid
schisms or what look like them, be strong in combination,
and combine strenuously to compel attention to our repre¬
sentations. We should lose no opportunity of educating the
public, giving them whenever and wherever we can true
views of the nature of insanity, especially as regards its
material and pathological character, and leading them,
therefore, to the necessary conclusion that the diagnosis and
treatment of mental diseases must follow the same course as
those of ordinary disease, and be entrusted only to skilled
physicians who have devoted their labour and their lives to
the work.
At present we have nothing approaching to our legitimate
influence. Anyone may cast a stone at us and think that
he does God service. The public generally, who are ignorant,
are told by those who have no excuse for being so that a
disease which has puzzled wise men in all ages, and involves
the most complicated organism in our bodies, can be recog¬
nized in all its subtle and delicate shades by any person of
ordinary observation and intelligence. This appears to arise
only from a form of agnosticism, which, in order to prove
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359
1887.] by Frederick Needham, M.D.
that there is nothing which it does not understand, pro¬
nounces that which it fails to comprehend as having nothing
in it which may not be understood of all the people.
Among the causes to which this want of influence is
attributable is undoubtedly the unfortunate readiness with
which medical opinions as to insanity in legal cases are to
be obtained in direct antagonism to each other.
A common gibe, and I have heard it from the lips of a
judge in open court, is that for every six men who are pre¬
pared to testify to one view of a case, six others are to be
obtained who will say exactly the reverse. This is, of
course, not confined to the profession of medicine, but it still
has a disastrous effect on the public estimate of our know¬
ledge and consistency.
The non-professional public is unable to distinguish
between evidence which is specially skilled and that which
is the result of ordinary medical knowledge and experience.
It naturally places both on the same level, and, finding them
divergent, attaches no value to either.
Here combination and a reasonable amount of self-sacrifice
would, in the end, secure for the whole profession a position
to which it has never yet attained, and sooner or later we
might hope to see members of each specialty in it consulted
by the courts as assessors, instead of being brow-beaten by
opposing counsel and depreciated by the bench and juries.
All this may seem to be theoretical and visionary, but it is
at least worth trying for, if only from the standpoint of self-
interest, and it has been found practicable in other countries
which are not ordinarily more practical than ourselves.
The longer the Lunacy Bill is in passing, the fuller the
opportunity for the study of insanity by the public, for there
is, I think, little doubt that, in consequence of the difficulty
of obtaining certificates, numbers of patients are at large or
in confinement with relatives who would otherwise be under
care in asylums. Whereas in 1875 the proportion of patients
admitted into asylums and into single care was one in every
1,932 of the population, in 1885 it had fallen to one in every
2,059. This has probably not been altogether due to the
cause referred to, but its influence has undoubtedly been
considerable.
The year of Jubilee, which has just been celebrated, closes
a period which in nothing has been more remarkable than
in the changes which have occurred in the treatment of the
insane. Most of them have been recorded at length by a
xxxii i. 24
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360
Presidential Address ,
[Oct.,
predecessor in this chair, whom I may fitly term the
historian of our specialty. I need scarcely say that I refer
to Dr. Hack Tuke, of whose ability and industry I dare not
say in his presence all that I feel. He has traced, in his
“ History of the Insane in the British Isles,” the progress
of the asylum system and the improvements in the treat¬
ment of the insane in a manner, and with a fulness, which I
could not hope even to approach, and the picture is quite an
astonishing one.
It is less than the 50 years celebrated by the Jubilee since
Dr. Conolly went to Hanwell, and commenced there the non¬
restraint reform which has been followed, in a greater or less
degree, by every civilized country in the world.
Forty-two years ago a Lunacy Bill, introducing the present
system of asylum constitution and inspection, was passed by
the Legislature, practically under the influence and personal
guidance of Lord Shaftesbury, to whom both our patients
and ourselves owe a deep debt of gratitude, which no lapse of
time ought ever to be able to efface, and from that time
there has been an uninterrupted course of improvement in the
management of asylums and the care of their inmates.
In 1837 the amount of restraint and seclusion throughout
the country, although greatly diminished, was still very
excessive. In 1857 it had, to a large extent, ceased in the
best asylums, while in 1876, omitting one asylum of 1,000
patients in which it had been used 67 times, it had so far
been discontinued as a method of treatment that only one
patient in every 575 had been brought under its influence.
It may have been an accidental circumstance, but I regret
to say that in 1886 this proportion had risen again to one in
every 420. It would be most unfortunate if this could be
taken as an indication of any general revulsion in favour of
this method of treatment. The temptation to use it in
other than surgical cases is, no doubt, considerable, from
motives of economy and other similar reasons; but I venture
to think that, though allowable as a means of treatment, its
use still requires to be closely watched as peculiarly liable to
abuse, and as, therefore, needing to be defended in every
instance in which it is employed.
I wish it had been possible to point to a largely increased
percentage of recoveries and a diminished death-rate as a
result, and it would have been a most desirable one, of the
great changes to which reference has been made. There
is no evidence that it is so, although statistics are wanting
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861
1887.] by Frederick Needham, M.D.
from which any very reliable inference could be drawn.
But it is, on the other hand, probable that general paralysis,
and the more severe and fatal lesions of nervous structure,
have increased of late years with the greater complexity
of our social system, and the more continuous and prevalent
over-taxing of the energies of the nerve centres.
The means at our disposal for the treatment of the
symptoms of insanity have recently been materially increased.
While deprecating what has been called chemical restraint,
there can be no doubt in my mind that it is a distinct
advantage to have alternative remedies for the control of
excitement, and to procure that rest for the brain which
restores energy to its cells, and is the first element in the
re-establishment of its functional activity; and these we
have in paraldehyde with the bromides, hydrobromic acid,
hyoscyamine, and the salts of hyoscine, and other drugs of
this class. Perhaps, however, the greatest gain has resulted
from our realization of the material character of disorders
of the mind and their treatment, not so much by specific
remedies as by pursuing the principles of general medicine.
It is a sign of good omen for our specialty that we have all
come to rely upon these, and upon hygienic effort in the
shape of fresh air, exercise, and what Dr. Clouston has
termed the gospel of fatness. Personally, I have great
doubt as to the wisdom of the abolition of beer as an
ordinary article of diet in asylums; but there are, no doubt,
many excellent reasons to be adduced in favour of the
practice.
The moral treatment of insanity has continued to make
steady advances, and none of us can have failed to realize
how great an influence is exercised upon the insane condi¬
tion by agencies which are not medical in any but the
widest sense. We know that all things in an asylum must
work together to a common end if the administration is to
be successful; that the ideal asylum of the present day, for
private patients at least, is one in which there is a single
controlling power, holding the threads of every department
drawn to a common focus ; where there can be no divergent
aims or antagonistic elements; where there are diverse
buildings, often at a distance from each other, in which
patients in varied mental states can be suited with the con¬
ditions of life which are most conducive to their happiness
or recovery; where* training of the best kind is given to
the attendants, as well by lectures and other instruction as
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Presidential Address ,
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by association with educated and refined lady and gentle¬
men companions, whose leaven of gentleness and intelligence
leavens the whole lump; where the rooms present not so
much the institutional character as the appearance of the
ordinary apartments of gentlepeople, and the furniture and
decoration combine to produce what has been fitly called
“ the harmony of a varied perfection ; ” where the amuse¬
ments are frequent and the multiple employments carried
out with completeness and success, and where each patient
is carefully individualized and made the object of moral
influences which are constantly exercising their power over
him, if insensibly to himself; where, in fact, Dr. Clouston’s
definitions of a hospital and a home are realized in the fullest
and most comprehensive sense.
On all hands there are, I think, evidences of distinct
advance. Increased attention is being paid to the structural
adaptation of buildings to the nature of the requirements
which they are to fulfil, and the defects of previous designs
form the stepping stones which assist and chronicle progress.
The standard of all is higher, and there is a healthy rivalry
which forbids to stand still and be content.
An earnest endeavour is being made everywhere to keep
in view the primary object of all asylums, that they should
be hospitals for the treatment of mental diseases, and not
prisons only for the safe keeping of those who are dangerous
to society. We are all combining to break down the middle
wall of partition which has for so long, to some extent at
least, divided the practice of medicine from that of medical
psychology. •
The abolition of walled airing courts and locked doors,
and the extension of parole, even where they have been
replaced by substitutes, have shown us that patients
generally may be more trusted, and have greater liberty
than we used to think wise or safe.
Outside our institutions, in the general affairs of the
Association and of our specialty, important advances have
been made.
The new examination at the London University in mental
physiology in relation to mental disorders, marks the begin¬
ning of a new era. This will, no doubt, ultimately develop
into an examination in psychological medicine generally,
and so proceed pari passu with the examination in the same
subject of this Association.
My friend Dr* Manning, the Inspector-General of the
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1887.]
by Fbedebick Needham, M.D.
363
Insane for the Colony of New South Wales, whom we are so
glad to see among us at this meeting, has succeeded in
inducing the Senate of the University of Sydney to include
psychological medicine in the compulsory subjects for their
examination for the degree of M.D.
It has been, I think, a step of great importance that our
own Association has been the pioneer of this movement in
this country by instituting the pass and honours examina¬
tions for certificates of efficiency in psychological medicine.
This has already been taken advantage of to a consider¬
able extent; and, by a fortunate combination of circum¬
stances, a sum of £1,000 has recently been vested in the
Association in memory of the late Mr. Gaskell, and its
interest devoted to an annual prize of the value of £30, to
be awarded to the most successful candidate in the honours
examination among those who shall attain to a certain
definite standard.
It is to be hoped that the future of these examinations
will be a successful one, and that the certificates and prizes
of the Association will be so regarded as to make them the
objects of a keen competition.
It is, of course, greatly to be desired that the subject
should be made compulsory at the examining boards which
admit to the profession; but meanwhile our own initiative
cannot fail to lead to valuable practical results.
The great increase of post-mortem examinations of late
years has assisted our diagnosis in a marked degree, and the
extension and refinement of microscopical investigation have
added largely to our differential knowledge, both of the
minute anatomical structure of the central nervous masses,
and of the changes which are undergone by them under the
influence of diseased processes.
The recent researches of inquirers like Meynert, Ferrier,
Hughlings Jackson, Gowers, Mickle, Horsley, and others,
both at home and abroad, would lead us to hope that, not
to-day, nor, perhaps, to-morrow, but still within a time which
shall be measurable, the evolutionary process may transform
the art which we love into the science of which we shall have
reason to be proud.
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[Oct,
Outdoor Work as a Remedial Agent in Insanity . By Lloyd
Francis, M.A., M.D. Oxon., Senr. Assist. Med. Officer,
St. Andrew’s Hospital, Northampton.
I propose to consider this subject exclusively in its re¬
lation to the insane of the better class. The pauper asylums
throughout the country have long been admirably organized
in this particular. Every such institution has attached to it
a farm, gardens, a multiplicity of workshops, and the ap¬
pliances for the pursuit of various trades—frequently those
special to the locality, as weaving sheds in the West Hiding
Asylums. In one or another department, all the labourers
and artisans, who comprise the majority of the inmates, can
find congenial occupation. Manual labour, thus systemati¬
cally provided for those able and willing to engage in it,
is coincidently the source of immense benefit to the mental
and physical health of the patients, and of considerable
profit to the institution ; the pauper lunatic, by one and the
same effort, works out his own salvation and helps to pay
for his care and treatment; the recovery rate is raised, the
rate per head diminished. There is obviously danger of re¬
garding the financial and not the remedial as the paramount
consideration; but no instance of such an abuse of thera¬
peutics has ever been brought forward. To the county
patient hand-work is neither a novelty nor a hardship: even
though his mental obliquity or confusion be such that he
fails utterly to comprehend or appreciate the motives of
those who urge him to employ himself; yet he is glad to
exchange the monotony of ward, airing court, or aimless
country walk, for the bustle and activity of farm or shop,
with the prospect, may be, of working at his own craft or
even acquiring a fresh one.
Turning now to private asylums and public hospitals for
the better classes, we find conditions materially different.
In the first place, economical considerations can be entirely
disregarded. There are no poor law guardians or heavily
burdened ratepayers to be reckoned with; the question,
freed from financial complications, is narrowed down into
one of treatment pure and simple. It is from the latter
standpoint that unfavourable criticism has sometimes been
bestowed upon the management of such institutions. The
lazy, listless, humdrum life of the private patient has been
contrasted with the busy, active, and varied one of his pauper
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1887.] Outdoor Work as a Remedial Agent in Insanity . 865
fellow sufferer. A writer, whilst lauding the county asylum
as a “hive of industry,” stigmatizes the private asylums
and lunatic hospitals as “ castles of indolence; ” and it is
asked why a system, the benefits of which in the one case
are so striking and unquestioned, should not be applied,
even to a limited extent and in a modified form, in the
other.
A plausible retort would be that the cases are in no sense
parallel; the great majority of private patients have been
brain, not hand-workers; gentlemen, professional men, and
sucli like have not been trained to manual labour; they
would not work, and could not if they would; it is extremely
difficult to arouse interest even in sports and amusements;
it would be impossible to elicit even toleration of outdoor
drudgery.
As the result of experience of this, the largest lunatic
hospital in England, I will proceed to show that neither the
criticism nor the rejoinder is of universal application—that
every lunatic hospital is not a castle of indolence, nor
every private patient of necessity a drone. In this institu¬
tion the proportion of male patients usefully employed or
rationally occupied is, I venture to think, at least equal to
the average of county asylums, a fact which I will en¬
deavour later to illustrate by figures. The facilities for
arriving at this result are possibly in some degree ex¬
ceptional. Not to mention the land (about 64 acres, laid
out in gardens and ornamental grounds) in which the
hospital stands, we are fortunate in the possession of an
annexe, to which is attached a farm of 500 acres, part
arable, part pasture; the whole making provision for manual
labour, practically unlimited in amount, and sufficiently
varied in character to suit the different mental conditions
and capabilities of the workers. Outdoor labour is looked
upon as a therapeutic means of the highest possible value,
and each year adds fresh evidence of its efficiency; it is put
to trial in one stage or another of every case, where physical
disease or extreme exhaustion do not contraindicate. The
means of persuasion are necessarily more limited than in a
county asylum; the bait of small extra luxuries and,
privileges—ale, tobacco, and the like—so tempting to the
pauper, cannot lure the private patient, whose diet is ample
and varied, and whose material comforts no amount of
industry can increase. There remains, then, only argument,
moral suasion; and hence oftentimes much difficulty in
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866 Outdoor Work as a Remedial Agent in Insanity , [Oct.,
overcoming tlie irrational scruples, more especially of lads
and young men. The idea of digging, road making, or
wheeling a barrow is, even in the guise of medical treat¬
ment, at the outset rather shocking to the schoolboy, the
undergraduate, the lawyer, or parson. He resents the pro¬
posal as an outrage to his dignity; declares that he was sent
here for rest and remedies, not to do labourer’s work, that
such toil is all very well for poor people, but not for gentle¬
men—that, in short, he will have none of it. His repug¬
nance, however, generally yields in time to reiterated advice
and the example of others; and, once vanquished, seldom
revives.
The result, in the immense majority of cases—I might
say in all—is beneficial. Over and over again do we note
instances of rapid and complete recovery following steady
application to outdoor work, when other means have signally
failed and the prognosis has become decidedly bad, and,
coincidently with the mental improvement, the establish¬
ment of physical robustness and vigour such as the patient
has often not previously possessed. Such patients have the
fresh ruddy complexion, fat cheeks, and happy contented
aspect, which one observes in convalescents from typhoid
fever.
In the treatment of chronic insanity, too, outdoor employ¬
ment, though of necessity rarely curative, is yet of unques¬
tionable value. A chronic lunatic of the worst type—
turbulent, noisy, destructive, a masturbator, treacherous,
violent, faulty in habits, an inveterate nuisance—shows
marked improvement after a few months of steady work.
Sleeplessness, which drugs have failed to influence, yields to
healthy fatigue; he no longer makes a scarecrow of him¬
self by tearing his clothes; his opportunities for self-abuse
are much curtailed; and he relieves his angry feelings by
vicious digs into the earth or kicks at his barrow in place
of murderous attacks upon fellow-patients or attendants.
Finally, his appetite is more keen, his food better assimilated,
and his general health improves. Now and then such a
patient even attains a state of fairly permanent partial
recovery—a placid, contented, feeble-minded condition, it is
true, but still enviable in comparison with his former miser¬
able existence.
It may be asked whether outdoor amusements, athletic
exercises, would not more agreeably serve the same end. The
answer must be in the negative. For one patient who is
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1887.]
by Lloyd Francis, M.D.
367
capable of taking part in outdoor games, at least 20 can be
put to manual work. An acute maniac or a dement can be
made nothing of on the cricket field or tennis Jawn, though
he may dig or break stones with energy and purpose.
Moreover, field sports and athletics are apt to be indulged
in spasmodically—a few hours of violent exercise and
excitement, followed by a long interval of rest and indolence.
Obviously, too, such pastimes as hunting, running with
beagles, coursing, &c., which involve mixing with the world
outside, presuppose a degree of natural manner and decorous
behaviour such as only a small minority of asylum inmates
are capable of. The working patient, on the other hand, is
ensured seven or eight hours daily in the open air, with con¬
tinuous employment, not severe enough to over fatigue, and
free from tendencies to unhealthy excitement. The ground¬
work of recovery is found by experience to be best laid in
steady plodding within the hospital boundaries ; later, when
convalescence is fairly established, play may safely vary the
monotony of work or even be substituted for it, though
frequently such a patient, recognizing as he improves what
a good friend work has been to him, goes on quite conten¬
tedly, making no complaint—not averse to recreation, but by
no means enthusiastic.
Most important amongst the remedial properties of out¬
door work is its favourable influence upon the physical
health; the disordered brain is benefited directly and in¬
directly through improved general nutrition. Indeed gain in
weight, improved colour, and other indications of physical
amendment, are always the first observed hopeful symptoms;
signs of mental improvement follow more or less rapidly.
Adverting next to the risks incidental to the above plan of
treatment, no serious casualty has so far occurred. We
occasionally hear of attacks of noisy excitement and threats,
but not actual violence, and with a sufficient staff of trust¬
worthy attendants, specially trained to this outdoor duty—
the whole scheme, moreover, under strict medical supervision
—the chances of a catastrophe are minimized. Each patient,
too, undergoes a species of preliminary training in simple
employments on the grounds and gardens—where, under
close surveillance, his capacities and temper can be gauged
—prior to engaging, with fuller liberty, in more dangerous
farming operations.
The system which I have endeavoured to describe is, I
believe, carried out on a more extended scale in this hospital
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868 Outdoor Work as a Remedial Agent in Insanity , [Oct.,
than in any other of the same type—with a completeness,
indeed, which frequently elicits expressions of interest and
astonishment from visitors, both lay and medical, and has
more than once been favourably commented on and held up
for imitation by the Lunacy Commissioners.
Putting on one side its proved remedial value in the treat¬
ment of recent insanity, its effect in raising the standard of
physical health, in combating excitement, turbulence, and
disorder, and lessening the discomforts and annoyances of
an asylum patient’s life, would fully compensate for the
trouble and expense of carrying it out. Nothing illustrates
this fact more clearly than the contrast between the be¬
haviour of working patients on a week-day and Sunday—a
contrast highly unfavourable to the day of rest. Missing the
accustomed round of work, incapable of intellectual occupa¬
tion of any kind, they become restless, noisy, mischievous,
destructive, quarrelsome, turning the ward into a bear¬
garden, and sorely trying the patience and temper of the
attendants. Still more marked is the difference between
male and female wards of the same class—the inmates of the
latter being noisier, more excitable, and difficult to manage,
to a degree far greater than can be accounted for by mere
difference of sex. At meals, for instance, the male dining
halls are generally a marvel of order and quietude, the
female often quite the reverse.
I will conclude by quoting the statistics of an ordinary
working day, and append a few illustrative cases.
Nov. 23rd, 1886.
Total number of male patients ... 160
Employed on farm, grounds, and gardens ... 66
,, in indoor work, carpentry, printing, Ac. 18
Hunting, riding, tricycling, Ac. ... 14
This yields a total of 74 engaged in manual labour—in all,
88 male patients healthily occupied. Of the remaining 72,
40 are incapacitated by age, infirmity, or physical disease.
This leaves 32 unaccounted for, of whom about one-half
confine their attention to books, drawing, billiards, cards,
Ac. The final residue, 16 only, comprises those who baffle
all efforts to improve them—are either hopelessly indolent,
or else so demented or intractable that nothing can be done
with them.
Cash I.—(Hypochondriacal melancholia. Recovery.) G. A. W.,
admitted June 1st, 1886, aged 19 ; single ; fishmonger. His illness,
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869
1887.] by Lloyd Francis, M.D.
of a year’s duration, was attributed to the shock of a domestic
bereavement, self-abuse, to which he had been addicted from the
age of 16, being added as a predisposing cause. After undergoing
twelve months’ medical treatment at his home without benefit he was
at length sent here.
He was stated in the certificates to be greatly depressed; to exhibit
confusion of ideas and defective memory and intelligence; to take no
interest in his surroundings, and to be unable to occupy himself in
any rational way; to be very indecent in behaviour, and to entertain
delusions that his food was poisoned, himself ruined, &c.
On admission he presented, physically, a wretched spectacle.
Though his height was 5ft. 6£in. he weighed but 7st. 71b.
He was a long-limbed, lank, slender lad, pale and miserably thin,
with pinched face and cold extremities.
His mental was on a par with his bodily condition. He was pro¬
foundly unhappy, moaning, crying, declaring that nothing could be
done for him, and begging to be sent home. He talked in a childish,
irrelevant way, and gave a very vague account of his past life. He
seemed especially concerned about his indulgence in self-abuse, pro¬
testing at the same time that he had not practised it for two months.
He believed his “ inside ” to be in an unnatural state, saying that it
was full of “ trash ”—cakes, biscuits, and the like—that his bowels
were completely blocked, that nothing would ever pass through, that
it was " of no use.”
During the first three weeks he gave much trouble. He was most
obstinate about food—the stomach tube being frequently necessary—
all the while declaring that the “ trash ” in his inside would not
allow him to swallow anything more, and begging for aperients (which
he did not need). He went crying about the ward, and would not
employ himself in any way. Once he made his escape, but was
brought back. He lost weight (7st. 61b.).
He was then sent to work out of doors at gardening. There was
immediate improvement, but for six or seven weeks it was slight, and
more physical than mental. He took food more readily, gained weight
and colour, and was less constant in complaints about his “ inside ”
and demands for purgatives. He worked fairly, but in a listless way,
and looked very miserable. On account of his fondness for exposing
his person he needed constant watching out of doors. Later, how¬
ever, his progress was much more rapid and satisfactory. He began
to take interest in his employment, worked harder and more to the
purpose. The keener appetite produced by increased muscular effort
did much to dissipate his hypochondriacal ideas. He ate heartily,
and as a consequence improved amazingly in bodily condition (weight
9st. 71b.). He recovered his natural spirits, ceased worrying about
the state of his interior, became patient and contented, and took a
natural interest in his surroundings.
Though he has been for more than a month to all intents and pur-
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370 Outdoor Work as a Remedial Agent in Insanity , [Oct.,
poses well, and will be formally discharged in a few days, he betrays
no impatience, but exhibits untiring industry in and a strange fond¬
ness for the gardening work, to which he owes so much. He is free
from all trace of morbid idea or emotion, and is cheerful, vivacious,
and quick-witted beyond the average. Physically, he looks the picture
of rude health.
Case II.—(Mania. Recovery.) P. J. L., admitted Nov. 18th,
1884, aged 21 ; single; clerk ; first attack. Mental symptoms first
appeared about a year previously; and for nine months he had been
treated in another asylum, from which he was transferred here. The
assigned cause was “ strumous disease of the testicle.*' The family
history was not favourable, his father having died of phthisis. The
initial phase of his disorder was one of melancholia. He was very
depressed, said he felt that he was lost; had morbid fears of having
injured various persons; entertained delusions— e.g., that a potato
which he touched with a spoon was turned into blood; and had an
unnatural dread of coming into contact with females, even his own
sisters, declaring that they took away his strength by merely looking
at him.
On admission he was maniacal rather than melancholic. He was
restless and unsettled, untidy in dress, pert, conceited, and unfriendly.
His answers to questions were entirely irrational, and he was con¬
stantly punning in an absurd way— e.g. t “ May I ask how died, for
this waistcoat has been dyed ? ” He frequently talked to himself.
Physically, he was tall, slender, fairly well nourished, dark com-
plexioned, with small, regular features. Both testicles were enlarged,
indurated, not painful or tender to touch ; no signs of pulmonary
disease.
He was forthwith sent to work in the grounds, but would do
nothing. He resorted to all manner of shifts and excuses, would
simulate bodily illness, and even wilfully pass his evacuations in his
trousers in order to be brought indoors. In short, he was so in¬
tractable that the attempt to keep him employed was perforce
abandoned.
For four months he led a life of idleness, growing worse rather
than better. He was restless, mischievous, destructive, at times
violent. He exposed himself indecently, and lost weight and colour
through excessive masturbation. Sometimes he would read aloud,
apparently with the sole object of annoying others. He obstinately
refused to entertain the idea of outdoor work, and was saucy and
flippant in response to well-intentioned counsel. Occasionally, for a
day or portion of a day, there were gleams of improvement—he
would be more natural, reasonable, and decorous, only, however, to
relapse into his former condition.
Five months from admission he was (for pecuniary reasons) made a
second class patient, and transferred to a ward where his indoor life
and surroundings were not nearly so refined and luxurious as before,
Digitized by L^ooQle
1887.]
371
by Lloyd I'bancis, M.D.
and inducements to outdoor employment would presumably be much
stronger. He felt bis altered position keenly ; but for a time remained
deaf to all advice, and in the same unsatisfactory mental state.
At the end of six weeks, however, during one of bis lucid intervals,
he was prevailed upon to resume his work out of doors, with excellent
results. His recovery was rapid and uninterrupted by a single relapse.
His general condition, too, improved greatly ; he gained weight very
considerably, and looked bronzed and healthy. On September 12th,
1885, he was discharged.
Case III.—(Acute Mania. Secondary Dementia. Recovery.)
This case possesses rather a special interest, on account of the patient’s
previous intellectual successes, and his subsequent brilliant career.
C.W., admitted March 2nd, 1882, aged 20; single ; undergraduate.
Second attack (first at the age of 15) of nine days’ duration. Sup¬
posed cause, low physical condition through overwork, prolonged
suspense as to its result. He was a scholar of his college, and just
prior to his attack had succeeded in winning the first place in the
annual college examination. On admission he showed maniacal symp¬
toms ; he was restless and noisy, laughing and talking to himself in
an irrational, punning way ; applied fantastic names to people around
him; and was sleepless and destructive to bedding at night.
He went steadily from bad to worse for several months, and seemed
to be passing into a condition of hopeless dementia; was silent, obsti¬
nate, faulty in habits, drivelling, fatuous in aspect, indifferent to his
surroundings.
In July he was sent to work on the farm, wheeling a barrow being
the only employment for which his then mental condition fitted him.
For four or five months he continued at this occupation, with benefit
to his bodily health, but no material improvement in mind.
At length he showed signs of amendment; the first indication
being a request for a change of employment. Subsequent improve¬
ment, though steady and continuous, was slow, and it was not until
August 31st, 1883, that he was finally discharged.
After a short period spent in travel he returned to the University,
renewed his studies, and not only obtained his degree, but won the
second place in the Classical Honours List.
The fact that nearly five months had elapsed from the
date of admission before this patient was put to outdoor
work, aptly illustrates another practical difficulty, not pre¬
viously noticed—objections emanating from the friends of
patients. To the proposal, made soon after his arrival, that
this youth should employ himself, his parents offered decided
opposition ; his mother being particularly emphatic in her
refusal, expressing herself as greatly scandalized at the
fancied affront to the family dignity. It was only when
the case had assumed a most unfavourable aspect, and the
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372 Outdoor Work as a Remedial Agent in Insanity . [Oct.,
patient’s discharge had been presented as the alternative,
that they yielded a grudging assent. It is but fair, however,
to add that later they made full acknowledgment of their
error, and were profuse in their expressions of gratitude. „
Such an incident is not at all an exceptional one. On this,
as on other questions affecting a patient’s welfare, friends
and relatives are frequently more unreasonable, shortsighted,
and trying, than the insane individual himself. The wisest
course, then, and the one adopted here, is to declare and insist
that any patient who is not allowed to accept treatment—
be it in the shape of sedatives, tonics, or manual work—must
be removed from the hospital. Such a display of firmness
generally has the desired effect.
JBtiology, Pathology , and Treatment of Puerperal Insanity .
By A. Campbell Clark, M.D. Edin., Medical Superin¬
tendent Glasgow District Asylum, Bothwell.
(Continued from p. 189.)
The value of an examination of the urinary constituents
in the present investigation depends on (1) the promptness
with which it is made, and whenever possible it should date
from the first warning of mental attack; (2) on qualitative
and quantitative analysis ; (3) on microscopic examination;
(4) on fluid and solid measures.
The first condition is rarely obtained, and is possible only
in private practice, but exceedingly improbable unless the
subject is to the physician in attendance one of special
interest. It has been attended to in my practice immedi¬
ately on the admissions of the patients, provided they were
sufficiently recent. Some were, though comparatively recent,
transferred from other asylums, while others had been treated
at home for two or three weeks prior to admission. These
have not been allowed to obscure the calculation. The diffi¬
culty, however, did not end here, for some were so perverse,
or wet and dirty in their habits, as to render complete or
prolonged investigation impossible. Latterly I have got
over the difficulty by getting the nurses to draw off the
urine by catheter, a proceeding which is possible even in the
most troublesome cases by administering hypodermic injec¬
tions of hyoscyamine. The latter course, however, I did not
need to resort to.
Digitized by L^ooQle
1887.] jEtiology, Pathology, $c. of Puerperal Insanity . 378
It is unnecessry to explain the methods of examination
further than to state —
(1) That the urine was collected and placed in a graduated
vessel by a trained nurse; so far as possible it was kept
separate from fasces; when admixture occurred a supplemen¬
tary estimate was made.
(2) The night urine was calculated from 8 p.m. to 6 a.m.,
and the day urine for the remaining 14 hours. As far as
possible—and this was the rule rather than the exception—
the day urine was examined after 8 p.m., and the night
urine between 10 a.m. and 12 noon.
(8) The tests used for albumen were (a) heat, (l) nitric
acid, (c) picric acid; for sugar , (a) liq. potass© and heat,
(6) Fehling's method, (c) picric acid and liquor potass©; and
for bile pigments GmeLin’s test.
(4) The volumetric estimation of phosphoric acid was
arrived at by means of standard solutions of acetate of soda
and uranium respectively (v. Thudichum).
(5) For urea and chloride of sodium I adopted Liebig's
methods.
The number of cases subject to examination was 17, and
the results are summed up as follows :—
First. —The earlier the urine was examined, the more
certainly was it found to be scanty and of high specific
gravity.
Second. —The lowest fluid measure per day was ... 2 oz.
„ „ ,5 „ ,, night was 8 ,,
The lowest measure for 24 hours was ... 6 „
The average total for 24 hours, not ex¬
tending beyond first three days and
nights of residence, was ... ... 16*6 „
Average health total . 40 to 60 ,,
Third. —The lowest solid measure, calcu¬
lated by Christison’s formula,
was per day ... ... ... 2*6 grammes.
Ditto ditto per night . 6*08 „
The lowest for 24 hours was ... 8* 3 „
And the average for 24 hours,
not extending beyond first
three days ana nights ... 30*62 „
Average in health ... 40 to 60 „
Fourth .—These figures are all the more remarkable
in view of the following facts :— (a) That on admission the
urine drawn off was in some cases the accumulation of more
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874 ^Etiology, Pathology , Sfc. of Puerperal Insanity, [Oct.,
than 12 hours; (b) the continuous excitement and sleepless¬
ness of several patients; (c) frequent dryness of skin and
frequent constipation of bowels. The deficient ingesta of
the first few days of residence, and notably of the days pre¬
ceding admission, will help but very insufficiently to counter¬
balance the discounting causes which have just been
described.
Fifth .—Taking a range of observation wider than is com¬
prised in my tables, albumen was present in 9 out of 23; the
precipitate was usually slight; in one it continued in day
urine long after its disappearance from night urine; in another
it continued day and night for 16 days, and faintly reappeared
during convalescence.
Sixth .—Sugar was not present, though Dr. Savage has
found it in some cases. I have tested for it carefully, and,
having failed to find it, conclude that in Dr. Savage’s ex¬
perience it was the result of choloroform inhalation or
chloral treatment. Dr. Johnson’s test for sugar in some
cases produced a result which I at first attributed to the
previous exhibition of chloral, but the same result was
obtained with other samples of healthy urine, and I was not
surprised to find that boiling liquor potassse and picric acid
effected a similar coloration, only less intense. On looking
up the discussion on the subject between Drs. Pavy and
Johnson in the “Lancet,” Yol. II., 1882, I find Dr. Pavy
disputes the validity of the test on the same grounds. I
have not yet found saccharine urine in the other cases when
the remaining mentioned tests were employed, and I
may remark that the Fehling’s solution was perfectly fresh.
Seventh .—Bile is a rare appearance, though I have looked
for it in cases where a jaundiced appearance or clay-coloured
stools would suggest its presence. It was not present in
more than three instances, and these were cases of septi¬
caemia.
Eighth .—Chlorides were found scarcely traceable, being
so low as *36 grammes in 24 hours; for 14 hours of day
urine the minimum was ’09 grammes, and for 10 hours of
night urine *24 grammes. The daily average in health is 16*5
grammes according to Vogel. The following facts must here
be taken into account:—(1) The diet deficient in quantity and
saline quality ; (2) the appetite impaired; (3) the low state
of health and nutrition ; (4) although the mental excitement
was considerable, the degree of muscular excitement was not
increased in proportion—indeed, the patient was often kept
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376
1887.] by A. Campbell Clabk, M.D.
in a recumbent position fairly well; (6) the sum total of
pyrexia could scarcely be regarded as high, and a rise of
temperature was in Case I. of the second series examined
accompanied by an increase of chlorides; (6) a movement of
the bowels was rarely or insufficiently obtained within the
first forty-eight hours of residence, though fasces might be
formed abundantly; (7) the arrest of mucus secretion implies
another diminution of chlorides, for chloride of sodium is
an important constituent in mucus, and a stimulant of its
secretion; (8) again the chlorides were the last of the uri¬
nary constituents to return to their normal quantity.
The following conclusions then become obvious:—
(а) That a deficiency of chlorides may be partially, but
insufficiently, accounted for by (a) the anorexia and atonic
dyspepsia; (b) saline deficiency in the food administered;
(c) sluggish digestion, owing to artificial, instead of natural,
alimentation. I have found, in a series of investigations,
that feeding by stomach pump (even with food to some
extent predigested) does not stimulate digestion or absorp¬
tion well, and that a third of the quantity so administered,
if voluntarily taken by the patient, stimulates the secre¬
tions better, and promotes more vigorous digestion ; (d) the
pyrexia, which must in these cases be regarded as only of
moderate import; (e) moisture of skin. The hysterical case
had the minimum of chlorides.
(б) That these causes can only be taken pro tanto , because
(a) of excessive mental and bodily activity, the former espe¬
cially, when sleeplessness is taken into account, being a con¬
siderable factor; (b) pyrexia was, in the case where it was
highest, attended by an increase in the chlorides; (c) the
great discrepancy between the normal output and the
shadowy quantity recorded in the tables; ( d ) deficiency of
other excreta as well: As bearing on the question of excreta,
it must be recorded that as a general rule respiration was
shallow, yet frequently, and that in the earlier days and
nights of residence, the skin was dry. It is exceedingly pro¬
bable that in some way yet to be ascertained chlorides
accumulate in the system, and have some pathological signi¬
ficance in this disease, which we know not. The loss to
urine and mucus secretions have three possible explanations:
(a) chlorine starvation; (b) chlorine infiltration of tissues;
(c) chlorinaemia.
Ninth .—Phosphoric acid was also decreased, being so low
as *2 grammes in 24 hours, the minima being *07 for day
xxxiii. 25
Digitized by L^ooQle
376 JEtiology , Pathology , tifc. of Puerperal Insanity , [Oct.,
urine, and *25 grammes for night urine. The average for
24 hours of health is 3*5 grammes. The amount of ingesta
is not so material a calculation here. The diminution varies
in degree; in the hysterical case it is least evident, and is
restored to the normal state when weets later the chlorides
are low. The hyperpyrexia already noticed was not attended
with any increase, nor can the variations be explained by
the degree of mental excitement, for they are all much
below par. The quality rather than the quantity of mental
excitement is more likely to account for changes in the
excretion of phosphoric acid.
Tenth .—The urea total descended to 3 # 68 grammes in 24
hours, the lowest daily quantity was 1*32 grammes, and the
lowest nightly quantity 2*26 grammes; the average quantity
in health being from 30 to 40 grammes in 24 hours. Dimi¬
nution can only be regarded as a striking feature in one
case, although in some degree visible in all. It is soon
recovered from, and in Case III. I was surprised by its
excessive quantity. This patient was overfed with custards,
and she showed, by the state of tongue and stomach, that
digestion was weak; she lost weight rapidly for a time; and
yet she excreted urea in inordinate amount for her size and
weight, unless we regard it as the sum total for all the
excretory channels and as a result of her mental and motor
excitement. A reference to the history of each case shows
that any increase was in proportion to the degree of sleep¬
lessness and mania in the cases. It must, moreover, be
regarded as remarkable, in view of the almost complete
absence of the chlorides, which, according to Barral, increase
the elimination of urea, and other nitrogenous excreta.
Eleventh .—The deposits on standing were heavier in the
earlier days of the disease. This would be expected on cool¬
ing, owing to the deficiency of water. They were of different
kinds: (a) phosphates; ( b) urates; (c) mucus. Microscopic
appearances yrere of no importance.
Twelfth .—The early appearance of bacteria in the urine of
the scarlatina patient suggests for future study an investiga¬
tion of fermentative and putrefactive changes.
I now pass on to the pathological complications.
The time is not yet ripe for classifying the complications
of puerperal insanity. They have been too much overlooked
on account of the mental disease itself; and they have been
mentioned by writers in vague and general terms merely to
indicate their gravity • and seriously to influence their
Digitized by
Google
1887.]
377
by A. Campbell Clark, M.D.
prognosis. According to Batty Tuke and others, they
affect the prognosis of puerperal insanity very seriously.
This I regard as a mistake. My experience leads me to
view pathological complications as something tangible, and
within the reach of the surgeon or physician, and something
that gives palpable indications for treatment. That a
strange fatality does follow the appearance of some com¬
plications goes without saying; but something of this is due
to our error in not recognizing them soon enough and often
enough. We frequently err in neglecting to ascertain their
existence, and too often in our examination lose sight of the
pelvic and genital regions altogether. In no class of cases
is gynaecological investigation of more importance than in
the study of puerperal insanity.
As already indicated, blood poisoning is an important
complication of puerperal insanity. Without an actual
examination of the blood, and an experimental investigation,
it is not possible to demonstrate the milder forms of
septicaemia; and though their seats of origin and areas of
secondary deposit may be strongly inferred in some cases, it
is difficult to assume the onus probandi in not a few cases
where the conclusions are not altogether free from a charge
of speculation. Under aetiology I have already referred to
this subject, and need not again go into detail, merely
contenting myself with a statement of some doubts and
difficulties that meet the observer from time to time.
(а) His first difficulty is to make sure of a local and
primary seat of infection, and this is not always easy with
insane patients. For one thing, the evidence of pain or its
absence must not be implicitly relied on, and the bowels
should be thoroughly evacuated before an attempt is made
to settle the question. Even then the restlessness of the
patient will disturb and distract attention, and as the septic
lesion is often slight enough to elude the tactile sense it may
be missed altogether.
(б) Sudden rises of temperature, whether preceded by a
chill or not, will often perplex the physician. They may be
septicsemic, phthisical, zymotic, neurotic, or simple inflam¬
matory, and they may refer purely to intestinal causes.
Zymotic disease will soon settle the question, so far as it is
concerned, and so will phthisis, unless it is a true tubercular,
but the differential diagnosis of the others is not so easy,
and in one case of periodic pyrexia I had difficulty in
deciding between hepato-intestinal disorder and scepticaemia.
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378 Mtiology , Pathology , fie. of Puerperal Insanity , [Oct.,
Next in importance to septicaemia and its congeners is
phthisis pulmonalis. Batty Tuke records three cases of
death from phthisis out of 73 patients labouring under
puerperal insanity, and Dr. Boyd gives two out of 63. My
number is three out of 40. Bronchitis, pneumonia, and
heart disease have, so far as these statistics go, been
less frequent, but they are recorded. I have found no
record of mammary abscess in the experience of others, but
it was a complication of two cases of melancholia under my
care. The abnormal conditions of the primes vice have been
already referred to.
Rarely was a recent case admitted that did not exhibit
uterine or allied symptoms of abnormal character, the most
frequent being pain on pressure in the hypogastrium, and
scanty, extremely offensive, lochia. Precision of examination
w&s not always possible, but if accuracy of diagnosis was not
assured, the certainty of some form of uterine or allied
disease was frequently established. Three post-mortem
cases showed pelvic inflammation, and a dirty sloughy
placenta site in the typhoid case. One case, which recovered,
had pelvic cellulitis; another, retention of clots in uterus,
with high fever and deeply seated pain in right iliac region;
while a third complained only of tenderness on pressure over
the uterus. These are fair illustrations of many other cases
which might be quoted, and suffice to show the importance
of attending to the condition of the uterus and pelvic cavity.
Anaemia is a complication which in varying degree is as
frequent as the insanity itself. It is a subject which in this
connection opens up a prospect of profitable study; and a
series of clinical estimates of haemoglobin and haemacytes, by
means of the haemoglobinometer and haemacytometer, would
4>e of great value.
The subject is new to me, and I have only data of two
cases, in which the percentages were as follows:—Haemacytes,
68’7 and 76*4; haemoglobin, 60 and 65; the cases being
respectively one of insanity following post-partum haemorr¬
hage, and one where a series of depressing circumstances
predisposed to insanity. With Dr. McPhail’s valuable
records for guidance and comparison a specially interesting
and utilitarian field is here open for research. The scope of
it must not, however, be limited by mere considerations of
percentage, quality, and composition; the foreign elements
are of still more account, and especially their toxic
significance. The state of the blood furnishes a veiy
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379
1887.] by A. Campbell Clark, M.D.
complex problem, and until we bring into view its whole
pathology, distinguishing the varieties of blood disorder to
which the puerperal subject is liable, and the different
indications furnished by each, the disease will be regarded
empirically, and its treatment will be founded on a narrow
incompetent pathology.
The Treatment of Puerperal Insanity will be considered in
a subsequent article.
(To be concluded in the next number .)
Our Laws and Our Staff 1* By Dr. Oscar Woods, Medical
Superintendent, District Asylum, Killarney.
As the British Medical Association does not often visit
Ireland, I think the present not an unsuitable time to lay
before this Section a few facts which I think of special bearing
on the management of Irish asylums, and largely affecting the
interests of their inmates. My object, however, is as much to
elicit the opinions of others as to impart information. When
the Psychological Association met in Dublin in 1875 an in¬
teresting paper was read by Dr. Stewart on the “ Obstacles to
the Advancement in Ireland of Psychological Medicine,” and
laid principal stress on the fact that 18 out of 22 Irish asylums
had no assistant medical officer. Suffice it now to say that
they have since been appointed to five other asylums, but that
there are still 13 asylums without a second medical officer.
I now, however, wish to draw your attention to two subjects :
1st. Our Laws ; 2nd. Our StafEs.
The Inspectors and several of the Irish superintendents have
frequently drawn attention to the admission forms in use, but
as their defect is great, we are bound not to let the subject rest;
when life is endangered , surely it is time to press for a remedy.
As, probably, many of you have not seen the forms in use, I
have one of each here. Form E, as approved by Privy Council,
is for general use, but as it causes unnecessary delay, and needless
trouble and expense to the friends, it is seldom used. Applica¬
tion has to be made for it at the asylum, and, when filled,
again returned before the patient can be transmitted. As a
consequence, in 1885, 862 patients were admitted as u ordinary
cases,” while 1,846 were committed by justices as “ criminal
lunatics.”
• Read at the Psychology Section of the British Medical Association,
August, 1887.
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380
Our Laws and Our Staff, [Oct.,
The objections to the committal of a patient on the warrant
of two magistrates as a criminal are manifest and manifold,
and have frequently been drawn attention to by the Inspectors
in forcible language; they, therefore, need not here be referred
to at length. Nervous patients are handed over to the care of
the police, and, in many instances, their recovery retarded. The
patient is made a criminal through no fault of his own ; as the
police know nothing of the history of the patient, little infor¬
mation can be gained. The Lunacy Inquiry Commission
reported in 1879 that 13 superintendents condemned it and
only one approved of it. An onus is thrown on the superin¬
tendent as regards the legality of these committals which is
scarcely fair, and a superintendent not long since was put to con¬
siderable cost in defending himself in an action at law for detain¬
ing a patient on a slightly informal warrant, although he took
all the required steps to have it corrected. An eminent judge
has quite recently stated that there is an important difference
between the English and Irish Acts; “ that in the former if
all the documents were regular, and if there was a reasonable
and probable cause for believing the man to be insane, that
amounted to a defence to an action for imprisoning him; but
that under the Irish Act it would not be a good defence, unless
it was also proved that the man was actually insane.” It will,
I presume, scarcely be questioned but that this law should be
amended.
With regard to both these forms, there is a general vagueness
as to dates, the length of time a committal will hold good for,
and Form E does not require the medical man to have seen the
patient within any specified time., But, perhaps, the chief
defect in the law is, that no one is made responsible for inquiry
as to the state of a supposed lunatic unless an overt act has been
committed, an information sworn, and the police put in charge
of the case. Asa consequence, I have known patients to be
kept at home for many months, an annoyance to their friends,
a danger to themselves and all around them, their prospect of
recovery interfered with, not unfrequently suicide, and, some¬
times, murder committed. Within the last few days a man
committed suicide whose friends had endeavoured to get him
into an asylum, and who had been for some time insane and
under supervision, but the magistrates refused to commit him,
as he was charged with no indictable offence. Not long since a
murder was committed by a man who was manifestly insane
for several days, but neither family, doctor, nor priest took any
step, although appealed to, believing he could not be sent to an
Digitized by L^ooQle
1887.]
881
by Oscab T. Woods, M.B.
asylum until lie was charged with some overt act, although he
was seen sharpening a knife, as he said, to kill his wife. The
offence was soon committed, and he is now deprived of his
liberty for life.
But, probably, the last case that occurred is fresh in the minds
of all, where a man in the County Down ran wildly through the
country and in the course of an hour murdered four people. “ Two
attempts had been made to commit him as a dangerous lunatic,
but no one could be found to swear he was such, and through a
legal technicality he was allowed to go loose.” On the other
hand, it is never difficult to commit as dangerous, feeble old
women and harmless idiots from the Workhouses, many of the
other inmates being only too ready to swear an information
in order to relieve themselves of some slight responsibility.
As proof that this Act was never intended for general use,
we have only to read the circulars issued from the Chief
Secretary to the magistrates from time to time, and to know
that it was drawn up on the lines of the Act of 1837 (i
and 2 Viet., c. 14), which regulates the committal of English
criminals. In 1885 there was but one committal in England
on this Act, while in Ireland, on the Act drawn on the same
lines, 1,846 were committed. A comparison of statistics for
the two countries is, therefore, incomprehensible. Now, had
the Irish Act of 1867 (30 and 31 Viet., c. 118) been drawn up
on the lines of the English Act of 1853 instead of that of 1837,.
much good might have resulted.
Why, then, you will ask, does not the Legislature pass a
short Bill to remedy this state of things ? In 1879 the late
Lord O’Hagan introduced into the House of Lords a Bill “ To
extend to Ireland some provisions of English and Scotch law as
to the care of Lunatics.” This was withdrawn to await the
report of the Lunacy Inquiry Commission. Mr. Litton intro¬
duced a similar Bill into the House of Commons in 1881, and a
third Bill was introduced by the then Lord President in 1883,
“ To make better provision for the care of the Lunatic Poor in
Ireland; ” but all these Bills were of too extended and sweep¬
ing a nature, admitted of too much debate, and had con¬
sequently to be withdrawn. Still, I believe if a strong
representation was made by this Association, pointing out the
advantages of a change, a short Bill might be passed un¬
opposed.
But the mode of committal not only injures the patient and
exposes the superintendent to unfair risks, but it deals more
directly with our Statistical Returns than one might at first
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382
[Oct.,
Our Laws and Our Staffs
imagine. As no official is made responsible for the absolute
correctness of the admission forms, the information given in
them is usually most meagre, sometimes altogether left out, and
often incorrect; and as friends rarely accompany a patient to
an asylum, it is, as a rule, impossible to obtain further history.
The causation table, among others, might be of much greater
value than it is. In 33 per cent, of the cases the cause is re¬
turned as “ Unknown,” and this percentage would be
increased but that two asylums, Carlow and Ennis, have only
failed to get information in three cases. I have taken a large
number of English Asylum Reports, and I find that in only 14
per cent, of the cases has no cause been assigned; and this
would be considerably lower but that Birmingham Asylum
returned the cause as “ Unknown ” in 48 per cent, of admis¬
sions. Referring further to this table, I find the different
causes are returned in 1886 as follows :—
Percentages.
t -;- K -\
Moral. Physical. Hereditary. Not known.
English Asylums... 25 75 27 14
Irish Asylums. 21 41 20 34
If we had a fuller history I am sure the hereditary predis¬
position would be much higher for Ireland, as consanguineous
marriages are more common. Of the patients admitted to the
Killarney Asylum in 1886, whose history I was able to
obtain, I found in 46 per cent, a hereditary taint.
I hope before long to see a similar set of Statistical Tables
adopted by English, Scotch, and Irish Asylums. Although
the Medico-Psychological Association Tables have not been
adopted in their entirety by the Irish superintendents, much
general information regarding staff expenditure, &c., is given
by them, which is excluded from many of the English reports.
The Consanguinity Table, which is of much interest, is also
published only in Irish Reports. Mortality Table No. VIII
should, however, in Irish reports, be given more fully, as it is
not easy to understand in a condensed form why the mor¬
tality, when there is little general paralysis, should range from
3*7 to 16 per cent.
And now with regard to our Staff. This subject, of course,
has a direct bearing on the recovery of our patients, and their
happiness while in the asylum. 80 and 31 Vic., c. 118, sect.
2, deals with it as follows: “ The said Governors shall
appoint all servants necessary for such asylum.” For my own
part I cannot easily imagine anything more detrimental to the
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383
1887.] by Oscar T. Woods, M.D.
interests of an asylum and the well-being of the patients than
this division of responsibility, as, of course, if a superin¬
tendent has not a trustworthy and competent staff he cannot
well be wholly responsible for the management of his asylum.
Kirkbride, on “ Hospitals for the Insane,” refers to this subject
as follows : u The superintendent should especially have that
kind of tact and judgment which will enable him to fulfil effi¬
ciently one of the most important functions of his office, that of
selecting individuals for every department, fully qualified to
discharge their appropriate duties, and who will be held by him
to a strict accountability in their proper performance.” “ The
power of appointment and discharge should be clearly and un¬
conditionally with the physician in charge. A single inter¬
ference with his power could hardly fail to lead to acts of
insubordination and a disregard of the proper authority, and to
prove to a greater or less extent destructive of all good
discipline and the thoroughly efficient working of any institu¬
tion.”
I believe in many asylums in England the head-attendant
and matron are, in the first instance, asked to select candidates
for the approval of the superintendent. Why in Ireland should
the superintendent be altogether relieved of the responsi¬
bility in this important matter ? I believe that some of my
colleagues will say it is better not to have the appointments.
It is hard to get good and trustworthy men and women, and
it is better to leave the onus on the Governors. Possibly for a
time we might have difficulties, but I with confidence assert
that no asylum can be managed as it should for the best
interests of the ratepayers, and for the happiness and recovery
of the patients, when the superintendent has not the absolute
appointment and control of all the attendants.
In many asylums the superintendent, no doubt, has a voice
in the election, but no superintendent will make a selection
from a limited number of inferior candidates drawn only from
the immediate neighbourhood, and, owing to previous canvass¬
ing, possibly not always have his choice approved of. The
secret of the good working of an asylum is a happy and
contented staff of long service, proud of the institution,
and doing their work for duty’s sake. To secure this,
Privy Council rules must throw the responsibility of selec¬
tion on the superintendent, and if they think right give
a vetoing power to the Board. Who would think it ad¬
visable to interfere with a medical man in regard to the drugs
he might order ? Why then interfere in what is of as much
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384
Our Lam and Our Staff, [Oct.,
importance, viz., the moral treatment ? It is quite as necessary
in the majority of cases as medicine; therefore, unless you have
this essential element in the treatment of your patients justice
cannot be done them.
I trust the day will soon come when ladies will enter the
wards of asylums, male and female, as they now do the
hospitals, and assist the medical staff in reasoning with and
comforting the melancholy, calming the excited, and training
the imbecile. I am certain that when such is the case the per¬
centage of recoveries will be largely increased, and that many
patients that now drift into dementia, and are left a burden on
the rates for life, will be cured, and possibly not unfrequently,
as the breadwinner of a household, save others also from be¬
coming chargeable on the rates. I would wish to see added to
the staff of every asylum at least two ladies, to be appointed
by the. superintendent, and be altogether under his control,
whose sole duty would be the moral treatment of the inmates.
To look at it in a monetary point, suppose their cost would be
£160 a year, might we not look to at least that saving in the
rates ? I feel strongly that if the nursing staff of our hospitals
for the insane were very considerably increased in numbers and
in intelligence, we should reap advantages untold in many
ways, and not have so often, as at present, to resort to bricks
and mortar. How can one nurse for every twelve or fifteen
patients be made accountable for their cleanliness, neatness,
and order, the care of their clothing, the sanitary condition of
the dormitories, closets, &c., and at the same time undertake
the proper moral control of her patients ? I contend that even
with the best will and the desire to perform her duties for con¬
science’ sake, she never has the time and seldom the intelligence.
At present our staffs are selected from the same rank in life as
our patients. How much more control would they have over
them if they were selected from a rank in life better educated,
with feelings more refined, hearts more sympathetic ? The
public would then indeed look on our asylums as hospitals for
the cure of disease, and not, as I fear they now too often con¬
sider them, houses for the detention of the dangerous.
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1887.]
385
On the Use of Galvanism in the Treatment of Certain Forms of
Insanity * By Joseph Wiglesworth, M.D.Lond., Ram-
hill Asylum.
The question of the value of electricity in the treatment of
insanity is one concerning which much difference of opinion
appears to prevail, although there seems to be a more or less
general idea that it is, or ought to be, of some service. We
every now and then read of cases which have progressed to
recovery under the application of this agent, but, as far as one
can judge from published records, very little has hitherto been
done in this country to study the question at all thoroughly or
systematically.
Germany, as usual, is ahead of us in this respect, and the
readers of the “ Journal of Mental Science ” will have seen occa¬
sional abstracts of laborious work done in this direction with¬
out perhaps feeling that their ideas on the subject have become
much more luminous.
Fourteen years ago Dr. Newth + reported a series of fifteen
cases in which galvanization of the head was tried, in several
of which much benefit appeared to result; and, more recently, J
the same author has again advocated this form of treatment.
Dr. Robertson § has also recorded a case of insanity of seven
years* standing which recovered under the use of galvanism.
We have lately || been indebted to Dr. de Watteville for
some much needed instruction as to the best method of ap¬
plying the current, and I am personally under obligations to
this author for kindly furnishing me with information on this
point.
There seems to be the more need for a thorough examination
of the question, as of late years the improvement in medical
batteries, and the introduction of apparatus for measuring the
strength of the current, have, for the first time, rendered it
possible to approach the subject in something like a scientific
manner.
It was with the view of testing the value of electricity in the
light of these more recent advances that the few observations
I have the honour of laying before you were undertaken, and I
can only regret that they are not nearly so numerous as I could
have wished.
* Paper read at the Psychology Section of the British Medical Association,
August, 1887.
t “Journal of Mental Science,” April, 1873. t Ibid., Oct., 1884.
§ Ibid., April, 1884. || Ibid., January, 1885.
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886
Galvanism in the Treatment of Insanity , [Oct.,
I am very hopeful, however, that the addition of facts by
other speakers will enable us to see our way more clearly than
before.
Previous to proceeding, however, to the actual narration of
cases, it is necessary to make some general remarks as to the
form of electricity and kind of apparatus employed. For much
useful information on the subject I am indebted to Dr. de
Watteville's admirable little work on €t Medical Electricity.”
My experience in the matter has been confined to the use of
the continuous current or galvanism. The battery selected was
one of fifty Leclanch^ cells, which gave fairly satisfactory re¬
sults. It was fitted with a dial collector for bringing the cells
gradually into action, two being added at a time. I may call
attention here to the fact that one essential point in the selec¬
tion of a battery is that the current should be capable of very
gradual increase, so as to avoid all sudden changes. For this
purpose it is advisable, if possible, that it should be fitted with
an apparatus for throwing the cells into action one by one.
A contrivance for reversing the poles of the battery without
moving the electrodes is also advisable. But one of the most
important points in a battery is that it should be provided with
an apparatus for measuring accurately the strength of the
currents used.
Dr. de Watteville especially insists upon this, and my own
experience has convinced me of the necessity of it. Without
it no results can be of scientific value. If anyone is doubtful
on this point, a little practice with a battery fitted with an
absolute galvanometer will suffice to convince him. To begin
with, if a battery is much used, the cells most in action tend
pretty rapidly to diminish in strength, and consequently the
same number of cells will give a different reading week by
week. But more important than this is the fact that the re¬
sistance to the passage of the current presented by the skin,
always considerable, varies very much in different persons, and
consequently for two given patients, although the same num¬
ber of cells be used, the actual strength of the current passing
is by no means the same.
Then, again, the resistance of the skin is always greatest
when the application is first commenced, and as this tissue be¬
comes permeated with moisture it diminishes considerably, so
that to produce a constant strength of current more cells have
to be used in the first instance than may become necessary in a
time which is of very variable duration. Furthermore, from
a failure of some of the connections, or exhaustion of the
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1887.]
387
by Joseph Wjglesworth, M.D.
battery, no current whatever may be passing, and yet the
operator, in ignorance of this, may be calmly noting down the
number of cells employed and the effects on the patient; for
when a person is in a state of stupor it goes without saying
that he cannot describe to us his sensations.
This is not an imaginary occurrence, for it has happened to
me more than once that I have only been made aware of the
fact that no current was passing by the needle of the galvano¬
meter remaining stationary. The ordinary galvanometer, or
galvanoscope, will indeed indicate whether any current is
passing or not; but, as Dr. de Watteville points out, the angle
of deflection in it is not proportional to the current, and there¬
fore for scientific purposes its readings are of no value.
What we require is an absolute galvanometer graduated in
milliamp&res, and with this we can measure accurately the
exact strength of the current used in every instance, and note
it down for future reference. The battery I employed was
fitted with such an instrument, and the current strength used
being in every case recorded in milliamperes, the data collected
are hence capable of comparison with those of other observers.
The electrodes used in my experiments were the flexible plate
ones, recommended by Dr. de Watteville. Medium sized ones,
3£ in. x in., were in the first instance employed, and the
method adopted at the commencement was to apply the cathode
or negative pole to the forehead, and the anode or positive pole
to the nape of the neck. Subsequently, whilst retaining the
anode in the same position and not altering the size of it, I had
a large plate constructed, 6| in. x 5i- in., for use as the cathode,
adapted to cover accurately the whole of the vertex of the head.
One practical point to remember here is that these flexible
plates require to be well covered, as eschars are very liable to
form under the point of application, especially at the edge of
the plate, when strong currents are employed. This has, of
course, to be guarded against all the more carefully when the
sensations of the patient operated upon are dulled, as is so
frequently the case with the insane. It is not sufficient, with
strong currents, to cover the plates with a single layer of wash-
leather, for I have several times seen eschars form under these
circumstances; a double layer of this material has, however,
always appeared to afford sufficient protection to the skin.
I shall not waste time in theorizing as to the way in which
galvanism acts on the nervous system, nor on the reasons
which are supposed to furnish indications for the use of either
pole, as authorities appear to differ considerably on the subject,
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388
Galvanism in the Treatment of Insanity, [Oct.,
and it seems doubtful how far we are treading on safe ground.
There appears to be no doubt, however, that the galvanic
current is capable of producing both powerful stimulating and
sedative effects, according to the manner and duration of its
application, and that it has also great influence on nutrition,
though whether this is exerted directly, or through the medium
of the blood vessels, does not seem certain.
I will now give an account, as brief as possible, of eleven
cases of insanity in which treatment by galvanism in this
manner was given a fair trial. I only include in this series
cases in which more than ten separate applications were made,
for in two or three instances attempts at galvanization had to
be abandoned, owing to the resistance or intolerance of the
patients when the number of sittings had not reached half-a-
dozen, from which consequently it would not be safe to draw
any conclusions.
All the patients were females.
Case I.—E. D., married, set. 23. Mental condition : Acute
dementia. Patient had a blank expression, was perfectly taciturn,
and sat usually with her head bent forward, taking no notice of any¬
thing ; she resisted everything that was done for her; had to be
washed, dressed, and fed, and was dirty in her habits. The cause of
the insanity was parturition, and its duration six weeks previous to
admission. Treatment by galvanization was not commenced until the
patient had been four months in the asylum, so that the case had then
lasted nearly six months without the slightest sign of improvement.
Flexible plate electrodes of medium size, 3| x 2~ in., were employed,
the cathode being placed on the forehead, and the anode on the nape
of the neck, and, with a few exceptions, these were the positions main¬
tained throughout the treatment. A start was made with a current
strength of three milliamperes, applied for six minutes, and this was
gradually increased to 25 milliamperes for ten minutes, as much as 30
being used on one occasion. The average current strength employed
may be put at 15 milliamperes, and the time of application ten
minutes. Usually there was a daily sitting, but sometimes a rest was
given of one or more days, so that 60 applications, which was the
total number used, were spread over a period of three months. At
first the current did not produce much effect, but as the strength was
increased patient resisted a good deal, and there was a good deal of
flushing of the face. No mental change was, however, noted until
after 27 applications, when patient was observed to be a little brighter.
She would occasionally do a little needlework, and at times answer
“ Yes ” to questions, in a whisper. She kept, however, dirty in her
habits. A day or two after this she was for one afternoon quite lively,
talking and singing. But little change occurred for auother three
Digitized by U^ooQle
t
1887.] by Joseph Wiglesworth, M.D. 889
weeks, when patient was described as decidedly brighter, and occupied
with cleaning windows. The improvement thus effected was main¬
tained, though it progressed in a very gradual manner, and three
months after the galvanization was stopped patient was bright and
industrious, answered questions readily and rationally, and her
memory appeared good. No relapse occurred, and she continued to
progress favourably until her discharge.
In this case, I think, a cure may fairly be claimed for the
treatment, for, though the case was one which usually termi¬
nates in recovery, and the age of the patient was distinctly in
her favour, it must be remembered that the case had lasted for
nearly six months without sign of improvement before galvani¬
zation was commenced, and this certainly appeared to me to
have a distinct influence in arousing the brain from its lethargy.
Case II.— C. L.,aet. 15, single. First attack. Melancholic stupor
of mild type. Treatment by galvanization commenced eleven weeks
after the onset of the attack. The flexible plates were applied, as in
the first case, to the forehead and the nape of the neck, the cathode
being on the forehead. A current of 3J milliamp&res, applied for five
minutes, was used to begin with, and the strength was gradually
increased to 20; the average may be put at 12 milliamperes for ten
minutes. In all 22 applications were made, which were spread over a
period of six weeks. For the first three weeks no change occurred,
but after this patient gradually became somewhat restless and talka¬
tive ; she developed, in fact, a mild maniacal attack, from which she
convalesced in about two months after the discontinuance of the
galvanization.
In this case the treatment appeared to be of some benefit,
and seemed to have an effect in changing the type of the
symptoms from melancholia to mild mania. Eighteen months
after her discharge, however, she was readmitted in a condition
similar to that which she presented in the first attack. No
special treatment was resorted to. Her case ran through very
similar phases, and she is now again convalescing.
Ca8B III.—E. P., aet. 30, widow. Simple melancholia, without
delusions. Patient was very fretful and depressed, wandering up and
down the ward, moaning and groaning, and could not be got to
employ herself in any way. The case had lasted two years previous
to admission, and galvanization was commenced two months subse¬
quently, no change having at that time taken place in the patient’s
symptoms. A large flexible plate (anode), in. by 3^ in., was
applied to the nape of the neck, the medium-sized one (cathode) being
placed on the forehead. Treatment was commenced with five
milliamperes, applied for ten minutes, this strength being gradually
Digitized by A^OOQle
390 Galvanism in the Treatment of Insanity , [Oct.,
increased to 14, which was the highest that could be employed, as
patient was throughout very intolerant of the applications. The
average current strength was seven milliamperes, continued for ten
minutes each time. Sixteen sittings only were resorted to, and these
were spread over a period of 23 days. Great and rapid improvement
resulted. When the galvanization was stopped patient was noted to
be much more cheerful and active, and to be working fairly well. In
three weeks more she was convalescent, and she was discharged the
following month recovered. This patient was seen a few months ago,
nearly two years after her discharge, and she had continued well up
to that time.
In this case there can, I think, be no question of the great
value of the treatment. I do not, of course, assert that recovery
would not have taken place without it, but when we consider
that the case had lasted upwards of two years before treatment
was commenced, and that the patient was practically well six
weeks after the galvanization was started, this conclusion
seems to be justified. I think, however, that in this case the
benefit derived was as much psychical as physical; the patient
disliked the applications immensely, and these appeared to act
in a reflex manner by giving the patient the stimulus she
required to make an effort to rouse herself from her lethargy.
Case IV.—M. A. G., set. 44, married. Melancholia of six weeks'
duration. The same 6ized electrodes were used as in the last case,
the larger one being placed between the scapulae and the other on the
forehead. The current strength employed varied from 4 to 20
milliamperes, 25 being used on one occasion, but this caused faint¬
ness. The average may be put at 17 milliamperes for ten minutes
each day. Twenty-six applications were used during a period of 27
days, and the treatment was then discontinued on account of a small
eschar forming on the forehead. At first slight benefit appeared to
result, but this proved only temporary, and no permanent improve¬
ment ensued. The patient is still an inmate of the asylum, and the
progress of the case has raised a suspicion of general paralysis.
Case V.—E. K., set. 28, married. First attack. Melancholia
agitans, the result of lactation. Duration, previous to admission,
three weeks; treatment by galvanization commenced two months sub¬
sequently. Five milliamperes were employed to begin with, gradually
increased to 20, the average being 14 for ten minutes. Twenty-six
applications were used in the course of one month, and the treatment
was then discontinued, as it seemed to be doing more harm than
good. Six months after this the patient began to improve, and she
was discharged recovered five months subsequently, but after this
length of time the recovery could not be in any way attributed to the
galvanization.
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Case VI.—H. C., married, set. 25. Second attack. Melancholia
due to lactation of three months’ duration previous to admission;
treatment by galvanization commenced four months afterwards. In
this case the plates were at first attached to the forehead and.nape
of neck as before, but the applications were afterwards varied by
placing the larger electrode between the scapulae, and the medium-sized
one beneath, each ear alternately. The highest current strength
employed was 15 milliamperes, but the average was only seven for
eight minutes. The patient, indeed, manifested such great intolerance
of the treatment that this had to be discontinued after 19 applications.
No improvement whatever resulted, and the patient is still an inmate
of the asylum.
Case VII.—M. C., aet. 29, married. Melancholia of two weeks*
duration previous to admission; treatment by galvanization com¬
menced five months afterwards. The large plate—anode—was placed
on the nape of the neck, and the medium-sized one—cathode—on
forehead. Four milliamperes were used to begin with, and this
number was increased to 20, 25 being used on a few occasions, the
average current strength being 15 milliamperes for ten minutes.
Thirty-one applications were resorted to, spread over a period of five
weeks. Patient throughout manifested great intolerance of the treat¬
ment, and, as it appeared, if anything, to aggravate the mental distress
and hyperesthesia, it was discontinued. No improvement has since
resulted, and the case has become chronic.
Case VIII.—M. A. D., set. 33, married. Melancholia, verging
on stupor of one week s duration on admission ; galvanization com¬
menced two months subsequently. The plates were at first applied as
on previous occasions, but after a few applications the medium-sized
one on the forehead was discontinued, and a very large plate, x 5£
inches, adapted to cover the vertex of the head, was applied to this
region, and used as the cathode. Commencing with eight milliamperes
the current strength was gradually increased to 20, and on one
occasion to 25, the average being 15 milliampbres for ten minutes.
The total number of applications was 35, spread over a period of two
months. After a month’s treatment an improvement set in, which
was continued with a slight intermission ; two months after the
galvanization was stopped the patient was convalescent, and she was
discharged the following month. In this case the galvanization
appeared to have a distinctly beneficial effect, and the recovery may,
I think, fairly be attributed to it.
Case IX.—M. J., aet. 30, single. Melancholic stupor, of six
months* duration previous to admission, three months after which
treatment by galvanization was commenced. The largest flexible
plate was applied, as in the last case, over the vertex of the head, the
smaller one being placed as usual on the nape of the neck or between
the scapulae. A strength of five milliamperes was used to begin
with, and this was increased to 15; the average being only nine
xxxiii. 26
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milliamp&res for ten minutes. Patient showed great intolerance of
the applications, and these had to be discontinued after 17 sittings
on account of a small eschar forming, so that the treatment scarcely
had a fair trial. No improvement whatever resulted, and patient is
still an inmate of the asylum.
Case X. —M. L., aet. 27, married. Melancholic stupor of eight
weeks' duration previous to admission; treatment by galvanization
commenced one month subsequently. The medium-sized flexible
plate (cathode), applied to the forehead, was used for the first 30
applications, but after this the largest plate, covering the whole of
the vertex of the head, was employed for the cathode, the scalp
having been first shaven ; the anode was placed in the usual position
on the nape of the neck. The treatment in this case was spread over
a period of nearly six months, 81 separate applications being made.
A current strength of five milliamp6res was used to begin with, and
this was increased to 35, and on one or two occasions to 40, the
average being 22 milliamperes. The usual time of application was ten
minutes, but the sitting was continued on several occasions to fifteen
minutes, the average being about 12. In addition to the uniform
steady application of the current, “ voltaic alternatives 99 were used
on 32 occasions, that is, the poles of the battery were rapidly reversed
several times in succession; by this means very powerful shocks can be
transmitted through the head.
In this case the treatment was persevered in for a longer
time, and the current strength employed was greater than in
any previous case. The result was that the patient's condition
was sensibly ameliorated ; instead of being obstinately taciturn,
and sitting still, taking no notice of anything, she was got to
occupy herself a little in the way of carrying things from ward
to ward, and she would at times answer simple questions; she
also washed and dressed herself. The treatment was dis¬
continued on account of a serious falling ofE in the strength
of the battery, which rendered it for some time practically
useless, and it was not again resumed. The patient retained
the ground she had gained under the use of the galvanization,
but her condition remained quite stationary for a few months
afterwards; since then she has brightened up gradually, but
still (18 months since treatment was stopped) remains an
inmate of the asylum, and is not, I fear, likely to leave it.
There seems to be no doubt that the galvanization had a
beneficial influence in this case, and I cannot help thinking
that had I been able to continue the treatment longer, and more
particularly' to keep on increasing the strength of the current,
a cure might have resulted.
Case XI.—B. N., aet. 20, single. First attack. Melancholic
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stupor of mild type, of five weeks’ duration. The largest electrode
was fixed on the vertex of the head, and the medium-sized one on
the nape of the neck. The current strength employed ranged from
6 to 28 milliamperes, the average being 18 for ten minutes. Forty
applications were made in all, and these were spread over a period of
seven weeks. When the galvanization was discontinued it did not
appear to have effected any change in patient’s condition ; shortly
afterwards, however, an improvement set in, in a couple of months she
had brightened up wonderfully, and two months later she was dis¬
charged recovered.
It is possible that the treatment may have had an influence
in producing this result, but one cannot feel at all certain of it.
If we sum up now the results of the foregoing cases we
shall find five (Nos. 4, 5, 6, 7, and 9) in which no benefit
whatever resulted from the use of the battery, though it is fair
to remark that three of these showed a great deal of intolerance
of the current, and hence this was not persevered in very
long. Two cases (Nos. 2 and 10) improved under the galvani¬
zation, whilst in one other (No. 11) the benefit derived seemed
more doubtful. In the remaining three cases (Nos. 1, 3, and
8) a cure resulted.
Three cures out of 11 cases can certainly not be considered
a very startling result, especially when one bears in mind the
fallacy that must always underlie an affirmative issue. If no
improvement ensues in a case we can, at least, be certain that
the treatment has done no good; but if recovery takes place
we cannot be equally sure that such recovery is due to the
agency employed. This fallacy is, of course, all the more
difficult to guard against when a small number of cases is
under consideration. In truth, the series of cases above given
is not, I think, of much value statistically, and this, not simply
on account of the smallness of the numbers, but also because
the cases were not altogether unselected. Several of the cases
were picked out, indeed, because they were either of some
severity or had lasted a considerable time, in order that the
efficacy of the treatment might be submitted to a thorough
test. They possess, therefore, more of a qualitative than a
quantitative value. To give my own opinion in the matter, I
must say that I have been a little disappointed at not getting
better results; at the same time, in some of fche cases, the
treatment appeared to be of real value.
The class of cases in which galvanism was tried has been
indicated above; cases of mental depression, stupor, and torpor
appeared to offer the best field for its use, and to these my
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observations have been mainly restricted. In cases of mental
excitement, even if the treatment were likely to be of benefit,
there are considerable practical difficulties in the way of its
application, and in the only case of mania in which I attempted
it, these were found to be insuperable. But in the case of
melancholia with excitement above described (No. 5), the treat¬
ment appeared to do harm rather than good. If I may judge
from the cases submitted to treatment, the more the case
departed from simple depression in the direction of stupor and
torpor, the more good did the treatment seem to do. Case No.
3 is, indeed, a notable example to the contrary, for here the
good effects seemed to be much more psychical than physical,
and this suggests that in appropriate cases treatment directed
in this way might be turned to good account. It would, how¬
ever, be necessary to take great care in the selection of cases,
as in some of the patients with melancholia the galvanism
appeared rather to aggravate the mental hypersesthesia—at
least at the time of application. When the treatment does
good psychically, as in the above-mentioned case, it probably
does so by supplying a sort of reflex mental stimulus to
exertion. But what we have to rely upon most is the
physical effect of the current, and though it is difficult at
present to say exactly how it acts, it probably produces a
powerful stimulating effect on the nervous centres, and at the
same time improves the nutrition of the parts, either by a direct
trophic influence or through the agency of the blood vessels.
But though we conclude that galvanism is capable of pro¬
ducing good effects in certain cases of mental disorder, we
must not overlook the reverse side of the question, namely,
whether it may not also at times be potent for harm. Certain
it is that it is an agency which requires careful employment.
I have seen faintness, retching, actual vomiting, and a peculiar
form of hysteroid convulsions result from too strong or too
prolonged currents, though never any permanent bad effects.
So that I think the applications should be conducted by the
medical man in charge, and not be entrusted to an attendant,
except in case of necessity, and after previous education in the
subject.
Briefly now to sum up the conclusions which present them¬
selves from the foregoing considerations, I should say—(I)
That whilst the usg of galvanism to the head is a proceeding
which is certainly not going to revolutionize the treatment of
insanity, this agent is nevertheless one that is capable of doing
much good in certain selected cases, and that by its judicious
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employment we may every now and then cure cases which
would otherwise drift into hopeless chronicity. (2) The class of
cases which offers the best field for the employment of this
agent is that which includes examples of mental stupor and
torpor—cases which are grouped under the specific designations
of Melancholia attonita and so-called Acute dementia •
CLINICAL NOTES AND CASES.
Cases of Masturbation (Masturbatic Insanity). By E. C.
Sfitzka, M.D., of New York.
(Continued /romp. 264.J
The following case presents us with an interesting picture
of alcoholic delirium, engrafted on a masturbatic neurosis.
When the former was recovered from, certain features of in¬
sanity, due to masturbation, prevailed.
VII.— Strumous diathesis , repeated over-exposure to the sun , masturba¬
tion , masturbatic character-change , alcoholic excesses, alcoholic
delirium , katatonic insanity , complete recovery.
Frank-, aged 23, no ancestral mental taint. Both parents are,
however, weakly persons, the mother particularly, who presents a
strumous appearance. His elder brother is a somewhat talkative, but
intelligent and sound man. As a child the patient was always healthy,
and in his adolescence nothing peculiar was noticed in him. There
was, at the time of my examination, and had been for some time
before, a swelling of the lymphatic glands on the right side of his
neck, which subsequently enlarged, and yielded to iodine applications
and surgical measures. His sister, at the age of three years, had the
same condition, which yielded to the former means. In his ninth
year the patient, while bathing in a hot sun, was taken with a fit of
so-called “malaria.” This name has been so often applied to any
obscure condition that I suppose it a safe assumption to consider it to
have been a partial insolation. In his eleventh year he had an attack
of sunstroke, since which he has never been able to go out in the sun
without bringing on a severe headache, and, if sufficiently prolonged,
a decided malaise .
Masturbation was begun in his fifteenth year, and it was carried to
extremes. During the last few years he has alternately indulged
in coitu to excess, masturbation, and occasionally intemperance.
Six years ago he was very much worried by business troubles. It
appears that his uncle objected to his being in the employ of the firm
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Clinical Notes and Cases .
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which he and the patient’s father were members of. The uncle in
question finally succeeded in driving him off, and then defrauded hig
partner. The discouragement of this first business association had a
bad effect on the patient, and the next situation he obtained, which
was a very good one, did not satisfy him. He secured a position in a
Customs Office, with light work &nd good pay. After having been
six months in this place he was noticed to act strangely; he would
laugh, joke, and be boisterously jovial, so that he had to be reproved.
These 6pells of elation frequently recurred, and alternated with fits of
depression, in which he would allow his work to accumulate, and sit
motionless, staring at his desk. He was removed from his position,
and taken into partnership by his brother. In this new relation it
was found that whatever work was laid out for him, or belonged to
the business routine, he could perform well, but in all matters in
which he was left to judge for himself, including his private affairs,
he had less judgment and self-reliance. All this time he worried
about the old grievance against his “ Uriah Heap ” uncle. His
brother was compelled to leave the city for a week, and during that
time the landlady noticed him to be very despondent, crying and
moping, and not having spontaneity enough to venture in the street
without his brother. Matters went on in this way for a year, when
the brother went to Europe, and, before leaving, laid out the patient’s
routine work for the period of his absence. But the steamer on which
he returned was six weeks in making the passage. The delay greatly
excited the patient. He was seen nervously twirling his moustache,
and broke down in health. His brother returning found the business
affairs in good order, and resolved to give F. a vacation. He
accordingly sent him to join his parents in Europe. He manifested
much irresolution as to leaving at all, had a disagreeable passage
over, and, on recovering from sea-sicknes§, indulged in bacchanalian
excesses, which were continued after landing. His mother observed
that he would sit before a letter for hours, as if mustering resolution
to write it, and then leave it uncompleted. He overdrew on his
letters of credit, and ran through a large sum of money in London.
It was ascertained that he indulged in the wildest sexual orgies. His
comrades in these excesses commented on the fact that the patient
was not drawn to the opposite sex when in good health and spirits,
but when he felt most dejected and “ blue.” All this time, as before
in New York, he expressed a great horror of contracting venereal
disease or becoming ruptured. To these morbid fears was finally
added a dread of kidney disease, and on one occasion, while in a
railway car, he urinated out of the car window while the train was in
motion, because he had “ a pain in the kidneys,” and wanted to see
whether he could pass water freely.
Finding that he grew worse instead of better, and was, to use an
expressive phrase of his comrade, “ saturating himself with whisky,"
he was started back to New York, much against his wish. He ceased
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Clinical Notes and Cases .
397
drinking abruptly on joining the steamer, and had nightmares the
first few nights. On the third day out he saw the 6ea-serpent in end¬
less coils following the vessel, in company with “ funny little men.”
He began to notice that the other passengers would purposely lay
newspapers containing references to the Dublin scandal — which
occurred about this time—on the table near him, and look at him in a
peculiar way, and (according to the ship surgeon's account) imagined
he was suspected to be a refugee from Dublin Castle.
As the steamer discharged its passengers, an appraiser, who was a
mutual friend, said to the brother, “ Frank looks very funny ; he
can’t pack his own things or make a declaration unless you will help
him.” His brother took him on board his private yacht, recently
built. The patient boarded it as if it was nothing new to him; met
an old friend whom he had not seen for years, and greeted him as if
he had been in daily communication with him. He had a ring in the
shape of a serpent, coiled as the Egyptian symbol of eternity, and gave
it to one of his acquaintances, saying “Take it away, I do not want
these snakes around.” At this moment the captain of the yacht was
examining the ring, when the patient, with glaring eyes, snatched it
from him and cried out for champagne. Meanwhile the yacht arrived
at its destination, and the patient took off his shoes and declined to
leave it. He could not be induced to go on shore until the others
threatened to leave him alone on board. On arriving at a hotel he
seized a water flask, ground it fiercely on the table, saying “ Give me
a glass of water; for God’s sake give me a glass of water! ” He
stared at the waiter, asking “What does he stand there for?”
Meanwhile the elder brother went out under the pretext of getting a
cigar, but in reality to make some arrangements about the patient’s
surveillance. On his return he found that he had eloped. A younger
brother, who was left behind, said that he mumbled something about
being put in a room previously occupied by a hotel guest who was
syphilitic. It seems that the landlady, who had been informed of the
nature of his trouble, had followed him on his disappearance from the
dining-room. The patient went to the room assigned him, and,
lighting his pipe, said “ I am lighting my pipe here, and he is light¬
ing his cigar there, and I ought to be with him.” The landlady
attempted to calm him down and keep him in the room, but he levelled
his cane at her as if to fire off a gun, and, dodging past her, darted
out and reached the street. His subsequent movements were traced.
He had gone into a restaurant and left it as if under some sudden
terror, leaving his cane, hat, and overcoat behind him. When his
brother found him he said that the devil was after him, that he would
have to go to a certain hotel and drink ice-water till midnight, when
the devil would leave him alone. He went, as he intimated, and stayed
out his time, when he received a bath and a hypnotic, not having
slept for ten nights previous. On dressing he declined to put on
dark clothes, as he was afraid of the “ black pox.” While dressing
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Clinical Notes and Cases.
[Oct.,
he bad an idea that a race was going on, and repeatedly counted
“ one, two, three.” Then he asserted that he would wait till three,
as Christ was about to pass, and take three pills. He was removed
to the yacht the following day, and by the fourth appeared calm and
more rational. But when sitting in the office after his return he
would be often found holding the newspaper upside down. He spoke
vaguely of a “ Wall Street scheme,” and appeared to have some idea
that his head was “ not sound.” On the fifth day he indulged in
alcoholic excesses, and was exposed to the sun’s heat. That evening
he laid out his clothing in a peculiar way, and a number of matches in
a special position. He would repeatedly cry out “ Is everything all
right as I left it ? ” for the first four hours of that night. He left
for Saratoga, and gave his companions a great deal of trouble, pick¬
ing up rolls and throwing them at other guests at a railroad restaurant,
declining to eat, and afterwards ravenously swallowing everything
within reach. He also developed a habit of picking up his hat and
bag and throwing them away, as if the victim of uncontrollable im¬
pulses. He was successfully turned from his path and taken back to
this city. Here, while in the bar-room of one of our largest hotels,
he would repeatedly slide down from his chair, keeping his heels on
the floor. The party were compelled to leave the place in con¬
sequence. In a public square he took off his coat and hat, and pro¬
ceeded to remove his shoes. His brother knew of no other device for
getting him out of the crowd which this procedure collected than to
hail a cab and suggest a trip to Coney Island. The patient saying
“ That is a good idea,” forthwith knocked an old gentleman’s
umbrella out of his hand. As soon as the cab came he went in at one
side and out of the other, exclaiming “ This is not the boat.” But
he was easily got in again, and the cab was kept driving round and
round till the detectives summoned arrived. In the cab the muscular
disturbance became very great. He touched the top with his feet, and
braced himself up stiff in that position. When he got out he re¬
entered the hotel. His hat fell off, and one of the detectives standing
by handed it to him, on which the patient threw it back into his face.
While on the way to a private asylum he would twist his hat, push
off and on the “ snake ” ring before mentioned, and look at his watch
or play with some pennies in a childish manner. He was transferred
to a carriage, and while it was summoned he lay down in the street,
again collecting a crowd. He refused to get up, and muscular move¬
ments occurred, which were almost convulsive in character. These
continued in the carriage, so that he reached the asylum with
scarcely a shred of clothing on his person. On arrival he was very
restless, and turned three or four summersaults # in the reception-
room ; then he took his trousers off. He was received on August
1st, and I examined him on November 3rd of the same year. The
most remarkable features were the peculiar movements he indulged
* He is an athlete and an exoellenb gymnast.
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Clinical Notes a/nd Cases.
899
in; he would contract his brows, and at the same time purse up liis
mouth as old-fashioned ladies are in the habit of doing when reprov¬
ing children before company. Simultaneously he would move his
hands from his forehead to his chin, make a pass, and resume the
motion. His facial contortions at times resembled those of typical
katatonia. While I examined him with a stethoscope he said, “ Yes,
understand it all—liver-disease, lung-disease, Bright's disease,
cancer, dropsy, death, and so on.” He seized an ornament on my
watch-chain, representing in negative relief a Roman warrior’s bust,
and said u Latin Principia.” To every question he began a rational
answer, but the movements would be resumed before he completed it,
and he would talk at random, grinning and grimacing as related.
His pupils were dilated. He said, u My memory is covered by a veil.”
On December 15 he was entirely rational and responsive. His pupils
were contracted more than at the last visit. Occasionally he repeated
his rhythmical movements in a faint way. He correctly reproduced
the history of his case as given by his brother ; forgot what he
noticed on my watch-chain, but remembers that lie seized it. On
being shown it, remembers what he said, and that the head of the
Roman suggested the school-boy reminiscence : u Latin Principia.”
He admits having masturbated excessively from his fifteenth to his
twenty-first year, and adds that he had attacks of alcoholic delirium
on more than one occasion at the appraiser’s office. On this occasion
his automatic movements could be checked by calling his attention to
them. To some extent this had been possible at my first visit, when
due firmness was employed.
The patient made an absolute recovery, and has continued in
perfect menial and physical health since his discharge, a period of
two years, and in spite of mental and emotional strain.
One of the most important modifying factors of masturbatic,
as of other forms of insanity, is heredity. Masturbaitc in¬
sanity proves no exception to a generalization which I have
not seen expressed elsewhere, but to which there are very few
exceptions, that heredity is a favourable element as regards the
immediate prognosis in the emotional vesanias , and an un¬
favourable element in the primary delusional and moral forms.
An illustration of its favourable influence under the former
alternative is the following case:—
VIII.— Heredity direct , two attacks of melancholia , precipitated by
self abuse and overstrain or anxiety , peculiar motor symptom in the
second attack , recovery .
A physician, examined at a large private asylum at the request of
his relatives. I had known the patient before ; his mincing gait and
peculiar manner had often been the subject of remark. He had once
before been in an asylum for the same trouble, the exciting cause
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Clinical Notes and Cases .
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being supposed to be an approaching medical examination ; bnt I am
informed by two American physicians, who studied at the same
University then, that it was a notorious fact that he masturbated
coram publico . His father had been an eccentric person, easily
depressed, and had attempted suicide. Several other relatives were
unsound, one cousin being in an asylum abroad.
About five years ago he came to this country and engaged success¬
fully in medical practice. The exciting cause of the present malady
grew out of a mortifying professional error. He had been treating a
sister-in-law of his cousin, being consulted by the father of the
patient, himself a physician. Both agreed in regarding the disorder
treated as a rheumatic affection of the ankle-joint. Dr.-, how¬
ever, expressed a suspicion that the disease might be deeper, but
continued treating the foot with palliative measures under the
influence of the older physician. The swelling and pain increased,
sinuses opened, and a surgeon was called in, who instantly took steps
to perform the necessary operation for tarsal necrosis. Evidently
something said, or supposed to have been said, by this surgeon
rankled in the minds of the family, and one female relative, an
elderly virago, stopped Dr.-in the street as he was leaving his
office and saluted him with most uncomplimentary epithets, re¬
proached him for his lack of skill, and threatened to spread the news
thereof among all his friends and patrons, and to drive him out of his
profession and out of the city. Her tongue attracted a great crowd of
people, and the timid victim stood before her hemmed in on every
side, held up. to the scorn of the street arab, and compelled to submit
to the deluge of her wrath without reply. This rencontre greatly
depressed him. The surgeon above mentioned delayed notifying him,
according to the custom, of the time and place of operation, and
Dr. P.-thought himself slighted, underrated, and contemned by
his colleagues. At and previous to this time he had indulged in his
bad habits, and he now became depressed. Always pale, his complexion
now was ghastly, and he lost flesh rapidly. Under other advice he
was sent to one of the numerous private asylums of a neighbouring
State, which would doubtless perish in the contest for existence if a
proper lunacy supervision existed. He was thence transferred to the
institution where I examined him. I found him very much changed
in appearance, so that I should certainly not have Tecognized him. He
was reticent, at first absolutely mute, but on being appealed to with
kindness and firmness, he answered questions in monosyllables. He
correctly gave my name, and the last occasion we had met on. He ex¬
pressed in. a vague unsystematized way a fear of attacks on his soul’s
welfare as well as of bodily injury. He also asserted that on his arrival
here the attendants wanted to strangle him, holding their hands over
his mouth and putting pillows around his head. He has never failed
to recognize persons or the nature of the places in which he was and
is confined. Whenever his morbid ideas are followed up, he becomes
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Clinical Notes and Cases .
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1887.]
apparently humiliated, and his face assumes an expression of mean
suspicion, looking downward. He has a peculiar habit—since being
in this institution—of standing on tiptoe. He would maintain this
uncomfortable position so persistently that the question arose as to his
possibly developing a spastic affection, but no objective 6ignsof spinal
disease can be found. He has repeatedly masturbated while in the
asylum, and done so quite publicly, holding a newspaper, as if reading
it, for concealment of the act. As he improved, he could be occasion¬
ally induced to settle down on the full sole of his foot in standing and
walking, and ultimately did so voluntarily. I observed that the hair
had grown considerably all over the convexity of his scalp, which
previously had been entirely bald. He was, according to the latest
information, recovering in his native land, to which he had been taken
after his discharge from the asylum. s
{To be continued.)
A Case of Epilepsy. By W. J. Dodds, M.D., D.Sc., Montrose
Boyal Asylum.
Harry S., a boy of 15, a baker by trade, was admitted into the
Birmingham Asylum under the care of Dr. Whitcombe, on May 24,
1883. He was unconscious, and during the quarter of an hour he
was in the reception-room he had four epileptic fits.
History .—Six years ago, when a boy of nine, he had a fall, and is
said to have hung with his head downwards for a minute or two.
There was no mark of injury on his head. Two or three weeks after¬
wards he was observed to go off in a sort of “ swoon ” occasionally,
but it was not until six months after the accident that he took his first *
fit. His right side was convulsed. He now began to take fits,
right-sided fits for the most part, at infrequent intervals, sometimes
having as many as four or five a day, but never having any series of
fits till Christmas, 1882. The series began on a Tuesday, and he
was in fits, more or less, till the following Friday. When this
attack passed off he was found to have lost the use of his right arm
and of speech ; but he regained both within a week, speech first, then
the use of the right arm. Since Christmas he had had single fits,
but not many, and his parents thought he was growing out of them.
He was able to go to work, and was not paralyzed or disabled in any
way. He was always a sharp lad. About a month before admission
he had begun to take fits more frequently, and their number had
steadily increased. During the last fortnight his speech had been
affected. Since May 20th, that is four days before admission to the
asylum, he had scarcely been out of fits ; and his right arm had ap¬
peared paralyzed since that time. During this attack, and in all his
previous ones, the fits had been mostly on the right side, but some-
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times his body was convulsed. On his father’s side his grandfather
and two uncles had been insane. Such, then, was the history.
Condition on admission .—The patient when brought to the asylum
was in the status epilepticus . The convulsions were mainly, but not
altogether, on the right side, and they followed one another with
great rapidity. They began in the right face, the muscles of the
angle of the mouth on the right side and the right orbicularis
palpebrarum being chiefly affected; the head and both eyes were
drawn to the right, and the pupils became widely dilated. Soon the
right arm became convulsed ; then both legs, but the right much
more so than the left, and lastly the muscles of the left shoulder and
neck twitched slightly. A long breath was taken, and the fit
suddenly ceased. The eyes turned to the left and the pupils became
contracted.
As the bowels were not acting properly an enema was administered,
which brought away soft, yellow faecal matter. At two o’clock in
the afternoon he had 40 grains of potassium bromide by mouth.
3.30 p.m.-—He has had 51 fits; temperature, 101*4; pulse, 120,
full, soft; no cardiac bruit, though there is a slight impurity of the
first sound in the aortic area. Respirations normal. Patient is
sweating profusely. The conjunctival reflex is retained on the left
side, but almost absent on the right. There is paralysis of the right
arm and apparently of the right leg ; he has not been noticed to move
either except in a fit. The left arm and leg he frequently moves. In
the intervals of the fits there is no puffing of the cheek or evident
paralysis of the face. The patient seems quite unconscious, but on
shouting to him and asking him to put his tongue out he does so.
His tongue is thickly coated white.
6.20 p.m.—The number of fits has risen to 92 ; they are the same
in character as the one described. Since the last note he has had an
attack of excitement, but it soon passed off. Immediately after a fit
he is often observed to open his eyes and turn to the left. Harsh
breathing is detected at the base of the right lung, with distant
rattling sounds on expiration. Ordered 60 grains of potassium
bromide in two doses.
11.20 p.m.—He is still taking fit after fit. When spoken to he
sometimes moans and mutters something. He has been taking small
quantities of milk occasionally. 30 grains of potassium bromide, and
of chloral hydrate, ordered every three hours.
May 25, 9.30 a.m.—He has had 364 fits. They are still of the
same character. The temperature has now risen to 103*1 on the left
side, 103*2 on the right side. The sweating ceased at 3 a.m. ; the
pulse is 148, the respirations 44 per minute.
11 a.m.—Ten drops of nitrite of amyl inhaled; a fit followed a few
minutes after.
1 p.m.—The temperature has risen to 103*8. The left conjunctiva
not so sensitive as it was. Once during an interval slight diverging
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strabismus of right eye was noticed. The pupils are contracted in the
intervals, and still dilate rapidly when fits come on. Ten drops of
amyl nitrite again given ; and four grains of calomel on tongue.
3.30 p.m.—Nitrite of amyl, gtt. x, given for the third time. The
blush was very distinct on the chest, but a fit occurred a few minutes
afterwards.
The fits continued steadily till 5.30 p.m., when they ceased ; that is,
a little less than 30 hours after admission. During this time there
had been 472 fits. The last fit was stated to be an unusually severe
one ; he got discoloured in the face and frothed at the mouth.
6.30 p.m.—Is lying comatose; temperature 104*2, pulse 140,
respirations 58 per minute.
11 p.m.—Temperature still rising, it is now 105° ; respirations 52,
pulse 144. He has had four slight fits since the last note, making a
grand total of 476. The face is drawn to the left, and he has become
very restless. He moves both legs.
May 26, 9.30 a.m.—Was very restless during night. The
temperature has fallen to 102*8, but the respirations are 48 ; the
pulse very rapid and weak, and scarcely to be counted. The right
leg is freely moved, the riglft rihn a little. He can speak, saying
“Yes, yes, sir;” but is only semi-conscious, answering different
questions in just the same way.
May 27.—The temperature has dropped to 99°, respirations to 26,
pulse 120. He is becoming more conscious and regaining power over
right leg, arm, and face. He cannot whistle. He takes food well.
May 28.—Speech is still muttering and indistinct; he is confused,
scarcely seeming to comprehend what is said to him, and not always
answering simple questions.
May 30.—Speech still ataxic. An eruption of acne on both sides
of face near nose, and a few spots on forehead.
June 1,—Lips tremulous ; he slurs words, scarcely getting them out.
Drags right leg in walking. Ordered potassium bromide, gr. x., three
times a day.
June 3.—Now walks with only a trace of weakness in right leg.
Ataxia in speech disappearing. Is slow at reading; is some time
before he can spell out a simple word.
June 15.—Very irritable and quarrelsome, threatening other
patients, and sometimes striking iliem ; makes use of bad language.
July 11.—Still some impairment of speech. Complains of being
unable to do anything with the right hand; it shakes when he uses
it; he finds it difficult to write with it.
July 15.—Home on trial. To take potassium bromide, gr. xx.,
twice a day.
July 30.—Has had no fits since he went home, and is looking well.
There is still some impairment of speech, a slight stutter occasionally
with a slurring of the words, and a difficulty in saying what he wants
to say. He complains, too, of weakness, and a feeling of deadness and
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numbness at times in his right arm, and he is rather clumsy with
it, letting things fall oftener than he used to do. The leg is quite
normal.
August 10,1883.—Discharged recovered.
He had no fits for about twelve months, but they came on again, and
caused his discharge from the Navy, which he had in the meantime
entered.
On May 20, 1885, he was again admitted to the Birmingham
Asylum.
The medical certificate stated that he had been violent, thought his
relations were against him, had shouted murder, struck his father and
mother, and seemed to be unconscious of what he was doing.
On admission he was calmer, and answered questions rationally,
but his memory was impaired, and he told a long and incredible story
about being assailed by his father and brother, and stated that his
mother had attempted to stab him.
While in the asylum he was excitable, quarrelsome, pugnacious,
striking and kicking freely at times. The excitement and irritability
seem to have been greatest after his fits.
A remarkable change had come qjei*the character of the fits. They
were no longer mainly unilateral, but were ordinary general epileptic
fits. The attacks were sometimes very strong. The number of the
fits varied greatly. In June, 1885, there were 94, in July 4, August
3 ; in the following March 4, in April 22.
In May he was well enough mentally to be sent home on trial, and
in June, 1886, he was discharged recovered.
The patient's father informs me (March, 1887) that his son still
takes fits, sometimes two a week. They are not so severe as they
were. At times the whole body is convulsed, at other times the con¬
vulsions are on the right side. He knows when the fits are coming
on, for half a minute before very peculiar thoughts come over
his mind.
Remarks .—The outstanding feature in this case is the large
number of fits the patient had. In 30 hours he had 472 fits,
or one every four minutes, and when we remember that for
four days previously he had scarcely been out of fits we can
form an idea of the vast number he must have had during the
attack. The case, as far as my reading goes, beats the record.
The boy seemed to have a perfect genius for fits.
Another feature in the case is the fact that the fits were
unilateral. They were not absolutely unilateral, for there were
often convulsive movements in the left leg and slight twitching
of the left shoulder and neck. But the convulsions were by
far the most marked on the right side, and the left face and arm
were not convulsed.
A third point of interest is the post-epileptic paralysis.
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1887.]
During the status epilepticus the arm and leg were apparently
paralyzed, and after the patient became conscious there was a
degree of ataxic aphasia and paresis of the arm and face, and,
in a slight measure, of the leg. The leg soon recovered, but it
is interesting to note that as long as two months after the
attack, there was still impairment of speech and deadness and
numbness of the right arm. This is an unusually long period
for symptoms of post-epileptic paralysis to last.
The pathology of the case is far from clear, but the symptoms
point to an irritative lesion, a fine, not a coarse, lesion, affecting
the cortical motor centres for the face and arm on the left
side. The mere fact (says Gowers in his “ Epilepsy,” p. 236)
of local commencement and deliberate march (of a fit) does not
alone constitute evidence that there is organic disease, since
fits begin thus in idiopathic epilepsy not at all rarely.
An important question arises. Was this a case of epilepti¬
form convulsions, or, as it is variously termed, Jacksonian
or organic or cortical epilepsy ; or was it a case of idiopathic,
primary, functional epilepsy ? My own view is that it partakes
of the characters of both; in its early stages it resembled a
case of epileptiform convulsions, in its later a case of idio¬
pathic epilepsy; the one stage passed into the other. The case
seems to me to show that the distinction between epileptiform
convulsions and true epilepsy is not a very deep one.
Two theories are held as to the pathology of idiopathic
epilepsy. By the one school it is considered essentially an
affection of the medulla oblongata or pons; by the other
school, with H. Jackson at its head, it is considered an affection
of the cerebral cortex. Our case may, I think, be fairly
adduced in support of the latter view that epilepsy is, like
epileptiform convulsions, due to a discharging lesion of the
cortex cerebri. It may be compared with a case recently
reported by Dr. Noel-Paton ("Brain,” vol. viii.) which pre¬
sented the two distinct classes of fits, Jacksonian epilepsy and
ordinary epilepsy, now one, now the other, after fracture of the
parietal bone.
I must, in conclusion, express my thanks to Dr. Whitcombe
for his permission to publish the case and for his kindness in
supplying me with the notes of its later progress.
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[Oct.,
OCCASIONAL NOTES OF THE QUARTER.
Lunacy Acts Amendment Bill .
And so once more this unlucky Bill has been arrested in
its development into a fully organized Act. It is very
wearisome to be obliged every year to consider proposed
changes in the Lunacy Laws and to have to insist upon the
necessity of not interfering with the prompt treatment and
care of the insane by vexatious preliminary proceedings and
complicated forms. Above all is it a thankless office to
attempt to convince the highest legal functionary of the
land that a medical man may be better qualified than a
lawyer to diagnose the nature of the mental disorder under
which a person labours. So long as a Lord Chancellor
having charge of a Lunacy Bill deliberately asserts from
the Woolsack that the lawyer is as competent as the physician
to determine whether a .man has or has not disease of the
brain, so long will any legislation which he initiates or sup¬
ports be liable to proceed on fundamentally false lines, and
so long will it be simply impossible to urge with any prospect
of success the profound objection entertained by the Parlia¬
mentary Committee of the Medico-Psychological Association
to allowing magistrates the opportunity of revising and re¬
versing the certified opinion of a medical man, or entrusting
them with the function of a personal examination of the
alleged lunatic with a view to determine his mental condition.
It would, however, be unfair not to acknowledge the
courtesy with which the Solicitor-General listened to the
representations made by a deputation which waited upon
him for the purpose of stating the objections entertained
by the Medico-Psychological Association to a number of
clauses in the Bill. Sir Edward Clarke wished the interview
to be of a somewhat private character. He entered into the
suggestions made in the most friendly spirit, and frankly
admitted the force of some of the objections which were
pressed upon his attention. There can be no doubt impor¬
tant amendments would have been introduced by the
Government in the House of Commons, and that if Mr.
Clarke has charge of a similar Bill next Session, important
modifications will be introduced, although the fundamental
principle—the personal intervention of the magistrate—will
no doubt be regarded as essential to the Bill.
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1887.]
Occasional Notes of the Quarter.
407
Irish Lunacy Law.
The Psychology Section of the British Medical Association
will not have met in Dublin in vain if the protest which it
made against the Lunacy Law in Ireland leads to an alteration
in some existing enactments. If in England we are in danger of
suffering from over-cooking in legislation, it is very clear that
the provisions hitherto placed upon the table of the Legislature
relative to the insane in Ireland have been underdone. The
result is an indigestible mess, which causes serious disorder in
the practical working of the legal formalities required in the
admission of patients into asylums and in the management of
these institutions. We commend to our readers the paper on
this subject, read by Dr. Oscar Woods at the above Section.
The following resolution was unanimously adopted at the
meeting of the Section, Aug. 5, 1887:—
iC The Psychology Section of the British Medical Association,
having had under consideration during their meeting in Dublin
(Aug., 1887) the Irish Lunacy Laws and their practical work¬
ing, and having strongly felt their grave defects when com¬
pared with those of England and Scotland, conclude to bring
the subject under the consideration of the Council of the
Association in the hope that they will take such steps as seem
desirable to bring under the attention of the Government the
urgent need of better regulations, and, if necessary, of further
legislation with regard to the matter.
“ The chief defects are the following :—
“ 1. The modes of admission of patients into asylums, which
often involve injustice and injury to the patient, and great
danger to the public.
“ 2. The defective powers possessed by the medical superin¬
tendent for the proper and efficient management of the asylum,
e.g., his having no power to engage or to dismiss the attend¬
ants, on whose loyal discharge of duty the welfare of the
patients so greatly depends.
“ 3. The want in the majority of cases of assistant medical
officers, so that the medical superintendent is unable to give
the necessary time to his strictly medical duties, and large
asylums, containing some hundreds of lunatics, may be left
entirely without resident medical supervision when the super¬
intendent is absent/’
XXXIII.
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408
Occasional Notes of the Quarter.
[Oct.,
Examinations and Prizes in Psychological Medicine.
The movement initiated by the Council of the Association
two years ago continues to make steady and satisfactory pro¬
gress. The opportunity afforded for examination, and the con¬
ditions attaching to it, are now generally known, and men see
the advantages which obviously attach to the possession of a
certificate of efficiency in psychological medicine. Its value in
applying for asylum appointments, and, indeed, in general
practice, is being more and more appreciated. We have no
doubt that in course of time the possession of the title of M.P.C.
will be one among the qualifications required by the com¬
mittees of asylums in the selection of medical officers.*
The institution of the Gaskell Exhibition of £30, to be
awarded annually as an Honours prize in psychological medicine,
has already induced competitors to come forward for examina¬
tion, and the prize was awarded, for the first time, in July last,
to Dr. J. D. Mortimer. As holding the efficiency certificate
or diploma is one of the conditions of this prize, a fresh induce¬
ment is offered to qualify for the pass examination.
The Assistant Medical Officers* Prize of £1010s. and a medal
led this year to a spirited competition, the successful competitor
being Dr. Wiglesworth, of the Lancashire County Asylum,
Rainhill. The essays sent in were remarkable for the careful
clinical work which they exhibited, and their excellence was
such that the adjudicators found some difficulty in determining
which bore the palm of merit.
We record these facts as proofs of increased activity in the
cultivation of a knowledge, at once theoretic and practical, of
medical psychology. We are not among those who attach
excessive importance to examinations and the winning of
prizes. They may be so conducted as to fail to secure what is
of primary utility, and may lead to superficial cramming. It
has, however, been the object of the examiners to make these
examinations of a thoroughly practical character; and it is to
be hoped that such will always be the case. We have reason
to know that this is the earnest wish of those immediately
concerned in placing the Gaskell fund at the disposal of the
Association. We think it a duty to put this desire on record
in order that it may help to ensure its being constantly borne
in mind by future examiners.
* The next pass examination will take place on the 22nd and 22rd December,
1887.
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1887.]
409
PART II.—REVIEWS.
The Life of Percy Bysshe Shelley . By Edward Dowden,
LL.D. Two Vols. Kegan Paul, Trench, and Co.
London, 1887.
(Continued from p. 310.)
It is an abrupt transition from the record of Shelley’s re¬
marriage to that of his parting from his wife. Let us con¬
sider the causes which led him to adopt this extraordinary
course. As Dr. Dowden puts it, Harriet awoke from the
grand theories of liberty, equality, fraternity, and human
perfectibility, and “was able to perceive her husband’s in¬
firmities, and he could perceive hers” (p. 404). No doubt
Harriet, being human, was not perfect, but we fail to discover
what these infirmities were. It would seem that, having to
attend to the practical duties of motherhood, she had less time
for the study and reading aloud of which she had been so
fond. We are told that she could not be Shelley’s companion
in his absorption in Laplace, Homer, or Tacitus, the dialogues
of Plato, or the poetry of Tasso, Ariosto, and Petrarch in the
original. On the other hand, to certain ladies (Mrs. Newton,
Mrs. Boinville, and Cornelia Turner) with whom he had
begun to spend much of his time, Shelley felt more power¬
ful attractions than to the young mother and her infant child.
As the biographer justly remarks, in reference to his new
acquaintances, Shelley’s “ delight in their society might
naturally have been a cause of uneasiness or heartache to
Harriet ” (p. 405). Naturally, also, the poor heart ached till
it was at last broken. There is an absurd mention of the intro¬
duction of a wet nurse into the house, as calculated to upset
Shelley’s romantic notion of married life. Then there was
the eldest sister, Eliza Westbrook, living in the house, to whom
Shelley, after finding her very useful, had begun to take
extreme dislike. It seems impossible to decide how far Shelley
was justified in his revulsion of feeling towards Harriet’s sister.
His violent antipathy was probably not less unreasonable than his
former excess of deference and blind compliance and concessions
towards a person whose counsels and direction could never have
been prudent, safe, or judicious (Hogg, “ Life,*' Vol. ii., p. 517).
Dr. Dowden thinks it useless to attempt to decide on the
nature of other causes which divided Shelley and his wife in
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[Oct.,
the early months of 18]4, but surely there was cause enough
for marital dissension in Shelley’s own conduct. Shelley says
that they were “ disunited by incurable dissension,” and in the
lines about to be quoted he actually owns that he was worthy
of her hate. Harriet was certainly alienated by his vagaries
and absence from home, and we cannot pretend to feel sur¬
prised. Shelley in May addressed beautiful lines to her as
“ only virtuous, gentle, kind, amid a world of hate,” and he
asks her to pity if she can no longer Jove.
Harriett! if all who long to live
In the warm sunshine of thine eye,
That price beyond all pain must give
Beneath thy scorn to die—
Then hear thy chosen own too late
His heart most worthy of thy hate.*
What Harriet replied to these lines is not known. Indeed
we are here, as always, at a disadvantage in judging her fairly
from having to trust almost entirely to Shelley’s own version
of their parting. Letters the former wrote to him, which would
doubtless tell a piteous tale, Shelley appears to have destroyed.
Thornton Hunt says that Harriet left Shelley. But, if so,
Shelley had already practically left Harriet by his frequent
visits to the ladies of whom he had become so much enamoured.
It is not surprising, therefore, to find Harriet at Bath early in
July, while Shelley was in London.
In the dedication to “ The Revolt of Islam 99 f he refers both
to his cousin Harriet Grove and to Harriet Westbrook :—
One whom I found was dear, but false to me :
The other’s heart was like a heart of stone.
And yet, as we have just seen, the last-mentioned’s eye pos¬
sessed such warm sunshine that all longed to live in it! As
there is really no evidence whatever of a stony heart, and as in
the same stanza Shelley says that he never knew one who was
* In her own hand writing , in poems Shelley prepared for printing.
f The original poem, “ Laon and Cythna,” re-named and modified in con¬
sequence of the protests of his own publisher and friends, ought not to be
overlooked as an indication of extraordinary moral perversion. Dr. Clouston
has spoken of Shelley as a man “ whose abilities were far above the average,
but whose moral qualities and volitional powers were twisted and perverted ”
(“Journal of Mental Science,” April, 1887, p. 163). Mr. T. Hall Caine writes—
“ The man who could regard as a vulgar prejudice the sacred instinct that holds
a brother and sister at once together and apart .... the man who did not
shrink from asking the wife he had abandoned to share the society of the
woman who had supplanted her, was a man who could have no moral
nature to endure a collapse.”—“ The Academy,” December 4,1886.
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1887.]
not false to him, or had not hearts as hard as stone and as cold
as ice, we are inclined to think that Shelley here, as in so many
other instances, swung back from one extreme to the other—
from a passionate admiration of the object of his love for the
time being to a reactionary dislike, which, however natural,
was altogether unreasonable. As his biographer cannot help
saying, “ Yet Harriet Shelley’s heart was, indeed, no heart of
stone, but a frail heart of woman, capable of love, of grief, and
of despair” (p. 416). Strong, indeed, must the case be which
forces such words of sympathy and chivalrous feeling from Dr.
Dowden.
During this summer (June) Shelley, in one of his visits to
Godwin, became hopelessly attracted to Mary Wollstonecraft,
then in her seventeenth year. Mention is made of Shelley’s
calling at Godwin’s shop in Skinner Street, on June 8th, 1814,
with Hogg, just before leaving London for ten days. “A
thrilling voice called ‘ Shelley 1 * A thrilling voice answered
4 Mary! ’ ” It is obvious from the familiar terms employed
that they were already well acquainted, although the actual
proof of their meeting more than once or twice is not forth¬
coming. But is it not probable that they had met more
frequently than is actually recorded ? Dr. Dowden supposes
that it may have been at this very date that Harriet went to
live at Bath, and that Shelley accompanied her during his ten
days’ absence from London. Before the end of June he was
writing passionate lines to one whose sweet accents fell upon his
heart like dew on half dead flowers, whose lips met his, and
whose dark eyes threw their soft persuasion on his brain. Yet
at this very time he was writing to Harriet as his wife, and
when a letter had not reached her for four days (which to her
was “ an age ”) she became extremely anxious about him. It
is difficult to reconcile this with continued coldness on his wife’s
part. She wrote anxiously (July 7th) to Hookham, enclosing
a letter to Shelley, and asking him to tell her by return what
had become of her husband —
As I always fancy something dreadful has happened if I do not hear
from him . If you tell me that he is well I shall not come to London;
hut if I do not hear from you or him I shall certainly come , as I cannot
endure this dreadful state of suspense . You are his friend , and you
can feel for me (p. 423.)
The epistle is characterized by Shelley’s biographer as “ this
pathetic letter,” and we see no excuse for the heartless conjec¬
ture, for which there is not a particle of evidence, that Harriet
would gladly have retraced her steps. There is no proof, that
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[Oct.,
we can discover, that she had taken any but involuntary steps
in the way of leaving Shelley. It was he who had left her.
He appears now to have entertained the idea (not unlikely to
arise in the mind of one who was himself unfaithful) that
Harriet had formed an attachment to a gentleman of the name
of Eyan, the friend of both in 1813, and he subsequently made
this an excuse for inducing Mary Godwin to elope with him.
In truth, Shelley's excuses for doing whatever he wished to
do were quite on a par with those of Henry VIII. But this
idea was either a delusion on Shelley’s part or a cruel inven¬
tion. a We may feel the most absolute assurance/’ Dr. Dowden
admits, “ that in the summer of 1813 Harriet loved her
husband, and loved him alone" (p. 424). Shelley’s animus
carried him so far as to make him assert that the child next
born was not his, but afterwards acknowledged his error. It
may be stated here, by way of parenthesis, that Mrs. Shelley
(Mary) wrote on one occasion to Leigh Hunt that Harriet and
Shelley did not part by mutual consent. Harriet declared that
the refusal to return to their former relations was not on her
part, and that she never ceased to love him devotedly. An
unprejudiced authority. Peacock, writes :—
I feel it due to the memory of Harriet to state my most decided
conviction that her conduct as a wife was as pure, as true, as absolutely
faultless as that of any who for such conduct are held most in honour.
Thornton Hunt also wrote that there was not a trace of evi¬
dence or a whisper of scandal against her before the separa¬
tion. And, again, Shelley's friend Trelawny says
I was assured by the evidence of the few friends who knew both
Shelley and his wife—Hookham, who kept the great librafy in Bond
Street, Jefferson Hogg, Peacock, and one of the Godwins—that
Harriet was perfectly innocent of all offence (p. 429).
Justly, therefore, does Dr. Dowden assert: “ No one who was
not a rash partisan would assert that Harriet was not inno¬
cent" (p. 429).*
* Mr. J. A. Symonds (a warm admirer of Shelley) argues conclusively “ that
it was not until 1817 that the suspicion of Harriets guilt before the separation
arose. This suspicion, however, did not harden into certainty, nor was it found
capable of verification ; else why did not Shelley use the fact as he proposed in
order to strengthen his case against the Westbrooks?’* It is a most striking
circumstance, and Mr. Symonds justly lays great stress upon it, that between
June, 1814, and May, 1816, there is no intimation whatever in any journals or
letters of Mary, Miss Clairmont, or Shelley himself, nor yet in the conduct of
the Godwin family, that any of them supposed that Harriet had wronged her
husband at the early period at which it was afterwards alleged that she had.
Then there is the fact of Shelley actually inviting his wife to join Mary and him-
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In Mrs. Godwin’s letter to Lady Mountcashell, Angnst 20th,
1814, occurs the following, corrected by Dr. Dowden
In May [March 30] Mary came home from Scotland, and then
began all our troubles. He paid her the most devoted attentions,
and my husband spoke to him on the subject. Mr. S— declared that
it was only his manner with all women. Shortly after, Harriet
Shelley came up from Bracknell suddenly, and saw me and my
husband alone. She was very much agitated, and wept, poor dear
young lady, a great deal, because Mr. Shelley had told her yesterday
at Bracknell that he was desperately in love with Mary Godwin.
She implored us to forbid him our house, and prevent him seeing
Mary. ... We sympathised with her, and she went away con¬
tented, feeling, as she said, quite sure that, not seeing Mary, he
would forget her. We then spoke to Mary on the subject, and she
behaved as well as possible; approved our renouncing his acquaint¬
ance, and wrote a few lines to pray her (Harriet) not to be unhappy,
as she would not see Mr. S— again. [Shelley’s visits to Skinner
Street ceased on July 7th. Harriet did not call at Godwin’s until
after she had come at Shelley’s request to London from Bath
on the 14th, as shown by Godwin’s diary.f She and Shelley called
on the 15th.] ... A week of tranquillity followed. Then one day,
when Godwin was out, Shelley suddenly entered the shop and went
upstairs. I perceived him from the counting-house, and hastened
after him, and overtook him at the schoolroom door. I entreated him
not to enter. He looked extremely wild. He pushed me aside with
extreme violence, and, entering, walked straight to Mary. “ They
wish to separate us, my beloved ; but death shall unite us,” and offered
her a bottle of laudanum. “ By this you can escape from tyranny;
and this,” taking a small pistol from his pocket, “ shall re-unite me to
you.” Poor Mary turned as pale as a ghost. ... I hastened to
my husband’s study. He hastened upstairs. . . . With the tears
streaming down her cheeks, she entreated Shelley to calm himself,
and to go home. She told us afterwards she believed she said to
him, “ I won’t take this laudanum ; but if you will be only reasonable
and calm, I will promise to be ever faithful to you! ” This seemed to
calm him, and he left the house, leaving the phial of laudanum on the
table (Appendix, page 544).
self during their Continental honeymoon. Mr. Symonds points out with great
force that Mrs. Shelley (Mary) in her novel “ Lodore,” which is allowed to be
her version of Shelley’s relations to his first wife, describes her gradual aliena¬
tion from her husband without breathing the slightest suspicion of her mis¬
behaviour. Mr. Symonds puts the whole case in a nutshell when he says :—“ An
irresistible passion for another woman had suddenly sprung up in his heart.
Upon these grounds, after undergoing terrible contention of the soul, he forced
on the separation, to which his first wife unwillingly submitted.” (“ Fortnightly
Review,* 7 April, 1887.)
f It does not follow that because a man keeps a diary he enters everything
that happens. Harriet may well have called on the Godwins previously.
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In Mrs. Godwin’s letter to Lady Mountcashell, dated August
20th, 1814, she writes:—
Shelley used to visit us frequently with his wife—a beautiful and
charming young lady of about 19. We grew very intimate ; they
came when they liked, and made themselves quite at home, and we
all loved them extremely. . . . Mrs. Shelley remained greatly at
home (Bracknell), but Mr. Shelley was busy with lawyers about
borrowing money, and ran up and down to and from town, and took a
lodging in Hatton Gardens in order to be near us (Appendix B,
p. 542).
According to Mrs. Godwin, Shelley paid immense attention
to her daughter Frances. She, therefore, sent her from home
to be out of his way. Mary was at that time at Dundee.
Lady Mountcashell, in a letter to Mrs. Godwin in November
of 1814, writes:—
The impression you gave me of Mary makes me think her conduct
perfectly natural. She only acted like a person who cares for nothing
but herself (Appendix, p. 546).
We now see Godwin “ hoist with his own petard,” although
his views on marriage had for some time undergone a change.
Never, surely, did man suffer more than he from an avenging
Nemesis. It was, as already recorded, on July 7 that Hookham
had received Harriet’s “pathetic letter.” It is supposed that
he saw what was likely to happen, and enlightened Godwin.
The latter spoke seriously to his daughter, and from that time
Shelley did not dine at Godwin’s house. In this same month
of July, Mary Wollstonecraft Godwin wrote in a copy of
“Queen Mab,” given to her by the author—she speaks of
the love they have promised to each other— €t I am thine, ex¬
clusively thine. ... I have pledged myself to thee, and sacred
is the gift” (p. 430). On the 14th, wishing to make a pro¬
posal of separation, Shelley met Harriet, who, at his request,
had come to London. His proposition proved so great a
surprise, and caused so terrible a shock, that it brought on a
severe illness, “alarming to one who looked forward to the
birth of a baby in December ” (p. 431). There seems nothing
improbable in Jerdan’s statement that Harriet, in an agony of
distress, exclaimed, “ Good God, Percy ! what am I to do ? ”
Nor is it unlikely that Shelley replied, “ Do ? do ? Do what
other women do ”—what he meant being that other wives,
under like circumstances, had managed to survive, and Harriet
might do the same.
Harriet, however, strove as much as possible to transfer the
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blame from Shelley's shoulders to those of Mary Godwin. Dr.
Dowden, after stating, on Peacock's authority, that no separa-*
tion by mutual consent had ever taken place, says that “ there
is some reason for supposing that Harriet, even after Shelley's
elopement to Prance with Mary Godwin, was not without ex-
pectation that her husband would tire of the stranger who had
displaced her in his affections, and would return to herself. It
was when the certainty gradually forced itself upon her at a
later date that all was over between her and Shelley—that he
was indeed Mary's and not her own—it was then, in solitude and
the dull constraint of her father’s house, that unhappy Harriet's
anguish grew to a height, and that she became willing to try to
forget it in excitement and change" (p. 482).
Shelley, in these days of distraction between duty and passion,
sought relief, as we have seen, in laudanum. When, at Shelley’s
urgent request. Peacock came to see him in London, he found
him in the condition thus described by his friend:—
Nothing that I ever read in tale Or history could present a more
striking image of a sudden, violent, irresistible passion than that under
which I found him labouring. . . . Between his old feelings towards
Harriet, from whom he was not then separated, and his new passion
for Mary, he showed in his looks, in his gestures, in his speech, the
state of a mind “suffering like a little kingdom the nature of an insur¬
rection.” His eyes were bloodshot, his hair and dress disordered. He
caught up a bottle of laudanum, and said, “ I never part from this.”
Quoting from Peacock's translation, he said he was always
repeating to himself the lines of Sophocles which represent
man's happiest lot as annihilation. He did not deny Peacock's
statement that he had been very fond of Harriet, and spoke of
her nobleness, although she did not feel poetry and understand
philosophy, essential, according to his present views, in the
partner of his life (p. 433). Had the law permitted, Shelley
would, according to his own account three years afterwards,
have been legally married to Mary Godwin. But as the law
would not lend its sanction to bigamy, the lovers escaped, on
July 28th, 1814, to France. Mary’s elopement was effected in
the early morning, without disturbing Godwin’s quiet slumber.
Her step-sister, J ane Clairmont, who accompanied her, thought
nothing more was intended than an early-morning stroll, but
said that she was induced by Shelley and Mary to go with
them, being skilled in the French tongue.
Mrs. Godwin pursued the fugitives to Calais, but did not
succeed in inducing even Jane to return home. That he had
not any reason to suppose Harriet to be unfaithful to him is
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very evident from a letter lie penned to her from Troyes,
•August 13th, 1814, commencing with “ My dearest Harriet,”
and ending with “ With love to my sweet little Ianthe, ever
most affectionately yours, S.” Strangely obtuse to Harriet’s
outraged feelings and inevitable indignation, he urges her to
join them in Switzerland, and he tells her that from none can she
expect such consideration for her feelings and interests as
himself, for all others “ have beloved friends of their own, to
whom their afEection and attention is confined.” It is difficult
to suppose that such a statement could have appeared to
Harriet otherwise than ironical. Even if Harriet’s condition
would have rendered it prudent to cross the Channel and
travel to Switzerland, her self-respect prevented her joining
her husband and her rival. One day Shelley asked Mary why
she suddenly looked so sad. Her answer has been preserved :
“ I was thinking of my father, and wondering what he was
now feeling.” Shelley then said, “ Do you mean that as a re¬
proach to me ? ” and she answered, “ Oh, no ! Don’t let us
think more about it ” (p. 453). What the father felt we know
from a letter which he wrote to Shelley in the spring of 1816 :
As long as understanding and sentiment shall exist in this frame , I .
shall never cease from my disapprobation of that act of yours , 'which
I regard as the great calamity of my life (p. 551).
Whatever Godwin’s “ anguish ” may have been, or Harriet’s
sense of desertion, or Mary’s occasional remorse, Shelley him¬
self, if we may accept Jane Clairmont’s testimony, was in the
greatest delight, and able to exclaim, in view of the Alps —
How great is my rapture! I, a fiery man, with my heart full of
youth and with my beloved by my side—I behold those lordly, im¬
measurable Alps. They look like a second world gleaming on one ;
they look like dreams more than realities, they are so pure and
heavenly white (p. 453).
And all this optimism in one who was living beyond his
means, and whose rapturous honeymoon on the Continent
plunged him still further into debt. It was on September 13th,
1814, that the joyful, but impecunious, travellers returned to
London, Shelley having, with some difficulty, induced the
captain of the vessel to trust them for the passage-money.
Godwin absolutely refused to have any communications what¬
ever with Shelley, except through his solicitor; on which
circumstance Mary disappointingly exclaims in her journal,
“ Oh, philosophy ! ” This action of Godwin’s was simultaneous
with a laudable attempt on Shelley’s part to obtain pecuniary
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1887.]
help for the man lie had once regarded as an idol, and who was
now so closely connected with him through his alliance with
his daughter. Perhaps, however, Harriet and the child wanted
the money quite as much, to say nothing of his own creditors.
But these notions are too commonplace for genius.*
{To be continued.)
The Life and Work of the Seventh Earl of Shaftesbury , K.G.
By Edwin Hoddee. Three Yols. Cassell and Company.
London, Paris, New York, and Melbourne. 1887.
(Concluded from j>. 289.)
To resume Lord Shaftesbury’s Diary, we extract the follow¬
ing interesting reference to Cowper :—
August 20th. Have been reading il Life of Cowper.” What a
wonderful story! He was, when he attempted his life, thoroughly
mad; he was never so at any other time. Yet his symptoms were
such as would have been sufficient for any “ mad doctor ” to shut him
up, and far too serious to permit any Commissioner to let him out,
and, doubtless, both would be justifiable. The experiment proved
that Cowper might safely be trusted ; but an experiment it was, the
responsibility of which not one man in three generations would
consent, or ought, to incur. We should, however, take warning by
his example, and not let people be in such a hurry to set down all
delusions (especially religious delusions) as involving danger either
* A biographer of Shelley, certainly not wanting in appreciation and praise
of Shelley, thus expresses himself'“ If a reunion of heart with Harriet was
possible before, it now became impossible. Shelley fell helplessly in love
with Mary; quitted Harriet; offered his heart-homage to Mary, Ac., &c.
.... Poor Harriet, who had behaved well to Shelley according to her lights
and opportunities, was much to be pitied, and as yet in no way pointedly to
be blfcmed.” “ Harriet was a frank, kind, nice girl, and in all ways worthy of
any ordinary man’s love” (“Shelley’s Poetical Works,” pp. 15, 17, edited by
Rossetti). But more than that, we have ample proof from Shelley’s own state¬
ment that she was worthy of an extraordinary man’s love also. Her fickle
husband had addressed lines to Harriet in 1813, in the dedication to 41 Queen
Mab,” which speak for themselves.
Beneath whose looks did my surviving soul
Riper in trouble and virtuous daring grow ?
* * * *
Harriet 1 on thine ; thou wert my purer mind;
Thou wert the inspiration of my song.
* * * *
Then press into thy breast this pledge of love;
And know, tho’ time may change and years may roll,
Each floweret gathered in my heart
It consecrates to thine.
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to a man’s self or to the public. There are, I suspect, not a few
persons confined whom it would be just as perplexing, and yet just as
safe, to release as the poet Cowper.
Mention is made of the attention paid by Lord Ashley in
1847 to the case of a lady who had been shut up in a lunatic
asylum whom the Commissioners regarded as perfectly sane,
and who was, in consequence, set at liberty. This lady was,
it is stated, a victim of a cruel conspiracy. Again, a lady who
was satisfied that a friend of hers had, under the same circum¬
stances, been carried away to an asylum fifty miles from
London, called on the Earl and told him her suspicions :—
It was evening when she arrived in Grosvenor Square, and dinner
was on the table, but within a quarter of an hour Lord Shaftesbury
was on his way to the railway station to go down to the asylum and
investigate the matter for himself. He did so, and on the following
day the young lady was released, it having been authoritatively .ascer¬
tained that she was not in a state to render it necessary for her to be
an inmate of an asylum. (Vol. ii., p. 230.)
Lord Ashley’s promptness and alacrity in the visitation of
asylums at other than the period of official inspection are
shown in the following entry:—
May 15th, 1849. Made a night visitation to Hoxton Lunatic
Asylum, having suspicions of misconduct; found, I rejoice to say,
things far better than we expected ; our system, therefore, of inspec¬
tion may be considered successful, and our terrors salutary. Ventila¬
tion of apartments very bad.
In the year 1851, Christmas Day, very shortly before he
became the Earl of Shaftesbury, he made the following review
of what he had been able to effect :—
Seventeen years of labour and anxiety obtained the Lunacy Bill of
1845, and five years of increased labour since that time have carried it
into operation. It has effected, I know, prodigious relief, has forced
the construction of many public asylums, and greatly multiplied in¬
spection and care. Much, alas ! remains to be done, and much will
remain ; and that much will, in the estimation of the public, who
know little, and inquire less, overwhelm the good, the mighty good,
that has been the fruit.
The next record of Lord Shaftesbury’s labours in lunacy
legislation has reference to the proper provision for criminal
lunatics. He had in 1852 brought the subject under the
notice of the House of Lords, and had urged the necessity of
the establishment of a State Asylum, in which they could be
separated from the insane who had not been convicted of
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Reviews.
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crime. His attempt at that time fell to the ground in conse¬
quence of the want of support he received from Lord Derby;
and it was not till eight years afterwards (1860) that an Act
was passed making special provision for this class, the result
of which was the establishment of the Broadmoor State
Asylum for Criminal Lunatics.
Reference is made to the attempt to establish, in 1861, a
benevolent asylum for the insane for the middle classes. As is
well known, the enthusiastic meeting held in the Freemasons’
Hall, with Lord Shaftesbury in the chair, ended in nothing but
the subscription of £760, which, doubtless, was afterwards
returned to the donors. It so happened, however, that the
notorious vendor of pills and ointments, Mr. Holloway, was
present at the meeting, and was so impressed with the state¬
ment of the need for such an institution as that advocated by
Lord Shaftesbury that within a few weeks of the meeting he
had an interview with the Earl, and expressed his willingness
to expend a very large sum of money upon a building for the
above purpose. It appears that Lord Shaftesbury advised him
to divide his munificent gift in more than one object, the result
being that Mr. Holloway eventually expended £300,000 upon
the Holloway Sanatorium, Virginia Water, and £450,000 upon
the Ladies’ College at Egham. We have heard Lord Shaftes¬
bury express his deep regret that the donor did not amply
endow the Institution for the Insane for the Middle Classes;
and with the information supplied in this biography, showing
the influence exerted by the Earl, we are surprised that he did
not bring about that which he regarded as so great a desider¬
atum. The result is that, with all its advantages, this in¬
stitution only partially meets the object which the benevolent
gentlemen who met at the Freemasons' Tavern, 19 April,
1861, had in view.
In 1862 the “ Act to amend the Law relating to Lunatics ”
which Lord Shaftesbury brought forward was passed. Among
other clauses it was provided that there should be an increased
visitation, a greater protection of single patients, and increased
safeguards against the improper confinement of alleged lunatics.'
In his speech Lord Shaftesbury related that on one occasion
he was sitting on the Commission as Chairman when the
insanity of a lady was being discussed. His view was opposed
to that of his colleagues. A medical man, who was present to
give evidence in support of her lunacy, came up to Lord
Shaftesbury and said, “ Are you aware, my lord, that she sub¬
scribes to the Society for the Conversion of the Jews?"
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420 Reviews. [Oct.,
“ Indeed! ” replied his lordship ; t€ and are jon aware that I am
President of that Society ? ”
We next come to Mr. Dillwyn’s motion for the tc Select Com¬
mittee to inquire into the operation of the Lunacy Law so far
as regards the security afforded by it against violation of
personal liberty.” This was on the 12th February, 1877, and it
was duly appointed. We must quote the entries made by Lord
Shaftesbury in his diary in reference to it.
February 13th, 1877. Mr. Dillwyn has obtained a Committee of
Inquiry into the operation of the Lunacy Laws. As in 1859, and so
now, I shall be summoned as Chairman to give evidence.
March 11 . . . My hour of trial is near ; cannot, I should think,
be delayed beyond the coming week. Half-a-century, all but one
year, has been devoted to this cause of the lunatics ; and through the
wonderful mercy and power of God, their state now, as compared with
their state then % would baffle, if description were attempted, any voice
and any pen that were ever employed in spoken or written eloquence.
Non nobis Donline.
It is clear that Lord Shaftesbury was very nervous as to
giving his evidence, and not a little anxiety was certainly de¬
picted on his countenance as he paced the corridor in attendance
for his examination; but those who heard him can bear witness
to his nerve, instead of his nervousness, and to the proof which
he gave of his thorough familiarity with the subject. It is
observed by his biographer tl that the worn look of Sir John
Millais’ portrait of him, painted about this time, sufficiently
attests the state of his nerves,” and the newspaper which he
had once ironically called “ my friend,” made the observation:
“ These lines in the face of the Philanthropist would be painful
were they not pathetic.”
Lord Shaftesbury made the following entry under date
July 22 :—
Sunday . . . Appeared again on Tuesday, 17th, before the Com¬
mittee. . . . Beyond the circle of my own Commissioners and the
lunatics that I visit, not a soul, in great or small life, not even my
associates in my works of philanthropy, as the expression is, have any
notion of the years of toil and care that, under God, I have bestowed
on this melancholy and awful question.
Two events are fresh in the memory of our readers, namely,
the motion made in the House of Lords by Lord Milltown for
an inquiry into the administration of the Lunacy Laws, and the
subsequent introduction of Lord Selbome’s Lunacy Amend¬
ment Bills in 1885. Mr. Hodder observes —“ Very pathetic are
the outpourings of his heart as he contemplates the possibility
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1887.]
of the labour, the toils, the anxiety, the prayers of more than
fifty years, being in one moment brought to naught, and cries
c Cast me not off in the time of old age/ &c. He felt that God
had manifestly blessed the efforts of this Commission; and it
was a grievous disappointment to him when Lord Milltown’s
motion was carried.” (Yol. iii., p. 504.)
Mr. Hodder states no more than the truth when he says :
“ Prom the moment when, in the midst of great bodily and
mental suffering, Lord Shaftesbury was summoned to London
to consider it, it was the source of almost constant anxiety. It
involved a long correspondence with the Lord Chancellor.”
His disapproval of the Bill was, as we know, followed by his
resignation of his office as Chairman of the Board.
The following entry in his Journal has reference to his feel¬
ings at this juncture:—
May 5th, 1885. My conclusions were—I could not go down to the
Lords and sit through the passing of such a measure, and be thus a
party to its enactment. I could not, while holding an office under the
Chancellor, oppose him by speech and division. He offered me per¬
mission to do so, but he knew, as well as I did, the indecency of such
a course.
In vain Lord Shaftesbury remonstrated with the Lord
Chancellor, whose disregard of his advice “ greatly embittered
his last days.” When the progress of the Bill was arrested, in
consequence of political events. Lord Shaftesbury was pre¬
vailed upon to resume his office, to the great satisfaction of his
colleagues in Whitehall Place.
Having now availed ourselves of all the references contained
in these volumes to Lord Shaftesbury’s work in Lunacy
Reform, and not only reform, but the prevention of what he
regarded, and what the Medico-Psychological Association
regarded, as mischievously meddlesome legislation, we have
only to express our admiration of his career in humane endea¬
vours to mitigate human suffering in all directions, although it
does not fall within our province to go beyond the services
rendered to the insane. On the occasion of his death we paid
a tribute to his memory, and were we to expatiate further here
upon his “record” We could do little more than repeat the
observations we made in that article. It is to be hoped that some
other nobleman will arise to supply his place, gifted with the
same unselfish love of his fellows, the same perseverance in
perfecting and sustaining the work upon which he entered, and
the same judgment in limiting the extent of legislative inter¬
ference to the action called for in the interests of the insane
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422 Reviews. [Oct.,
themselves as regards prompt treatment and the avoi dan ce
of unnecessary publicity.
For those who profess to reverence the memory of the Earl
of Shaftesbury, the volumes before us, so full of entries
revealing his inmost feelings, and so ably edited by Mr.
Hodder, ought to possess the greatest interest, and we trust
that the extracts which we have made will induce our readers
to procure the work for themselves. We have been astonished
to find how few among our friends, well acquainted as they are
with the near relation in which Lord Shaftesbury stood to their
daily occupation, and many, more or less, knowing him per¬
sonally, have sufficient enthusiasm to induce them to read,
still less to buy, this good man’s biography.
Magnetism# et Hypnotism#; expose des phenomenes observes
pendant le sommeil nerveux provoque. Par Dr. A.
Cullerre. Avec 28 figures. Paris: Librairie, J. B.
Bailli&re et fils, 19, Eue Hautefeuille. 1887.
M. Cullerre is known as a writer of works upon mental dis¬
orders: general paralysis; melancholia and stupor; alco¬
holism in relation to ideas of persecution; tuberculosis and
heart diseases in the insane; cerebral localization, &c. The
author, as would be expected, treats the whole question from
the Braid standpoint. He gives a very complete and readable
history of the fortunes of artificial somnambulism, the dis¬
covery from time to time of strange and unexpected phenomena,
the misinterpretations of these facts, the ignorance on both
sides, namely, the ignorance of the scientific explanation on
the one hand and the ignorant denial of the facts on the other.
Of the two forms of ignorance the last is the most inexcusable.
It has not died out yet. Progress is impossible in the presence
of this refusal to acknowledge facts. The morbid dread of
being imposed upon is a mania with a certain class of scientific
exquisites.
But Dr. Cullerre’s book is not merely a history. He dis¬
cusses many of the questions which arise out of the phenomena
witnessed in our own day in France, and offers judicious com¬
ments. An important section has reference to the dangers of
hypnotism, which, like chloroform, may be perverted to vile
ends.
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1887.]
Review 8.
423
Our space will not allow of more than a brief notice of this
book, which we commend to our readers as interesting, well
arranged, and free from prejudice. It forms a volume of the
(C Bibhoth&que Scientifique Contemporaire.”
The Health of Nations: A Review of the Works of Edwin
Chadwick , with a Biographical Dissertation . By
Benjamin Ward Richardson. Two vols. London:
Longmans, Green, and Co. 1887.
Dr. Richardson is to be congratulated on having completed
this laborious undertaking. The name of Edwin Chadwick
has been for so long a household word that it is difficult to
credit that he is still living, and to believe in the identity of
the author of so many articles, extending over the greater part
of the century.
To Mr. Chadwick the medical psychologist must be grateful,
because whatever tends to improve the health of a nation is
calculated to diminish the risks to the development of mental
diseases. Under the head of “ The Physiological Limits of
Mental Labour ” (Chap. IY.) and “ The Psychological Limits
of Mental Labour” (Chap. V.), Mr. Chadwick’s insistance
upon correct principles is lucidly set forth, and the reader will
peruse with interest a letter from him to Professor Owen, and
another from Owen to Chadwick, upon the latter, the psycho¬
logical aspect of the subject. They deserve wide circulation
even now, and no doubt had a salutary effect at the time they
appeared in disseminating wholesome views on the limits of
mental labour, though it is lamentable to think how many have
turned a deaf ear to these notes of warning.
It would carry us too far to attempt to analyse the contents
of these valuable volumes, which will remain not only a per¬
manent monument to the wisdom and practical sagacity of Mr.
Chadwick, but also to the industry, skill, and loving labour of
his friend, the editor and biographer. The work will always
be valuable for reference, and every medical man whose ken
extends upon the narrow horizon of his own selfish interests
would do wisely to possess himself of these volumes. No library
ought to be without them.
XXXIII.
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Before Trial: What should he done by Client , Solicitor , and
Counsel, from a Barrister's point of view ; together with a
Treatise on the Defence of Insanity. By Richard Harris,
Barrister-at-I aw. London : Waterlow Bros, and Layton,
24, Birchin Lane. 1886.
This little book, coming from a lawyer, is refreshing. It is
singularly free from prejudice. It will help to break down the
barrier between lawyers and doctors. The manner in which
the author tears to pieces the dicta of the judges in regard to
criminal responsibility is charming. “ Let me ask,” says Mr.
Harris, “with all reverence due to departed greatness, Can
anyone examine them for a moment and not perceive that they
are for the most part wrong ? . . . The closer you examine the
distinctions between sanity and insanity, the more clearly it
will appear that while Justice and Common Sense were for
acquitting the lunatic, Authority and Precedent were for
hanging him.” Again, “ 1 have always felt that the medical
profession is too little regarded in this question of insanity.
Medical men are the very best, nay, they are almost the only
persons capable of pronouncing a trustworthy opinion on the
subject. They are too often ignored, as if they always came
to get a prisoner acquitted, and as if they had a motive for so
doing. They pronounce their opinion on facts, and unques¬
tionably it is by facts that the condition of a man's mind must
be ascertained ; whereas the judges, for the most part, seem to
regard the question as one of law; as will be shown by the
answers I am about to examine. What was said in such and
such a case must be said in this; the man who has been in his
grave for fifty years must serve the case of to-day. In fact,
precedent, for the most part, may be described in the words of
the old song:
“ It was my father’s cnstom,
And so it shall be mine.’ 1
On the well-known legal test for insanity, our author irreverently
observes: “ The question whether the accused knew it was
wrong has, I venture to say, no more to do with tfie issue than
an inquiry as to whether the man at the time he committed the
murder could stand on one leg.” Mr. Harris says, in conclu¬
sion, “ that the defence of insanity has been rather a trap than
a means of escape. Happily, the tendency of modern practice is
becoming more and more in accordance with enlightened
reason; at least, my experience leads me so to believe. Judges
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425
do not like to abandon what almost looks like their prerogative
of life and death to the medical profession; but I feel sure that
a time will come when the question of sanity or insanity
will no longer be left to the misleading definitions of legal
ingenuity, but will be decided by the unerring test of scientific
experience.”
We purposely abstain from further quotations, because we
wish our readers to obtain for themselves this little book,
which can be had for a trifle, and is worth a great deal more
than many learned folios which have been written on the
subject; the reason being that it is the outcome of unprejudiced
common sense, and a determination to be guided by medical
facts.
The Defence of Insanity in Criminal Cases; being an Essay
by Lancelot Fielding Everest, M.A., LL.D., Barrister-
at-Law. London: Stevens and Sons, 119, Chancery
Lane. 1887.
This is a sensibly-written essay, which like that reviewed
above shows that there are lawyers who rise above the parrot-
cry of the defence of the legal tests of criminal responsibility
against the attacks of mental physicians. On the contrary, Mr.
Everest avers that “ no test at all is better than the imperfect
and unsatisfactory test laid down in the answers in McNaghten’s
case,” and he asks why should the law remain in such an un¬
satisfactory condition when a remedy might be afforded by
legislation ? With Pandulph he might say :—
Therefore, since law itself is perfect wrong.
How can the law forbid my tongue to ourse ?
He would have only a general principle laid down, namely, 1
that no man can be held responsible for an act if .at tho-timeh e
does itThe is labouring under insanity. Each case would then
be^determmeJ*by' the jury HL'Cofdmgto the evidence given by
medical men and others as to whether the alleged lunatic is
insane and ought to be acquitted on that account. There is
certainly much to be said in favour of this simplification of the
plea of insanity in criminal cases. At one bold sweep it gets
rid of the complex tests which the ingenuity of the puzzled
judicial mind has evolved with such great .elaboration and with
such little success. The author does not pretend to provide
any test whatever; and he practically leaves the jury to be
guided by the opinion of the medical witness as to the re-
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426 Reviews. [Oct.,
sponsibility of the prisoner, although the author does not
exactly say so.
Mr. Everest will, we hope, take every opportunity of instil¬
ling his views, both destructive and (with some exceptions) con¬
structive, into the minds of the judges. He proposes that —
The suggestion of insanity should come from some independent
source—say, from some medical authority appointed by Government
—and let the question of insanity be tried in some snch way as
follows :—Let a skilled physician, appointed by Government, go the
rounds of the gaols periodically before Quarter Sessions and Assizes,
and send those cases in which there is a suspicion of insanity before a
special tribunal for the purpose of trying the question of insanity,
and that only.
The judge ought, the author considers, to have studied
lunacy. We fear, however, that this is not practicable. He is
to judge of the admissibility of evidence without being bound
by the ordinary rules of evidence of Courts of Law.
Anatomy of the Brain and Spinal Cord. By J. Hyland
Whitaker. Edinburgh, 1887.
The author has no doubt used his experience as a demon¬
strator to arrive at such well-chosen words to convey his
descriptions of the brain and spinal cord. Admirable in clear¬
ness, and including everything of real importance, this little
book will be found to be a useful manual, not only to the
student, but to those who keep up or revive their knowledge
of the anatomy of the nervous centres. The verbal descrip¬
tions are concise and well expressed, and the illustrations show
special skill. There are twenty plates which portray in a
striking manner the most important structures in the brain
and spinal cord, as well as the vessels and enveloping mem¬
branes. Some of the most instructive are of the diagrammatic
kind, in which good use has been made of contrast in colours
in bringing out the most essential characters. It is curious to
observe how much Mr. Whitaker manages to describe in a
short space; with the help of his diagrams, he gives a wonder¬
fully clear description of the fissures and convolutions of the
brain in ten pages.
It would be too much to say that Mr. Whitaker has made
easy the anatomy of the brain and spinal cord, but it appears
to us that he has made it easier than any other manual we
have read.
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Reviews.
427
A Text Book of Pathological Anatomy and Pathogenesis . By
Ebnest Ziegler, Professor of Pathological Anatomy in
the University of Tubingen. Translated and edited by
Donald MacAlister, M.A., M.D., M.R.C.P., Fellow and
Medical Lecturer of St. John’s College, and Physician
to Addenbrooke’s Hospital, Cambridge. Second edition.
Three Vols. 1885-7. Macmillan and Co., London.
The present work appears in three volumes; the first
deals with general pathology, the second and third with
special pathology. A fourth volume, which will include a
department of special pathology,* is sub judice for the pre¬
sent. Its omission is, perhaps, a wise one, for the pathology
of this particular department is abundantly represented in
special treatises. As it stands, the work is a complete treatise,
and embodies a very large mass of information, for there is
no waste of words, the style being terse, without, however,
too much compression. Professor MacAlister has wisely
retained the plan, in the original work, of setting forth the
more essential teachings in larger type—the less essential,
illustrative, or reference portions, in smaller type. The
subject matter is broken up into a number of well-defined
chapters. To the order in which these are arranged in the
general part of the work one might perhaps object that the
plan adopted is not a very apparent one, and might be
improved on. We find, for instance, a chapter on malfor¬
mations taking precedence, whereas it would seem more
fitting that complex deviations from the normal should
succeed simpler deviations. But this may or may not be so,
and in any case the question is of minor import.
The chapter on tumours is preceded by one on the 66 infec¬
tive granulomata,” which of course takes in tubercle, syphilis,
leprosy, etc. The term “ infective granuloma ” is a happy
one, for it sets forth, as Ziegler insists, two important facts,
viz., clinically, the infectious nature of these formations, and
anatomically, the structure which characterizes them. We
may note as an omission in this chapter, that lupus is
spoken of as without a known exciting cause, whereas the
cause is generally held to be the bacillus of tubercle, lupus
being now described as a form of skin tuberculosis. Again,
in the case of glanders, the bacillary nature of the poison is
omitted.
* On the Eye, Ear, Bones, Muscles, and Genital Organs.
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On the etiology of tumours there is a good chapter. In it
Cohuheim’s hypothesis in particular is fully considered.
A very important feature in the general part of Ziegler’s
work, is a lengthy chapter on parasites. This subject is very
ably dealt with and abundantly figured. We find ourselves
here, of course, on somewhat unstable ground, and there is
evidence of this in the English version before us, for in
several places we note deviation from the text of the third
edition of the German work. Perhaps Prof. MacAlister has
wisely put the drag on a little, and not allowed himself to be
carried away by the too numerous winds of doctrine which
prevail in this region. The value of a certain amount of vis
inertioe is at times undoubted.
From the special part of the work we shall pick out the
nervous system for consideration. The topography of the
brain scarcely calls for notice, though we may observe
that the inclusion of the anterior occipital furrow and the
inferior occiptal furrow amongst the u most important sulci ”
is surely not usual. The physiology of the cortex cerebri is
very briefly referred to.
In the anatomy of the spinal cord we could wish that the
rational nomenclature advocated by Dr. Gowers were adopted,
and that in place of the columns of “ Goll,” or even of the
“ funiculus gracilis,” the name “ posterior median column ”
were substituted. In like manner the term “ postero-external
column” is far more easily remembered than “column of
JBurdach,” and, moreover, it describes itself as to locality.
In the further description of these two columns, the fact of
the former consisting of very long commissural fibres, the
latter of short commissural fibres, might well have been
insisted on since it helps the understanding in relation to the
ascending degenerations.
Under the heading of meningeal hydrocephalus, we find
the statement that occasionally the accumulation of fluid is
not preceded by cerebral atrophy. The effusion is thus de¬
scribed as a primary event, which may cause more or less
compression of the brain and dilatation of the skull. Is this
pathology really established ?
If space permitted we would refer to some other points of
interest in relation, e.g ., to the causation of microcephalus,
to the question of hypertrophy of the brain, to the prevailing
doctrine as to the so-called “ pachymeningitis of the dura
mater,” the discussion of which is, we think, somewhat
unsatisfactory. In the section on tumours affecting the
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429
central nervous system, we should like to have seen the
question of the frequency of metastasis from primary foci in
the nervous system touched on.
But it will be said, and the criticism will be just, it is
demanding too much from a text-book that all moot points
shall be solved. It is, and in defence we can only plead that,
having been taught so much, we naturally turned to the
same source for more. It would be instructive to ourselves
if we could examine other portions of the special pathology
volumes; but we are unable to do so, and must end a very
cursory review.
Of considerable importance in Ziegler's work are the
numerous references to the literature of the subject; this
has been greatly increased in value in the present edition by
fuller notice of English and French memoirs. This is a very
important addition. The work, as now completed, we
heartily welcome, and as heartily recommend. It will prove
invaluable as a text-book and as a book of reference, and
certainly is not replaceable by Cornil and Ramier's text-book
of pathological histology, which also figures in our English
dress. Were Birch Hirschfeld’s work on pathology trans¬
lated, there would be a serious rival in the lists. As it is,
and thanks to Professor MacAlister, Ziegler “ holds the field.”
The Cwrdbility of Insanity and the Individualized Treatment
of the Insane . By John S. Butler, M.D. G. P. Put¬
nam’s Sons, New York and London, 1887.
This little book, from the pen of the former Superin¬
tendent of the well-known Retreat for the Insane at Hart¬
ford, Conn., will receive a friendly welcome from all who
know the venerable physician, who here gives the results of
his life-long experience and reflections.
We note with interest Dr. Butler’s approval of the recent
attempts to separate the chronic from the acute and curable
insane. He records that at the meeting of the u Association
of Medical Superintendents of Institutions for the Insane,”
held in Pittsburg, in 1865, he stated to the Association that
“ the admission into the Hartford Retreat of a large number
of incurable State patients had greatly embarrassed the
remedial treatment of the recent and hopefully curable.”
Hence he suggested some kind of distinct provision for
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Reviews.
[Oct.,
chronic lunatics to be adopted by the State. The proposition
led to an excited debate, and all but unanimous disapproval.
The meeting in 18G6 reaffirmed the views which had been
always held by the Association, and Dr. Butler’s views were
shelved. We can understand the interest he takes in the
“ segregation ” movement and the compliment he pays to Dr.
Dewey, of the Kankakee Asylum. The testimony borne by
so honoured and experienced an asylum man to the advan¬
tages arising from variety in the arrangement of buildings,
and the wisdom of separating the demented and imbecile
from recent and acute cases, is very striking, and shows a
mind open to receive new impressions and experiments, which
is the exception rather than the rule in those who have
reached advanced life.
Elements of Physiological Psychology: A Treatise on the
Activities and Nature of the Mind from the Physical and
Experimental Point of View. By Geobge T. Ladd,
Professor of Philosophy in Yale University, U.S.A.
London : Longmans, Green, and Co. 1887.
We are obliged to defer a notice of the above work to a
future number, but in the meantime we commend it to our
readers as a valuable addition to the literature of psychology
studied by scientific and physiological methods. Professor
Ladd has spared no pains to make the treatise comprehensive
and suited to form a text-book for special students in this
department.
Three Lectures on the Anatomy of Movement: A Treatise on
the Action of Nerve Centres and Modes of Growth. By
Francis Warner, M.D., F.R.C.S., F.R.C.P. London:
Kegan Paul, Trench, and Co., 1, Paternoster Square.
1887.
These lectures were delivered by Dr. Warner at the Royal
Cpllege of Surgeons of England, and may be studied with
profit by psychologists. The author is ingenious and in¬
dustrious, and has succeeded in illustrating the truth that
the motor action of the brain is an integral portion of our
being, subject to the same laws and conditions, and that
“ the forces which, acting upon the brain, stimulate motor
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1887.]
action, are those 'which stimulate growth in other parts and
other tissues.” Dr. Warner endeavours to show that this
motor action may be described by a reference to the parts
moving, and the attributes of the movement, its time and
quantity. Growth, on the other hand, involves a reference
to u the parts growing, the time, quantity, and kind of
growth.” The resultant of the two (motor action and growth)
is frequently due to “the time and quantity of the com¬
ponent individual acts.” Further physical forces may
control the attributes. The author hopes that, by pursuing
the inquiry on these lines, our knowledge of motor actions
may be extended, and the origin of at least some modes of
mental expression may be elucidated. We do not find that
these lectures admit readily of analysis or quotation. Nor
can many very definite results be given as the outcome of Dr.
Warner’s researches. Still, they deserve every encourage¬
ment, and we hope he will continue to pursue them with
unabated ardour. We have before us also a syllabus of a
course of six lectures on “ The Children : How to study
them,” by the same lecturer, delivered at the request of the
Froebel Society. They appear well calculated to stimulate
observation, and to make the child a subject of study to a
much greater extent than is usual. They are in the direc¬
tion of thought so largely cultivated by the late Professor
Laycock.
Nervous Diseases and their Diagnosis: A Treatise upon the
Phenomena produced by Diseases of the Nervous System ,
with especial reference to the recognition of their Causes .
By H. C. Wood, M.D., LL.D. Philadelphia: J. B.
Lippincott Company. 1887.
This is a valuable work which can hardly fail to obtain a
large circulation in this country as well as in the United
States. The author speaks from a large and varied ex¬
perience, the matter is very clearly arranged, and the style
lucid and attractive. It will increase the reputation of this
physician.
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432 [Oct.,
PART lll.-PSYCHOLOGICAL RETROSPECT.
1. Scandinavian Retrospect .
Swedish Gymnastics: Educational and Medical .
By Ellen F. White, Certificated by the Royal Gymnastic Central
Institute at Stockholm.*
I. Educational .
Having had my attention drawn by special circumstances to the
Swedish gymnastics in England, I was induced to seek admittance
to the Royal Central Institute at Stockholm in order to become
thoroughly acquainted with the system, and as this system is beginning
to attract much attention now in England, it may be of interest to
have a short account of the Institution and of the course of instruction
pursued in it.
The building occupies a triangle where two streets meet. A large
gateway opens into a triangular court beyond, where various schools
are drilled in fine weather. Two sides, looking on to the streets, are
occupied by professors’ dwellings and large lecture-rooms and dressing-
rooms ; on the third side are the two large gymnasiums, one of which
is called the fencing hall.
The object of the course is to send out teachers, thoroughly trained,
to teach, both practically and theoretically. The course is carried on
in two great divisions, one for men and the other for women, and
in these two the methods of instruction employed are quite distinct
from each other. Of the former nearly all are young lieutenants
who learn fencing, with military and pedagogical gymnastics, anatomy,
and physiology. Their course lasts two years, one half of the students
changing each year.
I shall speak almost exclusively of the women’s course. None are
admitted over thirty years of age or under twenty, except under
special circumstances. The native students are limited to twenty in
number, the class being formed only every second year. The foreigners
are but three or four, Norway, Denmark, and Finland each having
usually a representative there. All must bring a certificate of health
and of freedom from deformity, signed by a doctor. The course of
study lasts two years, and is tolerably severe, embracing several sub¬
jects. The system consists of two main branches, the medical and
(as they are called in Sweden) the “ Frisk ” or health gymnastics, for
all in health, of whatever age or sex. Anatomy, physiology, and
* Miss White is the first English lady who has passed this examination.
The Medical aspect of the Swedish Gymnastics will be treated of in the next
number. The bearing of the subject upon the treatment of the insane is
obvious.—[E ds.]
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1887.] Scandinavian Retrospect . • 433
lessons in health are needed for both branches. The other subjects
are theoretical gymnastics, pathology, and the mechanics of the body.
There is a large staff of teachers, mostly gentlemen, many of them
officers in the army.
The day’s work begins at 8 a.m. with a practical lesson in medical
gymnastics, under the superintendence of a lady teacher. A “ table ”
of a certain number of movements is gone through by the students, so
that all may in turn both give and take the movements.
Stays and heels are of course strictly forbidden, and the students are
expected to wear a special gymnastic costume, consisting of a loose
tunic reaching to the knees, with a belt and knickerbockers of the
same length to match. A constant change of comrade is insisted on
to accustom the student to patients of different size and powers. This
lesson lasts an hour, and as the students become a little more expert
they help in turn, two of them together, for a month at a time, with
the patients. From 9 o’clock till 11 is free time, and is used mostly
for reading and breakfast. From 11 till 3 class follows class as
closely as possible.
Pathology is taken up the second year, when the students have be¬
come somewhat acquainted with the movements, and have gone through
the anatomy and physiology courses. It is not only stiff joints, spinal
complaints, and muscular contractions from burns and other causes
which are treated, but diseases of all kinds. Consumption, indiges¬
tion, and even spasmodic asthma and affections of the heart may be
greatly relieved, if not permanently cured. A Swedish author, writing
on gymnastics and medicine, says that gymnastics are the only radical
method for strengthening the digestive organs. Anatomy and
physiology are both taken the first year, each having three hours per
week devoted to lectures. The anatomy is taken by a doctor, and
most of the time spent on this subject is passed in the dissecting room.
The students are not expected to do the dissecting themselves, yet
they may do it if they please. Lessons in health are also taken in
the first year.
Sanitary science is not so far advanced in Sweden as in England,
and the benefits of open windows and daily baths are far from being
universally admitted even amongst the students, which renders these
lessons doubly necessary. The part which brings most life into the
course is the practical gymnastics. The students have an hour’s
“ health ” gymnastics every day, at which all must attend in their
costumes. The lightness and ease of this dress seem to have a cor¬
responding effect on the spirits of the students, who are brighter and
more lively then than at any other hour of the day. The work done
here is truly systematic, the movements following each other in a pre¬
scribed order. Progressive tables of movements having been drawn
up by those well versed in the subject, so that no new movement can
be taken without due preparation, the students are led on step by step
from simple easy movements to those more complicated and difficult
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434 Psychological Retrospect . [Oct.,
without the least danger of over-exertion. Thus, a balancing move¬
ment is introduced by resting the hands lightly on a support, and a
back-bending movement is taken, at first with the hands on the hips,
the exercise being increased in difficulty later on by stretching the
arms upwards or outwards.
Apparatus is largely used from the beginning, many movements
being performed with its aid which, without it, would be too difficult
for the beginner. For instance, to rise from a recumbent to a sitting
position is impossible for many without help; but if the toes are put
under a bar, or if another person press on the insteps, the difficulty
vanishes in most cases.
One of the most important principles laid down is that the aim of
gymnastics is not to strengthen the arms and legs to jump higher or
to run faster than others, but to develop the whole body, especially
the organs of respiration, circulation, digestion, &c.,indne proportion
to one another, and to the muscular system of the body, so that the
former may not be worn out by their efforts to supply the extravagant
demands made upon them by over-developed muscles.
There is a school of instruction in connection with the Institute
where the students learn to drill the children under strict supervision.
The children are divided into so-called “ squares," each square con¬
sisting of eight or ten children. Each student has a square com¬
mitted to her care, and six or seven squares are drilled at one time.
The children form in a long line, and at the word “ March ” from the
teacher each student takes her square to the appointed place and puts
them through the table of movements which she has prepared for
them. To the uninitiated looker-on the scene is at first confusing,
but it is soon perceived how everything goes in regular order, how the
apparatus is used in turn, and how well the squares keep to their own
place without interfering with one another. It would be doubtless
easier to have the whole room at one’s command ; but one learns
watchfulness, concentration, and readiness of resource which it would
be impossible to learn under easier circumstances. The teacher is
present the whole time, taking notes of mistakes to be commented
upon afterwards, and ready to help in any difficulty which may arise.
The success of a class depends entirely on the teacher. If she be
dull and uninterested, the children will become either sleepy or unruly.
She must make the children feel that she is watching each one, and
that nothing escapes her eye. ' She must be bright and lively, and
show that she enjoys the lessons as much as they. The children’s
costume need not be such a difficulty as it is commonly made in
England in girls’ schools. The children in a Swedish school, at any
rate the younger ones, often have their costumes of the same
materials as their dress, so that the skirt is worn over the gymnastic
dress, and slipped ofi for the lesson without time being wasted in
changing. Younger children are easier to teach than older. They
like to move about, but they must be kept occupied the whole time.
There must be no spare moments when they can begin to talk or play.
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1887.]
Let them rest and play, but let it be lawful rest. When once the
word “ Attention ” is said all must be on the alert. Older girls often
think it too much trouble, and are too fond of their stays and high
heels, so that whilst needing the exercise more than the little ones
they are more often excused attendance, and when they do come they
bring to the lesson a passive indifference which is more trying to the
teacher than the superabundant spirits of their juniors.
No protective apparatus, such as mats, pillows, &c., is used. If a
new movement is taken, and the children after two or three days
still fail to grasp the idea of it, this is a proof that it has been taken
too soon, and it must be discarded until simpler exercises have pre¬
pared the way for it. It is this care which renders the use of mat-
trasses, <$rc., unnecessary. To take an example. The first lesson in
jumping is (1st) to rise on the toes ; (2nd) to bend the knees, keep¬
ing the body straight and well balanced ; (3rd) to straighten the
knees ; and (4th) to lower the heels. When this can be done both
slowly and quickly without any loss of balance, the child springs
off the ground at 3, coming down with feet, knees, and body in good
position. The next step is to jump forwards and sideways. Then
to take one, two, or three steps before jumping. By the time
these movements have been gone through sufficiently, the children
are prepared to begin jumping down from a low elevation, and to
do other more difficult exercises, without the least danger of
tumbling forwards or backwards, or of injuring the back by coming
down on their heels. The teacher must, of course, be constantly
on the watch to give help at any moment if needed. Other exercises
are all graduated in a similar way, and the children know very well
that if they have to go back to an old movement it is because they
have not been fully attentive.
Protective apparatus is, however, occasionally used by the young
lieutenants under the trapeze. The feats then performed belong
rather to acrobatic than to gymnastic exercises. But in the schools
all movements done for show are carefully avoided, so that on a
review day the children who learn gymnastics take part in a table of
exercises which can be followed by all alike. This, of course, ex¬
cludes those feats of skill in which a few may excel to the neglect of
the many, but it ensures that all the children have their full share of
attention.
Such children as may have any special delicacy or deformity ought
not to be subjected to the same movements as the others. Still, they
need not be altogether withdrawn from the school gymnastics. In
my own division there was a child with a rupture. Such movements
as climbing a rope, or hanging from a bar, running, jumping, and others
she was not allowed to take. Before beginning with new pupils, the
teacher should always take means to discover if there are any children
with a special tendency requiring individual attention, so that, if
possible, they may be relegated to a class by themselves.
Onr gymnasium is most beautifully fitted up, the apparatus taking
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436 Psychological Retrospect . [Oct.,
tip no floor space when not in actual use. The great charm of it is
its exceeding simplicity. The chief qualities required in the apparatus
are—(1) that it can be used by persons of both sexes and of all ages;
(2) that a great variety of movements can be executed on it; (3)
that a considerable number can use it simultaneously ; (4) that it
takes up but little room when not in use ; (5) that its working is so
simple that children of 10 or 12 years of age can, if necessary, both
set it up and put it away ; (6) that it shall be inexpensive, and
capable of being made by an ordinary carpenter. This may seem a
formidable list of requirements, but it is one not impossible or,
indeed, difficult to meet. A light horizontal bar, which can be raised
or lowered at will from the floor to a height of seven or eight feet,
and which with its upright support may be sunk into the floor when
done with, is a most easily-managed piece of apparatus, admirably
suited to its purpose. At the Institute, the original bar put up by
Lingis still in existence. It runs the whole width of the gymnasium,
a length of about 30 feet. Its ends fit into grooves in the walls, and
it is raised and lowered by stout ropes running over pulleys. It is
heavier and, perhaps, more clumsy, but it is just as useful as the
lighter bar described above. It can be used by a larger number
owing to its greater length and strength. But its weight and size
place it beyond the power of children to raise and lower it. There is
no part of the body which cannot be exercised on the horizontal bar.
Another almost equally useful arrangement is the “rib stool,” or
climbing wall. This I have seen in England, in the Cheltenham gym¬
nasium ; but there were only two divisions there, whilst here two or
three walls are lined with them, so that from 20 to 40 children can be
at work together. The rib stool consists of upright posts fixed to the
wall, three feet apart, in which are inserted horizontal bars about five
inches from each other from the floor to a height of eight or nine
feet. This can be used in as many ways as the horizontal bar.
Now and then, perhaps once in three or four weeks, the children
are allowed, as a great treat and reward for good conduct, to play
games instead of having a lesson, and if the teacher does not join
she must at least watch the games to see that all goes rightly.
The exercises for the day are taken in a regular order, beginning
with the gentler movements, passing on to the more violent, and con¬
cluding with movements calculated to quiet both the quickened pulse
and the respiration. The table of exercises begins with (1) a short
march and a few quick, decided movements as an introduction ;
(2) an exercise which brings the circulation into more active play,
6uch an exercise being always followed by a simple leg and foot
exercise, which draws the blood away from the heart again ; (3) a
hanging exercise, which is suited to the powers of the class and acts
especially in widening the chest; (4) a balancing movement, with
or without support, according to the proficiency of the pupil or the
difficulty of the movement; (5) an exercise for the shoulders and
Digitized by A^OOQle
1887 .] Scandinavian Retrospect . 437
back; (6) a general trunk movement, acting directly or indirectly
on the circulation of the internal organs, and thus promoting their
healthy action ; (7) an alternate trunk movement, such as turning
or bending from side to side; (8) jumping, to which some
prominence is given, especially for the boys, as bringing every muscle
into play, as also developing quickness, decision, fearlessness, correct¬
ness of eye, and also a power of gauging accurately what they can or
cannot safely attempt. An infinite variety of exercises is included
under the common name of jumping, from the first jump on the spot
to springing on to a galloping horse’s back. Then the lesson
concludes with a few quietiftg leg and respiratory movements, and a
march if the children are to return to their desks at once. This is
the usual order followed, but it is subject to many modifications ac¬
cording to the time, space, and skill at the teacher’s command.
The question of drilling boys and girls together must inevitably
come prominently forward if, as in Sweden, the number of schools
common to both sexes should increase. At present it has not been
tried much, save in the preparatory schools, where no difficulty has
been found in drilling the children together up to the age of 12 or 13.
As they grow older their powers seem to diverge more and more.
The boys gain quickness and greater power for more difficult and
stronger exercises ; whilst the girls develop a sense of form, so that
they are able to execute slower movements without losing time or
form. The power of girls in gymnastics depends, however, very
much upon their bringing up. Were they allowed as much freedom
and activity as their brothers, and assisted by a rational dress in which
they might have the full use of their lungs and limbs, bloodlessness,
headaches, and backaches would become far less frequent than at
present amongst school girls.
I think it is not well to mix boys and girls above the age of 13 in
the gymnasium. But it has not been tried sufficiently at present to
draw any very definite conclusions. It does not seem to have been a
success in our own school of instruction at Stockholm. In this
school there were boys and girls from the age of eight to that of 16 ;
and the head-master would not allow them to be separated even for
this one lesson. For the junior classes it worked well ; but the senior
classes were difficult to manage, the girls keeping back the boys, and
the boys not being able to appreciate the more accurate and refined
work of the girls. The highest class of all consisted entirely, how¬
ever, of boys of 15 and 16 years of age, and this class was admirably
managed by one of our number, who had sufficient power of command
to keep them well under her control.
The length of the daily lesson should be from 30 to 40 minutes. If
the teacher is not up to her work and makes the class as dull and
spiritless as herself, the shorter the lesson the better. A daily lesson
should be the rule, even if it does not last more than 20 minutes,
rather than a long and exhausting lesson twice a week. In Sweden
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438 Psychological Retrospect . [Oct.,
seven or eight years is the age fixed by law for children to begin
gymnastics. From 30 to 50 children are in ordinary cases enough
for a class, but if the children are of fairly equal strength 80 to 90 may
be exercised together with advantage, provided space and apparatus
will allow. But in places where there are large numbers to be drilled,
100 at a time in some cases, it is exceedingly difficult to give
individual supervision, and the age of 9 or 10 is then quite early
enough to begin with. On the other hand, medical gymnastics, and
gymnastics given individually under the teacher’s hand, may begin
with the earliest years of childhood.
The boys’ drill in the senior classes prepares the way for military
drill, into which it imperceptibly merges. Ling defines educational
gymnastics as “ putting the body under the control of its owner; ”
military gymnastics as “ putting another’s body under one’s own
control.” Even in the military branch the harmonious develop¬
ment of the body holds a prominent place, no position being tolerated
which hinders a full and free respiration. The art of swimming is
also included in the system. It is taught on dry land and with great
success. Out of 60 children taught by this method in one of the
National Schools 40 could swim at once on getting into the water.
This method is fully described in a little book called “ Home
Gymnastics,” published by Isbister and Co., but space forbids me to
go into further details.
The whole subject is too wide to be more than touched upon in a
paper like this; .but there is one point to which I should like to draw
attention. It is this—that, whilst deprecating the gratuitous feeding
of the children of the poor, 1 should hesitate to give any which come
to our schools in a half-clad and half-starved condition a gymnasium-
lesson without their first being fed. Otherwise the lesson can only
be to them a pure loss of strength and warmth which they can ill-
afford to spare.
{To be continued,)
2. French Retrospect
By D. Hack Tuke, F.R.C.P.
We resume the analysis of the w r ork on Hypnotism, by M. Beaunis,
which we noticed in the April number of the Journal (p. 147).*
Hallucinations of hearing appear to be very clearly defined. Subjects
are easily made to hear words very distinctly. They resemble the
“ voices ” which the insane hear, commanding them to do things.
Nothing is easier than to suggest visceral sensations, hunger or thirst,
or the sensation of burning or shivering with cold. Motor hallucina¬
tions are most striking in their character, for certain movements may
be suggested to the hypnotized while they remain absolutely im-
* A second edition of this work has now been issued.
Digitized by L^ooQle
1887.] French Retrospect. 439
movable, as dancing, &c., just as happens in our dreams. Then
there is the question of the length of time hallucinations may persist
after the subject has been aroused from induced sleep. When a time
is assigned by the operator the hallucination generally lasts as long,
but of course there should be a limit to such an experiment lest some
danger arise. When the duration has not been fixed, the time the
hallucination lasts may be minutes, hours, or days without any assign¬
able reason. It is noteworthy that it does not disappear in a moment,
but gradually fades away.
Next as to what are called negative hallucinations. By suggestion
a person or object may be invisible to the subject. How shall we ac¬
count for this remarkable fact, known to us for many years, but
apparently regarded as novel by those who have at last woke up to the
importance and interest of these phenomena? It would probably be
no exaggeration to say that they have been quite familiar for at least
40 years to those who have turned their attention to the subject. M.
Beaunis has no difficulty in explaining negative hallucinations in
reference to simple sensations. 44 When 1 say to a subject * You do
not see red any longer,’ one may suppose that a number of retinal
elements (or correlative cerebral elements) have been paralyzed, just
as when I say 4 You cannot perform a certain movement/ I
paralyze a certain group of muscles.” It is more difficult to explain
how one can make a person who is present be neither heard, nor seen,
nor felt, however explicable the production of the phantom of an
absent person may be. We are accustomed to the effect of a dominant
idea if sufficiently intense in producing a visual sensation, but the
reverse experiment cannot be explained in the same way, for it is
altogether negative. Furthermore, a person may be made to dis¬
appear partially, e.g., is seen, but not heard, or seen and heard, but not
felt on contact.
Such marvels are authentic facts, and excellent illustrations are
given in M. Beaunis’s book. One unpleasant result of not seeing a
person who is actually present may be a personal remark which would
fall under the category of 44 things better left unsaid/’ as in the
instance of Miss A. E., who said of M. X., 44 He looks like a fool.”
We pass on to the spontaneity observed in somnambulism, the
subject proceeding to tile performance of an act with (as has been
well said) the fatality of a stone which falls to the ground, and not
from reflection. The subject hypnotized is ordered to do a certain
thing at a certain hour ten days afterwards. At that very time the
act is executed which has been suggested, A. all the time believing
himself to be a free agent. In certain cases, however, when the act
suggested is very singular or is criminal, the attention of the subject
is aroused, and he is himself astonished at this idea. It is accepted
by his intellect and implanted there like an obsession. He then feels
that his will is overborne, and he is conscious* that all resistance is
impossible. We see here the analogue of the lunatic who, dominated by
xxxiii. 29
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440 p8ychobgical Retrospect . [Oct.,
a delusion or an irresistible impulse, kills, steals, or burns with
complete irresponsibility. Again, all spontaneity is not abolished in
every instance. For example, M. Bcaunis asks A. E., during the
hypnotic sleep, “ Do you wish to dream ? ” and she replies, “ I do not
care.” “ What do you wish to dream ? ” “ What you wish.’’ “ Would
you like a good breakfast? ” The reply is “No.” Several kinds of
dreams are enumerated and proposed. To all the reply is in the
negative. Again, “ Do you wish to walk ? ” “ Yes.” “ Where ? ”
“ In Madame X/s garden/’ u You are there ; are you content ? ”
“ Yes.” “ What are you doing there ? ” “1 am walking on the
terrace.” Here we see the subject able to make a choice between
different proposals. However, M. Beaunis is disposed to admit in
theory the irresponsibility of somnambulists, while M. Pitres (Des
Suggestions Hypnotiques) takes the opposite view in consequence of
their resistance, in some instances, to a suggestive impulse. Pitres is,
notwithstanding, forced in the end to admit that a doctor will be
justified in regarding a somnambulist accused of crime as irresponsible.
Instances of attempts to resist a suggestion to do something dis¬
agreeable, are given by the author, and are very curious. He on one
occasion suggested to A. E. that she could no longer pronounce any
vowel except o, and that whenever she found a different vowel in a
word she should substitute for it the vowel o. She was then aroused
from sleep, but, as M. Beaunis had forgotten to suggest to her to speak,
she remained absolutely silent for nearly half ail hour, until she was
free from the suggestion. Had he suggested that she must speak she
could not have maintained the silence she desired. The refusal to
reply to questions during the induced sleep is sometimes obstinate and
prolonged, but an energetic affirmation and a deepening of the sleep
secure the wish of the hypnotiser. Somnambulists have been known
to reveal the secrets of their lives, as indeed has happened with per¬
sons merely talking in their ordinary sleep.
One chapter is devoted to the mental condition present during the
hypnotic sleep. M. Beaunis is inclined to think that there is an
absolute repose of thought so long as no suggestions are made. If
the subject is asked what he is thinking about, he almost always
replies “ Nothing.” And this accords with the motionless body, the
expression of his face, and, indeed, a tranquil calm which it rarely
presents in ordinary sleep. There are neither dreams nor thoughts,
for the subjects, who so well remember when re-hypnotized what
passed in the previous sleep, can never recall anything unless sugges¬
tions have been made to them. Incidentally, it may be mentioned that
the sleep which is without suggestions—a complete blank—is more
useful in therapeutics. The judgment seems to be good, and the
subjects reason in general very correctly and logically. Liebeault has
been much struck with the power of deduction. Hence M. Pitres
would seem to be wrong in regarding the hypnotized as an uncon¬
scious machine, incapable of reasoning or judging.
Digitized by A^OOQle
1887.] French Retrospect . 441
M. Beaunis, while not prepared to deny certain astonishing facts
vouched for by savants of good faith, asserts that he has never
seen anything like mental divination, or second sight, and the power
of predicting, except that a somnambule labouring under a disease,
especially of a nervous character, may announce the day and the hour
when an attack may occur, and predict the date of his recovery;
but this may be attributed to mere auto-suggestion. The question is
raised, Do somnambules tell lies during their sleep? Pitres says they
do, and that knowingly and voluntarily. Beaunis has not come
across a flagrant instance of lying, only a refusal to answer a question.
He has even found that when he thought a subject made a mistake in
certain details, he himself was wrong and the subject right. It
remains true that in hypnotism the moral being is fully laid bare, not
only in its acts, but in its thoughts and most secret feelings 1 Every¬
thing is exposed with the most complete naivete —vices, faults, irregu¬
larities, virtues, and passions. “ What a study for a philosopher/'
exclaims M. Beaunis, “ to see the naked soul of a Lacenaire. And
who knows whether in this examination lie may not meet with some
pure sentiment, a diamond lost in the dirt, some memory of child¬
hood, which, aroased by suggestion, may become the point de depart
of the moral reformation of the criminal, and his return to virtue ? ”
We are afraid that the practical English mind will hardly be able to
follow M. Beaunis’s hopeful expectation.
The last chapter takes up the difficult question of the relation
between the hypnotizer and the hypnotized. According to the author,
the somnambule is usually unable to hear what is addressed to him
by a third person, if he is en rapport with the person who has sent him
to sleep. This relationship does not obtain only in regard to hearing,
but to all the senses. If the hypnotizer takes the hand of the subject
after taking every possible means to prevent him knowing who does so,
the latter immediately recognizes whose hand it is, and he obeys the
gestures and movements which the hypnotizer, without saying a word,
impresses upon the limbs of the hypnotized. For example, if he raises
the arm of the subject, it remains extended, whilst if a third person
does this it falls inert. If the arm is cataleptic, this condition ceases
the moment the hypnotizer takes it, without speaking, in order to
make it execute a movement, whilst a third person who makes the
attempt meets with considerable resistance. Again, if passes are made
at a little distance from the subject, he recognises whether they are
made by the hypnotizer or by a stranger. M. Beaunis says he cannot
tell whether this is due to excess of tactile sensibility. If the subject is
asked how he knows who it is who has made the passes, he can give
no other explanation than “ I feel it.” Further, when rapport is
established, the hypnotizer may take the hand of one of his assistants,
and place it in that of the subject, and say “ I put you en rapport
with this person, obey him as you would me/’ The result is that the
subject is precisely as much in relation with the latter as with the
Digitized by t^ooQle
442 Psychological Retrospect [Oct.,
operator. In what does this singular phenomenon consist ? Noizet,
Bertram, and Li^beault attribute it to the subject thinking of the
hypnotiser on going to sleep. Just as, in fact, happens when a
mother, sleeping by the cradle of her child, does not cease to have an
ear open for it; and, while quite insensible to much louder sounds,
hears the least cry from the infant. So thought Dr. Carpenter, whom
M. Beaunis classes among " modern hypnotizers.” The subject is pos¬
sessed with the idea that a particular person is destined to exert a
particular influence oyer him. M. Beaunis, while adopting the same
view, has met with certain facts which seem inexplicable on this
theory, and appear to point to a real relationship between hypnotizer
and hypnotized.
In his “ conclusions ” the author states his belief that “ concen¬
trating attention ” fails to explain all the phenomena of hypnotism.
In seeking for a further explanation, he says, H How can you explain
by this means the fact that the subject will see a person when awake,
who has been impressed upon his mind when asleep, a week before,
if this suggestion has been made ? ” Here the suggested idea
remains in his mind all that time without his being conscious of it,
but it comes to the surface at the very hour fixed upon. M. Beaunis
cannot find here any proof that the mind was concentrated upon this
one idea. Again, physiological phenomena, such as palpitation,
redness of the skin, vesication, &c., are inexplicable, it is alleged,
upon the principle of volition or suggestion alone; there must be
also a modification of the cerebral innervation, a receptivity very
different from that of the normal state. But what is this cerebral
state ? To reply is confessedly very difficult. If the method by which
the condition of sleep-waking is induced is analyzed, it will be found
that one condition is essential to its production. It is necessary at
first to strongly arrest the attention in order to make a suggestion.
The course of thought is arrested suddenly ; in other words, there is
cerebral shock. This is the sine qud non of success, and the cerebral
change is produced which is necessary for suggestions in hypnotism,
although we cannot tell the essence of this change. The same result
may be produced gradually in the hypnotic sleep, or suddenly, as in
the somnambulistic waking just described.
In the Appendix a case of chorea, cured by hypnotism, is reported.
The number of cases in which relief of symptoms has followed the
employment of this process in various affections is now very consider¬
able. Mr. Braid, had he been alive, would have said “ I told you so.”
The “ Archives de Neurologic,” edited by M. Charcot, a review of
whose recent work (Vol. iii. of the “ Leyons sur les Maladies du
Systeme Nerveux”) will appear in our next number, contain many
interesting articles, which our space unfortunately obliges us to pass
over at present. The same remark applies to the “ Annales Medico-
Psychologiques,” and to “ L'Enc^phaie,” edited by MM. Ball and
Luys.
Digitized by L^ooQle
443
1887.] German Retrospect .
8. German Retrospect .
Changes in Visual Power , in Nervous Diseases .
Dr. L. Finkelstein has made some investigations in the diniqoe of
Professor Mierzejewski with a view to ascertain what are the changes
in visual power amongst those affected by disease of the nervous
system. His results were communicated to the Psychiatric Asso¬
ciation of St. Petersburg (“ Neurologisches Centralblatt,” No. 1,
1886). He has especially investigated the power of sight in
patients suffering from epilepsy, hysteria, neurasthenia, and chronic
alcoholism. With the help of the perimeter he has found, along with
the initial symptoms of an approaching epileptic attack, such as giddi¬
ness, headache, palpitation, that there is a narrowing of the field of
vision in the retina of both eyes. Sometimes this takes the form of
hemiopia, sometimes of concentric diminution. This narrowness of
the field of vision is greatest after the attack, and the capacity for
colours is unequal in different areas of the retina: thus the area
in which green light is seen is the smallest ; it is larger for red and
larger still for blue. Dyschromatopsia is frequent; green is often
seen indistinctly, or confounded with other colours. In like manner
the visual power for colours returns at successive times, green coming
last. Scatoma often occurs, and passes away in the same manner.
The same appearances are noticed in hysteria, especially after
hysterical attacks. In neurasthenia the visual area for white light is
unaltered, while that for coloured light is contracted. In ordinary
drunkenness there is no sensible diminution of the field of vision;
but it is constantly found in chronic alcoholism and delirium tremens.
In these cases hemiopia is the most common form of visual defect. It
is generally in both eyes, not in one, as Magnan states. In some
women, apparently healthy, there was observed periodical contraction
of the retinal visual area, especially during menstruation.
A New Symptom in Hemiplegia.
Dr. H. Oppenheim, in the “ Neurologisches Centralblatt ” (No. 28,
1885), has called attention to a peculiar symptom which he has
observed in four patients in the Nervenklinik of the Charity Hospital
at Berlin. In a woman suffering from right hemiplegia with aphasia,
the feeling of sensation and pain on the paralyzed side was but feebly
diminished, and the power of vision did not appear to be affected. On
holding out two keys, one to each eye, the image next the left eye
was found to be at once realized, while on the right the key had to be
brought nearer or moved up and down ere it was noticed.
While the prick of a needle was felt if applied to the right hand,
if two pricks were made, one on the right hand and another on the
left, one impression, that on the left, was realized. The same
abnormality was found in the leg. In another case of aphasia with
Digitized by L^ooQle
444 Psychological Retrospect . [Oct.,
right-sided hemiplegia the same symptoms were observed. On the
affected side a prick was felt in the right hand ; but in pricking the
right and left hand at once the prick was only realized on the left.
The same phenomenon was observed both in sight and hearing. The
experiment was repeated on two male patients, one suffering from
epileptiform seizures on the left side, the other from right-sided hemi¬
plegia and aphasia. Dr. Oppenheim tried the same experiment in a
great number of cases in nervous disease, but without finding a similar
result. He believes that no such result is ever met with in healthy
people.
Porencephaly.
Professor D. Lambl, of Warsaw, has published a case (“ Archiv.,”
xv. Band, 1 Heft) in which this defect, instead of being accompanied
with idiocy, went along with an unusual amount of sharpness.
Catherine, natural daughter of Marianne Kwiecen, used to go about
the district of Nowo Alexandrowsk. Under the guidance of her
mother, she gained great reputation as a clairvoyante, interpreter of
dreams, and healer, and many of the richer people in the country
went to consult“ the little witch.” Her grotesque appearance was of
service in keeping up such pretensions. Small and weak, somewhat
paralyzed on the right side, the body leaning to the left, squinting,
and with an unsteady gaze, she was ready of retort, cunning, and
quick of wit, and knew how to assume a tone of confidence which had
its effect upon the country people. Her materia medica was of a
striking character, such as to rub the limbs with dogs’ or cats’ fat, or
to take soup made from rats’ flesh. Her prescription for phthisis was
peculiar, a bath in decoction of rye-straw, and when the patient had
left the tub a cat was to be thrown in. If the cat were drowned the
patient would recover, otherwise not. As most cats are active enough
to leap out of a tub, this may be thought a roundabout way of con¬
veying an unfavourable prognosis. In 1872 the little witch was
brought by the police to the Hospital at Lublin, where she was
examined by Dr. Schmidt. She was then twelve years of age. He
found her very intelligent, with an excellent memory, although she
had never been at school. She wandered through the wards, showing
great curiosity about the patients, and asked questions from the
apothecary about the medicines which they got. The right side was
found feebler than the left, and the muscles more weakly developed.
She had divergent strabismus with nystagmus; the sight in the left
eye was weak. Her appetite was good ; the sleep troubled with wild
dreams. Examined about her pretensions as a healer and soothsayer,
the creature showed considerable tact and cunning in evading search¬
ing questions. She said that three years before, when she was
looking after some calves in a meadow, she had a vision of a beautiful
lady, who soon began to vanish, save the head and hat, and who cried
out, “ Be quiet, Catherine ; you will no more have to look after
Digitized by C^ooQle
German Retrospect .
445
1887.]
calves, but will go about towns and villages curing tbe sick.” After
she had been two months in the hospital, Catherine confessed that
she had been coached by her mother and two other persons, who
taught her the names of some diseases and popular remedies, and
instructed her how to play her part as a healer and soothsayer. In
consequence of this she was sent to the Hospital at Lublin, in which
she died two years after of anasarca.
On examining the brain, there was found to be porencephaly of the
left hemisphere, that is, a funnel-shaped depression from the upper
surface of the cortex, communicating with the lateral ventricle, which
was enlarged, and full of serum. The left hemisphere weighed
406*710 grammes, the right 440*054 grammes, the left hemispheres
being lighter by 33 grammes. The convolutions of the left side were
flattened, the grey matter pale and oedematus, and on microscopical
examination the nerve-tissue around the pons was found to be altered
and degenerated in structure. Dr. Lambl thinks that the strabismus
and the nystagmus were the results of intracranial pressure, and that
the paralysis of the right side was the result of the cerebral atrophy.
He discusses the question of why, instead of being imbecile, Catherine
was possessed of such unasual intelligence, without mentioning, what
seems to be the rational explanation, that there was no proof that the
left side of the brain was diseased ; and, indeed, no exact proof that the
greater proportion of the right hemisphere was functionally incapable.
Dr. Lambl discusses at considerable length the causes and pathology
of porencephaly, atid mentions several cases where, when only one
hemisphere was affected, the intelligence was preserved. His paper
is illustrated with some lithographic plates.
For other cases of porencephaly, the reader may see our Retrospect
in this Journal for April, 1882, p. 124, and April, 1883, p. 122.
Another Case of Porencephaly .
This is recorded by Dr. R. Otto (“ Archiv.,” xvi. Baud, 1 Heft)
in a child who died at the age of three-and-a-half years. He had
never spoken nor walked, and the mental manifestations seemed to
amount to little more than a slight attention to sounds and an occa¬
sional effort to push away what hurt him. The sensibility appeared
to be normal. The muscles were, during waking moments, stiff;
during sleep they were relaxed. The porus or opening on the right
side of the cortex was somewhat further back than usual, being in the
region of the parietal lobe. There were two openings on the left
side. Dr. Otto connects the failure in speech with a deficiency in the
third frontal, but there was no chance of a child of so little intellect
being able to speak. He cites the case of Ross, but does not seem to
be acquainted with the one described by Mierzejewski, reported in the
Russian Retrospect of the “ Journal of Mental Science,” 1882.
There is mention of a similar case in the “ British Medical Journal,”
11th March, 1882, in which the motor deficiency of the limbs was
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446 Psychological Retrospect . [Oct.,
supposed to be dependent upon failure of the development of the
motor area of the cortex.
Reflex Epilepsy .
Professor Eulembnrg gives in the " Centralblatt fur Nervenheil-
kunde” (No. 1, 1886) a good case of reflex epilepsy, which began
with a growth on the big toe of the right foot. The first nervous
symptom was cramp, which caused painful flexion of the foot. The
abnormal spasms then spread upwards, so that there was convulsive
bending of the knee-joint, and at last an epileptic attack with loss of
consciousness, which was repeated two months after. The growth
was touched with escharotics, and later on the nail was taken away,
on which there was found an exostosis of the phalanx of the great toe,
which was removed. Three weeks after, however, the cramps returned,
and about four months after there was a new epileptic attack. This
was followed by other fits, which in the end became very frequent,
sometimes implicating the right side only, and sometimes accompanied
by unconsciousness; at other times not. Stretching of the sciatic
nerve was tried, which caused au abscess. Other means were used —
local and general subcutaneous injections of atropine, hydriodide of
hyoscyamine, curare, bromic ether spray, galvanic baths, bromide of
potassium—all without effect. After six months' treatment the man
left the hospital rather worse than when he came.
Murder under Epileptic Insanity .
An instructive case of crime committed under the influence of
insanity is recorded in the “ Centralblatt fur Nervenheilkunde ” (1
November, 1885), quoted from a paper by Dr. F. Gierl (“ Friedrichs
Blatt fur Gericht. Med.," Jan. und Febr., 1885).
On the 20th of February, 1881, a servant in a brewery was found
murdered in his bed. The right side of the skull was completely
shattered, and on the face and breast there were twenty-three cuts
and stabs. The trunk of the deceased was open, and it looked as if
its contents had been searched. Suspicion at once fell upon J. R., a
day labourer, who had first entered the man's bedroom. He seemed
quite aghast at being arrested, and could give no explanation of
marks of blood on his clothes and boots. The next day some money
was found, wrapped in a handkerchief, in the court-yard near J. R.'s
dwelling, so poorly concealed that a corner of the cloth was sticking
out of the ground. At first J. R. denied the crime, but, under a sus¬
tained examination, on the 22nd he confessed that he had killed the
man with a cudgel. At that time he apparently denied stabbing him,
which, however, he admitted next day. The day after this, however,
he retracted his previous confession, saying that previously he had
been quite deranged. He admitted having had a scuffle with the
man. During all these examinations his manner was very apathetic.
Witnesses appeared, who represented him to be an industrious, honest,
and peaceable man. His wife testified that he had sometimes suffered
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German Retrospect .
447
1887.]
from fitB of insanity, and was actually passing through one of them
when he committed the deed. Before these attacks he remained for
days silent and apathetic, and then he would begin to rage and bite
the panels of the bed with his teeth. On one occasion he threw the
lighted petroleum lamp into the bed where his sick child was.
Another time he seized an older boy who did not immediately obey
some command, and threw him across the whole room into the bed,
regardless of the danger of hurting him. He had talked of suicide.
These attacks had come on several times, but she had tried to conceal
them, and could produce no witnesses to support her statements. A
fellow-labourer, however, said that he had observed that J. R. was
sometimes quite deranged and very dangerous when provoked, on
which account he had kept a knife by him to defend himself if attacked.
The accused was sent for six weeks to the asylum at Kaufbeuren* where
he was kept under observation. He was a powerful man, quiet, and
very apathetic in manner, and never spoke save when he was
addressed. He was easily led to say anything suggested. There was
a scar below the left axilla between the eighth and ninth rib, which,
however, did not seem to be sensitive to handling. The stage of
excitement seemed to commence with a burning feeling proceeding
from the scar, and then there were pains in the breast and giddiness.
The scar was the result of a stab in the left side which he had received
above three years before. After it had healed up the wound had again
been opened by an injury. When the. attacks of derangement came
on be had thoughts of suicide and hallucinations of the devil. He
professed to have a very imperfect recollection of killing the man, but
said that he thought he had done it to defend himself after an appari¬
tion of the devil. He said that he took the man’s money because he
thought he had no more use for it after he was dead. He retained no
remembrance of the attacks of fury in his own house after they had
passed away. Two physicians experienced in insanity certified that he
suffered from attacks of epileptic or epileptiform insanity, and that
he committed the action when there was suspension of will-power. In
spite of this he was found guilty by a jury and condemned to death,
which was commuted into imprisonment for life. He went through
the trial with apparent indifference.
On Aphasia and its Relation to Apprehension .
Dr. Grashey ( 4< Archiv.,” xvi. Band, 3 Heft) has given an article
of thirty-four pages on this interesting subject. He gives a careful
study of a patient whom he showed to the Wurzburg Medical Society.
This man had a fracture of the base of the skull, which resulted in
aphasia as well ns injury to the function of several of the cranial
nerves on the right side. During a careful and prolonged study of
this case Dr. Grashey considered the relation of the images of objects
to the images of sound, of sound images to spoken words, of words
to symbols and writing, and so on.
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448 Psychological Retrospect. [Oct.,
Dr. Grashey holds that there is a variety of aphasia which is
dependent neither upon the loss of function of the nerve-
centres nor injury to the conducting power of the nerve tracts, but
simply upon a diminution of the duration of the impressions of the
senses causing a loss of the powers of* apprehension and association.
Aphasia following diminished duration of the sensory impressions is,
to all appearance, not rare. It is to be sought for amongst patients
who suffer from concussion of the brain or from fevers. Dr Grashey
has found a number of cases in which all impressions are forgotten
immediately after being apprehended. He cites one instance from
Lichtheim of a man whose head was injured by a fall from a
waggon, and could not recall the names of objects. When one said
the words to him or wrote them he could repeat the words without
any difficulty. The power of writing was also much injured.
4. English Retrospect.
Asylum Reports , 1886.
(Continued from p. 326.J
Aberdeen.-— What might have been a very destructive fire broke out
in the roof of an upper storey. Fortunately it was almost immediately
discovered, and did little damage beyond consuming the roof it
originated in. Various suggestions have been made by one of the
Commissioners, by which the dangers of fire would be much
diminished, and no doubt the Managers will do all that is in their
power, now that they have seen what may happen, to protect the
patients and buildings.
A private patient, who had for several years been allowed to walk
beyond the asylum-grounds, accompanied by an attendant, suddenly
threw himself over a bridge. This is another illustration of what
chronic, and so-called harmless, lunatics will do.
Although 35 patients died during the year in only 15 cases was
the cause of death verified by examination. This must be considered
a small proportion.
Bedford, Hertford, and Huntingdon. —The Commissioners remark:—
There has not been any resort to seclusion or restraint. When it is found
necessary to dissociate a patient from the rest in a ward an attendant is always
placed in separate charge of the case. ,
In acute delirious mania, in the fury of epilepsy and general
paralysis, we should have expected that complete isolation would have
been preferred.
The importance of extended exercise beyond the airing courts is
also pointed out.
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449
1887.] Asylum Reports.
Cheshire. Macclesfield .—Among various works in progress or sug¬
gested is the heating of the dormitories with hot water.
The Committee still adopt the practice of asking the patients when they
come up to be discharged (the Medical Superintendent not being present)
whether they have any complaints to make of their treatment in the Asylum.
The result has been satisfactory.
This is an arrangement which should be adopted in every asylum.
In some large asylums the patients are discharged without ever see¬
ing the Visitors; and though means are adopted for obtaining
expressions of opinion as to the nature of the treatment experienced,
these cannot be considered quite satisfactory.
The following suggestion by the Commissioners may be usefully
adopted by those as yet unacquainted with it:—
We also visited the Chapel, where we observed a box placed for contribu¬
tions towards aiding discharged patients. In respect to this subject, on read¬
ing the Chaplain’s report we notice he advocates a yearly grant by the
Committee towards the “ Samaritan Fund ” to aid in supporting the patients
on discharge until they are able to obtain work. We are fully alive to the
great advantages accruing to patients from such pecuniary assistance, and the
practice in the Metropolitan Licensed Houses receiving paupers is to send
them out on trial for a certain period, giving them a weekly allowance during
that period, thus enabling them to live without unduly taxing their strength,
and helping them in a snort time to earn their own living. This system, it
appears to us, might well be tried here.
Dorset .—After a service of 32 years Mr. Syines retires in favour of
Dr. Macdonald. We cannot help expressing surprise at the manner
in which he was treated as to pension. No doubt the Pensions Com¬
mittee, consisting of such practical men as Dr. Murray Lindsay and
Dr. Williams, will give due consideration to the circumstances of this
case, although we are aware that it is said that, while it is not
agreeable to have a pension cut down from £600 to £450, the latter
sum is not to be despised in these days of retrenchment and general
discontent.
Improved means for testing the punctuality of the night attendants
have been provided. The apparatus is electrical and cost £103.
We commend Mr. Byrnes’ method of treating little offences by
attendants and nurses. He says :—
The duties of attendants on the insane are irksome and very heavy to bear,
and it needs considerable forbearance on their part to submit to the many in¬
dignities frequently heaped upon them; it is this knowledge which makes
me desirous of commending them to your kind consideration and favour, and,
feeling as I do, I have always endeavoured to put the most favourable con¬
struction on any little error or misconduct. The outside world knows little or
nothing of life amongst the insane; did they, I feel certain their remarks
would be sometimes more modest and leavened with more real Christian
truth and charity.
Edinburgh Royal Asylum .—It is exceedingly satisfactory to find
that the Governors have been successful in the suit raised by them
against the City and St. Cuthbert’s parishes for the recovery of the
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450 Psychological Retrospect . [Oct.,
boards of pauper patients at the rate which they considered they were
entitled to.
Intimation of a legacy of £5,000, with residue, has been received.
The money is to be held in trust for the benefit and relief of insane
persons, who, from their rank in society, or education and habits,
cannot properly be associated with paupers, but whose means are in¬
sufficient for defraying the expense of their comfortable maintenance
in the asylum conformably to their station and habits, though their
mental condition be such as to render it desirable that they should be
placed in such an institution. Careful provision is made by the testa¬
trix for the application of the whole annual income for the benefit of
insane persons of the class referred to, in no case more than £40 being
allowed for any one patient, and the fund not being allowed to operate
in any manner so as to lessen the burden upon parishes or other
public bodies legally liable for the support of paupers and others in the
asylum.
As usual, Dr. Clouston’s report contains much that is worthy of
reproduction, but space forbids.
Kent. Chartham Downs .—A hospital, to contain 20 beds and the
necessary rooms for attendants, &c., is in course of erection, at a cost
of £2,500.
A patient committed suicide by jumping down the well in the
engine-house. He had been nine years in the asylum and had never
exhibited any suicidal tendency. Dr. Spencer attributes the act to
uncontrollable impulse.
Kent Banning Heath .—The following paragraphs from Dr.
Davies's report will be read with interest:—
It is the diminution of discharges which explains this increase, and I am of
opinion that the general depression in trade and industry of all kinds, which
has been so severe lately, has directly conduced to this result, and this in two
ways:—Firstly, by lowering the vital power of those affected; and, secondly,
by curtailing the means of the patients’ friends, thereby rendering it impos¬
sible for them to do anything towards promoting recovery, by removing the
patients early, and completing their cure at home. I have great faith in this
early removal from an asylum. Let the wards be ever so cheerful, they lack
the nameless comforts of home, and relapse but too frequently ensues if
removal be unduly delayed.
Again I have the pleasure of reporting the total absence of seclusion and
mechanical restraint. The greater freedom allowed to, and the more varied
forms of occupation we now provide for the patients, are mainly the cause of
this most desirable result. This subject of occupation of patients under skilled
attendants in various trades has already received considerable attention from
you. I cannot express too strongly the very high opinion I have of its
advantages to my patients, apart altogether from its economic aspect,
though this latter is by no means inconsiderable.
Work, particularly skilled work, is more essential for the successful treat¬
ment of the diseases of the mind than all the drugs I know anything about.
This work, however, must be under the direction of trained attendants, and
also under the immediate supervision of the medical staff. I have proved
over and over again that it is worse than useless to send a semi-convalescent
patient to work with an ordinary artisan. I trust the day is not far distant
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451
1887.] Asylum Reports.
when the full resources of the asylum will be developed for the benefit of its
afflicted inmates by the extension, to its utmost limit, of this system, which
we have found to be so very advantageous, and absolutely free from any draw¬
back.
Killamey .—Dr. Woods notes that one death was due to general
paralysis of the insane, the second that has occurred in the asylum
during the past eleven years, and it is worthy of remark that the man
was not a resident in the county, but had served for many years in the
R.I.C., and was stationed in a part of the country where lately he
had hard and trying duties to perform.
The enlargement of the asylum is under consideration.
Lancashire . Lancaster .—We are pleased to learn that Dr. Cassidy’s
salary has been raised to £1,000 per annum. Various structural
alterations, including the drainage works, have been completed, and
others of much importance are contemplated.
Dr. Cassidy has recently introduced, the Commissioners report, the
practice of associating the sexes at meals on opposite sides of the
same table. This has caused no confusion or disturbance, indeed the
patients have taken little notice of their neighbours opposite. The
airing courts are little, if at all, used ; and the women get their
proper share of exercise on the boundary walk.
In connection with the amusements, an experiment has been tried
to make them self-supporting by admitting the public and charging
for admission. The Christmas pantomimes left a handsome profit.
The following paragraphs are from Dr. Cassidy’s report. His
opinions may be compared with Dr. Davies’s on the same subject—
early discharge of convalescent cases ;—
A curious instance occurred in a young man, readmitted after a considerable
interval of absence from the asylum, whose symptoms, those of suicidal
melancholia, were similar on both occasions, but where the same treatment,
self-applied, succeeded the first time but failed on a second trial. When here
on the first occasion he precipitated himself head foremost on a stone pave¬
ment, causing a nasty biuise and wound of the scalp, which was followed by
diffuse celluStis and suppuration, in the course of which he recovered com¬
pletely, and was ultimately discharged. After his second admission he was
closely watched, but found, in spite of this, an opportunity for repeating his
former tactics, and threw himself head foremost as before. The same results
short of recovery followed, and his scalp being now healed, he remains as he
was, melancholic and obviously watchful for some further opportunity to
injure himself. [Might not the next experiment succeed?]
With respect to readmissions within the year, I am afraid in some instances
premature discharge must be accountable for the relapse. Though holding
the conviction that premature discharge is more likely to be harmful than the
detention, and even the prolonged detention of convalescent patients, I find
it often very difficult to resist the importunity of the patient and of
patients’ friends, in which very often the latter have no measure. It is a
common experience to find, when this importunity has been resisted, the
patient in the end is grateful, and ready to acknowledge his previous non-fit¬
ness and his now better preparedness for discharge.
It seems hard to condemn a convalescent who is practically sane, but whose
nervous system has not yet recovered its tone or his mental powers their full
fitness for the ordinary calls of life, to spend a further portion of his days in
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Psychological Retrospect . [Oct.,
the society of the actively insane, and for such an one discharge from this
intercourse would be the best solution, could we be sure that his home and
surroundings would be such as to promote the full restoration of his powers.
Herein lies the difficulty, and in the sometimes astonishing inconsiderateness
of relatives, the bad conduct of husbands, wives, or parents, or the overwhelm¬
ing pressure of domestic or business cares, exists the cause of many an early
relapse. Therefore, the ideal asylum, in addition to a separate and detached
block for the newly-admitted acute cases, which it is generally admitted is an
urgent want in most asylums, should contain a building apart from the
asylum proper for convalescents, where a longer probationary period prior to
discharge should be passed, with such liberty, privileges, and surroundings as
would mitigate the hardness of detention, and gradually accustom the
recently-recovered lunatic to the responsibilities of freedom.
Lancashire . Prestwick. —Dr. Ley points out that of the admissions,
about 30 per cent, came directly from their own homes, and 60 per
cent, from workhouses. This method of passing patients through
workhouses to asylums is worthy of emphatic condemnation.
Suicidal tendencies exist in 40 per cent, of the cases in residence.
This is a most unusual proportion, and Dr. Ley reports that this dis¬
tressing complication has greatly increased during the last three years.
Lancashire. Rainhill .—Dr. Rogers reports :—
, In an unusually large number of cases, especially among the women, there
has been observed a very marked derangement of the bodily functions,
especially of the circulation, among those recently admitted. This disturb¬
ance of the circulation, accompanied with a very high temperature and great
exhaustion, has closely resembled continued fever, though without its special
characteristics, and the subjects of it have required very careful nursing, but
most of those who have been so affected have either already recovered or are
on the way to recovery.
Lancashire . Whittingham .—The following extract from Dr. Wallis’s
report shows that he is working in the right direction :—
This mention of nurses and attendants allows me to refer to their training.
Much of the successful treatment of the insane depends upon the care and
attention they should receive from those in immediate charge of them;
indeed, it may frequently be said of a particularly critical case that the life
of the patient absolutely depends upon the painstaking and faithful carrying
out of minute details of nursing. The asylum attendant receives, as a rule,
no systematic training, but depends upon his native sharpness, love of his
work, and energy for picking up from his charge attendant such atoms and
scraps of information as he may be favoured with from time to time. Beyond
this he is left to the perusal of his rule-book, his own powers of observation,
and an occasional word from the chief attendant. Some superintendents of
asylums, especially in Scotland, have endeavoured to systematize the training
of their attendants; and a manual has been edited and issued which has
received the approval of many of the members of the Psychological Associa¬
tion. Without going quite so far as the manual, I feel that something in this
direction ought to be done; and, with that object in view, I have in hand
some instruction classes, which I propose, at first, at any rate, to confine to
the charge attendants, by means of which I hope to be able to give them a
broader view of their, duties, and some more precise instructions as to nursing,
than they have hitherto enjoyed.
In their report the Commissioners state that, although the Irish
Roman Catholics are a large proportion of the inmates, Dr. Wallis
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453
1887.] Asylum Reports.
overcomes the objections usually made by the friends of such patients
to post-mortem examinations by refusing a certificate of the cause of
death unless verified by autopsy. Now we should like to know the legal
aspect of this question. Is it lawful for a doctor to refuse a certificate
of death although he knows the cause ? We believe not, though we are
not aware that the question has been authoritatively settled. Whether
it be morally right to bring such pressure to bear upon the relatives, is
a question to be settled by each man according to his conscience.
Leicester (Borough). —The whole of the drainage is in process of
being overhauled.
About 30 only of each sex are confined entirely to the airing
courts. Various structural improvements have been effected; the
most important being the erection of a block of workshops.
Leicester and Rutland .—So far as we can gather from the report,
for the subject is not even mentioned, the proposal to erect a new
asylum is abandoned in the meantime. It is quite evident, judging
from the Commissioners’ report, that the present building has many
structural defects, and much is required to bring it up to modem re¬
quirements, if, indeed, this be possible.
Lincoln.— No progress has been made in providing necessary
accommodation for pauper lunatics in this county. A separate asylum
for the southern division has been talked of, but nothing has been
done.
London .—The Commissioners point out that no fewer than 315 out
of 425 patients are entirely confined to the airing courts for exercise.
If the number of nurses and attendants is too small to permit of more
extended exercise, it is obvious that the number should be increased.
In reply to this Dr. Jepson remarks :—
This implied hardship is scarcely a justifiable stricture, having in view the
exceptional size of the grounds, which afford ample scope for exercise to
those who are able or willing to take it. The country walks are enjoyed by
the men, and all who can be trusted are invited to join them, but among
the women they are regarded with considerable disfavour, and various subter¬
fuges are resorted to to obtain exemption from the indulgence. A very great
number of both sexes are too old and too feeble to walk at all for any length
of time, or for any distance.
It will be found that, by a little persuasion and firmness, the women
will walk and obtain much benefit therefrom. The infirm should be
sent out in separate parties. Experience has abundantly proved that
female patients are much improved in their general condition by being
excluded from airing courts and being compelled to walk out in the
country. The advantages to the discipline of the nurses are obvious.
The results of actual experience are the best replies to the difficulties
urged against this practice.
Middlesex . Eanwell .—The laundry is now quite inadequate. The
contemplated additions and alterations will cost £8,491. To accom¬
modate the increasing number of female epileptics, plans have been
prepared for the erection of an annexe to the infirmary ward for sick
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454 Psychological Retrospect . [Oct.,
and feeble epileptics. The building will contain 20 beds, with five
single rooms, and the cost, including furniture, is estimated at about
£2,899.
Middlesex. Banstead .—The occurrence of the outbreak of fire late
at night in the bedroom of a male attendant afforded a practical
opportunity of testing the usefulness of the electrical alarm bells. The
fire brigade thus summoned mustered very promptly, although,
happily, their services were not required, as the fire had been pre¬
viously put out.
A 6itting-room has been provided for the male attendants, and fitted
up with a billiard table, presented by the chairman. This act of
benevolence might be imitated in other asylums, for such are singu¬
larly rare.
Monmouth , Brecon , and Radnor .—The addition of sixty acres to
the estate has been sanctioned, but not completed.
It is satisfactory to learn that only 10 men and 30 women of those
physically able to take more extended walks are confined wholly to
the airing courts.
Dr. Glendinning reports that only one death from phthisis occurred
during the year, and only one patient in the asylum is suffering from
that disease. This is a most satisfactory condition, for there is no
doubt, as he remarks, that this disease is chiefly due to impure air,
defective hygiene, and imperfect nutrition.
Montrose. —The long-standing controversy with the District Board
has been brought to a close; but the Managers have received notice
from the Board that it will seek to reduce the rate of board, £28 12s.,
to the old rate of £24 10s. The Managers have resolved to adhere
to the higher rate, and we sincerely hope that they will succeed in any
litigation that may arise thereon.
The following paragraph is from Dr. Howden’s report: —
It has been alleged that in English mining and manufacturing districts the
number of admissions into asylums is fewer during periods of commercial de¬
pression than in more prosperous times, and an endeavour has been made to
explain the supposed fact that, wages being low, working people spend less
on drink, and as a consequence fewer persons go insane from intemperance.
It would certainly be a considerable compensation for national misfortune if
the fact and the theoiy were alike true. I question, however, if either will be
corroborated by careful investigation. The theory w T as ventilated ten years
ago, at the commencement of a long period of depression. The depression
still exists, and in a more aggravated form, but I do not think the lunacy
statistics of the last ten years show a decrease of insanity as compared with
the previous decade. However it may be in England, the temperance theory
is not applicable to the districts from which the inmates of this asylum are
derived. Intemperance, as a direct cause, has always been a low factor in the
production of insanity with us, as compared with urban districts, though,
curiously enough, the number of cases of mania a potu (5) is larger this year
than usual.
Mullingar .—In his new appointment it is evident that Mr. Finegan
is not lacking in energy. In order to keep down the ever-increasing
number of patients in the asylum, he very properly makes an in-
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1887.] Asylum Reports.
variable practice of encouraging the surrender of inoffensive and
incurable cases to the care of their lawful guardians. He has also
recently instituted the keeping of medical case-books, “in which are
fully and accurately recorded information from every possible source
bearing upon the medical history of the case, together with statements
of the mental condition on admission, and the result of treatment
administered.” When one reads this sentence one is compelled to
ask, Is it possible that no case-books existed before in this asylum,
and are any other Irish asylums still without them ?
Murray's Royal Asylum .—This institution continues to prosper
under Dr. Urquhart’s efficient management. The following para-
graghs occur in his report:—
A wholesome competition among Royal Asylums in Scotland has, without
doubt, stimulated officials and benefited patients. That increase of personal
liberty, which is to be found in all the best hospitals for the insane in the
United Kingdom, is surely gaining the confidence of the public, and will as
surely result in a true appreciation of the highest aims of the medical care and
treatment of lunacy—“ the cure of the curable.” It is of little moment
whether this be ticketed the “ Open-door sy stem.” The main point is that on
both sides of the Tweed there is a system of granting liberty on parole, of
sending patients out on leaves of varying duration, of minimizing irksome
and degrading restraints, of encouraging intercourse with the outer world,
and of approximating asylum-life to the domestic ideal in so far as possible.
This is not the fashion of a day, but has been built up in studied evolution
since Conolly and his compeers began their labours; and we have to
acknowledge and found upon the experience of the men who showed how
asylums could be conducted without mechanical restraint.
The occupations have been continued on the same lines as in former years,
with manifest advantage to the patients. It is of the greatest importance
that those labouring under excitement or sinking into dementia should, so
far as consistent with prudence, be led to occupy themselves in useful work.
It is an advantage that has been widely recognized in pauper asylums, and it
is now being tried with benefit in hospitals of this class. I have felt that,
however important the amusement of the patients is, it is only subsidiary and
complementary to their occupation; and, therefore, since my appointment here
every effort has been made, from day to day, to induce patients to employ
themselves in some useful manner. The quiet and absence of turbulence, re¬
marked by the Commissioners from time to time, is in no small measure due
to this. The daily reports of the charge-attendants name the patients who
are unemployed, and state the reasons. Half are at work in one way or
another. It has been said that farm and garden labour is not the best work
for the town-bred insane patient. I am strongly of opinion, after an ex¬
perience of seven years in tnis asylum, that it is one of the most valuable aids
to recovery. It has been my fortune to have the unanimous approval of my
patients’ friends in this matter with one exception—an exception that proves
the rule. A young gentleman, suffering from chronic mania, was found
wheeling a barrow by his father, who pronounced bis occupation degrading,
and in consequence removed him to another asylum; but within a few
months the father wrote requesting me to receive his son again, without
stipulating for his exemption from the labours that had proved so salutary to
him.
(To be continued.)
XXXIII.
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456
Notes and News,
[Oct.
PART IV.—NOTES AND NEWS.
THE MEDICO-PSVCnOLOGICAL ASSOCIATION OP GREAT
BRITAIN AND IRELAND.
The forty-sixth annual meeting of the Medico-Psychological Association of
Great Britain and Ireland was held on Wednesday, 27th July, 1887, in the rooms
of the London Medical Society, Chandos Street, Cavendish Square, Dr. F.
Needham presiding. Among the members present were Drs. J. Bay ley, G. F.
Blandford, R. Baker, 1>. Bower, D. M. Cassidy, M. Cooke, T. S. Clouston,
Pritchard Davies, J. T. Kingston, H. Hicks, 0. Jepson, T. Lyle, H. R. Ley, W.
J. Mickle, H. C. MacBryan, II. Maudsley, G. Mickley, T. W. McDowall, H.
Hayes Newington, S. R. Philipps, J. II. Paul, A. Patton, J. Rutherford, H.
Rayner, T. L. Rogers, G. H. Savage, E. Swain, H. Sutherland, J. B. Spence,
A. H. Stocker, D. Hack Tuke, C. M. Tuke, F. W. Thurnam, A. R.Urquhart, W.
Wood, T. O. Wood, E. B. Whitcombe, F. J. Wright, &c. Among the visitors
were Dr. F. Norton Manning, Sydney, N.S.W., Mr. Clark Bell, New York, and
Dr. Hall, Northampton, Mass.
In the unavoidable absence, at the earlier stage of the proceedings, of Dr.
Savage, the outgoing President, Dr. Rayner opened the business of the
meeting, and expressed his regret that Dr. Savage was not present to say a
few preliminary words about the work of the Association during the past
year, which had been an unusually eventful one. Among others, one very
satisfactory feature of the past year’s work had been the development of the
system of examination for the Certificate of Efficiency in Psychological
Medicine, which had been attended with very satisfactory results, twenty-
four gentlemen now holding the certificate of competency. Then the Gaskell
Prize had been offered and won. Another circumstance which might be
referred to was the imveiling of the Guislain Statue at Ghent. The Belgian
Society of Psychological Medicine sent a circular to the various Psycho¬
logical Societies of Europe and America requesting them to send delegates
to be , present at the inauguration of the Statue of Guislain at Ghent
in the early part of the present month. The Council of this Associa¬
tion deputed Dr. Hack Tuke to attend, and that gentleman accordingly
represented the Association at the inauguration. As the important subject of
lunacy-legislation would be referred to in the President’s Address, in the
afternoon, Dr. Rayner said that he should not enter upon it, but simply ask
Dr. Needham to take the chair.
The President having taken the chair amid applause, said that he should
reserve any observations he might have to make for the afternoon meeting,
and that the formal business of the meeting would now be proceeded with
according to the agenda.
Dr. Hack Tuke said that in reference to the inauguration of the Statue of
Guislain, to which Dr. Rayner had referred, he would simply report that he
had attended as requested, and that the ceremony had passed off in the most
satisfactory manner.
The General Secretary submitted the minutes of the last annual meet¬
ing, which were printed in Yol. xxxii., No. 139, of this Journal. (October,
1886.)
The minutes, having been taken as read, were confirmed.
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.
Digitized by t^ooQle
THE MEDICO-PSYCHOLOGICAL ASSOCIATION.
1887.]
Notes and News.
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Examined and found correct,
H. HATES NEWINGTON, 1 . ... J - H - PAUL,
J. TREGELLES HINGSTONJ AW “ t0M * Teiasotbb.
July 27th, 1887.
458
Notes and News .
[Oct,
On the motion of Dr. Mubray Lindsay, seconded by Dr. Ubquhabt, the
balance-sheet was adopted, and a vote of thanks was conveyed to Dr. Paul,
which was suitably responded to by him.
Dr. William Wood proposed a vote of thanks to the Editors of the
Journal, saying that he felt sure he should have the concurrence of everyone
present in acknowledging the able manner in which the Journal was con¬
ducted, the value of the work commending itself not only to members of the
Association, but to the profession generally.
Dr. Ubquhabt seconded the motion, which was carried, the President
remarking that the Journal itself was the best testimony to the arduous
and excellent character of the work bestowed upon it.
Dr. Hack Tuke thanked the Association on behalf of Dr. Savage and
himself for the vote of thanks.
Dr. CLOU8TON proposed a vote of thanks to the Secretaries, saying that
without their Secretaries they could do nothing, and that everyone would
agree that the secretarial work was carried on very satisfactorily.
Dr. Outtebson Wood seconded the motion, which was carried.
Dr. Rayner, General Secretary, suitably responded, saying that as regarded
himself he only regretted that he could nut do the work better. It had
always given him great pleasure to serve the Association. He hoped that
next year a more efficient General Secretary might be appointed to relieve
him. He was sorry to have to read a letter from Dr. Courtenay, the Secretary
for Ireland, tendering his resignation.
Dr. Patton, of Farnham House, Finglas, Dublin, proposed that Dr.
Courtenay be requested to continue for another year.
Dr. Outtebson Wood seconded the motion as to Dr. Courtenay, and it was
resolved that a letter be addressed to him expressing the unanimous wish of
the Association that he would continue in office for another year.
Mr. Hayes Newington said that he hoped that Dr. Rayner would long
continue to be their Secretary—at all events, until the Lunacy Bill should be
passed. It was absolutely necessary that at this critical stage of the legisla¬
tion, someone should work the machine who knew how to work it. The
Association had for the last three years been devoting much attention to the
Parliamentary work, and it would be very hard if any of their labour were
lost by a change in their officers.
Dr. Wm. Wood supported this, saying it would be a great loss to the Asso¬
ciation if they were deprived of Dr. RaynePs services.
The President said that he endorsed every word which had been said as
regards Dr. Rayner, and he hoped the appeal which had been made to him
not to resign next year would be successful.
Dr. Rayner said that he would do the best he could to comply with the
wish of the Association.
The next business to be dealt with being the appointment of Officers and
Council for the ensuing year, the President explained the mode of voting,
and nominated Dr. Outterson Wood and Dr. Cooke as scrutineers. The lists
having been duly collected, the scrutineers retired to examine them, subse¬
quently reporting that the nominations of the Council had been unanimously
supported, whereupon the following gentlemen were declared by the President
to be elected as
OFFICERS AND OTHER MEMBERS OF COUNCIL OF THE
MEDICO-PSYCHOLOGICAL ASSOCIATION.
YEAR 1887-8.
President-Elect . T. S. Clouston, M.D., F.R.C.P.
Treasurer . John H. Paul, M.D.
Editoes OF JOCBNAIi... { g; hX™*? ItD?*
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1887.]
Notes and News.
459
Auditors
Honorary Sbcretarirs
J. T. Hinoston, M.D.
D. Yellowlees, M.D.
E. M. Courtenay, M.B. For Ireland.
A. R. Ubquhart, M.D. For Scotland.
H. Rayneb, M.D. General Secretary.
MEMBERS OF COUNCIL.
Fletcher Beach, M.D. | Hayes Newington, M.R.C.P.
F. H. Craddock, B.A. I F. Schofield, M.D.
S. W. D. Williams, M.D.
* ' The next business being the question of the time and place of the next annual
meeting, Dr. Ubquhart said that at the annual meeting last year he had the
honour of giving a notice of motion on this point It had been found that
the meetings had been getting smaller of late years, and to-day there was a
very poor show of members for a Society numbering nearly four hundred.
He thought it would be very much better if, instead of being brought together
there in the height of summer, the Association would decide to meet, say in
the month of May. It was, perhaps, begging the question to say that
the Association should meet in London, because they were perfectly aware
that it was originally intended that the Association should be peripatetic; but
of late years the meetings had been held, and very rightly so, generally in
London. They had travelled to Glasgow and to Cork, but the general tendency
was to meet in London, and if the annual meeting were held in London it
should be convened earlier in the year, when they would probably be
favoured with the presence of many physicians who usually went out of town
at the present period. In July, moreover, there was a difficulty as to the
rooms, the College of Physicians not being available on account of the
examinations. In support of the meeting being held about the present time
a reason had been adduced that it was very convenient for members of the
Association to take along with this annual meeting that of the British
Medical Association, but he thought that the time had come when they ought
to make some kind of stand against that. Last year the meeting was held
in London about this time, and afterwards many of the members went to
Brighton, where there was a most excellent meeting of the British Medical
Association, the psychological discussions being promoted by their own
members. Now he thought it would be very much better if they could get
their members to keep for the annual meetings of this Association the papers
which thus went away from the Association to the British Medical Associa¬
tion, and it would also be well if the time of the annual meetings could be
extended. Theirs was a Society to guard the interests of men who were
interested in asylums; but not only that, he presumed it was a scientific
society for scientific discussion. The latter feature had been somewhat over¬
looked at the annual meetings, especially of late years. It had been the
custom to have some kind of discussion on the President’s address. That was
a proceeding which he did not quite approve of. He thought that the ad¬
dress should not be discussed. They also laboured under this disadvantage, that
the papers read at the British Medical Association meeting were not utilized
in the “ British Medical Journal,” nor were they handed over to the editors of
the “Journal of Mental Science.” In effect it had been found hard to sum¬
marize them in their own Journal. Last year there had been one of the most
interesting discussions at Brighton which it had been his fortune to listen to,
in regard to the medical spirit in asylums, and that was perfectly burked, for
the notice that appeared of it was inadequate to do it justice. There had
been another objection proposed to the annual meeting being held earlier in
the year, and that was as to the closing of the accounts, but that had been dis¬
posed of on consultation with the Treasurer, Dr. Paul, who said it could be done
earlier with equal facility. In conclusion he said that perhaps it might suit the
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460
Notes and News,
[Oct.,
convenience of many of those present to meet in July or August, but he
thought there were many in the country who would prefer an earlier meeting,
and he should be very glad to have the opinion of the Association at large
on that point. He would, therefore, move, “ That the annual meeting be held
in the month of May, and that the proceedings shall not be limited to a single
day, but be continued for the reading and discussion of such papers as may
be offered.”
Dr. Rayner said that, in regard to the difficulty of arranging for papers
with a one-day meeting, for some years past it had been found that their
formal morning business generally extended up to the luncheon hour or a
little over, while in the afternoon the Presidents address and the discussion
following it lasted until it was time to adjourn for their evening reunion.
On several occasions they had had papers down for reading, but there had
been no time to read them, and in some instances considerable offence had been
given to members who had papers down to be read, and who had come to
town specially for the purpose. He hoped that if Dr. Urquhart’s proposal as
to the change of the time of the year for the meeting were adopted, that the
Association would also agree to extension of the time of meeting. He
quite agreed with Dr. Urquhart that a meeting in May might attract a great
number of men who might not be able to come otherwise, and, moreover, the
Association would not be competing with the British Medical Association.
He believed that many members would have been present to-day if they were
not next week going to Dublin. The Association had suffered from this in
years past, and would continue to suffer from it unless an alteration were
made.
The President pointed out that the order of the agenda had been a little
departed from in the discussion, it being necessary, in the first place, to fix the
place of the next Annual Meeting.
Dr. Hack Tijke thereupon moved—“ That the next Annual Meeting be held
in Edinburgh.” As Dr. Clouston was to be their President next year, this
would obviously be the most suitable arrangement.
Dr. Murray Lindsay seconded the motion.
Mr. Swain said that if they should meet at Edinburgh next year, would it
not be well to fix the same time as that of the visit of the British Medical
Association at Glasgow ?
Dr. Urquhart said that he saw there was a difficulty in dealing that day
with the matter which he had brought forward. Last year he had given a
notice of motion, but as the President-elect was willing that the annual
meeting next year should take place in Edinburgh, he felt a certain hesitation
in proposing that the next annual meeting should be held earlier. Still, he
thought if there was one thing clearly understood in years past it was that the
Medico-Psychological Association was not to be an appendix to the British
Medical Association. He was himself a member of the latter Association, and
was deeply interested in its success, but he thought, nevertheless, that they
must make a stand on that point.
Mr. Hayes Newington said that he had great sympathy with Dr.
Urquhart’s views in many respects; but what ne proposed would be an
enormous change. As, he believed, was pointed out last year, there was
practically no necessity at all for Dr. Urquhart’s motion. The rule was as
follows:—“ An annual meeting of the Association shall be held at such time
as shall, in the judgment of the Council, be most convenient, such meeting to
be called both by advertisement in the medical papers and by circular to each
member, giving at least four weeks’ notice.” It seemed to him that, unless
they were going to alter the rule, the right way would be for the members to
make representations to the Council. The rule at present left the matter
entirely in the hands of the Council, and he did not think that sufficient cause
had been shown to take it out of the hands of the Council. It was entirely in
the Council’s power next year to make what arrangements they liked, and he
Digitized by t^ooQle
1887.]
Notes and News .
461
would suggest that Dr. Urquhart, and those members of the Association who
agreed with him, should write their views to the Council, and state their
reasons for those views, and the Council would then take the communications
into their consideration. As to the two-day meeting, the rule would meet that.
This would, he took it, come within the powers of the Council. He thought
that if the Council were pursued by representations made to them they would
adjourn the meetings. Instead, therefore, of carrying such a very strong
motion as was proposed by Dr. Urquhart, the way would be for members to
send communications to the Council on the subject. It struck him that the
reason they were suffering in regard to attendance at their annual meetings
was the very fact that they only met for one day. He did not see any reason
to suppose that the British Medical Association should really interfere with
their annual meetings. Of course the psychological members of the British
Medical Association went to the meetings of that Association for psycho¬
logical work, and no doubt very little psychological work was done at the
annual meeting of the Medico-Psychological Association. The best way would
be for the Council to try what was proposed as an experiment: next year to
have a two-days* meeting; if necessary, try it later on; and then, perhaps, if it
were found successful, change the rule. He should therefore move, as an
amendment, “That, having regard te the powers at present in the hands of
the Council to make such arrangements as would include the objects of the
motion now before the meeting, it is inexpedient to tie the hands of the
Council by a radical alteration of the rules.**
Dr. Clouston said that Mr. Hayes Newington’s suggestion would meet with
his approval. Next year, as the Association was going to Scotland, perhaps
the Council might fix the next day to the meeting at Glasgow; but as the
British Medical Association met on Tuesday, that would practically limit their
meeting to Monday, so that a second day’s meeting might be inexpedient.
In 1889 let them try a two-days* meeting, and if at next year’s meeting a re¬
commendation to that effect could be given, and also as to meeting in May,
the Association would probably be satisfied as to the expediency of adopting
that course as a rule. Possibly next year it might be considered desirable that
most of the psychological papers for the annual meeting should be taken as
transferred to the British Medical Association.
Dr. Rayneb said, if so, could the Medico-Psychological Association have a
proprietary right in those papers ? Might they take their own reporter on to
Glasgow?
Mr. Swain : Are the papers read before the British Medical Association the
property of the British Medical Association?
The Pbesident : Yes.
Dr. Hack Tuke : It is only through Mr. Hart’s courtesy that we have them.
They are clearly the property of the British Medical Association.
Dr. Rayneb asked whether some compromise could not be made. If they
were to forego a day of their meeting, might they not fairly expect to be
allowed to take reports of the papers read at the British Medical Association ?
Mr. Cooke said that it was a great convenience to members of the British
Medical Association to be able to attend the several branches of its annual
meeting. Let the Medico-Psychological Association next year be content
with one good annual meeting, and then the members would be free to
attend the various surgical, obstetrical, and medical sections of the British
Medical Association. At subsequent annual meetings they might have two
days’ sittings.
The Pbesident suggested that it might be best to send a circular round to
the members.
Dr. Ubquhabt said it was with that in view that he had moved his
resolution. At the last meeting they were told precisely what they had heard
that day, that the Council should take the matter into their consideration.
He thought it best that the Association at large should give the Council
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462
Notes and News .
[Oct,
their decision in the matter. He should be very sorry to press the motion
against the general feeling; but he believed it would be a good thing for
the Council to get the opinion of the meeting to-day. He had given his
reasons, and he had adduced similar reasons last year. He did not see what
was to be gained by writing to the Council and giving those reasons again.
He, therefore, thought they should now come to some general understanding
as to what should be done in future. There was no doubt that the annual
meetings would be usually held in London. Next year would be exceptional.
Mr. Hayes Newington said he thought the reason why the Council had
not moved in the matter was because there had been no sufficient expression
of opinion from members of the Association. Dr. Urquhart had said that he
believed there were other members who felt like himself, but there might be
others who did not feel so about it. His motion presupposed a radical altera¬
tion in the rules of the Association. He (Mr. Newington) still ventured to
suggest that such a resolution as Dr. Urquhart’s was not called for, and that
ample power already existed for them to do what they liked. He should,
therefore, move as an amendment that Dr. Urquhart’s motion be not ac¬
cepted.
Dr. T. W. McDowall said that if some of the members of the Association
did not express their feelings it was not because they had no feeling in the
matter. They did feel that the comparatively small attendance at the annual
meeting was largely due to the fact that their meeting clashed with that of
the British Medical Association. Persons situated like himself could not go
to London and then on to Dublin. He thought a good beginning would be
to have their annual meetings in May.
Mr. Swain asked whether an alteration of a rule did not require previous
notice to be given.
Dr. Urquhart referred to the minutes of the proceedings at the last annual
meeting, and said that, a year’s notice had been given. It was, moreover, on
the agenda to-day. If they could now get the sense of the meeting as to when
future annual meetings should be held, that would serve their purpose perfectly
well.
Dr. Murray Lindsay said that he thought it very desirable to obtain the
sense of the present meeting. He had strong sympathy with Dr. Urquhart,
and thought, moreover, that they were not acting very respectfully towards
the editors of their Journal. They were making their editors play second
fiddle to the editors of the “ British Medical Journal.”
Dr. Pritchard Davies said that he should very strongly support the
motion of Dr. Urquhart. The British Medical Association had for many years
past ignored the claims of psychology. It was in evidence that they did not
publish proper accounts of papers read, and that they did not hand over the
papers read. No amount of courtesy could get away from the fact that the
service was not rendered. If the papers referred to were read here by mem¬
bers of this Association, clearly they would be published. Therefore,
all they were now asked to do was to afford members of this Association
proper facilities for the reading and discussion of their papers. It seemed to
him that hitherto they had been proceeding in a wrong way. There was a
motion on the agenda that the title of the Association should be changed so
as to make it the Medico-Psychological Association of Great Britain and Ire¬
land. This should imply enlarged scope and renewed energy, and he thought,
therefore, that the present occasion was very opportune for Dr. Urquhart’s
proposal to be considered. He did not see that there was anything diametri¬
cally opposite between Dr. Urquhart’s motion and the rules of the Association.
It was surely competent for the meeting to consider what was advised, and if
the present meeting expressed an opinion to the Council, the Council would
probably act upon the feeling of the meeting. Accordingly, he had very great
pleasure in supporting Dr. Urquhart’s motion that the annual meetings should
be extended. He hoped that the members would then be made to understand
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Notes cmd News.
463
1887 .]
that papers were required from them, and he believed it would be found they
would duly respond.
Dr. Clouston said he felt inclined to move—“ That a circular be sent to each
member of the Association asking his opinion as to the time at which the
annual meeting shall be held.”
Dr. Wood seconded this.
Mr. Whitcombs said that he was of opinion that the Association should
read its own papers, and that proper time should be given to the members for
the preparation of those papers. It seemed to be taken for granted that the
annual meeting in 1889 was to be held in London. Was that so?
The President said that he did not think it was competent to the present
meeting to consider the question of the 1889 meeting. He then put to the
meeting Dr. Clouston’s amendment, “That a circular be sent to each member
of the Association asking his opinion as to the time at which the annual
meeting shall be held,” when there appeared—In favour, 15; against, 0.
The amendment was thereupon declared to be carried unanimously.
Mr. Hayes Newington's amendment was then put to the meeting, and
declared to be lost.
Dr. Urquhart's original motion was then put, the words “as a general
rule ” being understood to be added to it, when there appeared—In favour,
18; against* 2.
The motion being thus carried,
Mr. Hates Newington asked whether it would now be necessary to send a
circular round to ascertain the opinion of members.
Dr. Pritchard Davies urged that, the amendment moved by Dr. Clouston
having been carried, the original motion should not have been put to the
meeting.
Dr. Clouston suggested that it should be put again.
Dr. Spence said he was prepared to move “ That the opinion of this meeting
to the effect that an experiment of holding the annual meeting during the
month of May, 1889, and extending its duration, should be placed before the
Council of the Association at their next meeting."
Mr. Hayes Newington suggested that, as a way out of the difficulty, the
Association should adopt the amendment he had moved, which he had pur¬
posely framed to avoid that difficulty. The Council were appointed to look
after these matters.
Dr. Urquhart said that, if he rightly understood it to be the sense of the
meeting to-day that they wished the meeting to be held in the month of May,
then he was willing to withdraw his motion.
Dr. Pritchard Davies submitted that there was only one thing now to
be done. The amendment had been put and carried, and the substantive
motion could not be carried. The only thing was to put the amendment a
second time. Although he warmly sympathised with Dr. Urquhart, he ac¬
cepted the mistake, and felt sure that the Council, having heard the views of
the meeting, would adopt the feeling so strongly shown.
Dr. Urquhart said he was quite willing to withdraw his motion if it was
understood that it was the sense of the meeting that the annual gathering of
the Association should be about the month of May.
Dr. Clouston asked whether Dr. Urquhart would limit his motion to 1889.
Then the circular might still be sent out.
The President said that he should now put again Dr. Clouston’s amend¬
ment. He wished them distinctly to understand that in voting for that
amendment they were voting for a circular being sent round, and if they did
not vote for that they would be voting for Dr. Urquhart’s motion, “ That the
annual meeting be held in the month of May,” &c.
The result of the voting showed—For Dr. Clouston’s amendment, 16;
against, 9.
The amendment was then put as a substantive motion, and declared carried.
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464
Notes and News .
[Oct.,
Dr. Spence then moved—“ That the opinion of this meeting to the effect
that an experiment be made of holding the annual meeting during the month
of May, 1889, and extending its duration, be placed before the Council of the
Association at their next meeting.”
Dr. Lyle seconded the motion, which was put to the meeting and declared
carried.
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.:—Mr. J. Harrington Douty, Medical Super¬
intendent of the Berks County Asylum; Dr. W. Armstrong, Ararat Asylum,
Victoria; and Dr. Thos. Brushfield, jun., Assistant-Medical Officer, Chartham
Asylum, Kent.
The General Secretary read a letter in Latin from Dr. J. N. Ramaer,
Haarlem, Inspector of Asylums, thanking the Association for the honorary
membership conferred upon him at the last annual meeting of the Association.
Shortly after last year’s meeting, letters of acknowledgment and thanks had
been received from M. Roussel and Dr. Godding on becoming Honorary Mem¬
bers, and from M. Jules Morel and M. Parant on becoming Corresponding
Members.
Dr. Hack Tuke, in proposing the election of three distinguished honorary
members, said that the gentlemen whose names he was about to propose
should, perhaps, have been put forward long ago; but by the rules the ap¬
pointment of honorary members was limited to three every year, although
they were not limited as to the total number. The names which had up to
the present time been proposed had been, it would be admitted, those of very
good men. Some of them had been removed by death, and vacancies, there¬
fore, occurred. He felt that care was required not to confer honorary member¬
ship upon anyone too hastily. If this were done, it would cease to be an
honour. Good reasons mast be adduced for conferring the honour in each
case, and the names proposed have to be in the hands or members, according
to the rules, for one month before the annual meeting. With regard to the
gentlemen now proposed for election, he felt sure that they all met the con¬
ditions laid down in Chapter 7 of the Rules of the Association. They were
all “ distinguished members of the medical profession, who had rendered
signal service to the cause of humanity in relation to the treatment of the
insane.” He, therefore, claimed for each of these gentlemen that they met this
requirement. Dr. Chapin, whom he had met in Philadelphia, was the Super¬
intendent of the Pennsylvania Hospital for the Insane. He had previously
organized and superintended the Willard Asylum in the State of New York,
which wa 9 carried out on what wa9 called the plan of segregation (as opposed
to mere aggregation) of the insane—a course which at one time met with con¬
siderable opposition in America. On the death jo f Dr. Kirkbride he had been
elected as the best man to succeed him, and he had now been several years in
office in the asylum in Philadelphia. As to Dr. Lentz, he was the respected
Medical Superintendent of the Asylum at Tournai, Belgium, which some of
the members had visited two years ago. That asylum was the newest, and
largest in Belgium, and those who had seen Dr. Lentz there, had formed a very
high opinion of his administrative ability. Dr. Lentz was the author of
several works; one in particular, on “ Alcoholism,” was a standard work on
the subject. Dr. Heinrich Schiile, of the Illenau Asylum, Baden, where he
had visited him, was an able man, and took a very high position among
German alienists. He wa9 the author of the “ Klinische Psychiatric ” in
Ziemssen’s Handbuch, and had written some years previously a Manual of
Mental Diseases. His name ought, in his opinion, to be added to their list
of honorary members. He could say much more in relation to these three
gentlemen, but he trusted he had said enough to obtain for their election the
approval of the Association.
Dr. Rutherford cordially seconded the motion.
Digitized by L^ooQLe
1887.]
Notes and News .
465
Dr. Clouston said that he rose not from any feeling of opposition to the
motion. They were all very much indebted to their learned confirbre , Dr. Hack
Tuke, for the way in which he had gone into the important matter of select¬
ing honorary and corresponding members, but he wished to suggest this, that
they ought to be very careful in regard to the absolute numbers of the
honorary and corresponding members whom they elected. It was a fact, as
appeared in their last Journal, that the Association consisted of 392 ordinary
members and 63 honorary and corresponding members. That implied that a
copy of the Journal was posted to each of these members; and, looking at this
aspect of the case, it meant that they expended at least £33 a year on their
honorary and corresponding members. He would only say that it was a matter
which they ought to rather draw their hand in as regards the future; and
perhaps most of the members would agree with him that, in an Association
of this size, fifty of that class of members ought to be the largest standing
number. He felt sure that Dr. Tuke would not misunderstand these remarks.
He only wished to draw attention to the point.
Dr. Hack Tuke said he felt that Dr. Clouston’s remarks were well-timed.
As regards the actual expense, however, he did not think it was quite so high
as Dr. Clouston had put it at. Corresponding members were not entitled to a
copy of the Journal.
Dr. Pritchard Davies said that, knowing two out of the three gentlemen
proposed for election as honorary members, he should like to speak very
strongly indeed in favour of Dr. Tuke’s motion. It had been his honour, in
visiting the United States, to make the acquaintance of Dr. Chapin before he
was appointed to the Pennsylvania Hospital. He had visited him at his great
place at Seneca Lake (Willard), and was much impressed with the great grasp
which he exhibited on all points. One matter which had not been mentioned
was that he was connected also with a beautiful place at Poughkeepsie, which
was in telephonic communication with the asylum at Seneca. As regards Dr.
Lentz, he could assure them that they were all much impressed with the man
and his asylum when he and others visited that gentleman in Belgium. The
work on “ Alcoholism ” was by no means the only work which had emanated
from Dr. Lentz. He felt sure that if they were to adopt Dr. Clouston’s
suggestion to the letter, and limit their honorary members to fifty, or even to
thirty, the names Of the three gentlemen now proposed for election would
most rightly be included in the number.
The names having been taken en masse , the gentlemen referred to were de¬
clared to be duly elected.
Dr. Hack Tuke, in accordance with a notice given on the agenda, drew
attention to the present title of the Association, which did not state what
country it represented. He had several times thought that this was an important
omission, and in no other country did it occur; but it came to a definite point
recently in connection with the “ Gaskell Prize Trust.” The solicitor who drew
up that tru8t8aid that for such a purpose the law required that there should be
more than appeared in the existing title as given in the Rules of the Associa¬
tion ; he could not put into the document simply “ The Medico-Psychological
Association” as a sufficient description. Thereupon Dr. Paul and himself
agreed that “Of Great Britain and Ireland” should be added. The solicitor
advised that the rules should be altered in accordance with this fuller title.
Accordingly, they wished to get the alteration made at this meeting. He
might add that the proposed title was already adopted by the Association in
the certificate of efficiency in psychological medicine. He, therefore, moved
“ That the words * Of Great Britain and Ireland’ be added to the present title
of the Association (‘The Medico-Psychological Association ’).”
Dr. Rutherford seconded the motion.
Dr. Rogers moved the previous question, saying it was a bad sign when an
old firm altered its name. He thought that the grounds for the alteration
brought forward were very feeble indeed, and he did not see why they should
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[Oci,
alter the title of the Association after so many years on the mere suggestion
of a solicitor.
Dr. Hack Tuke replied that he did not put the solicitor’s opinion as the
•ole reason. He had for some time thought the change should be made. He
must say, moreover, that the words proposed to be added were now inserted
in the trust; and unless the title of the Association was altered as sug¬
gested, it would not agree with that engrossed in the trust-deed, which
might prove very inconvenient.
Dr. Savagb said that the question of addition did not involve alteration.
A Arm might add a name to its number without prejudicing itself. To add
the words “ Of Great Britain and Ireland ” would merely be an addition and
not an alteration. He decidedly supported Dr. Tuke’s proposition.
Dr. Mubbay Lindsay said he thought that strong reasons had been adduced
for adding the words proposed.
Dr. Rogers’ amendment not being seconded, the motion was put and carried
nem, con.
The Gbnebal Secbetaby (Dr. Rayner) stated, in regard to the work of
the Committees of the Association during the past year, tnat the report of the
Parliamentary Committee had been already circulated. He might say that
that Committee had met upon seven occasions, with lengthy sittings, and had
had one interview with the Attorney-General on the Lunacy Bill question.
No doubt that Bill would come on next session, and it would, therefore, be
necessary for the Parliamentary Committee to be reappointed. He would also
suggest that as medical superintendents of asylums had of late been much
vexed by the question of pensions, that a separate Committee should be ap¬
pointed to thoroughly investigate and thresh out that subject.
The names of the members of the Parliamentary Committee, as printed at
page 35 of the October, 1886, number of the Journal, having been read,
It was resolved, on the motion of Dr. Hack Tuke, seconded by Dr.
Hing8TON, that Dr. T. W. McDowall’s name be added to the Parliamentary
Committee.
It was further resolved, on the motion of Dr. Outtebson Wood, and
seconded, that, with the addition of Dr. T. W. McDowall, the members ap¬
pearing in last year’s list of the Parliamentary Committee be now re¬
appointed.
Mr. Hayes Newington, referring to Dr. Rayner’s suggestion as to a
Pensions Committee, said that he thought it would be extremely desirable
that that branch of the work of the Parliamentary Committee should be put
into the hands of a separate Committee, because the subject was a most im¬
portant one, and involved a great deal of consideration. There would also be
more time for other important matters to be settled by the Parliamentary
Committee if the pensions question were put into the hands of a special
Committee.
Dr. Rayneb said he should like all three countries to be represented.
Dr. Mubbay Lindsay said the matter resolved itself now practically into
two things : either the restoring to Committees of Visitors of the power they
formerly had up to 1862 of granting pensions, or of obtaining the present
optional scheme. He thought they must be prepared to make some sacrifice,
either by adopting the Civil Service scale or some other scale. There was a
very strong feeling at the meeting in London the other day as to the restoring
to Committees of Visitors the power they formerly held, and it was only
by the casting vote of the chairman that the clause was carried in favour of
this power being restored to Committees of Visitors. At that meeting it was
suggested that the same confidence did not now exist as formerly existed in
regard to those bodies, and that there was now a strong element of
“ guardianism.” They were all aware of the last instance—the case of Dr.
Palmer, of Lincoln. There had been a great hubbub, and Boards of Guardians
had protested. Dr. Palmer’s pension had to go before six Quarter Sessions,
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1887.]
and it was referred back again, with the probability that he would have to
accept a reduction of twenty-five per cent.
It was then resolved that Dr. Murray Lindsay and Dr. Williams be appointed
a Pensions* Committee, with power to add to their number.
Dr. Savage, the outgoing President, being now present,
Dr. Mtjbbay Lindsay proposed a vote of thanks to Dr. Savage, saying
that his presidency had reflected honour upon the Association. For Dr.
Savage’s exertions in the matter of the Lunacy Bill alone the Association
was greatly indebted to him, and he felt sure that a hearty recognition would
be accorded to him.
Dr. Rogebs seconded the motion, which was carried with acclamation.
Dr. Savage said that first of all he felt he must apologize for his absence
that morning. He simply could not help it. It happened to be his Com¬
mittee day, and as he was just leaving for his holiday and going to America
he felt that he must be present at the Committee meeting. He thanked the
Association most sincerely for the vote of thanks, which was more than he
deserved, inasmuch as he looked upon the honour of serving the Association
as its President as an honour of which anyone had a right to be proud, especi¬
ally when everything had gone on as smoothly as it had done during the past
year. Of course, one came into office thinking that the year would be a very
long year, and that there would be opportunities of doing something new and
fresh; but perhaps it was just as well that things had gone on quietly. The
meetings had been large; questions of practical account had been considered
—pensions, diets, strong clothes, crib beds, and so forth ; in fact, the last year
had been marked by the practicalness of the discussions. Everything had
gone on so smoothly that he felt that the year had passed almost without his
knowing it. He resigned the chair with regret that his year of office was
over, and that after all there was so little to be shown for it. He had hoped
that, it being Jubilee year, there might have been a Lunacy Bill; but Sisy¬
phus had still to roll that stone up, and he hoped his successor would
nave the luck to see it rolled right up to the top. Whether it would roll down
on the other side remained to be seen. (Laughter.) He was glad to know
that he resigned the presidency in favour of one who would add lustre to the
chair in as complete and successful a manner as was possible. (Applause.)
AFTERNOON MEETING.
The Pbesident reported that the Association prize and medal had been
awarded to Dr. Wiglesworth for his essay on Pachymeningitis. The ad¬
judicators were very pleased with this paper, and also with the other papers,
which were two in number.
The Pbesident read his A ddress, which will be found at p. 343 of this
Journal.
Dr. Maudsley moved a vote of thanks to the President for his Address,
saying that all present would agree that there was no need for the President
to have claimed indulgence, for the Address was admirable throughout, and
was characterized by the principal characteristics of his mind, namely,
thorough sincerity and keen practical sense. As regarded Dr. Needham’s
criticisms on the newly-proposed Lunacy Bill, he (Dr. Maudsley) felt a
particular sympathy with them, as he could not help thinking now that
their Parliamentary Committee might have taken, perhaps, a stronger post
than they had ventured to do in reference to the local and general public
opinion which was prevailing. They had spent a great deal of labour and
time in criticizing the details of that Bill, and in protecting it as far as
possible; but be should almost have preferred, if it were practicable, that
they should have refused to take any responsibility on it whatever in any
way. If they had said, “ This Bill proceeds entirely upon the incarceration
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468 Notes and News . [Oct.,
point of view, and not from the medical point of view, we will have nothing
to do with it,” it seemed to him that it might have been possible to bring
into some sort of harmony the legal and medical views, especially if they had
said, 44 We grant you any tiling you like in the way of stringency of legisla¬
tion or form in chronic cases, or cases which have been ill a certain time; but
we ask you not to make the treatment of recent and acute cases impossible,
as you are doing now.” In fact, why should there not be some arrangement
whereby some simple forms might suit for fresh cases, and then, after a period
of six months or so, bring in all those restrictions ? If the Bill were to pass
in its present form, early treatment of insanity in its present sense would be
practically abolished. Instead of cases of insanity being sent to asylums in
the early period of the disease, they would be relegated to attics and other
places; and, in fact, put out of the way for so long a time that the cases
would really become hopeless. He was quite sure that would be the case,
because he believed that during the last two years there had been more cruelty
and more neglect than during twenty years past. During the last two years
he had seen restraint practised which he had never in his life seen before,
simply on account of the impossibility under the present system of getting
the patients under care. That was what the late Lord Shaftesbury felt—it
was the real reason of his resignation—and that was what would happen
again if that Bill were to pass in its present form. Before it was again
brought in he would suggest that the Parliamentary Committee of the
Association might take into consideration the question as to whether they
should not propose some modified treatment for the first six months or so of
early and recent cases; and then, after that period, if the patient did not get
well, bring into action all the legal stringent rules they liked.
Dr. W. Wood rose to second the vote of thanks, saying that he did so with
perfect pleasure, because Dr. Needham’s paper set forth what was in his mind
a very important omission on the part of the Parliamentary Committee. He
thought they ought all to have looked at the question from a much broader
field than they had done. They had done too much with the details, and too
little with the principles. It seemed to him that the medical profession was
expected to discharge a very arduous and important duty, and yet it was dis¬
trusted. Throughout all the Bill it was taken for granted that the doctor
would, if he could, do something which he ought not to do, and thus, instead
of causing trust in the patient’s mind, distrust was created. He was not
sorry the Bill had failed to pass, because he hopd there might still be time to
get the lawyers to look at it from the medical point of view. It was at
present a 44 lawyer’s Bill.” He hoped the time given to its consideration would
not be lost if they could succeed m this. It was fortunate that they were so
well represented in the presidential chair, and he was very glad that Dr. Need¬
ham had taken the view which he did of the matter.
Dr. Clouston said, that in rising to add a word or two to the remarks
which had been made so vigorously by Dr. Maudsley and Dr. Wood, he would
agree with them most strongly as to the admirable character of the address
to which they had listened. If there was anything which would justify him
in adding a few words to what had already been said, it would be this: that in
Scotland they had had for many years actual experience of the practice and
working of a system differing somewhat from the English one, but under
which they had had the opportunity of treating patients at first without an
order from anybody, and lie would simply, in strengthening Dr. Maudsley’a
statement, say that that medical provision by which the family had the power
to get a patient treated for six months without any distinct legal order, had
been the means of doing good, both to the friends of the patients and to
the patients themselves, and also of extending a knowledge of insanity to the
medical profession generally. Of course the Association was compara¬
tively a small body, and if there was anything which would supplement
the force of the remarks which had been already made, it would be the
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enlistment of the sympathy of their professional brethren and of the great
medical press in the view taken of the matter by the Association. Could
they not hope to eradicate the prejudice which had shown itself to prevail
even in the medical journals, and which had done so much harm ? If they
could see the time when the “unity,” to which reference had been made,
should exist, and they could see themselves supported by the medical journals
and the medical profession generally, he thought they would then be able to
convince the Government much better. They knew that the “British Medical
Journal” had helped them, and helped vigorously. Without at all saying
that their system in Scotland had been better than that in England, he would
say that in Scotland, wherever the element of the civil magistrate had been
called in—where it had been in action—it at all events did not seem to have
done any harm. He did not think they need fear it.
A Member : But the magistrate does not see the patient.
Dr. Clouston said that was what he was coming to. Could they not
impress upon the Legislature that the medical aspect must be taken ? The
Scotch system did not in any way imply an inspection of the patient by the
sheriff. This should be accentuated in the Bill now under discussion. The
Bill began by saying that it was founded largely upon the Scotch system, but
it departed from the essential spirit- of the Scotch system by adopting that
wretched idea of the magistrate seeing the patient. This was not sufficiently
known. The English Bill was a bad legal accentuation and a perversion of the
Scotch system. It was not like the Scotch system, and that fact couldBOt be
too widely known. In regard to a remark made in the first part of the
address, he could not help adverting to an extraordinary paragraph which he
had seen in a social paper lately, where it was laid down that lunacy was a
moat objectionable thing, and all men and women should do everything they
could for its eradication, and that, therefore, as public opinion was everything,
every lunatic’s name should be published as widely as possible, and that it
ought to be published in the newsapers so that no one should marry into that
family, aDd the lunatic should thus, for the good of society, be branded as a
lunatic for all time. Those were the errors which were promulgated. Any
man with a spark of philanthropy in his heart would detest such a mode of
thought. With reference to the remark made as to the clauses affecting the
registered hospitals of England, for his part he was simply amazed that such
clauses should find their way into any Lunacy Bill. That such a body as the
Commissioners in Lunacy should have those arbitrary and extravagant powers
in regard to hospitals, which it wa9 proposed to give them, was what he could
not fancy anyone would agree to, seeing that those hospitals were started by
great public charitable contributions, and were managed by committees con¬
sisting of persons chosen on account of high position and responsibility. He
hoped they would all try to put pressure on the various members of Parlia¬
ment whom they knew to modify those clauses relating to the great
registered hospitals.
The motion was then put to the meeting by Dr. Rayner, and carried with
applause.
The President, after thanking the Association for the vote of thanks, said
that they had one or two distinguished visitors from whom they would be glad
to have any remarks.
Mr. Clark Bell said it gave him very great pleasure to record his ap¬
preciation of the excellent address, the earlier part of which he had been un¬
fortunately precluded from hearing. Candidly, he might say that he believed
if they had in England a Medico-Legal Society, analogous to that over which
he had the honour of presiding at New York, many of the questions which he
gathered had arisen, and which, as far as he was able to judge, he believed
they looked at correctly, would be better understood by the legal gentlemen
with whom they frequently had to work in the matter of insanity. The
Medico-Legal Society at New York met for the purpose of discussing such
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Notes and News.
[Oct.,
points m these, just in the same way as the meeting to-day, and the reflex of
their deliberations went to the Legislature and the general public through the
medium of the press. The difficulty in the present case, if he correctly under¬
stood the criticisms which had been made, and which were summed up in the
expression he had heard made use of as to the Bill being a “lawyer’s Bill/*
doubtless arose from the feeling in regard to what was popularly called the
44 liberty of the subject.” That feeling existed in other parts of the world
besides Great Britain. In America it was said that no person should be
deprived of his liberty except by due process of law, and his incarceration in
an asylum might possibly be construed into an invasion of the constitutional
rights of a man. Dr. Maudsley had urged that a period of six months might
be allowed before the limitations, called “ stringent,” which had been refeired
to, should come in. The laws of almost all the American States provide that
before a person could be put into an asylum there must be a judge’s order,
which, however, was more 44 ministerial ” than judicial, and did not override the
medical certificates, but in emergency cases in the State of New York a patient
could be placed in an asylum For five days, at the end of which time, if a
judge’s order had not been obtained, the patient would have to be discharged.
In England the law relating to lunacy was in many respects so much better
than that in the United States that he had been striving to bring the law of
his own country up to the standard of that work which culminated the
labours of the late Earl of Shaftesbury in England, especially as to Commis¬
sions in Lunacy and supervision of establishments. He felt that in Eng¬
land much had been done in the way of useful and careful lunacy legislation,
and he was not sure that in doing more than enough it might not end in doing
badly. He advised them to let “well enough” alone. There had been
agitation in regard to this matter in other countries besides England. In
franco and Italy the question had forced itself upon public attention. In
the different States of America they had for years been endeavouring to change
their statutes where they were greatly more in fault than those existing in
England. About four years back one of the States attempted a modification
of their lunacy statutes, proceeding in a manner very similar to that in
which the English lunacy statutes had been enacted, namely, by means of a
governmental proceeding analogous to a Parliamentary inquiry. The governor
of that State appointed of his own motion seven or eight gentlemen chosen horn
both legal and medical professions—one or two ex-governors of the State,
some members of legislative bodies, and some alienists of acknowledged
position—and asked them to consider the whole subject of the Lunacy Law of
Pennsylvania. They did so. A Bill was brought in on their report to
Governor Hogg, who made it the subject of a message to the Legislature,
and recommending its passage. It was a most extraordinary thing that
almost all the medical superintendents of Pennsylvania opposed that Bill.
The Bill, however, which was drawn up in many respects upon the theory of
the English law, passed. It seemed to lift the law of Pennsylvania up to the
platform of English law. For instance, hitherto there had been no such
thing in Pennsylvania as a Lunacy Commission. The medical superintendent
of an asylum was a perfect autocrat, had absolute authority, and could not
be got at in any way except by the Local Board appointing him. One man
would have one idea as to the best way of treating an insane person and one
another, and there were, of course, abuses and public scandals. The new law
to which he referred had a clause in it giving full freedom as to the corres¬
pondence of patients. As to trial by jury, it existed in the State of Illinois,
except in regard to the estates of patients. He highly disapproved of it on
principle, and yet in its practical use there was very little harm in it, and the
people of Illinois refused to change it. It would certainly prevent improper
incarceration. That was the legal and lay side of the question. Things had
in America got to such a state that something had to be done. Some unfor¬
tunate drcumstances had lately happened exhibiting the need for further
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1887.]
Notes and News .
471
legal provisions, and there was more trouble coming on. What with accidents
and convictions of attendants before juries for cruelty and brutality to
patients, the public impression had got to be that things were not as they
ought to be in many institutions. Still he thought things all right, and the
public mind not wisely inflamed. He did not believe that the intervention of
the magistrate would be found to do a very great deal of harm, if any at all.
The great thing was to educate the public mind as to insanity being not a
crime, but a disease requiring prompt and efficient treatment in the same way
as other diseases, and that the patient should accordingly be placed under
circumstances favourable to his cure. As regards the question of mechanical
restraint and seclusion, there had lately been a marked change in America.
He remembered that at an asylum in Philadelphia not very long ago he had
heard of a woman being sent up in chains from an almshouse to the Norris¬
town Asylum. In many asylums mechanical restraint was now abolished
entirely, and one after another medical superintendents of insane hospitals
were coming to dispense with it. Dr. Gray, of Utica, had maintained and
defended restraint, but his successor had come out entirely in favour of non¬
restraint. Mr. Clark Bell concluded by saying that it gave him the greatest
possible pleasure to see the faces of so many gentlemen of whom he had
heard and known. He had stayed so long m London on purpose to meet
them. He had never seen so many “ mad doctors ” in one box before.
(Laughter and applause).
Dr. Manning, of New South Wales, said that he had had a veryjpeculiar
pleasure in listening to the President's address. He had known Dr. Needham
tor more than twenty-five years as an intimate friend, long before he (Dr.
Manning) had ever been in an asylum ward, and then Dr. Needham was the
honoured superintendent of an asylum. It was, therefore, very gratifying to
him to see Dr. Needham now occupying the chair of the Association. With
respect to the particular question of the law of insanity he had only to
report that the law in New South Wales was founded very closely indeed
upon the English law. They had the intervention of the magistrate, but the
magistrate’s interference only went as far as certifying to the correctness of
the signature—to, as he might say, the bona fides of the person signing the
request, and the correctness of the legal documents. He had no standing
whatever as to the certificates; he was bound to pass those. The magistrate
was only asked to give them some certified guarantee that the person signing
the request was a person of some respectability and standing. It had been
found that that satisfied the scruples of the public. He should be very sonw
indeed to see any alteration in the direction of the new English Lunacy Bill,
and quite agreed with one of the speakers that it would be very much better
to let the English law alone. He was quite sure that a great deal of harm
would be done by the passing of the Bill as it was framed at present, and he
thought it very advisable that the Parliamentary Committee should take
some steps in the direction indicated by Dr. Maudsley. The statutes of New
South Wales were founded closely upon the English model. They were
about eight years old, and during the period they had been in existence there
had been no trouble in their working.
Dr. Urquhabt said that some years ago there was a proposal made as to
the introduction of reception houses as half-way places between lunatics’
homes and asylums. As Dr. Manning had had great experience in regard to
that particular point, they would be very glad to hear something about the
reception house at Sydney.
Dr. Manning said that the establishment of the reception-house was more
or less an accident, but it had worked most satisfactorily, and now about
600 patients passed through it annually. It contained about twenty-four
beds, twelve or fourteen for men and the remainder for women. There were
two classes of admissions. The first class consisted of those who were
brought before the magistrates and were remanded by them so that medical
xxxm. 31
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472
Notes and News,
[Oct.,
men should have an opportunity of examining and certifying. On being
taken up by the police the cases were taken before the magistrate and seen by
him in his private room. The medical man would sometimes be unable to
certify, ana would advise that they should be seen again. These cases would
accordingly be sent to the reception hospital. At the end of a week or ten
days these cases would again be seen, and then, if necessary, sent on to
an asylum. About three hundred cases were of that sort. Of course a very
large proportion of them did not reach asylums at all. The other class of
admissions to the reception hospital were those “upon certificate.” These
cases were admitted upon one certificate, and it was necessary that another
certificate should be signed before they could be sent on to an asylum. Many
of those cases were discharged, and never reached the asylum at all. The
medical officer of an asylum had the power to certify that the cases might be
benefited by remaining in the reception hospital, otherwise they must be
discharged m the course of a fortnight. Thus by the use of this reception-
house a very large number of cases were spared going to the asylum at all.
Out of the 600 admissions not more than 300 passed to the asylums. Many
of those were cases of delirium tremens, and many of temporary aberration
which recovered in a week or ten days. The only institution of the same
kind with which he was acquainted was one in Paris, but there, he believed,
the cases could only be admitted upon certificate. It was found that some of
those ca*es which were brought up and remanded were very much injured by
being taken to the police cells, and the reception-house was established to
meet that particular class of case. The number of people who recovered in
the reception-house very materially lessened the proportion of recoveries in
asylums. All the same, it had done a very good work, and certainly the
treatment there, and the care bestowed, was much better than was likely to
be afforded to that class of cases in the poor-houses, where he understood
such cases were sent in the first instance in England.
Dr. Hack Tuke said that upon the point of magisterial intervention the
difficulty arose, that under the existing law the magistrate was already called
in in pauper cases, and, therefore, it was not easy to argue against this course
being taken in private ones. It should, however, be remembered that all
along the Parliamentary Committee had entered a protest against the calling
in of the magistrate, and especially against his seeing the patient. The
Parliamentary Committee, moreover, had gone on to say that whether that
proposal passed or not, there were certain clauses in the Bill which this
Association wished to have modified. He believed it would have been a
mistake for the Association to have looked silently on and not to have done
anything in the matter. Possibly the opposition which they had raised had
helped to prevent the Bill passing so soon as it might have done, and prolonged
the discussion till another session. It must also be borne in mind that
unfortunately both political parties had felt equally strongly about the inter¬
vention of the magistrate, and thus no party feeliDg could be aroused. These
difficulties ought to be borne in mind in considering the action, or what
might be thought the want of action, on the part of the Parliamentary
Committee. As regards the trial by jury described as existing at Illinois, he
might say that he was present at one of these trials in Chicago, and although
he did not see anything particularly objectionable, he inferred from what he
heard from thosfc well able to judge in that State, that there were very strong
reasons against the publicity which was occasioned in consequence of cases
being taken before juries, and certainly he heard that cases were kept back
from the fear of being involved in legal proceedings. He would only add
that he had been extremely interested and pleased by the admirable address
which had been delivered by the President.
The proceedings then terminated, the members of the Association and
visitors subsequently dining together at Greenwich.
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473
1887.] Notes and News.
BRITISH MEDICAL ASSOCIATION.—DUBLIN MEETING, AUGUST,
1887.
(Psychology Section.)
President: J. R. Gasqnet, M.B., Brighton. Vice-Presidents: Frederick
Needham, M.D., Gloucester; Oscar T. Woods, M.D., Killamey. Secretaries:
Conolly Norman, F.R.U.S.I., Richmond District Lunatic Asylum, Dublin; T.
Lyle, M.D., Rubery Hill Asylum, Bromsgrove, Worcestershire.
The interest in the meetings of this section was well sustained. The discus¬
sion on the papers read will appear in the 44 British Medical Journal.” Some,
if not all, of the papers themselves will be published in this Journal. That by
Dr. Oscar Woods will be found among the Original Articles of the present
number. The outoome of this article promises to be of practical importance.
The President, Dr. Gasqnet, gave, as might have been expected, an able and
thoughtful discourse, whose only fault was its brevity. We append it.
The following was the order in which the papers were read:—
Wednesday, August 3.
President’s Address.
41 Folie k Deux,” D. Hack Tuke, M.D.
44 On the Use of Galvanism in the Treatment of Certain Forms of Insanity,”
Joseph Wiglesworth, M.D. (see Original Articles).
44 Nervous Disorders following the Use of Anaesthetics,” Dr. George H.
Savage.
Thursday, August 4.
44 Case of M. R., a Medico-Legal Study,” Prof. Einkead.
44 Expectancy as an Element in the Exaggeration of Railway Injuries, Real
or Imaginary,” H. C. Tweedy, M.D.
44 Our Laws and our Staff, 1 ’ Oscar Woods, M.D. (see Original Articles).
44 How ought Society to deal with Habitual Criminals P ” Isaac Ashe, M.D.
Friday, August 5.
Resolution passed asking the Council to memorialize the Government in
regard to the defects in the Irish Lunacy Law.
44 Are Airing Courts, Locked Rooms, and Restraint neoessary in Asylum
Practice ? ” John Keay, M.B.
44 On Private Treatment versus Asylum Treatment,” D. Yellowlees, M.D.
Vote of thanks to President and Secretaries.
The President’s Address.
Gentlemen, —I will not waste the time allotted to me—which, happily for
you, is short—by dwelling upon my own unfitness for the post which I have
the honour to fill to-day. You will do me the justice to believe that I never
realized my own shortcomings so fully as I do now, when I am called to preside
over men of greater knowledge and experience that myself. I therefore put
aside at once all personal considerations, and rely, solely but confidently, upon
your kindness to make the work of our Section a success, in spite of all my
deficiencies.
But I approach the subject of my address with greater diffidence, being
aware that many will think it needs more apology than my position here. I
know there is hardly a matter connected with insanity which you have not had
larger opportunities of studying, and, I fear, used those opportunities more
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[Oct.,
profitably than I. On these it would be almost an impertinence that I should
dwell; but there is one subject which, as it seems to me, we all alike neglect,
and to which I may without presumption direct your attention, as well as my
own. I propose to ask whether the abundance and importance of the bodily
conditions that come before ns do not unduly distract our minds from the
mental and moral phenomena of insanity ? Whether we do not look too much
upon the physical side of the object of our study, and neglect its psychical
aspect ? Let no one be alarmed. I have not the slightest wish to disturb our
tacit agreement that questions of philosophy should be set aside by us, and
that our business is to study the concrete manifestations of mind. Nay, I am
quite prepared, with a physician who was also a great philosopher (Lotze,
Logic , chap, v.), “ by one general formula of ready worship, to purchase a dis¬
pensation from any further glorification ” of the principle that insanity is due
to disease of the bodily organism, and must be studied as such. No doubt there
has been much need in the past of the frequent repetition of this fundamental
truth; still “ any moral sermon becomes intolerable if it goes on for ever.’
Nor does there seem to bo much present risk of its being forgotten ; while
there is, on the contrary, the danger of a reaction if we dwell too unduly upon
the bodily side of our duty. The zigzag progress of human thought may at the
next turn of the path bring the psychical aspect into undue prominence.
A few examples will show what I mean, and, perhaps, enable ub to ascertain
better how far my fears are justified. Let us take the causation of insanity.
It is impossible to exaggerate the importance of heredity in all biological
study j it is the first law of motion applied to the organic world, and must,
therefore, be the starting point of all our inquiries. But has not our daily
increasing recognition of the universal extent of heredity somewhat lessened
our attention to all those factors of insanity which used to be called (and still
figure in the text-books as) “ moral causes ”—education, precept, example, and
all the manifold ways in which one human mind can influence another P Of
course they all have a common physical basis in that tendency to imitation
which is inherent in the nervous system as the highest form of reflex action,
yet the connecting link between mind and mind is none the less purely
psychical. I have not forgotten that we are about to have the pleasure of
hearing a paper on a striking instance of what I refer to— -folie ct deux —by one
of our most accomplished members ; but what fields remain unexplored ! Who
has sought to unravel the tangled skein of family histories, and tried to esti¬
mate the share which the early example and training of neurotic parents have
in strengthening the evil tendencies which they have already transmitted to
their children ? Happily we seldom now have the opportunity of studying the
effect of imitation on the largest scale in those epidemics of insanity which have
been so notable in the history of the world ; but their records are still accept¬
able to our study, and appear to justify abundantly my contention.
I need only just mention the influence of the various passions, even in their
most refined developments. Jealousy, remorse, anxiety, grief, act, indeed, only
by and through the nervous system, but in their nature and origin are mental
rather than cerebral.
If we pass from the causation of insanity to its symptoms, we shall, I believe,
find their psychological aspects equally deserving of more careful investigation
than they receive at present. Thus many of the phenomena of insanity, if
tested by psychology, turn out to be quite different from \y]?at they at first
sight appear. For instance, I suppose we are all apt to class as disorders or
loss of memory states which would be more accurately defined as disordered
recollection or attention, which no doubt have very different physical correlates
from loss of memory proper. It may even be suggested that the slowness with
which psychiatry progresses may be largely due to our imperfect psychological
analysis, which connects symptoms really dissimilar, and separates others which
are only different in appearance.
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1887.]
Turning to symptoms as we find them, we may say roughly and generally
that the bodily condition supplies the general direction which the insanity takes,
while the details by which each individual seeks to account for his altered feel¬
ings are derived from his past mental experience. This is, of course, most
plainly seen in cases of recent melancholia. The religious belief to a great
extent supplies the data on which delusions are constructed, so that we find
many delusions of this kind are “ endemic ” among the members of various
religious bodies.
The way in which the systematic delusions of chronic insanity are gradually
built up, if more difficult to study, appears to be more curious and remarkable.
For instance, we have all seen patients who start with delusions of persecution,
and gradually go on to construct the belief that they must be personages of
exceptional rank or importance to be the victims of such persistent conspiracy
and hatred. Or again; it is very interesting to watch the growth of delusions
in educated lunatics, by their continual attempts to meet real or fancied objec¬
tions, so that the very reasoning that is employed to disabuse their minds leads
to their increased confusion.
A question of greater delicacy and difficulty has sometimes been approached,
but still, I believe, awaits adequate investigation. It needs a very subtle
analysis to discover whether all the mental faculties are alike liable to perver¬
sion, or whether any laws of thought or processes of mind remain standing
amid the general ruin, and are always normal as long as they are manifested
at all.
So, too, no one will say that the several groups of symptoms which we
include under the term “ moral insanity ” have been sufficiently studied. Many
problems still await solution by the application of psychological analysis,
though it has been carried much further in this than in other directions, owing
to the pressure of medico-legal requirements.
After all, the ultimate test of all our medical knowledge is its practical
value. Fortunately for you, this excludes from tny consideration the services
we might render psychology, were we trained psychologists. But it leads me
to ask all the more urgently—Is the psychological side of our speciality unduly
neglected in treatment ? As a proof that it is, I need hardly go further than
the very term “ moral treatment,” which has been used so vaguely as to become
almost ridiculous, and fallen into disrepute. It is, indeed, true that the
mental and moral influence of one mind upon another is hardly ever more
wonderfully displayed than in the management and cure of the insane. To
rouge the apathetic, to cheer the melancholy, to control the excited, to bring
the self-centred lunatic face to face with the realities of life—these are noble
powers indeed, which are being constantly exercised in asylums. But the tact
which can do all this is personal and incommunicable, born of long practice, of
frequent success, and still more frequent failure; it is the skill of an artist
bringing forth harmony and order from the instrument on which it plays.
What a gain it would be if the principles on which one skilled in dealing with
the insane proceeds, instead of being intangible, because unconscious, could
take shape and definiteness under scientific treatment, and the beginner start
in some measure armed with the experience of past generations. That the
thing is not impossible is shown by the success in a parallel profession of Mr.
SullVs excellent “ Teacher’s Manual of Psychology.” It is from this point of
view that such experiments as Dr. Savage, in particular, has recorded are of
great interest where lunatics are reasoned out of their delusions, and cured, so
to speak by psychology. We may naturally expect that by the continuance of
such attempts upon some fixed method we should gradually arrive at fixed
principles of treatment. .
A profound conviction of the practical importance of my subject could alone
have induced me to occupy your time to-day with what must, at first sight,
look like mere fault-finding and criticism. A heavy responsibility lay upon me
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476
[Oct.,
Notes and News .
to/use the moments in which I was privileged to address yon to the best of my
power. I felt I could not do better with them, than to enforce the old sentence,
which might well be the motto of our profession: “ Ars artium regimen
aninia ram ,” “ The art of arts is the government of souls.”
INAUGURATION OP THE STATUE OP GUISLAIN.
Early in the second week of July an interesting ceremony took place at
Ghent. Although the distinguished Belgian alienist performed his great work
some fifty years after the reformers in England and France performed theirs,
his labours are equally creditable to his heart and understanding. He found
the customary abuses in the management of the insane; he determined that
his country should be at least abreast of the age in which he lived ; he demon¬
strated to his countrymen the possibility of a more excellent way, and insisted
upon the duty of the authorities in providing proper accommodation and
humane treatment for the insane. To say that the results fell far short, as
regards the whole kingdom, of what Guislain desired, is only to say that
reforms initiated by far-seeing men are not adopted beyond the immediate
circle of their influence for a long period, often not during their lifetime. But
the seed has been sown, some of it doubtless scattered on stony ground, some
of it among thorns and briars which choke it, but, as in the case of Belgium,
enough haw fallen on good ground to ensure the success of Guislain’s humane
efforts to arouse popular sentiment and to overcome official apathy and neglect.
The reformer’s work must not be measured by contemporaneous results; these
are prolonged far beyond his lifetime. Of this common truth the inauguration
of Guislain’s statue is the best illnstration possible. The man it commemorates
showed what could be done for the insane in the asylum he superintended, and
which bears his name. He also urged their claims in the municipal and
national conscience, but whatever he effected or failed to effect while he lived
is powerfully influenced by the ceremony of July, 1887. In honouring
Guislain as a public benefactor the people of Belgium admit the necessity and
righteousness of the principles of action for which he contended. The suffi¬
cient provision for and proper treatment of the insane and idiotic are not
secured at any period once for all. They must be sustained by continual
appeals to official authority and benevolent action made by an authority
springing from the combination of philanthropy and science, for the former
single-handed goes too far, and the latter does not go far enough.
Returning to the Guislain ceremony, we have to record that a striking bronze
statue of the citizen of Ghent and the alienist of Belgium was unveiled on the
10th of July in the Place de Beguinage of that place. On the pedestal wag
inscribed : Joseph Guislain, 1797-1860. M. Hambresin was the sculptor, and
was congratulated on his success. The cost of the statue was £1,000. From
the covered platform erected in the Place, speeches appropriate* to the occasion
were delivered by the President, M. Lentz, Inspector of Asylums, delegate of
the Minister of Justice, Director-General of the Bureau of Justice, President of
the Committee of Organization, by his brother, Dr. Lentz, the Superintendent
of the Tournai Asylum (who was made an honorary member of our Association
at the recent annual meeting), by M. Lefebvre, M. Boddaert, President of the
Academy of Medicine, and others. M. Lentz, the chairman, was supported by
the Governor of the Province (Flandre Occidentale), M. de Kerchove, and by
the Mayor of Ghent, M. H. Lippens, who also delivered an address. Various
countries were represented at the ceremony by physicians deputed to attend;
Holland by Dr. Bamaer, Inspector of Dutch asylums; Denmark by Dr. Steen,
berg; Russia by Dr. Dektereff; Britain by Dr. Hack Tuke. A telegram received
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Journal of Mental Science Oct. JS8/1
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visited the prisoner in his cell as well as the neglected lnnatic in the out¬
house and garret. “There is a spectacle which this town (London) now
exhibits, th*^ T v ill venture to call the most solemn, the most Christian, the
most affecun b -wnich any human being ever witnessed. To see that holy
woman in the midst of wretched prisoners—to see them calling earnestly upon
God, soothed by her voice, animated by her look, clinging to the hem of her
garment, and worshipping her as the only human being who has ever loved
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/• I /
7 7 ct •
- /?* /v/?/
, 7
/-V
f /
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Notes and News.
477
1887.]
from fi&ebr, Berlin, stated that unavoidable oircnmstanoes prevented his attend,
anoe. Apologies and congratulations were also received from Prof. MierzejewBki
(St. Petersburg), Prof. Kowalewsky (Kharkoff), Prof. Tibaldi (Padua), Prof.
Wille (Switzerland), Dr. Semal (Mons), Dr. Van der Lith (Utrecht), Dr. Chris¬
tian (Charenton), Dr. Brosius (Bendorf), Clark Bell (New York), etc.
Prior to the ceremony most of those who took part in it assembled at the
Hospice Gnislain, and were received by the present superintendent, M. Morel,
who recently succeeded the lamented M. Ingels. M. Morel introduced the
members of the deputation to the Commissaire d’Arrondissement and the
President des Hospices, gave a rapid review of the past history of the insane
in Belgium, and then escorted the visitors over the asylum, the condition of
which reflects great credit upon the successors of Gnislain, no less than Gnislain
himself.
In the evening a banquet, given in honour of the occasion at the Hdtel
de la Poste, brought the proceedings to a close. Speeches were delivered by
M. Lentz, M. H6ger, Professor in the University of Brussels, and President of
the Belgian Societe de Medecine Mentale, M. de Kerohove, Dr. Poirier, Dean of
the Faculty of Medicine of the University of Ghent, Dr. Vermeulen, Physician-
in-Chief of the Asylums of Ghent, Dr. Ramaer, Dr. Steenberg, and a tribute
again paid to the services rendered by Gnislain to the cause of the humane
treatment of the insane in Belgium.
We cannot conclude this notice of the ceremony and the whole proceedings
without an acknowledgment of the admirable manner in which the business of
the day was carried out, the success of which was in great measure due to the
active thoughtfulness of M. Morel.
[Since the foregoing was written, the Bulletin of the Society of Mental
Medicine of Belgium contains a full description of the proceedings, including
reports of the discourses of MM. Morel, Lentz, Lefebvre, Boddaert, Lentz,
Lippens, Tuke, Heg6r, de Kirchove, Poirier, Vermeulen, Ramaer, Steenberg,
etc.]
Obituary ,
DOROTHEA L. DIX.
No name in connection with reforms in the condition of the insane in the
United States is worthy of more honour and veneration than that of Dorothea
Dix. Early in the field, never disheartened by the difficulties which beset her
path, firm as a rock, yet a lady in all she did, this resolute woman succeeded
in not only exposing the once revolting condition and shameful neglect of
the insane, but in inducing the State Legislatures to erect suitable receptacles
for them. More than this, she encouraged efficient medical men to come for¬
ward to superintend these institutions, and exercised her influence in obtain¬
ing their appointment. Furthermore, she watched over the hospitals for the
insane after their establishment, and promoted their successful working by all
the means within her power. She frequently visited them, and was always a
welcome guest. What Mrs. Fry was to prisons, Miss Dix was to asylums.
The homage paid to the former by Sydney Smith may be fittingly applied to
the latter, and, indeed, the reference is doubly appropriate because Miss Dix
visited the prisoner in his cell as well as the neglected lunatic in the out¬
house and garret. “There is a spectacle which this town (London) now
exhibits, th^+ T w »11 venture to call the most solemn, the most Christian, the
most affecting w nich any human being ever witnessed. To see that holy
woman in the midst of wretched prisoners—to see them calling earnestly upon
God, soothed by her voice, animated by her look, clinging to the hem of her
garment, and worshipping her as the only human being who has ever loved
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478
Notes and News .
[Oct.,
them, or taught them, op spoken to them of God—this is the sight which
breaks down the pageantry of the world, which tells us that the short hour of
life is passing away . . . that it is time to go, like this blessed woman,
among the guilty, the broken-hearted, and the sick, and to labour in the
deepest and darkest wretchedness of life.” Well do we remember Miss Dix
telling us that as she was travelling one night along a lonely road she was
attacked by a highway robber, who demanded her purse. She spoke to him,
and when he heard her voice his whole demeanour changed. He expressed his
contrition for his conduct, and said he remembered her visits to the prison
where he had once been confined. On another occasion, after staying for
a week at an inn, she asked for her bill, but the landlord refused to take a
cent, stating that he had received kindness and good counsel from her when
he had the misfortune to be in a prison which she visited. Unlike the thief
just mentioned, he had endeavoured to lead a better life.
Those who would adequately estimate the courage displayed by Miss Dix
in penetrating into the dens in which the insane and idiots were once concealed,
must read her narrative of cases and her Memorials to the American Govern¬
ment some forty years ago. Her Report shocked the feelings of the commu¬
nity and aroused sympathy on behalf of the suffering insane for whom she
pleaded. State hospitals were built, and she had the satisfaction of witnessing
a great reform carried out, although even her powerful influence was unable
to induce the authorities to do all that she wanted them to do, the State
provision being often very inadequate for the needs of the insane, and numbers
being allowed to remain in inferior almshouses. But if the condition of the
insane in the United States at the time of her death were compared with that
in which she found it, some five-and-forty years ago, the contrast would be at
once startling and gratifying. To Miss'Dix the change is mainly due. She
laboured first, and others happily entered into her labours. The superinten¬
dents of asylums paid her the greatest respect; she was always welcome to
their houses as a guest, and the American Association of Medical Superinten¬
dents of Hospitals for the Insane welcomed her on one occasion in terms
of the most flattering description, and passed a special resolution in
her honour. And the writer lias observed in at least one asylum-chapel
in the States the portrait of this saintly woman on the wall where
in a Roman Catholic Church the Virgin Mary would have been placed. Miss
Dix’s philanthropic labours were not confined to the States. She was
interested in the asylums in Canada, and at one period was painfully impressed
with their bad condition. Again, everyone who knows the history of the
reform in lunacy in Scotland knows that her visit to that country in 1855, her
exposure of the dreadful state of things she discovered, and her vigorous
onslaught on the authorities who supported them, led to a complete revolu¬
tion in the care and treatment of pauper lunatics. Those who heard from her
own lips the stirring incidents of that raid upon Scotland after her return to
England, and her interview with the Home Secretary only a few hours before
the Provost of Edinburgh arrived in hot haste on the scene in order to antici¬
pate and nullify the good woman’s appeal—but just teo late—are not likely
ever to forget her graphic story. Her clear statement of facts, her dignified
presence, her obvious sincerity, and her dogged perseverance triumphed.
She could afford to smile at the epithet bestowed mockingly upon her, “The
American Invader,’ 1 a soubriquet which she adopts in the autograph we have
appended (from a letter) to the portrait facing the title page.
Miss Dix’s health was feeble, but her indomitable energy overcame al t
obstacles.
During the Secession War, Miss Dix’s activity was diverted into another
channel. She saw her duty then lav in tending the sick and dying, and it is
needless to say she was an angel of mercy in the hospitals where the wounded
were nursed. Her eventful life when written, as we believe it will be, should
be an interesting one. Her pen was never weary, so that out of her
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1887.]
Notes and News.
479
voluminous correspondence there ought to be material for much valuable per¬
sonal experience and opinion. The only drawback is the not easily read
handwriting, written on thin paper and frequently crossed. Of letters
received by the writer during thirty years, the last was dictated on the 17th
April, 1886, in which she expresses herself thus:—
“ I have for many weeks been wishing to write, and, with the expression of
affectionate remembrance and regards, I must now say illness only has inter¬
posed. I have of late been very ill. This morning Dr. Ward brought me a
message from Mr. Rathbone (M.P.) which again reminded me of, and took
me to, the more immediate remembrance of my English friends. May I not
ask that you soon write and inform me of hospital affairs in England ? ”
Although Miss Dix’s health had become much impaired for some years, she
retained her interest in the great work of her life. She resided in rooms set
apart for her use in the upper storey of the State Asylum for New Jersey at
Trenton, of which Dr. Ward is the medical superintendent.* Dr. and Mrs.
Ward did all in their power to render her declining years as comfortable as
possible, and for their kind care of one who had spent her life in caring for
others, the friends of Miss Dix in England, as well as in America, ought to
feel very grateful.
During the period Miss Dix spent in her rooms without once leaving them,
her death has many times appeared to be imminent; but there had, it appears,
been a slow decline in her bodily powers, whose failure seemed to be sudden
at last. She became unconscious about twelve hours before her death, and
continued so to the end. Dr. Ward attributed her death to heart disease.
Miss Dix died on the 17th July, 1887. We are not able to state her length
of days, but they must have extended considerably beyond 80. She was not
exempt from the feminine disinclination to disclose her age, and many have
been the innocent attempts to induce her to betray the secret, but all in vain.
On one occasion the question was abruptly put to her, but she evaded it with
characteristic tact. The occurrence took place one day as she went round
an asylum. It happened to be the birthday of one of the female patients.
Addressing the well-known visitor she announced her own age, and imme¬
diately added (perhaps previously prompted by the superintendent) “And
what age are you, madam ? ” The inquisitive bystanders thought that there was
no escape. On the contrary, Miss Dix promptly replied, “ About a hundred! ”
and passed on, leaving her interrogator and others thoroughly discomfited.
We are glad to be able to accompany this obituary notice with an admirable
likeness of Miss Dix. With great difficulty we induced her to allow herself to
be daguerreotyped during her visit to York in the year 1885. Even when
taken, it nearly suffered destruction at her hands.
Her remains were laid in the Mount Auburn Cemetery, near Boston (Mass.),
on the 21st, having been conveyed from Trenton, a distance of 300 miles.
Among those who attended her funeral was Dr. Charles H. Nichols, of the
Bloomingdale Asylum, N.Y. We cannot better close our imperfect notice of
this devoted woman, whose memory will be cherished by all who have at
heart the amelioration of the condition of the insane, than by the following
tribute to her honourable career by one who knew her so well and can so
justly estimate the benefits she has conferred upon humanity. Dr. Nichols,
in commenting on the decease of Miss Dix, writes to us:—
“Thus has died and been laid to rest in the most quiet, unostentatious
way, the most useful and distinguished woman that America has yet pro¬
duced.”
* To prevent what has already led to a misconception, it may be as well to state that Miss
Dix did not seek this asylum "on account of mental failure." It had repeatedly been her
home in former years, when Dr. Buttolph was superintepdent.
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480 Notes and News. [Oct.,
CERTIFICATE OF EFFICIENCY IN PSYCHOLOGICAL
MEDICINE.
PASS EXAMINATION.
The following candidates for this certificate passed the examination held at
Bethlem Hospital, July 23-24,1887:—
English, Edgar, M.R.C.S.Eng., L.S.A.Lond., Dip.P.H.ILC.P.Lond., Stoke
Newington.
Mortimer, Jno. Desmond Ernest, M.R.C.S.Eng., L.S.A.Lond., Ass. Med. Off.
Portsmouth Borough Asylum.
Nairn, Robert, M.R.C.S.Eng., L.R.C.P. Lond., Bethlem Hospital. London.
Simpson, Samuel, M.B., B.Ch.Dublin University, Bethlem Hospital, London.
Slater, William Arnison, M.R.C.S.Eng., Fisberton House, Salisbury.
Thompson, Geo. Matthew, M.D., M.Ch.Q.U.I., Bellaghy, Castledawson,
Co. Derry, Ireland.
(The following are the writt en que stions asked at the Pass Examination
Examiners:
D. Hack Tuxe, M.D.
Geo. H. Savage, M.D. . ... - --^
(It is not necessary to answer more than Four of these Questions.)
I. —Give the symptoms, bodily and mental, of General Paralysis of the
Insane, distinguishing between the several stages through which it may run.
Note the different mental forms which may characterize the invasion of the
Disorder.
II. —With what other diseases may Acute Delirious Mania be confounded ?
Give the differential Diagnosis.
III. —What forms of mental disorder may be classed under “Alcoholic
Insanity ”?
IV. —Enumerate the bodily and mental symptoms of Mental Stupor with
Melancholia. In what does it differ from Mental Stupor without Melancholia
(“ Primary Dementia ”) ?
V. —Give the treatment (General and Medical) of a case of Puerperal Mania.
VI. —In what form and dose would you prescribe Hyoscyamine, Hyoscine
Hydro-bromate, Urethane, Paraldehyde, and Hypnone ?
Questions asked at the Honours Examination:—
{Same examiners.)
I. —Trace the relationships of Alcohol and Syphilis to General Paralysis of
the Insane.
II. —How would you subdivide cases of Insanity depending upon morbid
sense impressions ?
III. —Explain the relationship of Heredity to various forms of Insanity.
PSYCHOLOGY.
I. —Enumerate the most important classifications of Healthy Mental
Phenomena, indicating the one you prefer, with your reasons.
II. —Give the psychological bearings of Word-Deafness and Word-Blindness.
Illustrate by a diagram.
III. —What is meant by the influence of the Mind upon the Body, and the
Body upon the Mind ? Illustrate the modus operandi by an example of each.
IV. —How would you define Volition ? State the main differences in the
mode of regarding the Will by psychologists.
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1887.]
Notes and News.
481
~1
V. —Distinguish between Emotion and Desire* (
VI. —Descnbe what happens when subjective sensations are experienced. 1
Are the terminal sense-organs involved ?
IRISH EXAMINATION.—JULY, 1887.
The following candidate passed the examinatio n for the Certificate of
Efficiency in Psyeholo gical Medicine /th^x&nrfherfrH^ing
/ ICING ROSE ATKINS, M.A., M.D^-
VUONOLLY NORMAW. F.R.(j).S.I— ^—--
Moore, Edward Erskme, M.D:; A&islant Medical Officer District AsylumN
Downpatrick. -*
The following written questions were asked:— ~ =•
I. —What is Insanity? State shortly the modern views as to its nature.
II. —Contrast the classification of Esquirol with that of Skae. Say which
you consider to be the most generally useful, and give your reasons.
III. —You are brought to two “chronic” so called “harmless lunatics,” in
a workhouse ward, presenting generally the same mental symptoms. De¬
scribe the special conditions which would lead you to infer that one was
labouring under congenital mental defect, and the other suffering from
acquired mental disease.
IV. —What is “OthaBmatoma?” Describe its mode of onset, its nature,
course, probable pathology, and the significance it possesses in any case of
insanity with which it is associated.
V. —Describe briefly the morbid changes observed in the brains of the chronic
insane:—
(a) In the Blood Vessels.
(b) In the Nerve Cells.
( c ) In the Neuroglia and Nerve Tubules.
. VI.—Describe the various methods of artificial feeding now employed, and
state in detail how you would conduct the treatment of a case of obstinate
refusal of food in an insane person.
VII. —Describe a case of acute delirious mania; its symptoms and course;
its prognosis and sequelae.
VIII. —Distinguish between the conditions which have been described as
acute primary dementia and melancholia with stupor.
IX. —Describe the proceedings requisite to place a lunatic in an asylum in
Ireland under the provisions of the Act 30 and 31 Vic., c. 118. What are the
various conditions under which such patient can be discharged?
X. —What is the prognostic significance of hallucinations of hearing, and
with what other symptoms are they commonly associated ?
XI. —Briefly detail the physical diseases and affections most frequently
found to stand in an antecedent relation to Insanity.
XII. —What circumstances in the personal history and condition of a patient
would lead you to recommend treatment in an asylum ?
SCOTCH EXAAn mTION.--JTJL Y J 1887.
Examiners:
[ James Rutherford, M.D.
IT.
The following candidaTeirpassed the examination for the Certificate of
Efficiency in Psychological Medicine held in Edinburgh on July 15 and 10,
1887:—
Black, Victor, M.B., C.M.Edin., Royal Edinburgh Asylum.
Cowper, John, Merchiston Aven, Edinburgh.
Steel, John, M.B., C.M.Edin., Royal Edinburgh Asylum.
Wood, David James, Hope Park Square, Edinburgh.
The following"were the questions asked at the Written Examination
(r
Digitized by v^ooole
482
Notes and News.
V
I. —Describe the chief and essential features of a case of Melancholia; and
mention the principles of Treatment you would adopt.
II. —Mention the forms of insanity in which Motor Symptoms necessarily
exist, stating shortly the kind of Motor Symptoms to be expected in each,
and the theory of such Association of Mental and Motor Symptoms in each.
III. —Give the chief symptoms of a case of Adolescent Insanity; describe
the treatment of this form of Mental Disease ; and mention the grounds on
which you would conclude that complete recovery had taken place.
IV. —State briefly the general method you would adopt in examining a
Patient supposed to be Insane; how would you distinguish Meningitis from
Acute Mania? Under what circumstances would you recommend home in
preference to Asylum treatment ? Correct the accompanying faulty Certificate.
V. —Name the various forms of Alcoholic Insanity. Describe the condition
commonly known as Chronic Alcoholism. Give the Prognosis and Treatment.
VI. —What Mental and Physical symptoms, other than the expressed desire
of theJVrttent, would lead you to adopt precautions against Suicide?
MEDICO-PSYCHOLOGICAL ASSOCIATION.
Certificate of Efficiency.
The next examination for the Certificate of Efficiency in Psychological
Medicine will take place on the 22nd and 23rd December, 1887, at Bethlem
Hospital.
MORNING EXAMINATION:
11 to 1.
AFTERNOON EXAMINATION:
2 to 4.
For further particulars apply to
HENRY RAYNER, M.D.,
September, 1887. Hanwell, W.
For information respecting the corresponding Examination in Scotland
apply to Dr. Urquhart, Murray Royal Asylum, Perth, N.B.; and in Ireland
to Dr. M. Courtenay, District Asylum, Limerick.
SIR ARTHUR MITCHELL, K.C.B.
The honour bestowed upon Dr. Arthur Mitchell will, we are sure, give
universal satisfaction. The Medico-Psychological Association is proud to
number him among its members, and this Journal, as its organ, congratulates
him upon the well-merited distinction conferred upon him by Her Majesty.
As a Commissioner in Lunacy, Sir Arthur Mitchell has left his mark deeply
impressed upon the Scotch Lunacy system, with which his name is indelibly
associated. Moreover, as an archaeologist and as a writer on primitive man,
our distinguished confrere is well known outside the circle of Psychological
Medicine. May he long live to continue his good work and to enjoy his
honours!
Appointments.
White, Ernest, M.B.Lond., M.R.C.P.Lond., A.K.G., appointed Resident
Medical Superintendent, City of London Asylum.
Lys, H. G., M.R.C.S., appointed Resident Clinical Assistant to St. Luke f s
Hospital.
Brushyield, T., M.B., M.R.C.S., appointed Second Assistant Medical Officer
to Kent County Lunatic Asylum, Chatham Downs.
King, Thomas Radford, M.D.Ed., appointed Medical Superintendent of the
Porirua and Wellington Lunatic Asylums, New Zealand.
Levinge, E. G., M.B., L.R.C.S.I., Medical Superintendent to the Christ¬
church Lunatic Asylum, New Zealand.
Digitized by t^ooQle
INDEX MEDICO-PSYCHOLOGICUS.
Absence, leave of, in asylums. Die Beurlaubung in den Irrenanstalten. Dr.
Kessler. Allg. Ztschr. f. Psychiat., Berlin, 1886, xlii., 371-373.
Acetophenone, or Hypnone, as a sedative in insanity. Dr. Key. Ann. Med:
Psych., Paris, 1886, 7 s., iii., 433-436.
Acute Mania, a case of, during which there was complete remission of the
symptoms dining a temporary plugging of the sinuses. Dr. Hyslop.
Brain, 1886-7, ix., 90.
Aesthesiometry, duration of the mental factor in, in the insane. II tempo del
processo psichico nell ’estesiometria negli alienati. Dr. Sombrom, Riv.
sper. di freniat., Reggio Emilia, 1885-6, xi., 369-403.
Albuminuria, transitory, in nervous diseases. L’albuminurie transitoire, dans
quelques maladies du syst^me nerveux. Dr. Henri Michel. Lyon, 1886,
94 p., 4o.
Alcoholism, hereditary transmission of. Ueber erbliche Uebertragung des
alkoholismus, etc. Dr. Demme. Wien. Med. Bl., 1886, viii., 1525 ; 1561;
1697.
Alcoholic Paralysis. Dr. Dreschfeld. Brain, 1886-6, viii., 433-446.
Alcoholism mistaken for General Paralysis. Alcoolisme pris pour une
paralysie gdn^rale. Marandon de Montyel. Ann. Med. Psych., Paris,
1886, 7 s., iii., 232-236.
Antwerp Medical Congress. Compte rendu analytique des scdances. Bull.
Soc. de M6d. ment. de Belg., Gand, 1885, No. 38, 39-84.
Assassins, study on. Studio* sugli assassini. Dr. Manouvrier. Archiv. di
Psichiat., Lorino, 1886, vii., 33.
Asylums, on Scotch, English, and French. Ueber schottische, englische und
franzosische Irrenanstalten. Dr. Siemerling. Arch. f. Psychiat., Berlin,
1886, xvi., 677-598.
-and insane colonies. Asiles et Colonies d’alienSs. Dr. Lentz. Bull.
Soc. de Med. ment. de Belg., 1886, No. 42, 46-52.
Attendants, manual for, how to care for the insane. Dr. W. D. Granger, New
York and London, 1886, Putnam, 105 p., 12o.
-Handbook for the instruction of Attendants on the Insane. Boston,
1886, Cupples, Upham, and Co., 137 p., 12o.
Attention and Will, some points in the physiology of. Dr. Cappie. Brain,
1886-7, ix., 196-206.
-Mechanism of the will and the motor centres of the brain. Prof. Victor
Horsley. Notices, Proc. Roy. Inst. Great Britain, 1884-6, xi., 260-252.
Bone-disease in nervous affections. Des lesions osseuses dans les maladies du
systeme nerveux. Dr. Carrieu. Gaz. hebd. de Science. M6d. de Mont¬
pellier, 1885, vii., 602-605.
Borderland of Insanity, the. Les frontieres de la Folie. Dr. A. Motet.
EncSphale, Paris, 1886, vL, 169-172.
Brain, the functions of the. Dr. Ferrier. 2nd Ed., London, 1886, Smith,
Elder, and Co., 521 p., 8o.
■-On the physiology of the, and its relations in health and disease to
the faculties of the mind. Dr. Buttolph. Amer. Joum. Insanity, Utica,
N.Y., 1885-6, xlii., 277-316.
-On the functions of the. Ueber Functionen des Grosshims. Dr. E.
Hitzig. Berlin, Klin. Wchnschr., 1886, xxiii., 663.
-Doctrines of Goltz, Les fonctions du Cerveau, doctrines de Goltz.
Dr. Joury. Encdphale, Paris, 1886, vL, 267, 554.
Digitized by t^ooQle
2
Index Medico-Psychologicus.
Brain-rest, disquisition on the curative properties of prolonged sleep. Dr J.
L. Coming. 2nd Ed., New York, 1886, G. F. Putnam and Sons, 12o.
-Irritability and congestion in young children. Dr. Day. Brit. Med.
Journ., 1886, i., 646.
-Exhaustion. Dr. Beemer. Med. Rec., New York, 1886, xxix, 652-555.
Cafeisme chronique. Dr. Gueillot. Reims, 1886, 8o.
Case in which an old amputation of the right arm was associated with an
atrophied left ascending parietal convolution. Dr. Wiglesworth. Journ.
Ment. Science, 1886, xxxii., 60-52, 1 PI.
Cephalometry. Recherches surla c^phalometrie a l’aide de nouveaux appareils
c^phalographiques. Dr. Luys. Bull. Acad, de Med., Paris, 1886,2 s., xvi.,
260-268.
Cerebral localisation. Die Functions-Localieation auf der Grosshimrinde, an
Thier-experimenten, und klinischen Fallen nachgewiesen. Drs. Luciani
and Sepilli. Leipsic, 1886, Denicke, 8o.
— Ueber die Frage der Localisation der Functionen der Grosshimrinde.
Dr. von Gudden. Allg. Ztschr. f. Psychiat., Berlin, 1886, xlii., 478-499.
-Contribution to the history of. Contribution k l'histoire des localisa¬
tions c6r6brales. Dr. Salesses. Encdphale, Paris, 1886, vi., 286-307.
Cerebral tumour, case of. Dr. Greenlees. Amer. Journ. Insan., Utica, New
York, 1886-6, xlii., 334-341.
Chloral, abuse of. Chronischer Chloralmissbrauch. Dr. Rehm. Archiv. f.
Psychiatrie, Berlin, 1886, xvii., 36-62.
Chorea. Report on capillary embolism of brain and cord experimentally
studied; its relations to the various forms of chorea. Dr. Angel Money.
Brit. Med. Journ., 1886, ii., 99-101.
Choreic Insanity. De la folie chor&que. Dr. B. Ball. France M6d., Paris,
1886, i. t 325-331.
Circular Insanity, a case of, in an insane family. Een geval van insania
cyclica uit een familie van krankzinnigen. Dr. Wellenbergh. Psichiat.
Blad, Dordrecht, 1886, iv., 123-130.
Classification of mental diseases as a basis for international statistics regarding
the insane. Clark Bell, New York, 1886, 8 s.
-On, in asylums for the insane. Dr. Bannister. Neurol. Rev., Chicago,
1886, i., 206-212.
Coloured Races, insanity in the. Dr. J. M. Buchanan. New York Med.
Journ., 1886, xliv., 67-70.
Consanguineous Marriages in relation to insanity. Dr. Shuttleworth. Journ.
Ment. Science, 1886-7, xxxii., 363-359.
“Contagion, Mental.” Ueber psychische Kontagion. Dr. Kreuser. Irren-
freund, Heilbronn, 1886, xxviii., 69-80.
Convalescence. Note sur la convalescence dans les maladies mentales. Dr.
Paris. Enc^phale, Paris, 1886, vi., 648-653.
Corpus Callosum. Prof. Hamilton. Liverpool Med. Chir. Journ., 1886* vi.,
3-11.
Convulsions, a contribution’ to the comparative study of. Dr. Hughlings
Jackson. Brain, 1886-7, ix., 1-23.
Convulsive Tic, with explosive disturbances of speech (so-called Gilles de la
Tourette’s disease). Dr. Dana. Journ. Ment. and Nerv. Diseases, New
York, 1886, n. s., xi., 407-412.
Craniometric and Cephalometric Methods. Dr. Benedikt. Wien, Med.Blatt.,
1886, ix., 636 639.
Cretin, the. Le crfetin: essai anatomique et physiologique. Paris, 1886, 38 p.,
4o., No. 263.
Crimes, etc., in the insane. Dr. Simon. Bailliere et fils, Paris, 293 p«, 8o.
Delirium tremens, a case of, caused by chewing tea. Dr. Slayter. Lancet,
1886, i„ 784.
Digitized by t^ooQle
Index Medico-PeychologicuB. 3
Dementia, on the curability of. Sur la curability de la D6menoe. Dr. Kowa-
lewski. Ann. Med. Psych., Paris, 1886, 7 s., iv., 40-60.
Destructive impulses in the insane, on the forecast of. Dr. T. Claye Shaw. St.
Barthol. Hosp. Reports, 1886, xxi., 1-21.
Development, the frontal, of the brain. Die frontale Entwicklung des
Gehirnes. Dr. T. Meynert. Wien, Med. Bl., 1886, ix., 448-460.
Dietary, on Irish Asylum. Dr. Courtenay. Journ. Ment. Science, 1886-7,*
xxxii., 16-22.
Dietetics, experimental dietetics in lunacy practice. Dr. A. C. Clark. Brit.
Med. Journ., 1886, ii., 680.
Digestive system and brain, relations between. Dr. Mann. Alienist and
Neurol., St. Louis, 1886, vii., 73-78.
Dipsomania and its hereditariness. Ueber die Trunksucht und ihre Erblickeit.
Dr. Thomsen. Arch. f. Psychiat, Berlin, 1886, xvii., 627-646.
Dirty habits in the insane, their occurrence and significance. Das Vorkom-
men und die Bedeutung der Unreinlichkeit der Geisteskranken. Dr.
Tuidenbom. Allg. Ztschr. f. Psychiat., Berlin, 1886, xvii., 322-364.
Duration of curable insanity. La durata delle frenosi guaribili. Dr. Riva.
Riv. sper. di freniat., Reggio Emilia, 1886-6, xii., 607-614.
English Asylums, observations on. Dr. Nims. Alienist and Neurologist, St.
Louis, 1886, vii., 237-436, Disc., 306-309.
Epilepsy, a practical treatise on, its successful treatment and cure. Dr. J.
Berry Mblett. London, 1886, Harrison and Sons, 80 p., 12o.
■ Recherches cliniques et therapeutiques sur l’^pilepsie, ITiyst&ie et
l’idiotie. Compte rendu du service des epileptiques et des enfants Hrri6r6s
et idiots de Bicetre, pendant Fannie 1886. Paris, 1886, Delahaye et
Lecrosnier, 136 p., 8o.
-On a case illustrating the cortical nature of, and its relationship to
Jacksonian convulsions. Dr. D. N. Paton. Brain, 1886-6, viii., 474-
491.
■ Epileptiform seizures due to sudden anaemia of brain. Dr. Benham.
Med. Press and Circ., London, 1886, n. s., xli., 424.
-Softening of occipital lobes in epilepsy. Ramollissement des comes
occipitales dans F6pilepsie. Dr. Zohral. Archiv. de Neurolog., Paris,
1886, xi., 405-419.
■ Ligature of the vertebral arteries, for the relief or cure of epilepsy. Dr.
J. L. Gray. Neurol. Rev., Chicago, 1886, i., 132-143. .
-Hysteria and Idiocy. Dr. Bourneville. Recherches cliniques et th£ra-
peutiques sur l’epilepsie, lTiysterie et l’idiotie. Compte rendu du service
des gpileptiques et aes enfants idiots et arrier^s de Bicetre pendant 1’annfe
1884. Par., 1886, A. Delahaye and E. Lecrosnier. 264 p., 6 pi., 1 plan.,
8o.
-An interesting case of. Dr. Byron Bramwell. Brit. Med. Journ., 1886,
i., 876.
-Pathology and therapeutics of. Zur Pathologie und Therapie der
Epilepsie. Dr. Deutech. Med. Chir. Centralbl., Wien, 1886, xxi., 663.
■ -■■■ Special establishments for. Des ytablissements sp4ciaux pour les
dpileptiques. Dr. Rieger. Ann. Med. Psych., Paris, 1886, 7 s., iv., 402-
423.
-Dr. J. Harley. St. Thomas’s Hosp. Reports, 1886, n. 8., xiv., 179-199.
— (Sensory). A case of basal cerebral tumour, affecting the left temporo-
sphenoidal lobe, and giviDg rise to a paroxysmal taste-sensation and
dreamy state. Dr. J. Anderson. Brain, 1886-7, ix., 385-395.
-or Hysteria in relation to acute rheumatism. Notes pour servir a
l’etude des relations et de l’influence de l’epilepsie ou de lliystfrie avecle
rhumatisme articulaire aigu. Dr. Souza Zeite. Archiv. de Neurologic,
Paris, 1886, xi., 216-233.
Digitized by L^ooQle
4 Index Medico-Psychologicus.
Epilepsy, the principles of management of. Prof. Erlenmeyer. Wiesbaden,
1886, Bergman, 80.
-r- some certainties in the therapeutics of. Dr. Dana. New Tork Med.
Journ., 1886, xliii., 453-456.
-the “ personal equation ” in. L’equazione personale degli epilettici.
Dr. Tanzi. Archiv. di Psichiat., Torino, 1886, vii., 168-175.
r -Epileptiform seizures due to sudden anaemia of brain. Dr. Benham.
Brit. Med. Journ., 1886, i., 826.
-on the state of the knee-jerk and the occurrence of foot-clonus after
epileptic attacks. Dr. Oliver. Edin. Med. Journ., 1886-7, xxxii., 209-
212 .
- ■ ■ New symptom of megrim and epilepsy. Dr. Money. Brit. Med.
Journ., 1886, i., 207.
-Treated by Borax. Dr. Folsom. Boston Med. and Surg. Journ., 1886,
cxiv., 145-147, Disc. 157.
-Trephining in traumatic. Dr. Mills. Journ. Ment. and Nerv. Diseases,
New York, 1886, n. s., xi., 39-43.
-Trephining in, from old fracture of skull. Dr. Clark. Lancet, 1886,
i., 243.
—— ■ Trephining for. Ein Fall von Trepanation des Schadels wegen
Epilepsie. Dr. Erlenmeyer. Centralbl. f. Nervenheil., Leipsic, 1885, viii.,
605-507.
-a boy who had been trephined in parietal region for traumatic
epilepsy. Dr. Oliver. Lancet, 1886, i., 69.
Errors, common, theoretical and practical, relating to insanity. Dr. Everts.
Amer. Journ. Insan., Utica, New Y'ork, 1886-7, xliii., 221-242.
Erotomania. L’Srotomanie. Prof. Ball. Gaz. d. h6p., Paris, 1886, lix., 1059-
1061.
Expectancy as method of treating Delirium Tremens. De l’expectation comme
methods de traitement du delirium tremens. Dr. J. Christian. Ann.
Med. Psych., Paris, 1886, 7 s., iii., 196-210.
Falling, on. Dr. Wilks. Brain, London, 1886-7, ix., 207-217.
Fatigue. Report on experiments and observations relating to the process of
fatigue and recovery. Dr. A. Waller. Brit. Med. Journal, 1886, ii., 101-
103.
Fear. La peur: etude psycho-physiologique, traduit de Titalien sur la 3rd Ed.
Dr. A. Mosso. Paris, 1886, F. Alcan, 187 p., 12o.
Fissures and Convolutions, arrested and abnormal development of, in the brains
of paranoiacs, criminals, idiots, and negroes; description of a Chinese
brain. Dr. C. K. Mills. Journ. Nerv. and Ment. Dis., New Y'ork, 1886,
n. s., xi., 617-653, 2 PI.
-Preliminary study of a Chinese Brain. Dr. Parker and Dr. Mills.
Ibid ., 650-553, 1 PI.
Gambetta’s Brain, weight of. Le poids de TencSphale de Gambetta. Bull.
Soc. d’Anthrop. de Par., 1886, 3 s. t ix., 399-416.
General Paralysis. Dr. W. J. Mickle. 2nd Ed., London, 1886, H. K. Lewis,
466 p., 8o.
--Rarity of in the St. Alban’s Asylum; contribution to the study of the
aetiology of general paralysis. Dr. Camuset. Ann. Med. Psych., Paris,
1886, 7 s., iv., 187-197.
-a new view of. Dr. W. Leah. Birmingham, Med. Review, 1886, xix.,
241-258.
-Allgemeine Paralyse der Irren. Dr. T. Meynert. Jahrb. f. Psychiat.,
Vienna, 1885-6, vi., 188-205.
-tm early sensory disturbance in. Ueber eine friihe Stoning der Sensi-
bilitat bei Dementia Paralytica. Dr. Ziehen. NeuroL Centralbl., Leipzig,
1886, v., 480.
Digitized by L^ooQle
Index Medico-Psychologicus. 5
General Paralysis. Paralysie g4n4rale. Dr. Mabille. Ann. Med.'Psych., Paris,
1886,7 s., iv., 898-401.
— Contribution to a study of the reflexes in. Contribution a l’ltude des
reflexes dans la paralysie g6n6rale des aliens. Dr. Bettencourt-Rodrigues.
Paris, 1886, 87 p., 4o., No. 156.
- Einiges zur allgemeinen Paralyse der Irren. Dr. Nasse. Allg.
Ztschrift. f. Psychiat., Berlin, 1885, xlii, 316-880.
■ ■■■ Cases resembling. Dr. J. A. Ormerod. St. Barthol. Hosp. Reports,
1885, xxi., 23-35.
-associated with aphasia. Allgemeine paralyse mit sensorischer
aphasie associirt. Dr. A. Rosenthal. Centralb. f. Nervenbeilkunde,
Leipsic, 1886, ix., 225-231.
-Syphilis, relations between. Dr. Hurd. Am. Journ. Insan., Utica,
Yew York, 1886-7, xliii., 1-18.
Gheel, on a recent visit to. ' Dr. Hack Tuke. Journ. Ment. Science, 1886,
xxxvi., 489-497.
-a visit to. Dr. C. W. Pilgrim. Amer. Journ. Insan., Utica, New York,
1886-6, xlii., 317-327.
Hematuria and appearances as of severe bruising, occurring spontaneously in
the course of maniacal excitement, with pachymeningitis found post¬
mortem. Dr. Savage. Journ. Ment. Sc., 1886, xxxvi., 601-504,1 pi.
Hair, accumulation of, in the stomach, with remarks. Dr. Cobbold. Journ.
Ment. Science, 1886-7, xxxii., 52-66.
Hallucinations (unilateral). Dr. W. A. Hammond. Boston Med. and Surg.
Journ., 1886, civ., 14-16.
■ ■ Dr. Christian. Diet. Encycl. d. Sc. M6d., Paris, 1886, 4 s., xii., 77-121.
- ■ ■ persistent, in an imbecile. Hallucinations continues chez un imbecile.
Dr. Paris. Enc4phale, Paris, 1885, v., 670-673.
-■■■ Physiology of. Physiologic des Hallucinations. Dr. Baillarger. Ann.
Med. Psych., Paris, 1886, 7 s., iv., 19-39.
-Dr. Gurney. Mind, London, 1885, x., 161-199.
Hereditary Insanity, physical, intellectual, and moral signs of. Des aignes
physiques, intellectuels, et moraux de la folie h6r6ditaire. Dr. Charpen-
tier. EncSphale, Paris, 1886, vi., 369-377.
-dtude clinique sur la folie h6r6ditaire. Dr. H. Saury. Paris, 1886,
Delahaye and Lecrosnier, 8o.
Heredity. L , h6r6ditd dans les maladies du syst&me nerveux. Dr. Dejdrine.
Pans, 1886, Asselin et Honzeau, 308 p., 5 pi., 8o.
Hereditary lunatics. Etude clinique sur les alien& hdrdditaires. Dr. Taty,
Paris, 1885, Bailli&re et ills, 114 p., 8o.
Headache. Dr. F. Le Gros Clark. St. Thomas’s Hosp. Rep., 1886, n. s., xiv.,
16-20.
Head-injuries, mental disturbances after. Geistesetorungen nach kepfver-
letzungen. Dr. Guder. Jena, 1886, Rev., lrrenfreund Heilbronn, 1886,
xxviii., 34-45.
Heat. Disturbances of the regulation of animal heat in the insane. Ueber
Stoning der Wiirmeregulirung bei Geisteskranken. Dr. Gmelin. Stutt¬
gart, 1885, Schweizerbart, 12 p., 8o.
Historical. La possession de Jeanne Fery, religieuse professee du couvent des
Sceur8 Noires de la ville de Mons (1584). (First published Paris, 1586.)
Paris, 1886, Delahaye and Lecrosnier, 114 p., 8 o.
■■ Care of the insane in the Middle Ages iD Germany. Ueberblickeueber
die Geschichte der deutschen Irrenpflege im Mittelalter. Dr. Kirchoff.
Allg. Ztschr. f. Psychiat.. Berlin, 1886, xliii., 61-103.
Hypochondriasis and imaginary diseases. Hypochondria und eingebildete
krankheiten. Dr. Weber. Berlin, 1886, Steinitz, 8o., im., 60.
Hypochondriacal Delirium in certain kinds of insanity. Du ddlire hypochon-
Digitized by L^ooQle
6 Index Medieo-Psychologicus.
driaque dans certaines formes d’ali&iation mentale. Dr. Vertault. Par.,
1886, Ollier-Henry, 80 .
Hypochondriacal Insanity. Ueber hypochondrische Verrucktheit. Dr. W.
Taube. Dorpat, 1886, H. Laakman, 74 p., 8 o.
Hypnotism, suggestion in the hypnotic sleep. Dr. SeppillL I fenomeni di
suggestione nel sonno ipnotico e nella veglia, Riv. Sper. di freniat.,
ReggioEmilia, 1885, xi. f 325-350.
-study of. Studio sull’ ipnotismo. Dr. Lombroso. Arch, di Psichiat.,
Torino 1886, vii., 257-281, 5 pi. (fac-simile handwritings).
-telepathic, and its relations to other forms of hypnotic suggestion-
Dr. Myers. Proc. Soc. Psych. Research, London, 1886-7, iv., 127 - 188 .
■ and suggestion, contribution to the study of. Contribution a l’etude
de l’hypnotisme et de la suggestion. Dr. Authenac. Gaz. d. Hopitaux,
Paris, 1886, lix., 976.
-De Phypnotisme, historique, modes de production, symptdmes, medicine
legale. Drs. Pitres et R. Gaube. Rev. de Sciences Med., Paris, 1886,
xxvii, 325-348.
-Contribution k l’fetude de 1’hypnotisms. Dr. Dufour. Ann. M 6 d
Psych., Paris, 1886,7 s., iv., 238-254.
-De PHypnotisme. Dr. Jendrassik. Archiv. de Neurologie, Paris,
1886, xii., 43-53.
-and its relations to the civil and penal code. II grand ipnotismo e la
suggestione ipnotica nei rapporti col diritto penale e civile. Dr. Campili*
Roma, 1886, Frat. Bocca, 177 p., 8 o.
-and Insanity. Hypnotisme et Folie. Dr. P. Gamier. France Med.»
Paris, 1886, i., 554-568.
-Dr. Jendrassik. Archiv. de Neurologie, Paris, 1886, xi., 362-380.
Hypnotic suggestion, treatment of mental diseases by. Traitement des
maladies mentales par la suggestion hypnotique. (Discussion.) Ann.
Med. Psych., Paris, 1886, 7 s., iv., 93; 238.
-on the treatment of mental disease by. Du traitement des maladies
mentales par la suggestion hypnotique. Dr. Voisin. Ann. Med.
Psycholog., Paris, 1886, 7 s., iii., 452-466; also Encfcphale, Paris, 1886,
vi., 377.
Hysteria, a few notes on. Dr. Oliver. Brain, 1886-7, ix., 218-223.
-Hysterical women. Dr. Legrand du Saulle. Med.-Leg. Joum., New
York, 1886-7, iv., 118-124.
-in men. Hysterie chez lTiomme. Prof. Charcot. Semaine Med.,
Paris, 1886, vi., 125.
-La grande hysterie chez lTiomme. Dr. Berjon.
■ ■ — Ph 6 nom 6 nes d’inhibition et de dynamogdnie, changements de la per-
sonnalit^, action des medicaments a distance. D’aprfcs les travaux de
MM. Bourru et Burot. Par., 1886, J.-B. Bailliere et nls, 80 p., 10 pi., 8 o.,
fr. 3.
-in the male. (Translation from Progres M 6 d.) Prof. Charcot. Med.
Press and Circ., 1885, n. s., xl., 549, 567; 1886, xli., 4, 23.
-Remarques sur Phystferie de Phomme. Bull. Soc. Med. d. Hdp. de
Paris, 1886, 3 s„ ii., 386-388. Dr. Debove.
--in a male. Dr. Pinero. Alienist and Neurol., St. Louis, 1886, vii.,
362-375.
■ . in man. De Physt5rie chez Phomme, difficult^ dans certains cas du
diagnostic entre cette affection et la phthisie pulmonaire an d 6 but. Dr.
Quinqueton. Paris, 1886,54 p., 4o.
- in the male. Zur kentniss von der Hysterie beim Manne. Dr. S.
Rosenberg. Berlin Klin. Wchnschr., 1886, xxiii., 670.
in children. Zur Lebre von der Hysterie der Kinder. Dr. Luczek.
Berlin Klin. Wchnschr., 1886, xxiii., 511, 534.
Digitized by L^ooQLe
THE
MEDICO-PSYCHOLOGICAL ASSOCIATION.
THE COUNCIL, 1887-88.
president.— F. NEEDHAM, M.D.
PRESIDENT-ELECT.— T. S. CLOUSTON, M.D., F.R.C.P.
TREASURER.— JOHN H. PAUL, M.D.
EDITORS OP JOURNAL
D. HACK TUKE.M.D.
GEO. H. SAVAGE, M.D.
AUDITORS
J. T. HINGSTON, M.R.C.S.
D. YELLOWLEES, M.D.
HON. SECRETARY POR IRELAND.— E. M. COURTENAY. M.B.
HON. SECRETARY POR 8COTLAND.— A. R. URQUHART, M.D.
GENERAL SECRETARY.— HY. RAYNER, M.D.
J. A. CAMPBELL, M.D.
J. M. LINDSAY, M.D.
CONOLLY NORMAN, F.R.C.S.I.
J. G. McDOWALL, M.B.
H. T. PRINGLE. M.D.
G. E. SHUTTLEWORTH, M.D.
H. SUTHERLAND. M.D.
FLETCHER BEACH, M.D.
F. H. CRADDOCK, M.D.
HAYES NEWINGTON, M.R.C.P.
F. SCHOFIELD, M.D.
8. W. D. WILLIAMS, M.D.
PARLIAMENTARY COMMITTEE.
Dr. LUSH. Dr. NEEDHAM.
Dr. BLANDFORD. Dr. RINGROSE ATKINS.
Mb. G. W. MOULD. Dr. PAUL.
Dr. H. HAYES NEWINGTON. Dr. STOCKER.
Dr. WILLIAM WOOD. Mr. H. R. LEY.
Dr. SAVAGE. Dr. HACK TUKE.
Dr. CLOUSTON. Dr. T. W. McDOWALL.
Pensions Committee— Dr. Murray Lindsay and Dr. 8. W. D. Williams.
With power to add to their number.
Members of the Association .
Adam, James. M.D. St. And., Private Asylum, West Mailing, Kent.
Adams, Josiah 0., M.D. Durh., F.R.C.S.Eng., Brooke Hoose, Upper Clapton,
London.
Adams, Richard, L.R.C.P. Edin.. M.R.C.S. Eng., Medical Superintendent, County
Asylum, Bodmin, Cornwall.
Agar, 8. H., L.K.Q.C.P., Hurst House, Henley-in-Arden.
Agar, S. Hollingsworth, jun., B.A. Cantab., M.R.C.S., Hurst 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.
Amsden, G., M.B., Medical Supt., County Asylum, Brentwood, Essex.
ApHn, A., M.R.C.S.E. and L.R.C.P. Loud., Med. Supt. Co. Asylum, Sneaton,
Nottingham.
Digitized by L^ooQLe
ii.
Members of the Association .
Argo, G. C., M.B., Assist. Med. Officer, County Asylum, Sedgefield, Ferry Hill,
Durham.
Ashe, Isaac, A.B., M.D., Medical Superintendent, Central Criminal Asylum,
Dundrum, Ireland.
Atkins, Ringrose, M.A., M.D. Queen’s Univ. Ire., Med. Superintendent, District
Lunatic Asylum, Waterford.
Atkinson, R. y B.A. Cantab., F.R.C.S., Sen. Assist. Med. Officer, Powick, near
Worcester.
Baillarger, M., M.D., Member of the Academy of Medicine, formerly Visiting Phy¬
sician to the Salp£tri£re; 7, Rue de rUniversit4, Paris. {Hon* Mem.)
Baker, Beaj. Russell, M.R.C.S. Eng., L.S.A., Assist. Med. Off., Prestwich Asylum
Manchester.
Baker, H. Morton, M.B. Edin., Assistant MedSoal Officer, Leicester Borough
Asylum, Leicester.
Baker, Robert, M.D. Edin., Med. Supt., The Retreat, York.
Ball, Professor, Paris, Professor of Mental Diseases to the Faculty of Medicine,
179, Boulevard St. Germain, Paris. (Hon. Member.)
Banks, J. T., A.B., M.D. Trin. Coll. Dub. F.K. and Q.C.P. Ireland, Visiting
Physician, Richmond District Asylum, 45, Merrion Square East, Dublin.
Banks, William, M.B. Lond., 3, Dunstanville Vilias, Falmouth.
Barnes, J. F., Northumberland Hoose, Finsbury Park, N.
Barton, Jas. Edwd., L.E C.P. Edin., L.M., M.R.C.S., Medical Superintendent
Surrey County Lunatic Asylum, Brookwood, Woking.
Bayley, J., M.R.C.S., Med. Supt., Lunatic Hospital, Northampton.
Beach, Fletcher, M.B., M.R.C.P. Lond., Medical Superintendent, Darenth Asylum,
Dartford.
Benedikt, Prof. M., Franciskanes Platz 5, Vienna. (Hon. Menib.)
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., Medical Superintendent, The
Priory, Roehampton.
Blair, Robert, M.D., Ass. Med. Off. Woodilee Asylum, Lenzie, near Glasgow.
Blanchard, E. S., M.D., Medical Superintendent, Hospital for Insane, Charlotte
Town. Prince Edward’s Island.
Blanche, M. le Docteur. 15, Rue dee Fontis, Auteuil, Paris. (Hon. Member.)
Bland, W. C., M.R.C.S., Med. Supt., Borough Asylum, Portsmouth.
Blandford, George Fielding, M.D., Oxon., F.R.C.P. Lond., 71, Grosvenor Street, W.
(President, 1877.)
Bower, David, M.B. Aberd., Springfield House, Bedford.
Bowes, John Ireland, M.R.C.S. Eng., L.S.A., Medical Superintendent, County
Asylum, Devizes, Wilts.
Boys, A. H., L.R.C.P. Edin., Lodway Villa, Pill, Bristol.
Bramwell, Byron, M.D., F.R.C.P. Ea., 23, Drumsheugh Gardens, Edinburgh.
Brayn, R., L.R.C.P. Lond., Invalid Convict Prison, Knapp Hill, Woking.
Brodie, David, M.D. St. And., L.R.C.S. Edin., Beverley House, St.Thomas'Hill,
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, Summer-
land House, Montague Road, Richmond, Surrey.
Browne, Sir 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. Menib.)
Brushfield, Dr., Budleigh Salterton, Devon.
Bryant, S. W., M.B. Ed., Assist. Med. Officer, Colney Hatch, Middlesex.
Bucknill. John Charles, M.D. Lond.,F.R.C.P. Lond., F.R.S., J.P., late Lord Chan¬
cellor’s Visitor; The Albany, Piccadilly, W. (Editor of Journal , 1862-62.)
(President, I860.)
Burman, Wilkie, J., M.D. Edin., Ramsbury, Hungerford, Berks.
Burrows, Sir George, Bart.. 18, Cavendish Square. London, W. (Hon. Member.)
Butler. J. &.. M.D., late Medical Superintendent oi the Hartford Retreat, Hart¬
ford, Connecticut, U.S. (Hon. Member.)
Byas, Edward, M.R.C.S. Eng., 26, Belsize Park, Hampstead, N.W.
Digitized by t^ooQle
Members of the Association. iii.
Cadell, Francis, M.D. Edin., 5, Castle Terrace, Edinburgh.
Cameron. R. W. D., M.D., Midlothian and Peebles District Asylum.
Campbell, Colin M., M.B., C.M., Medical Snpt., Perth District Asylum, Murthly,
Campbell, John A., M.D. Glas., Medical Superintendent, Cumberland and West-
m or land Asylum, Garlands, Carlisle.
Campbell, P. E., M.B., C.M., Senior Assist. Medical Officer, District Asylum.
Caterham. *
Calmeil, 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, and Bute Asylum,
Lochgilphead.
Case, H., M.R.C.S.. Med. Supt., Leavesden, Herts.
Cassidy, D. M., M.D., C.M.McGill Coll., Montreal, D.Sc. (Pub. Health), Ediu.,
# F.R.C-S.Edin., Med. Superintendent, County Asylum, Lancaster.
Chapin, John B., M.D., Pennsylvania Hospital for the Insane, Philadelphia, U.S.A.
{Hon* Member.)
Chapman, Thomas Algernon, M.D. Glas., M.R.C.S. Edin., Hereford Co. and City
Asylum, Hereford.
Charcot, J. M., M.D., Physician to SalpAtribre, 17, Quai Malaquais, Paris. (Hon.
Memb.)
Christie, Thomas B., M.D. St. And., P.R.S.E., F.R.C.P. Lond., P.R.C.P. Edin.,
Medical Superintendent, Royal India Lnnatio Asylum, Ealing, W. (i/on.
General Secretary , 1872.)
Christie, J. W. Stirling, M.D., Med. Supt., County Asylum, Stafford.
Clapham, Wm. Crocbley S., M.D., M.R.C.P,, The Grange, Rotherham.
Clapton, Edward, M.D. Lond., F.R.C.P. Lond., Physician, St. Thomas’s Hospital,
Visitor of Lunatics for Surrey; 10a, St. Thomas Street, Borough.
Clark, Archibald C., M.D. Edin., Medical Superintendent, Glasgow District
Asylum, Both well.
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.R.C.P. Edin., F.R.S.E., Physician Superintendent,
Royal Asylum, Morningside, Edinburgh. (Editor of Journal, 1873-1861 .)
Cobbold, C. S. W., M.D., Med. Supt., Earlswood Asylum, Redhill, Surrey.
Collins, G. Fletchei^ M.R.C.S.E., &c., County Asylum, Knowle, Fare ham, Hants.
Compton. T. J., M.B., C.M. Aberd., Heigham Hall, Norwich.
Cooke/ Edwd. Marriott, M.B., M.R.C.S. Fug., Med. Supt., County Asylum,
Worcester.
Cope, George P., L.R.Q.C.P.I., Richmond District Asylum, Ireland.
Courtenay, E. Mazifere, 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.
Crallan, G. E. J., County Asylum, Fulbourn, near Cambridge.
Curwen, J., M.D., Warren, Pennsylvania State Hospital for the Insane, U.S.A.
(Hon. Member.)
Dalzell, W. R., M.B. Ed., Ass. Med. Off., Colney Hatch, Middlesex.
Daniel, W. C., M.D. Heidelb., M.R.C.S. Engl., Epsom, Surrey.
Davidson, John H., M.D. Edinburgh, Medical Superintendent, County Asylum,
Chester.
Davies, Francis P., M.B. Edin., M.R.C.S. Eng., Kent County Asylum, Bann¬
ing Heath, near Maidstone.
Deas, Peter Maury, M.B. and M.S. Lond., Medical Superintendent, Wonford
House, Exeter.
Delany, Barry, M.D. Queen’s Univ., Ire., Med. Supt., District Asylum, Kilkenny.
Delasiauve, M., M.D., Member of the Academy of Medicine, Physician to the
Bicbtre, Paris, 35, Ruedes Mathurins-Saint-Jacques, Paris. (Hon. Memb.)
Denholm, James, M.D., Duns, Berwickshire.
Denne, T. Vincent de, M.R.C.S. Eng., Colman Hill House, Halesowen, Worcester¬
shire.
Dlspine, Prosper, M.D., Rue du Loizir, Marseilles. (Honorary Member.)
Dic*6on,F. K., F.R.C.P. Edin., Wye House Lunatic Asylum, Buxton, Derbyshire.
Dodds, Wm. J., M.D., D.Sc. Edin., Royal Asylum, Montrose.
Digitized by L^ooQle
IV.
Members of the Association ,
Donaldson, R. L., M.B., District Asylum, Monaghan.
Down, J. Langdon Haydon, M.D. Lond., F.R.C.P. Lond., late Resident Physiciau,
Earlswood Asylum; 81, Harley St., Cavendish Sq., W., and Normansfield,
Hampton Wick.
Drapes, Thomas, M.B., Med. Supt., District Asylum, Enniscarthy, Ireland.
Duncan, James Foulis, M.D. Trin. Coll., Dub., F.K. and Q.C.P. Ireland, Visiting
Physician, Farnham House, Finglas; 8, Upper Merrion Street, Dublin.
(President, 1875.)
Dunlop, James, M.B., C.M., 423, St. Vincent Street, Glasgow.
Dwyer, J., L.R.C.P.I., Med. Supt., District Asylum, Cork, Ireland.
Eager, Reginald, M.D. Lond., M.R.C.S. En£., Northwoods, near Bristol.
Eager, Wilson, LR.C.P. Lond., M.R.C.S. Eng., Med. Superintendent, County
Asylum, Melton, Suffolk.
Earle, Pliny, M.D., Med. Superintendent, Northampton Hospital for the Insane,
Mass., U.S. (Honorary Member.)
East, Edward. M.R.C.S. and L.S.A., Upper Berkeley Street. W.
Eastwood, J. William, M.D. Edin., M.R.C.P. Lond., Dinsdale Park, Darlington.
Eoheverria, M. G., M.D., Havanna. [Honorary Member.)
Elliot, G. Stanley, M.R.C.P. Ed., L.R.C.S. Ed., Medical Superintendent, Cater-
ham, Surrey.
Eustace, J., M.D. Trin. Coll., Dub., L.R.C.S,I.; Highfield, Drumoondra, Dublin.
Ewart, D. C. Theodore, M.B. Aberd., C.M., Leavesden Asylum, near Watford,
Herts.
Falret, Jules, M.D., 114, Rue du Bac, Paris. (Honorary Member.)
Finch, W. Corbin, M.R.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, L.K. and Q.C.P.I., Med. Supt., District Asylum,
Mullingar.
Fletcher, Robert Vicars, Esq., F.R.C.S.I., L.R.Q.C.P.I. and L.R.C.P. Ed., Medical
Superintendent, District Asylum, Ballinasloe, Ireland.
Forrest, J. G. Stracey, L.R.C.P.Lond., M.R.C.S.Eng., Senior Assistant Medical
Officer, Camberwell House, Camberwell.
Foville, Achille, M.D., 177, Boulevard St. Germain, Paris, Franoe. (Honorary
Member.)
Fox, Edwin Churchill Pigott, M.B. and M.C. Edin.
Fox, Charles H., M.D. St. And., M.R.C.S. Eng., Brislington House, Bristol.
Fox, Bonville Bradley, M.A. Oxon., M.D., M.R.C.S., Brislington House, Bristol.
Francis, Lloyd, M.A., M.D. Oxen, St. Andrew’s Hospital, Northampton.
Fraser, Donald, M.D., 44, High Street, Paisley.
Fraser.John., M.B., C.M.., Deputy Commissioner in Lunacy, Merchiston Avenue,
Edinburgh.
Fraser, Thomas, M.A., M.B., Crichton Royal Institution, Dumfries.
Gairdner, W.T., M.D. Edin., Professor of Practice of Physic, 225, St. Vincent St.,
Glasgow. (President, 1882.)
Gamer, W. H., Esq., F.R.C.S.I., A.B.T.C.D., Medical Superintendent, Clonmel
District Asylum.
Gasquet, J. R., M'.B. Lond., St. George’s Retreat, Burgess Hill, and 127, Eastern
Road, Brighton.
Gayton, F. C., M.D., Brookwood, Surrey.
Gelston, R. P., L.K. and Q.C.P.I., L.R.C.S.I., Medical Supt., District Asylum,
Ennis.
Gill, Stanley A., M.R.C.P. Lond., M.R. C.S. Eng., Med. Superint., Royal Lunatic
Asylum, Liverpool.
Glendinning, James, M.D. Glas., L.R.C.S. Edin., L.M., Med. Supt,, Joint Counties
Asylum, Abergavenny.
Godding, Dr., Medical Superintendent Government Hospital for Insane, Wash¬
ington, U.S. (Honorary Member.)
Gordon, W. S., M.B., Med. Supt., District Lunatic Asylum, Armagh.
Granville, J. M., M.D., Harewood Place, Hanover Square, London.
Greene, Richard, L.R.C.P. Edin., Med. Superint., Berry Wood, near North¬
ampton.
Greenlees, T. Duncan, M.D., City of London Lunatio Asylum, Stone, near Dart-
ford.
Digitized by L^ooQle
Members of the Association ,
v,
Grierson, S., M.R.C.S., Border Counties Asylum, Melrose, N.B«
Grubb, J. Strongman, L.R.C.P. Ed., Silsoe Villa, Uxbridge Road, Ealing, W.
Gwvnn, 8. J., M.D., St. Mary’s House, Whitechurch, Salop.
Hall, Ben., M.B.Loud., Assist. Med. Officer, Tue Brook Asylum, Liverpool.
Hall, Edward Thomas, M.R.C.S. Eng., Blacklands House Asylum, Chelsea.
Harbinson, Alexander, M.D. Irel., Al.R.C.S. Eng., Assist. Med. Officer, County
Asylum ? Lancaster.
Harding, William, M.B., C.M. Ed., Assist. Med. Officer, County Asylum, Lancaster.
Harmer, Wm. Milsted, F.R.C.P. Ed., Physician Sapt., Nortn Grove House
Asylum, Hawkhurst, Kent.
Harrison, R. Charlton, 15, Sandringham Gardens, Ealing W.
Harvey, Crosbie Bagnall, L.A.H., Asst. Med. Officer, District Asylum, Clonmel.
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 Physio, 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.
Henley, E. W., L.R.C.P., County Asylum, Gloucester.
Hetherington, Charles, M.B., Med. Supt., District Asylum, Derry, Ireland.
Hewson, R. W., L.R.C.P. Ed., Med. Supt., Coton Hill, Stafford.
Hicks, Henry, M.D., Hendon Grove House, Hendon.
Higgins, Wm. H., M.B., C.M., Med. Supt., County Asylum, Leicester.
Hill, Dr. H. Gardiner, Assist. Med. Officer, Cane Hill Asylum, Parley, Surrey.
Hills, William Charles, M.D. Aber., M.R.C.S. Eng., Thorpe, St. Andrew, near
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, York.
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. (President,
1856.)
Howden, James C., M.D. Edin., Medical Superintendent, Montrose Royal Lunatic
Asylum, Sunnyside, Montrose.
Hughes, C. H., M.D., St. Louis, Missouri, United States. ( Hon . Memb.)
Humphry, John, M.R.C.S. Eng., Medical Superintendent, County Asylum,
Aylesbury, Bucks.
Hutson, E., M.D. Ed., Medical Superintendent, Lunatic Asylum, Barbadoes.
Hyslop, James, M.D., Pietermaritzburg Asylum, Natal, S. Africa.
Hes, Daniel, M.R.C.S. Eng., Resident Medical Officer, Fairford House Retreat,
Gloucestershire.
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. Officer, 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.R.C.S Eng., Cranbourne Hall, Grouville, Jersey.
Jamieson, Robert, M.D. Edin., L.R.C.S. Edin., Medical Superintendent, Royal
Asylum, Aberdeen.
Jepson,Octaviu8, M.D. St. And., M.R.C.S. Eng., Conservative Club, London, S.W.
Jeram, J. W., L.R.C P., Hambledon, Cosham, Hants.
Johnston, D. G., M.B., C.M. Glas., Med. Supt., Moorcrofb House, Hillingdon,
Middlesex.
Johnston, J. A., L.R.C.S.I., Assist. Med. Officer, District Asylum, Monaghan,
Ireland.
Johnstone, J. Carlyle, M.D., C.M., Medical Superintendent, Roxburgh, Ac., Dis¬
trict Asylum, Melrose.
Jones, Evan, M.R.C.S. Eng., Ty-mawr, Aberdare, Glamorganshire.
Jones, D. Johnson, M.D. Edin., Senior Assistant Medical Officer, Kent County
Asylum.
Digitized by L^ooQle
vi. Members of the Association .
Jones. B., M.D Lond. f B.S., F.R.C.S., Colnej Hatch Lunatic Asylum.
Kay.W alter S.. M.B., Assistant Medical Officer, Booth Yorkshire Asylom, Wadsley,
near Sheffield.
Eeay, John, M.B., Med. Supt., Mavisbank, Polton, Midlothian.
Keegan, J. T., Indianopolis, Ind., U.S.A.
Koch. Vincent, M.B.C.M., Borough Asylum, Cottingham. near Hull.
Kornfeld, 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 “ Zeitschrift fur Psychia¬
tric.” ( Honorary Member.)
Lawrence, A., M.D., County Asylum, Chester.
Layton, Henry A., L.R.C.P. Edin., Cornwall County Asylum, Bodmin.
Leeper,Wm. Waugh, M.D. Ed., L.R.C.S.P., Loughgau, Co. Armagh, Visiting
Physician to the Retreat Asylum, Armagh.
Legge, R. J., M.D., Assist. Med. Offi< er, County Asylum, Derby.
Leidesdorf, M., M.D., Universitat, Vienna. ( Honorary Member.)
Lennox, David, M.D., Dundee.
Lentz, Dr., Asile d’Ali6n£s, Tourrai, Belgique. {Hon. Memb.)
Lewis, Henry. M.D. Brass., 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., Med. Supt.. W*st R'ding Asylum, Wakefield.
Ley, H. Booke, M.R.C.S. Eng., Medical Superintendent, County Asylum,
Prestwich, near Manchester.
Lindsay, James Murray, M.D. St. And., F.R.C.S. and F.R.C.P. Edin., Med. Supt.,
County Asylum, Mickleover, Derby.
Lisle, S. Ernest de, L.K.Q.C.P., Three Counties Asylums, Stotfold, Baldock.
Lovett, Henry A., M.R.C.S., Pins Newydd, Swansea, Tasmania.
Lush, John Alfrtd, F.R.C.P. Lond., M.D. St. And., 13, Redcliffe Square, 8.W.
(PBE8IDENT, 1879.)
Lush, Wm. John Henry, F R.C.P. Edin., L.M., M.R.C.S. Eng., F.L.S., Fyfield
House, Andover, Hants.
Lyle, Thos., M.D. Glas., Rubery Hill Asylum, near Bromsgrove, Worcestershire.
MacBryan, Henry C., County Asylum, Hanwell^ W.
Macdonald, P. W., M.B., C.M., Assist. Med. Officer, Dorset County Asylum, near
Dorchester.
Macfarlane, W. H., Hew Norfolk Asylum, Tasmania.
Mackew, S., M.B Edin., Hertford British Hospital, Rue de Villiers, LevaUois-
Perret, Seine.
Mackenzie, J. Cumming, M.B.,C.M., County Asylum, Morpeth.
Mackintosh, Donald. M.D. Durham and Glas., L.F.P.S. Glas., 10, Lancaster
Road, Belsize Park, N.W.
Maclaren, James, L.R.C.S.E., Stirling District Asylum, Larbert, N.B.
MacLean, Allan, L.R.C.S. Ed., Harpenden Hall, Herts.
Macleod, M.D., M.B., Med. Superintendent, East Riding Asylum, Beverley, Yorks.
Macphail, Dr. S. Rutherford, Assist. Med. Superintendent, Garlands, Carlisle.
Madden-Medlicott, Charles W. C., M.D. Edin., L.M. Edin., Ivy Dene, Tedding-
ton Park Road. Teddington.
Major, Herbert, M.D., 144, Manningham Lane, Bradford, Yorks, etd Wakefield.
Manley, John, M.D. Edin., M.R.C.S. Eng., Denton House, Victoria Road, South-
sea, 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., formerly Medical Superintendent,
Royal Lunatic Hospital, Cheadle ; 9, Hanover Square, London, W. {Editor
of Journal, 1862-78.) (President, 1871.)
Maye, John, M.IUC.S. and L.S.A., Ass. Med. Off., Burntwood Asylum, Lichfield.
McCreery, James Vernon, L.R.C.S.I., Medical Superintendent, New Lunatio
Asylum, Melbourne, Australia.
McDonnell, Robert, M.D., T.C.D., F.RC.S.I,, M.R.I.A., Merrion Square, Dublin.
Digitized by L^ooQle
Members of the Association . yii.
McDowall. T. W., M.D. Edin., L.R.C.8.E., Medical Superintendent, Northumber¬
land County Asylum, Morpeth.
McDowall, John Greig, M.B. Edin., Assist. Med. Officer, South Yorkshire Asylum,
Waasley, Sheffield.
McNaught&n, John, M.D., Med. Supt.. Criminal Lunatic Asylum, Perth.
McPherson, John, M.B., Assistant Physician, Royal Edinburgh Asylum, Morn-
ingside.
Melville, H. B., M.B., C.M., Crichton Royal Institution, Dumfries.
Merson, John. M.D. Aberd., Medical Superintendent, Borough Asylum, Hull.
Merrick, A. 8., M.D. Qu. Uni. Irel., L.R.C.S. Edin., Medical Superintendent,
District Asylum, Belfast, Ireland.
Meyer, Ludwig, M.D. University of Gottingen. {Honorary Member.)
Mickle, Wm Julius, M.D., M.K.C.P., Med. Superintendent, Grove Hall Asylum,
Bow, London.
Micklev, George, M.A., M.B. Cantab., Medical Superintendent, St. Luke’s
Hospital, Old Street, London, E.C.
Miersgjewski, Prof. J., Medico-Chirurgical Academy, St. Petersburg. (Hon.
Miles, Geo. E., M.R.C.S., Res. Med. Officer, Northumberland House, Finsbury
Park, N.
Millar, John, Esq., L.R.C.P. Edin., L.R.C.S. Edin., Bethnal House, Cambridge
Heath, London, E.
Miller, Alfred. M.B. and B.C.L. Dub., Sen. Asst. Med. Officer, Hatton Asylum,
Warwick.
Mitchell, Sir Arthur, M.D. Aberd., LL.D., K.C.B., Commissioner in Lunaoy for
Scotland; 84, Drummond Place, Edinburgh. (Honorary Member.)
Mitchell, R. B., M.D., Assist. Med. Officer, Royal Asylum, Morningside, Edin-
burgh.
Mitchell, S., M.D. Edin., Medical Superintendent, South Yorkshire Asylum,
Wadsley, near Sheffield.
Moloney, J. C., L.K.Q.C.P., Med. Supt., Patrick Hospital, Dublin.
Moody. James M., b\ .R.C.S. Eng., L.R.C.P. and L.M. Edin., Med. Supt., County
Asylum, Cane Hill, 8urrey.
Moore, E. E., M.B., Dub., Assist. Med. Officer, District Lunatic Asylum, Down¬
patrick, Ireland.
Moore, W. D., M.D., Assist. Med. Officer, Wilts County Asylum, Devizes.
Monro, Henry, M.D. Oxon, F.R.C.P. Lond., late Visiting Physician, St. Luke’s
Hospital; 14, Upper Wimpole Street, London, W. (President, 1864.)
Morel, M. Jules, M .D., Hospice Gui»»lain, Ghent. {Corresponding Member.)
Mortimer, J. D., Assist. Med. Off., Milton Asylum, Portsmouth.
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-
versitftt, Vienna. (Honorary Member.)
Murray. Henry G., L.K.Q.C.P. Irel., L.M., L.B.C.S.I., Assist. Med. Off., Prest-
wich Asylum. Manchester.
Myddelton-Gavey, E. H., M.R.C.S. and L.S.A., 64, St. Stephen’s Street, Ipswich.
Myles, W. Luchery. L F.P.S., Sen. Asst. Med. Officer Richmond Asylum, Dublin.
Needham, Frederick, M.D. St. And., M.R.C.P.Edin., M.R.C.S.Eng., late Medical
Superintendent, Hospital for the Insane, Bootham, York j Barn wood House,
Gloucester. (President Elect.)
Neil, James, M.D., Asst. Med. Officer. Warneford Asylum, Oxford.
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.
Newtb, A, H., M.D., Haywards Heath, Sussex.
Nichols, C. H., M.D., Bloomingdale Asylum, New York. {Honorary Member).
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. Med. Supt., State Asylum, Broadmoor, Wokingham, Berks.
Digitized by t^ooQle
Vlll.
Members of the Association .
Nielsen, Fred Wm., M.A. Cantab., M.R.C.S., &c., County Asylum, Sedgfield, Ferry
Hill, Durham.
Niven, William, M.D. St. And., Medical Staff H.M. Indian Army, late Superinten¬
dent of the Government Lunatic Asylum, Bombay, St. Margaret’s, South
Norwood Hill, S.B.
North, S. W., Esq., M.B.C.S. E., F.G.S., 84, Micklegate, York, Visiting Medical
Officer, The Retreat, York.
Norman, Conolly, F.R.C.S.I., Med. Supt., Richmond District Asylum, Dublin,
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.)
Oakshott, J. A., M.D., Assist. Med. Offioer, District Asylum, Cork.
O’Meara, T. P., M.B., Med. Supt., District Asylum, Carlow, Ireland.
O’Neil, E. D., L.K.Q.C.P., Med. Supt., District Asylum, Castlebar.
Orange, William, M.D. Heidelberg, F.R.C.P. Lond., C.B., 36, Lansdowne Place,
Brighton. (President, 1883.)
O’Shauffhnessy, Th>mas H., M.D., Ballinailoe District Asylum, Ireland.
Owen, R. F„ Tue Brook Villa, Liverpool.
Palmer, Edward, M.D. St. And., M.R.C.P. Lond., M.R.C.S., Medical Superin¬
tendent, County Asylum, Lincoln.
Parant, M. Victor, M.D., Toulouse. {Corresponding Member.)
Pater, W. Thompson, M.R.C.S. Eng., L.S.A., Medical Superintendent, County
Lunatic Asylum, Stafford.
Patton, Alex., M.B., Resident Medical Superintendent, Farnham House, Finglas,
Co. Dublin.
Paul, John Hay ball, M.D. St. And., M.R.C.P. Lond., F.R.C.P. Edin.; Camber¬
well House, Camberwell. {Treasurer.)
Peeters, M., M.D., Gheel, Belgium. {Hon. Memb.)
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.
Philipps, Sutherland Rees, M.D., C.M. Qu. Univ., lrel., 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.
Pilkington, F. W., L.R.C.P. Lond., Ass. Med. Off., Littlemore, Oxford.
Pirn, F., Esq., M.R.C.S. Eng., L.K. and Q.C.P. Ireland, Med. Supt., Palmerston,
Chapeliaod, Co. Dublin, Ireland.
Pitman, Sir Henry A., M.D. Cantab., F.R.C.P. Lond., 28, Gordon Square, W.C.,
Registrar oi the Royal College of Physicians. {Honorary Member.)
Platt, Dr., 138, Abbey Road, Kilbura.
Plaxton, Joseph Win., M.R.C.S., L.S.A. Eng., Lunatic Asylum, Kingston, Jamaioa.
Powell. Evan, M.R.C.S. Eng., L.S.A., Medical Superiutendent, Borough Lunatio
Asylum, Nottingham.
Powell, John, L.R.C.P., Senr. Asst. Med. Off., Joint Counties Asylum, Carmarthen.
Pringle, H. T., M.D. Glasg., Medical Superintendent, County Asylum, Bridgend,
Glamorgan.
Rayner, Henry, M.D. Aberd., M.R.C.S. Eng., Medical Supt, County Asylum,
Hanwell, Middlesex. (President, 1884.) ( Honorary Gen. Secretary.)
Ram aer, Dr. J. N., Haarlem, Holland, Inspector of Asylums. {Hon. Member.)
Reid, William, M.D., Royal Asylum, Aberdeen.
Revington, Geo. M B., Asst. Med. Off*. Prestwich Asylum, Manchester.
Richardson, B. W., M.D. St. And., F.R.S., 25, Manchester Square, W. {Hvnorcury
Member.)
Robertson, Alexander, M.D. Edin., 16, Newton Terrace, 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, 1855-62.) {Editor of Journal, 1862-/0.) (President, 1867.) (Honor -
ary Member.)
Robertson, A. L. Fullarton, M.B., C.M.Ed., St Andrew's, Billing Road,
Northampton.
Digitized by L^ooQle
Members of the Association.
ix.
Robertson, G. M., M.B., C.M., The Palace, Falkland, Fife.
Rogers, Edward Coni ton, M.R.C.S. Eng., L.S.A., Co. Asylum, Fulbourn, 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. EJin, Medical Officer, District Asylum, Haddington.
Root*, William S., M.R.C.S., Canbury House, Kingston-on-Thames.
Rorie, James, M.D. Edin., LR.C.S. Edin., Medical Superintendent, Royal Asylum,
Dundee. (Late Honorary Secretary for Scotland.)
Roussel, M. Th6ophile, M.D., S6nateur, Paris. (Honorary Member.)
Rowe, E. L., L.R.C.P. Ed., Assist. Med. Officer, Gloucester County Asylum.
Rowland, E. D., M.D., C.M. EJin., the Public Lunatio Asylum, Berbice, British
Guiana.
Russell, A. P., M.B. Edin., The Lawn, Lincoln.
Russell, F. J. R., L.K.Q.C.P. Irel.. 48, Lupus Street, London, W.
Rutherford, R. Leonard, M.D., Medical Superintendent, City Asylum, Digby's,
near Exeter.
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 , 1876-86.)
Rutherford, W., M.D., Ballinasloe District Asylum, Ireland.
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, Clifton Street, Bond Street. (President, 1868.)
Savage. G. H., M.D. Lond., Resident Physician, Bethlem Royal Hospital, London.
(Editor of Journal.) (President, 1886.)
Schofield, Frank, M.D. St. And., M.R.C.S., Medical Supt., Camberwell House,
Camberwell.
Schiile, Heinrich, M.D- Illenau, Baden, Germany. (Hon Mem.)
Scott, J. Walter, M.R.C.S., <fcc., Assist. Med. Officer, County Asylum, Fareham,
Hants.
Secoombe, Geo., L.R.C.P.L., The Colonial Lunatio Asylum, Port of Spain, Trini¬
dad, West Indies.
Seed, Wm., M.B., C.M. Edin., Assistant Medical Officer, Whittingham, Lanca¬
shire.
Sells, H. T., care of Dr. Eager, 8uffolk County Asylum, Melton, Woodbridge.
Semal, hL, M.D., Mons, Belgium. (Hon. Memo.)
Seward, W. J., M.D., Med. Superintendent, Colney Hatch, Middlesex.
Shaw, Thomas C., M.D. Lond., F.R.C.P. Lond., Medical Superintendent, Middle¬
sex County Asylum, Banstead, Surrey.
Shaw, James, M.D., 63, Kensington, Liverpool.
Sheldon, T. S., M.B., Med. Supt., Cheshire County Asylum, Parkside, Macclesfield.
Sherrard, C. D., M.R.C.S., 17, The Avenue, Eastbourne.
Shuttleworth, G. E., M.D. Heidelberg, M.R.C.S. and L.S.A. EngL, B.A. Lond.,
Medical Superintendent, Royal Albert Asylum, Lancaster.
Sibbald, John, M.D. Edin., F.R.C.P. Ed., M.R.C.S. Eng., Commissioner in Lunacy
for Scotland, 3, St. Margaret’s Road, Edinburgh. (Editor of Journal,
1871-72.) (Honorary Member.)
Skae, C. H., M.D. St. And., Medical Superintendent, Ayrshire Distriot Asylum,
Ayrshire, Glengall, Ayr.
Smith, Patrick, M.A. Aberdeen, M.D., Sydney, New South Wales, Resident
Med. Officer, Woogaroo Lunatio Asylum, Brisbane, Queensland, Australia.
Smith, Robert, M.D. Aberd., L.R.C.S. Edin., Medical Superintendent, County
Asylum, Sedgefield, Durham.
Smith, R. Gillies, M.R.C.S., B.Sc. Lond., County Asylum, Sedgefield, Ferry Hill,
Durham.
Smith, R. Percy ? M.D., B.S., M.R.C.P., Bethlem Hospital, St. George’s Road, S.E.
Smith, W. Beattie, F.R.G.S. Ed., Yarra Bend Asylum, Melbourne, Australia.
Snell, Geo., M.R.C.S., Asst. Med. Off., Berbice, British Guiana.
Soutar, J. G., Barn wood House, Gloucester.
Spence, James B., M.D. Ire., Med. Snpt., Bumtwood Asylum, Liohfield.
Digitized by L^ooQle
X.
Members of the Association .
Spence, J. B., M.D., M.C.Q.U.I., Asylum for the Tnsane, Ceylon.
Spencer. .Robert, M.R.C.S. Eng., Med. Superintendent, Kent County Asylum,
Cnartham, near Canterbury.
Squire, R. H., B.A. Cantab., Assist. Medical Officer, Whittingbam, Lancashire.
Stewart, James, B.A. Queen’s Univ., M.R.C.P. Edin., L.R.C.S. Ireland, late
Assistant Medioal Officer, Kent County Asylum, Maidstone Dunmurry,
Sneyd Park, Clifton, Gloucestershire.
Stewart, Robert L., M.B., C.M., Assistant Medical Officer, County Asylum,
Glamorgan.
Stewart, Rotbsay C., M.R.C.S., Assist. Med. Officer. County Asylum, Leicester.
Stilwell. Henry, M.D. Edin., M.R.C.S. Eng., Moorcroft House, Hillingdon,
Middlesex.
Stocker, Alonso Henry, M.D. St. And., M.R.C.P. Lond., M.R.C.S. Eng., Medical
Superintendent, Peckbam 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.
Stephenson, R. B. Tydd, M.B., and C.M., District Asylum, Murthly, Perth.
Street, C. T., M.R.C.S., L.R.C.P., Assist. Med. Officer, Prestwioh Asylum, near
Manchester.
Suffern, A. C., M.D., Borough Asylum, Winson Green. Birmingham.
Sutherland, Henry, M.D. Oxon, M.R.C.P. London, 6, Richmond Terrace, Whitehall,
S.W.; Black 'ands House, Chelsea; 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.R.C.S., Medical Superintendent, Three Counties' Asylum,
Stotfold, Baldock, Herts.
Swanson, George J., M.D. Edin., Lawrence House, York,
Symes, G. D., M.R.C.S.. County Asylum, Rainhill, Lancashire.
Tamburini, A., M.D., Reggio-Emilia, Italy. (Hon. Memb.)
Tate, William Barney. M.D. Aberd., M.R.C.P. Lond., M.B.C.S. Eng., Medical
Superintendent of the Lunatic Hospital, The Coppice, Nottingham.
Terry, John, M.R.C.S. Eng., 35, Grosvenor, Bath.
Thomson, D. G., M.D., C.M., Med. Supt., County Asylum, Thorpe, Norfolk.
Thurnam. Francis Wyatt, M.B. Edin., C.M., 40, South Grove, Highgate, N.
Toller, Ebenezer, M.R.C.S. Eng., formerly Med. Supt. of St. Luke’s Hospital,
London, late Supt. of the Gloucester County Asylum, 10, Royal Crescent.
Holland Park, W.
Townsend, W. C., M.D., Visiting Physician, District Asylum. Cork.
Tuke, John Batty, M.D. Edin., 20, Charlotte Square, Edinburgh. (Honorary
Secretary for Scotland , 1869-72.)
Tuke, Daniel Hack, M.D. Heidel., F.R.C.P. Lond., M.R.C.S. Eng., formerly
Visiting Physician, The Retreat, York; Lyndon Lodge, Hanwell, W., and
63, Welbeck Street, W. (Editor of Journal.) (President, 1881.)
Tuke, Thomas Harrington, M.D. St. And., F.R.C.P. Lond. and Edin.,
M.R.C.S. Eng. ; 37, Albemarle Street, and The Manor House, Chiswick.
(General Secretary , 1862-72.) (President, 1873.)
Tuke, Chas. Moulsworth, M.R.C.S., The Manor House, Chiswick.
Tuke, T. Seymour, M.R.C.S., Manor House, Chiswick.
Turnbull, Adam Robert, M.B., C.M., Edin., Medical Superintendent, Fife and
Kinross District Asylum, Cupar.
Urquhart, Alexr. Reid, M.B., C.M., Physician Supt., James Murray’s Royal
Asylum. (Hon. Secretary for Scotland.)
Virchow, Prof. R., University, Berlin. (Hon. Memb.)
Voisin, A., M.D., 16, Rue S6guin, Paris. (Hon. Memb.)
Wade, Arthur Law, B.A., M.D. 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.R.C.P. Edin., Medical Superintendent, County
Asylum, Whittingham, Lancashire.
Walmslcy, F. H., M.D., Leavesden Asylum.
Walsh, D., M.B., C.M., Assistant Medical Officer, Kent County Asylum, Banning
Digitized by t^ooQle
XI.
Members of the Association .
Ward, Frederic H., M.R.C.S. Eng., L.S.A., Assistant Medical Officer, Oonnty
Asylum, Tooting, Surrey.
Ward, J. Bywater, B.A., M.D. Cantab., M.R.C.S. Eng., Medical Superintendent,
Wameford Asylum, Oxford.
Warwick, John, F.R.C.S. Eng., 26, Woburn Square, W.C.
Watson, William Kiddell, L.R.C.S. & P. Edin., Govan Parochial Asylum, Glasgow.
Weatherly, Lionel A., M.D., Bailbrook Bouse, Bath.
West, Geo. Francis, L.R.C.P. Edin., Assist. Med. Officer, District Asylum, Omagh,
Ireland.
Westphal, C. Professor, Kronprinzenufer, Berlin. (Honorary Member.)
Whitcombe, Edmund Banks, Esq., M.R.C.S., Med. Supt., Winson Green Asylum,
Birmingham.
White .Ernest, M.B. Loud., M.R.C.P., City of London Asylum, Stone, Dartford,
Kent.
Wickham, R. H. B., F.R.C.S. Edin., Medical Superintendent, Borough Lunatic
Asylum, Newcastle-on-Tyne.
Wiglesworth, J., M.D. Lond., Rainhill Asylum, Lancashire.
Wilks, Samuel, M.D. Lond., FJt.C.P. Lond., Physician to Guy's Hospital; 72,
Grosvenor Street, Grosvenor Square.
Wilkes, James, F.R.C.S. Eng., late Commissioner in Lunacy; 18, Queen’s
Gardens, Hyde Park. (Honorary Member.)
Will, Jno. Kennedy, M.B., C.M., Bethnal House, Cambridge Road, E.
Willett, Edmund Sparshall, M.D. St. And., M.R.C.P. Lond., M.R.C.S. Eng.,
Wyke House, Sion Hill, Isleworth, Middlesex; and 4, Suffolk Place, Pall Mall.
Williams, S. W. Duckworth, M.D. St. And., L.R.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.C.P., Irel.,
Commissi* ner in Lunacy. 19, Whitehall Place. (Bon. Memler).
Wilson, G. V., M.D., Assist. Med. Officer, District Asylum, Cork.
Wilson, Jno. H. Parker, 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.
Wood, William, M.D.St. And., F.R.C.P.Lond., F.R.C.S. Eng.. Visiting Physician,
St. Luke's Hospital, formerly Medical Officer, Bethlem Hospital; 99,
Harley Street, and The Priory, Roehampton. (President, 1866.)
Wood, Wm. E. R., M.A., M.B., F.R.C.S. Edin., Leighton House, Stanmore,
Sydney, New South Wales.
Wood, Thomas Outterson, M.D., F.R.C.P., F.R.C.S. Edin., M.R.C.S. Engl., 40,
Margaret Stieet, Cavendish Square, W.
Wood, B. T., Esq., M.P., Chairman of the North Riding Asylum, Conyngham
Hall, Knaresboro. (Honorary Member.)
Woods, Oscar T., B.A., M.B. Dub., Medical Superintendent, Asylum, Killarney.
Woods, J. F., M.R.C.S., Med. Supt., Hoxton House. N.
Workman, J., M.D., Toronto, Canada. (Honorary Member.)
Worthington, Thos. Blair, M.A., M.B., and M.C. Trin. Coll., Dublin, Med.
Supt., County Asylum, Knowle, Fareham, Hants.
Wright, Francis J., M.B. Aberd., M.R.C.S. Eng., Northumberland House, Stoke
Newington, N.
Wyatt, Sir William H., J.P.. Chairman of Committee, County Asylum, Colney
Hatch, 88, Regent's Park Road. (Honorary Member.)
Yellowlees, David, M.D. Edin., F.F.P.S. Glasg., Physician-Superintendent, Royal
Asylum, Gartnavel, Glasgow.
Young, W. M., M.D., Assist. Med. Officer, County Asylum, 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.
Ordinary Members.366
Honorary and Corresponding Members - - - 60
Total.416
Members are earnestly requested to send changes of address , ifc,, to Dr* Rayner, the
Honorary Secretary , County Asylum, Hanwell , Middlesex, and in duplicate
to the Printer of the Journal, H. W. Wolf , Lewes , Susses,
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X1L
List of those who have passed the Examination fob the
Cektificate of Efficiency in Psychological Medicine,
entitling them to append M.P.C. (Med. Psych. Cebtif.)
TO THEIB NAMES.
v *\
4 Blaok, Victor.
Cowper, John.
^ ^ Cram, John.
*■ x English, Edgar.
‘ Fraser, Thomas.
Howden, Robert.
Hyslop, Thomas B.
Maepherson, John.
Melville, Henry B.
'' Moore, Edward Erskine.
* Mortimer, John Desmond Ernest.
Nairn, Robert.
Neil, James.
Pearce, Walter.
Rigden, Alan.
Robertson, G. M.
Scott, J. Walter.
Steel, John.
Simpson, Samuel.
Slater, William Araison.
Smith, Percy.
Symes, G. D.
Thompson, George Matthew.
Wood, David James.
* To whom the Gaskell Prize (1887) was awarded.
S')
v
\
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V
THE JOURNAL OF MENTAL SCIENCE.
[Publishedby Authority of the Medico-Psychological Association]
No. 144. “VS!"’ JANUARY, 1888. Yol. XXXIII.
PART 1-ORIGINAL ARTICLES.
The Distribution of Lead in the Brains of two Lead Factory
Operatives dying suddenly . By A. Wynter Blyth,
M.R.C.S.
Five cases of fatal lead poisoning occurred between 1884-6
among the employes of a certain white lead factory in the
East of London. The cases presented the following common
characters. They were all adult women, aged from 18 to 33.
They had all worked at the factory for short periods from
three to twelve months. They all exhibited mild symptoms
of plumbism, such as a bine line round the gums and more
or less ill-defined indisposition; paralyses were absent.
They were all in their usual state of health within a few
days or hours preceding death. Death was unexpected—
mostly sudden. In four cases it was preceded by epileptic
fits and coma, but in the fifth case no convulsions were
noted, although they may have occurred during the night.
Lastly, in four cases, in which there was an autopsy, the
vital organs were reported healthy or nearly so.
In the fourth and fifth cases portions of the liver, kidney,
and brain * were submitted to me for analysis, and the
results obtained afford a clue to the action of lead upon the
nervous system.
Fourth Case. —I received in December, 1885,402 grms. of
liver; the whole of the right kidney, weighing 81 grms., and
.01 grms. of the brain tissue.
The liver was incinerated, the ash treated with dilute
nitric acid, filtered, the portion of the ash insoluble in acid
fused with sodic carbonate to convert any possible lead sul¬
phate, and the fusion was lixiviated with water, the insoluble
portion being treated as before with dilute nitric acid and
• By Dr. F. M. Corner, Medical Officer of Health for Poplar, nnder whose
observation the patients were, and who was kind enough to furnish me with
details of the symptoms of the patients so far as could be ascertained.
xxxm. 32
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484
The Distribution of Lead in the Bram , [Jan.,
filtered ; the two acid filtrates were then diluted and saturated
with hydric sulphide, the precipitate collected, converted into
lead sulphate, gently ignited and weighed. The amount
obtained was 24*256 mgrms. of lead sulphate.
The kidney, treated similarly, yielded 5*416 mgrms. lead
sulphate.
The 401 grms. of brain, which comprised the entire
cerebellum and a considerable portion of the cerebrum, was
dehydrated with alcohol, then divided up as finely as possible
and exhausted with successive quantities of boiling alcohol,
then with ether, and lastly with chloroform; these three
different extracts were united, the solvents driven off, and
the residue ignited, and any lead dissolved out of the ash in
the usual way precipitated as sulphide and weighed as
sulphate.
The alcohol in which the brain had been soaked was also
treated similarly. Lastly, the insoluble or albuminoid
residue was incinerated and dealt with on the samq lines.
The results were as follows :—
Mgrms.
Soluble in cold alcohol (aqueous extract) ... 1*108 Pb S0 4
Portion soluble in alcoholic and ethereal solvents ... 25*473 „
Albuminoid residue. 7*759 „
Total .. 34*340 „
The brain was unfortunately not weighed by those who
made the autopsy, but, presuming the weight to have been
1,235 grms., which is the average for women of the age of
the deceased, the quantities would then be as follows :—
Mgrms.
Aqueous extract . 3 41 Pb S0 4 *
Portion soluble in alcohol and ether... 78*47 „
Insoluble or albuminoid residue ... 23*89 „
Total ... ' ... 105 77 „
The albuminoid residue is mainly composed of albumen
differing in no essential feature from albumen found in the
blood and tissues generally. On the other hand, the portion
of the brain soluble in alcoholic and ethereal solvents
contains the peculiar nitrogenous and phosphorised prin¬
ciples which there is every reason to believe take part in
thought and volition. Hence this preliminary research
rendered it probable that 74 per cent, of the total lead in the
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by A. Wynter Blyth, M.R.C.S.
485
1888.]
brain was in chemical combination with one or several of
the complicated nitrogenised and phosphorised brain fats.
Fifth Case.- — I had an opportunity of following out this
clue in the chemical investigation of the fifth case of sudden
death among the employes at the lead factory. The death
occurred in December, 1886, and the substances transmitted
to me for analysis were the whole of one kidney, weighing
78-9 grins., 299*16 grms. of the liver, and 617 grms. of the
brain.
I may at once say that the liver and kidney were perfectly
healthy; the 299 grms. of liver yielded 24 ingrms. of lead sul¬
phate, and the kidney 78*9 mgrms.
The brain which reached me comprised the whole of the
cerebellum, the pons, and medulla, but not the whole of the
cerebrum.
The cerebral tissues were placed in strong alcohol for
three weeks. When they were thus somewhat dehydrated
the cerebellum was separated with the attached medulla and
treated separately from the hemispheres.
The extraction by solvents was the same in principle as
that already detailed, with this difference, that first alcohol
was used, and then ether, but no chloroform.
The various alcoholic extracts were filtered hot, and then
exposed to cold, by which means most of the white matter
separated out. This white matter, after filtration from the
mother liquor, was well washed with ether to free it from the
kephalins, and this ether extract was added to the ether
extract of the brain tissues. From the ether extract impure
kephalin was precipitated by absolute alcohol, and the
kephalins filtered off, the result of these various operations
being the following solutions and substances:—
1. —Alcohol, in which the whole brain had been soaked
for some weeks, containing much water and substances ex¬
tracted with the water. This may be called “the watery
extract.”
2. —White matter (a) from cerebrum; ( b ) from cerebellum.
3. — Kephalin (a) from cerebrum; (b) from cerebellum.
4. —Ether extract, kephalin free; (a) from cerebrum; ( b)
from cerebellum.
5. —Substances soluble in cold alcohol (a) from cerebrum;
(b) from cerebellum.
6. —The albuminoid residue (a) from cerebrum; (b) from
cerebellum.
From these various solutions and solids the ash was
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486
The Distribution of Lead in the Brain , [Jan.,
obtained, and any lead present extracted and weighed as
lead sulphate.
The general results are as follows:—
Cerebrum Cerebellum
460*8 grins. 186*2 gnus.
Lead Sulphate. Lead Sulphate.
White matter freed from kephalin by ether
Mgrms.
00
Mgrms.
5*0
Kephalin
1*5
60
Ether extract, kephalin free .
0*0
o-o
Substances soluble in cold alcohol...
00
0*0
Albuminoid residue...
40'0
60
41-5
17*0
The aqueous extract contained 1/5 mgrms. of lead sul¬
phate. Dividing this in proper proportion between cerebrum
and cerebellum it will bring the weight of the lead sulphate
to 42*6 mgrms. in the cerebrum and 17*4 mgrms. in the
cerebellum.
Presuming the whole of the cerebrum was contaminated
with lead in the same proportion to that actually found, and
that the cerebrum weighed 1,097 grms., then the weight in
the whole cerebrum of lead sulphate would be 99'7 mgrms.,
which, added to the 17*4 mgrms. of lead sulphate in the
cerebellum, pons, and medulla, makes a possible total of 117*1
mgrms.
It may be significant that the cerebellum contains more
lead relatively than the cerebrum, the cerebellum yielding
1*07 per 10,000 parts, the cerebrum *92.
Thudichum has described a lead salt of kephalin C 42 H 76
Pb 2 NF0 13 easily soluble in ether, insoluble in alcohol;
probably the lead found in the impure kephalin was this or
an analogous compound. Small as the amount of lead-
kephalin found is, yet, if considered in its relation to the
whole kephalin, it is not so small. Thudichum’s analysis of
the brain gives the percentage of kephalin as 5*4, and
calculated on this basis a brain weighing 1,235 grms. would
yield 19*3 mgrms. of lead-kephalin, i.e., nearly 25 per cent.
(*238) of the total kephalin would be transformed into lead
salt. So important a modification as the replacement of
hydrogen in its molecule by lead must profoundly modify if
not annihilate whatever functions kephalin may possess.
The pathology of lead intoxication has always been most
obscure; no theory of any value has been suggested which
sufficiently accounts for its persistence, its cumulative
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487
1888.] by A. Wyittee Blyth, M.R.C.S.
effects, and Protean characters. A great part of the mystery
is capable of explanation if it is at once allowed that the very
minute fractions of lead which may be carried dissolved in
the blood so far overcome the vital resistance of grey
matter bioplasm, as to decompose a portion, forming a
definite substitution compound. Presuming, for instance,
lead-kephalin to be formed in the living cell, it is improbable
that a cell thus lead-saturated would be capable of high
function, but rather that, so far as conduction, inhibition,
or volition, the cell is in effect dead. Nor will any function
it possesses be restored until the lead-kephalin is slowly
eliminated or the extra work taken up by healthy cells.
The change being not one of structure, but of composition,
will evade all ordinary kinds of pathological research, and
the essential difference between this kind of toxic action
and that which is produced by the irritant effects of a large
single dose of sugar of lead is that in the latter case the
effects are produced for the most part on mucous surfaces
outside, as it were, the organism, while bere the effects are
within.
According to these views Plumbism, whether expressed
by colic, paralysis, epilepsy, or insanity, is analogous to some
very refined method of vivisection by which an operator is
able to destroy not nerve centres, but thousands of the
ultimate parts of nerve centres. Hence the pursuit of this
investigation will open up a method of studying the use of
groups of cells and of the brain principles.*
JEtiology , Pathology , and Treatment of Puerperal Insanity .
By A. Campbell Clark, M.D. Edin., Medical Superin¬
tendent, Glasgow District Asylum, Bothwell.
(Continued from p. 379J
The Treatment of Puerperal Insanity may now be con¬
sidered.
Considerable diversity of treatment has hitherto obtained,
especially with regard to sedatives. No systematic experi¬
ments are recorded, and no very conclusive data have been
published. The following quotations from some of the best
authorities, placed side by side, will summarise our present
knowledge of the subject.
* Should any of the readers of this paper meet with a fatal case of lead
encepholopathy, the author would be very pleased to undertake the chemical
part of the investigation.
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488 JEtiology, Pathology , <$*c. of Puerperal Insanity, [Jan.,
First. — Diet and Stimulants .—Dr. Clouston, true to his
practice in other cases, believes in heavy egg custards—three
eggs in each pint of milk, and sometimes cream in addition—
beef tea, port, sherry, brandy. “ Give much food and give it
often.” Dr. Leishman, of Glasgow, is more afraid of over¬
burdening the digestive organs. He regulates the diet care¬
fully and increases it cautiously.
Second .— Open-air Exercise. —Dr. Clouston lays great stress
on this.
Third. — Anii-py reties. —The same physician gives as much
as 40 grains of sulphate of quinine in eight hours, and believes
in it.
Fourth. — Uterine Treatment. — (a) Clouston :—Vaginal in¬
jections of carbolic lotion. Poultices, (b) Bucknill and
Tuke :—Vaginal injections of condy. Emetics of ipecacu¬
anha.
Fifth. — Treatment of Constipation and Indigestion. —Bnck-
nill and Tuke:—Calomel, black draught, aloes, scammony,
castor oil, enemata.
Sixth. — Anaemia. Iron. —(Bucknill and Tuke.)
Seventh. — Dry Shin and Scanty Urine .—Saline diaphore¬
tics. (Bucknill and Tuke.)
Eighth. — Sedatives. —(a) Clouston seems to use them rarely
and gives chloral, (b) Dr. Batty Tuke gives morphia in
melancholia in large doses, and says that “ sedatives in large
doses are contraindicated in mania.” (c) Dr. Blandford gives
chloral in mania, (d) Bucknill and Tuke believe in morphia
for mania, and put less faith in chloral and bromide of potas¬
sium. (e) Leishman says that chloral favours sleep. Opium
makes matters worse.
An aetiology so intricate and a pathology so widespread as
the foregoing facts reveal must needs furnish indications for
treatment of unusual variety and extent. It is not always
easy to ascertain the indications most urgent, because there
is a danger of ignoring some symptoms, undervaluing others,
and overestimating what is secondary and conditional to
what is obscure and ill-defined. The mental symptoms too
often engross attention to the exclusion of causes which may
operate to produce them; and mistaken notions of pathology
have ere this led to heroic measures with disastrous results.
It is clear from the facts elicited that no simple and specific
lines of treatment can be laid down, for there is an endless
variety of feature presented by the disease. It is, however,
desirable to classify in this connection according as one or
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489
1888.] by A. Campbell Clabk, M.D.
more of the following morbid states gives a pronounced
character to the disease. These are:
(1) Digestive, Hepatic, and Intestinal Disorders.
(2) Inflammatory, Septicsemic, and Anaemic conditions.
(3) Hysteria.
(4) Mania, with intensity of symptoms and sleeplessness.
(5) Melancholia ,, „ „ „
That these blend together with or without other abnormal
states in one and the same patient is clearly understood, but
they are now separately identified as being the conditions
most frequently and urgently calling for specific attention.
It is beyond the province of the present paper, and it would
indeed be rather presumptive to enter into a dissertation on
every-day therapeutics. The treatment of disorders and
diseases of the first and second classes will be pursued by
every practitioner on lines which he has made good by study
and experience. Without therefore, dictating a course of
treatment under these heads, I will give an epitome of my
own practice and results.
I. Digestive , Hepatic , and Intestinal Disorders .—One patient
was fed, owing to refusal of food, by the stomach pump, with
rare intermissions of voluntary alimentation for eight weeks.
The tongue and root of mouth were coated with creamy fur,
the lips were cyanotic and crusted, the saliva white and in¬
spissated often frothy, the pharynx relaxed, stomach irritable,
faeces dry, dark or greenish, and slimy. Septicaemia with
diaphragmatic and pleuritic deposits, and boils often com¬
plicated these states.
She was fed liberally with custards (two eggs in each), beef
tea, milk, and whisky. Calomel 1 grain bis die; and Acid
Nit. Mur. Dil. with Tr. Nucis Vomicae ter die were ad¬
ministered, the calomel powders being intermitted at end of
three days, to be repeated as occasion suggested. Castor oil
was prescribed from time to time with good effect. Cod-
liver oil was given, and for a month she was under mild
bromide of potassium treatment. Result .—Af ter three weeks,
during which occurred two moderate pyrexial crises, she still
refused food, the tongue and mouth cleared up a little, and
then got heavily furred again, the appetite returned for a day
only once, and she was getting so weak as to threaten collapse
during feeding. Codliver oil was stopped, then custards,
then bromide, and last of all artificial feeding, but neither of
these changes of treatment seemed to encourage a healthier
state. The stomach was now evacuated from time to time to
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490 ^Etiology , Pathology , fc. of Puerperal Insanity , [Jan.,
ascertain the progress of digestion, and after 3| hours cus¬
tards were withdrawn little altered in bulk or character from
the hour of injection.
Her weight was now taken, 6st. 21bs., the stomach was
washed out with 1-500 carbolic lotion, and a diet-scale
arranged, to be pumped (after predigestion with Benger’s
liquid pepsine) at intervals of four hours, four times a day. The
diet was thus prepared : —8 a.m. f pint milk with 1 egg as a
custard ; 12 noon | pint beef tea with finely grated potato in
suspension ; 4 p.m. custard as at 8 a.m.; 8 p.m. milk gruel f
pint. Two ounces whisky were given in 24 hours. No medi¬
cines given. She lost 51bs. in the first week. Bismuth was
now prescribed, and a combination of the bromides of potas¬
sium and ammonium. Up to this time food regurgitated in
an undigested state on introduction of tube, hence the bis¬
muth treatment. At end of second week had lost 41bs.;
seemed on the whole better under bis-bromide combination,
but at end of third week this was given up, as lips and tongue
were becoming dry, and a copious rash had appeared. The
pyrexial crises were less marked during these three weeks.
At end of third week the weight was stationary. The tri¬
bromide combination of potassium, sodium, and ammonia was
tried, and suffered a like fate as its predecessors. At end
of fourth week weight was still stationary. She complained
of diaphragmatic pain to left side, and had a short trouble¬
some cough at end of fifth week, with the highest tempera¬
ture yet reached (over 103° for two days and three nights).
Eructations and regurgitation of food had not been trouble¬
some for some days, but secretions very scanty, and tongue
and lips were dry, so that bromides were stopped.
At end of seventh week weight 5st. 61bs., having lost lib.
in three weeks, during which beef peptonoids were used, and
later, with apparently more gratifying effect, Carnrick's pep¬
tonized codliver oil and milk. I judged at this time that
although the 4£ turn of the scale 99 had not been reached, she
was stronger, less limp in our hands, and less cyanotic during
the artificial feeding. • It ought to be stated that the method
of alimentation was by means of the soft oral tube, that four
nurses were at band, each trained to a particular duty, and
that from the first handling of the patient to the last the
operation took—as 1 have frequently calculated—not more
than 40 seconds. Therefore exhausting struggles were
averted.
From this period onwards she slowly recovered, she began
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491
18Q8.] by A. Campbell Clare, M.D.
to take her food herself, but in very small quantities com¬
pared with what had been injected into the stomach hitherto
—sufficient, however, to turn the scale. Soon she was able
—the weather being propitious—to go out into the open air,
and in two months had risen from 5st. 61bs. to 6st. 91bs. She
was of phthisical habit, had not menstruated three months
after recovery, and her doctor then wrote me that she was
under treatment at home, “ with rusty sputum and dulness
over left lung.”
This, of course, was an extreme case; the patient was limp,
almost pulseless, extremely atonic, and absolutely anorexic.
With such a case again, I would at first try nutrient and
stimulant enemata, and give the upper digestive tract as little
work as possible. At the outset I found that calomel or blue
pill, followed by castor oil or a saline cathartic, according to
the specific indications, was a valuable resource in the great
majority of cases. Where the hue of the skin changed from
clear to saffron, or a deeper tinge, and these changes came
and went, I found minute doses of calomel, £ grain once or
twice a day, combined with Acid Nit. Mur. Dil. and Tr.
Nucis Yomicse aa trv v. thrice a day before meals, most useful.
This indication, however, was usually observed in slow cases,
and the restoration to health was gradual. One case with
alcoholic history was treated in the manner just described
(but with larger doses of calomel). Fora few days at a time
the tongue would clear up, the digestive functions assert
themselves, and mental calm and coherence become restored.
Relapse as surely followed, and now she is a hopeless
“ chronic ” with a hearty digestion and a voracious appetite.
Many examples of puerperal insanity become chronic or die
for want of alcoholic stimulant. These are so-called “ typhoid
cases,” and in them the use of stimulants undoubtedly saves
life and ofte** .eason. It must be administered, however,
with discrimination, for there comes a stage beyond which it
simply feeds the flame of excitement and hastens the end.
The following preliminary considerations should be kept
always in view in prescribing the treatment of puerperal
insanity. (1) That there is a defective bile secretion or
defective bile elimination in very many cases. (2) That the
other digestive secretions are deficient in quantity, and that
the mucus secretion is often very scanty and altered in
quality. (3) That involuntary muscular tone is lost, and (4)
that reflex excitability is impaired. What will restore or
normalize the secretions, recharge the reflex centres, and
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492 Aetiology, Pathology , $c. of Puerperal Insanity, [Jan.,
restore the muscular tone? To answer this we require
deeper penetration and further experiment.
II. Inflammatory Septiccemic and Anaemic Conditions .—
The effect on the pelvic and mental conditions of pelvic
poultices was in many cases remarkably gratifying. This
treatment was indicated where there were signs of pain;
iodine being more frequently reserved for the deeper
metastatic deposits. Of vaginal injections my favourite is
carbolic lotion, and I pin my faith to it because the patients
liked it best. In their more lucid intervals they said it soothed
them, and in their hyperaesthetic state this was no small boon.
To soothe is to reduce excitement and produce sleep, and
uterine medication may have a more direct and salutary
influence on the mental condition than has been suspected.
Direct uterine injection will probably be found more ser¬
viceable than mere vaginal irrigation where there is fever
and local distress with signs or threatenings of septicaemia.
Superficial evidence of septicaemia was found in abscesses,
boils, scalp deposits often resembling wens, and a copious
pustular acne. It is unnecessary to linger over their appro¬
priate treatment.
Constitutional means may be employed in two directions:
(a) to increase nutritive processes, (6) to arrest fermentation.
The first of these has already been discussed, and in addition
to its more immediate purpose of bringing up nutrition to
its normal standard, it exercises a double purpose in
septicaemia by also increasing physiological resistance to
fermentative change. The latter is a world-wide subject
in itself, and can only be referred to here as having recog¬
nition in the treatment of suitable cases. Albeit, in the
present state of our knowledge, not of the most exact and
definite character, mention might be made of many remedies
employed for the purposes just indicated; but they were
attended with no aggregate results of surpassing excellence,
and must be held in reserve.
Further, if it be admitted that septicaemia has in this
instance a wider meaning than that of a mere germ disease,
if it be accepted that puerperal septicaemia may arise also
from the diffusion through the primae viae into the blood of
putrid gases, or from retained and decomposing excreta
within the blood-vessels, from the absorption of puerperal
disintegrations, or from the retention and accumulation of
the elements of secretions, then the question is one not only
of germicide, but also of depurative treatment. That septic
absorption may, secondarily, carry in its train the absorption
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1888.] by A. Campbell Clabk, M.D. 493
of lesser impurities, and by secondary deposits induce local
and constitutional changes enough to account for a hetero¬
geneous septicaemia such as I have described, is possibly or
approximately true; but local absorption does not always
take place, and secondary deposits more rarely still.
Septicaemia has many grades, and often tapers into the
finest and least nocuous attenuations; yet we still have
evidences of grave blood impurity arising manifestly from
the sources above indicated, these being primary, and in¬
dependent of septic absorption. We, therefore, must
consider three kinds of treatment: (1) germicide; (2)
depurative; (3) secretory stimulant. Here again, are indi¬
cations for careful research. The treatment of anaemia, in
so far as it may be regarded as specific, was confined in
recent and extreme cases to either enemata of defibrinated
blood {vide article in “ Lancet ” already referred to) or
Blaud's Pill. The treatment of the more chronic forms was
chiefly by means of arsenic and iron. Defibrinated blood is
undoubtedly of value, especially where the anaemic state has
been induced suddenly and intensely. Why it should be so
I cannot say; and whether it can be as strongly recom¬
mended in what may be called sub-acute anaemia remains to
be seen. We certainly have not given it the full and
exhaustive trial it deserves.
III. Hysteria .—This variety gives a distinctive character
to some cases, and, having a special interest from the point
of view of treatment, it is desirable to place on record my
results. In one patient a quick recovery followed purgative
treatment; in another this had no proximate effect, and a
definite and satisfactory result followed the exhibition of
bromide of potassium, 45 grains every four hours. Copious
diuresis soon followed, and in three weeks the patient was
convalescent. I had hoped to find in bromide treatment
something specific for the hysteric group; but the cases are
often too asthenic, and my one good result was exceptional.
Certain hysterical cases will probably benefit in this way,
but there must be no flaccidity or inertia; rather, there must
be acute excitement, distinct nervous tension, and response
to reflex stimuli.
IV. Mama .—A moment’s consideration of the somatic
relations of puerperal insanity will suffice to show that there
is no cutting of the gordian-knot by means of neurotic
remedies, unless in exceptional cases where the disease has
been anticipated. The whole mass of evidence before us
leads to the conclusion that treatment must be of a com-
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494 ^Etiology, Pathology , ft. of Puerperal Insanity , [Jan.,
posite character, that, in short, it is a case of having many
strings to our bow. To many of the various neurotic
remedies advocated I have given a fair trial; in no case
with exceptional results, as the following experience
testifies :— (a) (Case I.) Morphia administered in £-grain
suppositories every 8 hours thrice daily for 18 days, with
gastro-intestinal correctives; it reduced the muscular excite¬
ment, moderated the mental furore, did not arrest the
cutaneous secretion nor diminish appetite, and at first
seemed to induce a return to mental stability and coherence.
Soon the mental habit acquired a new phase : previously it
was eccentric, impulsive, explosive, irrelevant, invertebrate;
now it resolved itself into a definite character. Frankness,
good nature, and playfulness gave place to sullen obstinacy
and dogged antipathies; suspicions and delusions of perse¬
cution, hitherto fleeting and superficial, became more deeply
rooted and intensified.
The last entry in the case-book regarding this patient
after a long interval is as follows :—“ She still manifests
strong antipathies to all the nurses, the matron, and the
doctor, and has not a good word to say of anyone. She is
a sour, cross-grained woman, and yet the shadow of a smile
betrays that she is—even at her worst—not so severe as she
would have us believe. The morphia treatment does not
seem to have been successful. It has prolonged and altered
the morbid habit, rendering her less facile and amenable,
easily put out, discontented, never satisfied, and decidedly
cranky; otherwise she is coherent, knows what she is about,
has no definite delusions, and will probably do well at
home.” Three weeks later she was discharged, considerably
subdued, and has now remained out for two years.
In another case the suppositories were given every eight
hours at first, after two days every six hours. Here, also, the
same appearance of returning reason quickly occurred, as
soon to disappear, for the dregs of mental disease remained.
The same gastro-intestinal correctives were used as in the
preceding case. The appetite remained good, and she gained
in strength; often she had angry explosions, was unusually
threatening, and said silly, childish things. She evinced a
strong animus to nurses, and on all and every occasion took
the part of the patients against the nurses, believing that
the latter invariably abused them. Morally she was utterly
depraved in her ideas; her conceptions of right and wrong
were of the lowest character. By-and-bye she seemed,
after a close study of some weeks, to be free from delusions,
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495
1888.] by A. Campbell Clabk, M.D.
when suddenly one day she expressed outrageous ideas as to
being married, and her child (an illegitimate) being fathered
by a third party. Later on menstruation appeared, ushered
by premonitory epistaxis, and after a long interval she
gradually recovered. I have since discarded morphia, for
the recoveries were not so complete as they might probably
have been otherwise, and convalescence was much more
tedious than in our usual experience. At the same time
I use morphia to relieve peripheral irritations, and thus
subdue excitement and produce sleep. It is given in form
of suppository, and not pushed to anything like the extent
above indicated.
The effects of chloral have been noticed where this treat¬
ment was pursued prior to the patients coming under our
care. It has usually suspended morbid action temporarily,
and even induced a saner perception of surroundings, de¬
lusions of identity of persons and place having vanished
for a time, and a pause being marked in the course of the
excitement—an ominous pause, indeed, for the mental re¬
action is greater than before. In combination with bromide
of potassium, 25 grains of the latter to 20 of the former, I
have used it as an hypnotic to ward off exhaustion from
prolonged mental excitement and insomnia, and its effect—
a good one in itself—has been, after two or three exhibitions,
to restore the periodicity of sleep. As to any specific action
on the mental state, I fear this combination has none; but
it is a safer hypnotic and sedative than either of the others.
My experience of bromide, bis-bromide, and the tri-bromide
combinations has been confined to one case already described,
and simple potass, bromid. to the case of acute hysterical
mania which I have mentioned. It is unnecessary to repeat
what has already been said of them.
Y. Melancholia .—Morphia was given in one case of
melancholia—the Liq. Morph. Mur. 10 minims four times
a day for three weeks. The appetite, which had not been
good before, got worse; she refused food, and the mental
symptoms became intensified. The skin was all along dry
and the bowels costive. At the commencement of morphia
treatment a pill was prescribed as follows :—
R Ext. Nucis Vom.
„ Belladou., an gr.
Ferri Sulph., gr.
Pil. Col. cum. Hyoscy., gr i.
Pill mas. q. s.
big. One or more daily as directed.
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496 ^Etiology, Pathology, fyc. of Puerperal Insanity , [Jan.,
As with mania, so with melancholia, there is no certain
course of neurotic treatment. We want a brain stimulant,
alterative or sedative as the case may be, and we think
these virtues are to be found in drugs which act directly
and promptly on the brain. The teaching of pathology and
clinical research contraindicates such a belief. The braiu
nutrition is below par, and neurotic drugs are not brain
nutrients; till nutrition is restored to the normal standard
there cannot be normal function, and a course of neurotic
treatment is decidedly mischievous. Moreover, the blood is
often impure as well as impoverished; and, therefore, where
indicated, depurative treatment must be early attended to.
The neurotic , remedies that can exercise any good purpose
are those that can subserve a trophic function, either
directly cerebral or visceral. Nux vomicae will probably
suggest itself in this connection.
In conclusion, let me observe that I prescribe (1) the open .
air , with a degree of exercise suited to the strength of the
patient, when the weather is agreeable or the walks sheltered,
where there is no serious complication, and the patient will
not lie in bed; (2) a private room with a nurse to herself
when she keeps in bed, is weak and exhausted, and suffers
from pyrexia, septicaemia, or active inflammatory disease ;
(3) above all things, the utmost quiet and isolation , for the
nervous system is high strung, the senses are most acute and
intolerant of the slightest disturbance. Every scrap of
conversation is suggestive to an excited puerperal patient,
every strange sight or sound has a personal meaning; and
the less suggestiveness there is the better. This is the
sedative treatment par excellence. The state of the bowels
and digestion are of the very first importance; but in their
treatment no uniform plan can be laid down, for iu
these respects each case is very much a law unto itself.
Several useful indications have been already stated which
will serve as guides for different classes.
The subject is yet far from exhausted. I am deeply
sensible of the wide range of undiscovered truth which it
contains, but hope this article will be suggestive of lines
for future research in this interesting labour-field.
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497
The Neuropathic Diathesis , or the Diathesis of the Degenerate.
By Gr. T. Revington, M.A., M.D., County Asylum,
Prestwich, Lancashire.
When we examine the purpose and the progress of the
animal world from the scientific standpoint, we find that
“ life is a cycle, beginning in an ovum, and coming round to
an ovum again,” and the history of the human race, the
failures and triumphs of nations, the loves and hates, the
baseness and nobility of individuals, appear to be “ the mere
by-play of ovum bearing organisms.” Whatever other
purpose is served by our existence, we are certainly placed
here to reproduce our kind, and to furnish human figures to
play their part in the next scene of the perpetual panorama
of life. Moreover, we make man in our own image, after
our likeness, and endow him with the characteristics we
have inherited from our ancestors, and with those which we
have created, for good or evil, in our own life. One of the
oldest of books teaches us that the sins of the fathers will be
visited upon the children to the third and fourth generations,
and we might go further and say that physiological sins will
penalize the race for many generations, and even lead to its
utter extinction, unless counteracted by the strong antidotes
of physiological morality, perfect hygienic conditions, and
judicious intermarriage with untainted breeds.
This great law of Heredity seems to me to be the
corollary of the general law, that u the life of the individual
organism is the recapitulation of its ancestral history.” As
in the hourly changes of early intrauterine life we reproduce
some characteristics of our Piscine, Batrachian, or Avian
ancestors, so in the more protracted stages of later intra¬
uterine life, and of independent existence, we reproduce the
physical and mental features of our human progenitors.
And the features of the parents produce more effect than
those of the grandparents, and so on in lessening degree, till
the influence of the primordial parent is lost in the accumu¬
lation of the influences of more recent ancestors. And as
we endeavour to advance to our higher developments —
Move upward, working out the b^ast.
And let the ape and tiger die,
we find that it is the more recent influences of the race
which are most difficult to eradicate. “ In the far-reaching
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498
The Neuropathic Diathesis ,
[Jan.,
influences which go to every life,” says Robert Colly er, “ and
away backward as certainly as forward, children are some¬
times born with appetites fatally strong in their nature. As
they grow up the appetite grows with them, and speedily
becomes a master, the master a tyrant, and by the time he
arrives at manhood the man is a slave. I heard a man say
that for eight-and-twenty years the soul within him had to
stand like an unsleeping sentinel, guarding his appetite for
strong drink. To be a man under such a disadvantage, not
to mention a saint, is as fine a piece of grace as can well be
seen. There is no doctrine that demands a larger vision
than this of the depravity of human nature. Old Dr. Mason
used to say ‘ that as much grace as would make John a saint
would barely keep Peter from knocking a man down.’”
Moreover, if the heredity of coarse physical characteristics,
the Bourbon lip, the Napoleonic nose, or supernumerary
digits be so marked, how terribly potent must be the influence
of ancestral taints upon the delicate and intricate organiza¬
tion of the human brain, the acme of the evolution of the
vertebrate nervous system. Jonathan Hutchinson has
formulated the principle of heredity in the general diatheses.
He says, “ I tried to show that rheumatism is a modification
of the catarrhal diathesis, mainly nervous in its origin, in
which the stress of the reflex disturbance falls upon the
tissues of the joints. I traced a close parallel between gout
and leprosy, alleging that both are food diatheses, being
distinctly and definitely caused by certain peculiar articles of
diet. Respecting both, we had to remark upon the facts
that having been acquired by food, they became capable of
transmission from parent to child, and that gout at any rate
was prone to receive important modifications in such in¬
heritance.” He then proceeds to prove the reality of tem¬
peraments, and to discuss the importance of recognizing
their existence, and he proposes that parents should keep
a life-history of each child ; in other words, he suggests that
we should each carry a log-book, which should be produced
for the inspection of the medical adviser under whose care
we place ourselves in the stress of physiological storms.
None know better than alienists what a boon such informa¬
tion would be when called upon to give a prognosis in a
difficult case. Mr. Hutchinson would place the bilious and
melancholic temperaments together as the “ hepatic
diathesis,” and he denies that the latter is commoner in
persons of dark complexion. Contrasting, however, in-
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by G. T. Revington, M.A., M.D.
499
dividuals of dark and fair complexions, he points out that
the former bear mercurial treatment well, and require larger
doses, that they do not bear direct tonics well, that the need
of purgatives is greater in them, and that they are often not
helped by sea air. This would seem to show that the in¬
heritance of a dark complexion connotes the inheritance of a
group of more or less definite characteristics. He further
states that “ the haemorrhagic diathesis, so strongly hereditary
when once produced, unknown in the lower animals, and
frequently coincident in the individual with gout, has its
origin in the peculiarities of vascular structure which are
developed by gout, and which have become modified and
specialized by transmission through many generations.
With regard to the occurrence of xanthelasma as a family
and almost as a congenital disease, he points out that in
such cases the affection is most probably inherited from
some ancestor who had acquired the ordinary hepatic form
of adults. In these two cases the disease is generally in¬
herited without the bodily condition which originally pro¬
duced it, and if we follow the argument to its legitimate
conclusion, we must believe that the numberless idio¬
syncrasies as to drugs or foods, the liability to take the
contagion of the specific fevers, or to suffer from erysipelas
on the smallest provocation, are all examples of diatheses,
developed, intensified, and specialized, diatheses brought to
a point, in which all trace of the original causation has been
lost. Mr. Hutchinson also speaks of malaria and bronchocele
as climatic diatheses, capable both of being acquired and
inherited. For the explanation of many of the above facts
we must appeal to the nervous system, as it alone seems
capable of satisfying all the demands of our ignorance. We
see the accuracy of the development of hereditary influence
upon the nervous system, in the appearance in generation
after generation of a peculiar gesture of the hand, a special
attitude in sleep, or of characteristic writing. And just as
these objective signs, which may correspond to a subjective,
intangible mental bias, are inherited, so fundamental modes
of mental activity must be born with us —
Grow with our growth, and strengthen with our strength.
We all feel the tyranny of our organization, we sometimes
like what our education would teach us to abhor, and we
cannot admire what we know to be admirable, and we can
thus realize the mental organization of the neurotic, we
xxxiii. 33
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500
The Neuropathic. Diathesis ,
[Jan.
understand that they will inevitably develop in certain
grooves. And though we may affect much by judicious
education, we had surely best begin earlier, and prevent
what we cannot cure. There are thousands who rush
annually to obey the great instinct of reproduction, and who
are certain to produce neurotic offspring. Hinc illw lachrymce.
Hence an enormous lunacy population and a host of mentally-
unstable individuals, authors of half the crimes and follies
which disgrace our race. It is, indeed, time that the
physician from the physiological standpoint, not the lawyer
from the monetary, should be the arbiter of marriage.
The study of the neurotic individual who never trans¬
gresses the boundary line of certifiable insanity has been
much neglected, and yet much may be learnt here. I may
venture to give a short history of a case, such as anyone
may meet, if he does not lay aside his psychological habits
the moment he passes the asylum gate. A. B.; a remote
history of insanity in the family, an immediate history also, a
paternal aunt is insane, and a brother suffers from petit mal;
father and mother of normal mental equilibrium. A. B. is
of slight build, with delicate irregular features, brilliant
eyes, and a sharp, restless manner, and with an extra¬
ordinary aptitude for unusual acquirements. We note his
instability, he varies —
Ib everything by starts, and nothing long.
While refined to a romantic degree about women, he is
morally lax in his actions. He is hypersensitive, is not
muscular, and does not put on flesh. These remarks apply,
mutatis mutandis, to his two sisters. To such as these, Dr.
Clouston would preach “ the gospel of fresh air and fatness/*
and would say with Caesar —
Let me have men about me that are fat,
Sleek-headed men, and such as sleep o’ nights.
But it would be more scientific to prevent their existence by
putting a veto on the union of the neurotic.
I need not delay to further consider the general laws of
heredity, but will pass to my special subject.
There are many functional and organic diseases of the
nervous system which appear to be the result of an
ancestral taint, and which interchange in the life-history of
the individual or of the race, and we may roughly divide the
various affections thus related into the following groups:—
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501
by G. T. Revington, M.A., M.D.
Group 1.—Forms of neurotic manifestations, the heredity
of which is well-marked, but which are not apt to develop
unless the individual liabilities are incurred.
The irritable and excitable temperaments.
The liability to shock from slight causes.
The liability to outbursts of extreme passion.
The liability to be easily affected by drink or by injury to
the head.
Eccentricity.
Group 2.—Forms of neurotic manifestation, the heredity
of which is well-marked, and which are apter to develop in the
life-history of individual or of race into the severer neuroses
of the succeeding groups.
Neuralgia and migraine.
Headaches, “ nerve-storm ” headaches, the sensory epilepsy
of Hughlings Jackson.
The various conditions comprised under the term “ neuras¬
thenia.”
Spasmodic asthma.
Group 3. —Development of inherited and acquired neuroses,
manifesting themselves at the later periods of life, being of
moderate strength, and not necessarily ending in mental
death.
Various vesanim of adults.
Group 4.—Development of inherited, and more especially
of acquired neuroses, which attain great strength, and
result in complete mental extinction in the individual, and
in the inheritance by the offspring of a strong neurotic
tendency.
General paralysis.
Group 5.—Inherited neuroses, mild as regards the form,
severe as regards the time of their manifestation, and very
apt to develop in the life of the individual to more definite
forms.
Chorea.
Hysteria.
Various forms of epilepsy of milder variety.
Group 6.—Forms in which a strong neurotic inheritance
manifests itself early in the life of the individual, and often
ends in permanent mental perversion or mental death.
Various vesanim of adolescents.
Epilepsy of adolescents.
Moral insanity.
Criminality.
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502 The Neuropathic Diathesis , [Jan.,
Primiire Verrucktheit.
Group 7.—(a) Strong inheritance manifesting itself in
infancy.
Infantile convulsions.
Infantile epilepsy.
Hydrocephalus.
(b) Extreme development of neurotic inheritance, mental
death from birth, or rather the entire absence of any in¬
tellectual life.
Idiocy.
One further step is possible, when the law of the limited
dissimilarity or similarity of parents is broken there is no
offspring, as in many cases in the following pages.
Group 8.—Anomalous forms, as yet but indifferently as¬
sociated with the neurotic group which is the subject of this
paper.
Locomotor ataxy.
Diabetes.
This classification is merely an enumeration of the forms
in which the neuropathic diathesis manifests itself, and the
grouping is provisional. No doubt other diatheses co-operate
or antagonize the neurotic, but I shall not venture upon such
theoretical grounds. I must ask the reader to remember that
in the following pages, I shall not discuss this classification
nor confine myself to the order of the groups. I shall merely
enumerate and illustrate the laws which seem to have
governed the alternations and manifestations of the various
neuroses of the 258 men with well-ascertained heredity,
admitted here between January, 1885, and September, 1886,
together with a much larger series of cases of neurotic mani¬
festation in the families of the 258 patients. I hope, how¬
ever, that each group will be found to be illustrated under one
or more laws. In the cases in which neurotic inheritance is
denied, I can only plead the ignorance of the lower classes
with regard to their ancestors, and our imperfect knowledge
of the general laws of heredity. Neurotic manifestations
occur in a large number of individuals, in whom no neurotic
inheritance can be proved, just as each individual develops
characteristics which we cannot account for by heredity. I
can only express my belief that as our knowledge increases,
so will the number of inexplicable developments diminish, as
has been the case in all departments of science. All the so-
called freaks of nature are examples of general laws. More¬
over, the influence of acquired neuroses is very extensive. As
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503
by (3. T. Revington, M.A., M.D.
Dr. 0. W. Holmes quaintly says, “ Each of us is only the
footing up of a double column of figures that goes back to the
first pair. Every unit tells, some of them are plus, and some
minus. If the columns do not add up right, it is commonly
because we cannot make out all the figures.”
I may now briefly give the headings of the fifteen sections
which follow:—
Section 1.—An individual may start a neurosis in his own life.
2. —An individual may start a neurosis in the life-
history of his family.
3. —The neurosis may increase in strength from gene¬
ration to generation.
4. —The neurosis may diminish in strength from gene¬
ration to generation.
5. —The neurosis may skip a generation—Latency.
6. —Postponement of the neurotic tendency under
favourable circumstances ; its appearance as pre¬
mature senility.
7. —The forms of neurotic manifestation may alternate
in the life of the individual.
8. —The forms of neurotic manifestation may alter¬
nate in the life-history of the family.
9. —The form of the neurotic manifestation may be
determined by the superior influence of one or
other parent—Prepotency.
10. —Transmission of identical tendencies—a form of
prepotency.
11. —The inheritance of a slight neurotic tendency
connotes a ready breakdown but rapid recovery.
12. —The inheritance of a strong neurotic tendency
connotes—
A. Perpetual instability.
B. Early and complete breakdown.
13. —Influence of inherited and acquired neuroses in
epilepsy.
14. —Influence of inherited and especially of acquired
neuroses in general paralysis.
15. —Summary of ideas suggested by investigation,
but not substantiated. Conclusion.
Section 1.—An individual may start a neurosis in his own
life. The alcoholic man may, under slight causation, inj ury
to the head, or shock, or worry, develop a sharp attack of
insanity, or may completely break down as a general paralytic.
This is a law which I would venture to insist upon. The man
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504 The Neuropathic Diathesis , [Jan.,
who indulges to excess in alcohol, puts himself in the position
of a man who has inherited a slight neurotic tendency,
which manifests itself as a temperament, or as one of the
liabilities of the neurotic which I have placed together in
Class 1. The Nemesis of natural law in the one case visits
the sins of the parents upon the offspring, and in the other
visits the sins of the individual upon himself in the first
instance. And the man who has thus created a neurosis in
his own lifetime, is in a worse plight than the man who has
inherited one, for the former will develop under a slighter
stimulus than the latter. I am very anxious to avoid repe¬
tition, and it is very difficult to attain my object, as most of
the cases illustrate several laws. The acquirement of neu¬
roses will be most abundantly exemplified as we proceed, and
I may refer the reader to the cases related in Sections 2, 3,
and 14, and for statistics to Sections 3, 11, 14.
The Eev. J. Horsley, in his recent “ Jottings from Jail,”
lays great stress on the relation between drink and crimi¬
nality.
Section 2.—The individual may start a neurosis in the life-
history of the family. The children of alcoholic parents who
have not incurred their liabilities may be imbecile or epi¬
leptic, or may break down at any of the physiological crises
of life; or a mere predisposition to alcohol may be trans¬
mitted, which, if not overcome, may, later in the life of the
individual or of the race, manifest itself in the form of a
definite neurosis.
Case 5.—Melancholia. W. E., single, age 24, first attack;
admitted July, 1886. Has been a heavy drinker, especially
during the two weeks preceding his attack. March, 1887, is
slightly improved. Family history: Father and mother drank
heavily. This case illustrates the inheritance of a predisposition
to drink, a liability to be easily affected by drink, and the early
development of a definite neurosis. Recovery is exceptionally slow.
Case 7.—Acute mania. W. D., single, age 31, duration a year;
admitted July, 1886, heavy drinker. Family history: Father
drank, uncle insane. Here the alcoholic and neurotic diatheses
combine, and an incurable attack results. With regard to the
details of this and other cases, 1 must ask the reader to take it for
granted that when not given, they are either unascertainable or
have no bearing on my subject.
Case 28.—Melancholia. J. B., married, two children, age 57,
first attack, duration a year. Has indulged freely in alcohol, is
prematurely senile both in body and mind. Attack induced by
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505
1888.] by G. T. Revington, M.A., M.D.
shock received on witnessing the sudden bursting of a canal.
Family history : Father and uncle drank hard. Brother phthisis.
Here we have an inherited predisposition to drink, the indulgence
of the tendency, a premature senility as the result, culminating in
an attack of insanity, which develops when the liability to be easily
affected by shock is put to the test.
Case 30.—Acute mania. J. C., age 37, first attack; admitted
March 30th, 1886, recovered May 21st. Very alcoholic, as was his
father, who also became insane.
Case 31.—Active melancholia. P. T., age 51, single, first attack,
has always been of a melancholy turn of mind, and has drunk
freely. Is an incurable case. Father drank. Here is a remark¬
able sequence, father alcoholic, son predisposed to alcohol, melan¬
cholic temperament, active melancholia.
Case 68.—General paralysis. A. S., age 39, first attack, heavy
drinker, noted for his irritable and excitable temperament. Father
clrank hard.
Case 74.—Acute mania. G. S., age 42, first attack. Has in¬
dulged freely in alcolipl, and had an attack of delirium tremens
when 36. At 39 epilepsy developed, at 40 he received a severe
injury to the head, which laid him up for six months. Five weeks
before admission he had a second attack of delirium tremens. Ad¬
mitted May, 1885, recovered September. Readmitted December,
1885, after a bout of drinking, recovered February, 1886. Family
history: Father drank hard. A remarkable sequence is here seen,
and the development of a predisposition to a definite neurosis is well
illustrated. He indulged his predisposition, and incurred his lia¬
bility to be easily affected by drink or by injury to the head. He
breaks down first with delirium tremens, then in three years epi¬
lepsy develops, in another three years suffers from an attack of
delirium tremens passing into mania, and in four months after his
recovery from this, he develops, after a bout of drinking, a second
attack of mania without a preliminary attack of delirium tremens.
Case 84.—Acute delirious mania. J. A., age 25, first attack,
duration five days, died on eleventh day of illness. The attack
developed on cessation of erysipelas of foot. Has been a steady
man. Family history: A. A., his mother, age 45, admitted Sep¬
tember, 1884, with climacteric melancholia of an active type, re¬
covered November, 1886. Father drank, a brother drank. The
influence of the father is prepotent in one son, and of the mother
in another. The son breaks down at a physiological crisis, just as
the mother had done.
Case 101.—Acute general paralysis. J. S., age 33, first attack,
duration one month, admitted April, 1885, died July. Heavy
drinker; parents drank.
Case 104.—General paralysis. W. B., age 36, first attack,
duration two years, died a week after admission. Drank hard.
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506 The Neuropathic Diathesis , [Jan.,
Family history: Father drank hard, and died of general paralysis
at W— Asylum.
Case 109.—General paralysis. J. B., age 47, first attack, dura¬
tion six months, has been a drunkard all his life, as was his father
before him.
Case 112.—General paralysis. W. H., age 32; first attack,
duration a fortnight; admitted December, 1885. March, 1887:
The case now presents a good example of almost complete remis¬
sion. Family history: Father, a drunkard, became epileptic;
brother, J. H., nervous temperament, brain fever at 20, became
insane when 27, and is now in a state of terminal dementia at
L— asylum.
Section 3.—The neurosis may increase in strength from
generation to generation, if it is not counterbalanced by
physiological morality and the judicious antidote which
marriage into a healthy stock affords. Neuralgia or megraine
in the parent, under circumstances favourable for the develop¬
ment of a neurosis, may be represented in the offspring by
epilepsy or insanity, and the neurosis will generally manifest
itself at an earlier age in the second generation. The general
law of development teaches us that characteristic features
tend to be reproduced in the offspring, at the period corres¬
ponding to that in which they appeared in the parent, and
the instances which Darwin quotes are too well known to
require repetition. But my investigation has taught me
conclusively, that the neurosis manifests itself at an earlier
age in the second generation, and many instances will be
quoted as we proceed. Moreover, while the general law is
undoubtedly true of certain special features, the whole his¬
tory of the development of the animal world shows conclu¬
sively that accidental improvements in the parents are
emphasized in the offspring, both by more distinctive form
and by earlier appearance, else surely evolution were at an
end and perissodactyls would be born with the full number
of toes. And what is true of development is true also of
degeneration. Mr. Hutchinson has proved that psoriasis,
which is never congenital, is very hereditary, is prone to
skip a generation, but rarely occurs in more than one
member of a family, may culminate in ichthyosis, which is
very hereditary, occurs in several members of a family, and
at a very early age. Let us see what statistics teach us
upon this point. Of the 723 males admitted between January
1st, 1885, and September 10th, 1886, reliable family histories
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1888.]
by G. T. Revington, M.A., M.D.
507
were obtained in 471, and evidence of the existence of a
family neurosis in 54*7 per cent, of these (for details see
Section 14). I tabulated the average age on first attack in
all cases, exclusive of general paralytics, with the following
results:—
With a family history of both insanity and drink ... 28*
With a family history of insanity ... ... ... 32*37
With a family history of drink ... ... ... 35*48
Said definitely to have no family neurosis . 38*7
Case 12.—Melancholia. J. L., age 36; first attack; always
eccentric ; very alcoholic. Father and mother were hard drinkers.
Here we have a neurosis started by alcohol, manifesting itself at
an early period as eccentricity and culminating in insanity.
Case 66.—Senile dementia. I. M., age 72 ; first attack, dura¬
tion three months ; married, seven children, one daughter imbecile.
Family history : All the family have been hard drinkers, includ¬
ing the patient, his parents, and his children. Here we have a
culmination—first generation, drink; second, drink and senile
dementia; third, imbecility in one member of the family and
alcoholism in the others. If it were possible to trace the family
history further, doubtless we should find other developments.
Case 83.—Mania. J. W., age 32, married, no children; first
attack. Personal history: Alcoholic for years, severe injury to
head when seventeen, epilepsy when twenty-five, which persists;
said to have become suddenly insane twenty-four hours before
admission. Family history : Maternal uncle insane, cousin phthisis.
The neurosis was here not a strong inheritance, and displayed
itself as a liability to be easily affected by drink or by injury to
the head. These individual liabilities being incurred, the neurosis
is strengthened during the life of the patient, and we have epilepsy
at twenty-five, and incurable insanity at thirty-two, and a non-
reproductive existence, the extinction of a bad stock.
Case 87.—Dementia. H. B., age 67; duration of attack, six
years. Epilepsy developed at fifty-seven. Daughter became
insane at an early age.
Case 89.—Acute mania. J. B., age 17 ; first attack; admitted
March, 1885; recovered July. Family history: Grandfather
alcoholic ; father had five attacks of insanity, the first occurring
when he was 19, and he died during the last, aged 46, from
phthisis.
Section 4.—The diathesis may decrease from parent to
child, and die out if the tendencies are repressed, the general
hygienic conditions are good, and the breed is strengthened
by crossing with healthy stock. It is not necessary to men-
Digitized by A^OOQle
508
The Neuropathic Diathesis .
[Jan.,
tion examples of this. We know, chiefly by the negative
evidence that the cases do not come under our notice, that
the majority of the offspring of neurotic stock do not become
epileptic or insane. It were indeed a bad look-out for the
race if the tendency to develop did not generally over-ride
the tendency to degenerate. That we do not meet with a
larger number of cases is accounted for by the facts, that
family histories are forgotten or concealed, that the females
marry and thus they or their offspring may be admitted
under different names, that the neurotic members of a
family are those most likely to die young or leave their
native place. Moreover diatheses may oppose diatheses (see
below), and favourable crossing with healthy breeds prove
antidotal. Finally we know that any peculiarity, such
as the haemorrhagic diathesis or the appearance of super¬
numerary digits, may be most irregular in its appearance.
It has been suggested that even the numberless sporadic
cases of tuberculosis are instances of a diathesis with occa¬
sional manifestations, just as there is, according to Mr.
Hutchinson, a “ cancerous diathesis,’ 5 and “ it is clear that a
state of health may be transmitted which gives proclivity to
the disease without actual conveyance of the cell germs/’
With regard to the development of the neurotic diathesis,
the nemesis of natural law may sometimes be satisfied with
its development in single instances. And we must suppose
that each embryo, in the power of its tendency to develop,
and in its receptivity to malign influences, differs from every
other. Finally there is the law of ‘‘individual variation,”
which, as Hr. Maudsley says, is particularly strong in the
human species, “ because it affords infinite scope for modifi¬
cations, neutralizations, and variations of qualities.”
(To be continued.)
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1888.]
509
(hi Htvmorrhages and False Membranes within the Cerebral Sub-\
dural Space, occurring in the Insane (including the so-
called Pachymeningitis.)* By Joseph Wiglesworth, i
M.D.Lond., County AsWm, Rainkill, Lancashire^
With Plate. OJ
The title of this paper implies the assumption that the
current doctrine with reference to the condition known as
pachymeningitis is not the true one ; obviously the use of this
term signifies that the pathological process underlying the
morbid changes met with is one of inflammation, and that
without the operation of this agency they would not occur.
Now, without denying the possible occurrence of a condition
to which the name of cerebral pachymeningitis might with
appropriateness be applied, my endeavour will be to bring^
forward arguments and proofs to show that the condition
which usually passes under that term is not the result of
*1 i nflammation at all , but that all the phenomena met with may
I be explained as the simple result of effusion of blood into the
subdural space (arachnoid cavity). /y ^
This view is not a netf one ; it was aavocated before Vi rchow
described the morbid changes in terms of in flammati on, and
it is to the authority of that great name that we are indebted
for the predominance of the inflammatory theory. Having
myself been indoctrinated in this latter view, it was only after
the repeated observation of cases in which the signs of in-
fla romation were cons picu ous by their absence7 whiist thoseof
ha emorrhage were a bundantly manifest, that the conclusion
was forced upon me that this view was not a tenable one.
It may be well to illustrate by a few quotations the teach¬
ings of the books in this matter.
Thus, in Bristow£s well-known work on “ The Theory and
Practice of 5ledicine/’t we read —
A peculiar chronic form of inflammation of the dura mater of the
brain or cord is now usually termed pachymeningitis. ... In the
head it commences for the most part in the area of distribution of
t he middle meninge al artery, with the formation over a greater or
less extent of surface of a delicate adherent film which consists
partly of embryonic corpuscles, but mainly of large irregular thin-
walled capillaries. O ther sim ilar films become_develo ped in «1n W
* Essay to which the £10 10s. Prize and Medal of the Association were
awarded.
t P. 952, 1st Ed., 1876.
^ -
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)10 On Hcemorrhages and False Membranes , [Jan.,
succession, one upon the other, o yer the diseas ed area, until th e
adventitious formation attains considerable thickness ; the deeper
seated laminae meanwhile becoming denser, more fibrous, and less
vascular. Owing to the large size and extreme delicacy of th e
newly-formed blood-vessels, rupture with ext vava~sa?T oiiQf hloocTis
of frequenT occurrence. For the most part the haemorrhages are
rninufe and numerous/and result in the precipitation of crystalline
and other forms of blood pigment; not unfrequently, however, they
are abundant, and form large accumulations between the lamina?,
giving, it may be to the whole, the aspect of a mere clot.
That t his quot a tion accura tely repre sents the tea< rtp*ig jvE-
t he German Schoo l may be seen by a reference to Ziegler’s
“ Pathological Anatomy/ 5 * where a description, in all respects
similar to the above, is given of the affection under the name
Chronic Internal Pachymeningitis .
Gowers J whil st des c ribing the affection un der the name o f
Hcematoma of the Cerebral Meninges , nevertheless detines it as
Inflam mation of the inner surface of thc_dura m ater T attende d
with the formation of a membranous vascular tissue into which
“^hg&alovrhage takes place.
Turning to more special works we find Dr. Savagef de¬
scribing 'pachymeningitis as occurring in general paralysis —
Occasionally one meets with false membranes occupying the
whole or half of the vertex immediately under the dura mater.
This false membrane is due to pachymeningitis, and may vary in
thickness and consistency.
Dr. Mickl e describing this same condition in his exhaustive
I work, § seems to leave it an open question a whether this
organized formation is primarily of haemorrhagic or of in¬
flammatory origin . 55
On the other hand, I am glad to find myself in accord with
I no less an authority than Dr. Clouston , who writes || —
In a number of cases [of general paralysis] we find under the
dura mater and attached to it, lying betwee n^ it a nd the arachnoid)
a new substance of a morbid and peculiar kind, commonly called
a False membrane. ... In some cases it looks like a clot, in others
like an extra layer of dura mater, but it can always be easily
scraped away. When it is removed from the dura mater, that
membrane is not congested or inflamed looking. It always con¬
tains new blood-vessels, and nearly always blood corpuscles or
( blood-colouring matter. . . . This is the so-called pachymeningitis
* Part II., article G64—English translation, 1886.
f Quain’s “ Dictionary of Medicine,” p. 953.
t “ Insanity and Allied Neuroses,” p. 345.
§ t( General Paralysis of the Insane,” 2nd Ed., p. 279.
|| “ Clinical Lectures on Mental Diseases,” p. 373.
J />ic zed by
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1888.]
by Joseph Wiglesworth, M.D.
511
hemorrhagica interna of the Germans, a ridiculous and misleading [
name, for it is not the result of inflammation at all. *
Having regard to the diversity of opinion expressed in the j
above quotations, it will be conceded that the question is one |
requiring further investigation.
My experience in this matter is based upon a series of 400
unselected post-mortem examinations of persons dying with
various forms of insanity. Of these 400 cases 195 were
males and 205 females. Out of the 195 male cases 80 were
examples of general paralysis, a percentage of 4102; whilst in
the 205 female cases there were 39 general paralytics, a per¬
centage of 1902. The percentage of general paralytics on the
whole series of 400 cases was 29*75.
Now, out of this series of 400 cases, in no less than 42 —
10*5 percent.—the cerebral subdural space contained either
blood or membrane or both combined. I group these two
conditions together because, in practice, it seems impossible
to separate them, and, as I shall endeavour to show, the one
appears to be but a later stage of the other. I may add that no {
cases of death from severe injury to the head, such as fracture I
of the skull, are included in this series, and lienee the possible }
aerenev of traumatism has been ns far as possible excluded.
ave appended a table, giving details of the 42 cases in
which blood and membrane, singly or combined, were present
in the cerebral subdural space.
The age of the youngest patient given in this table is 32,
that of the oldest 83 ; tlie'average being 51*07. Now, as the
average age of the asylum population is about 43*33,* these
figures indicate that the conditions noted are most frequently
met with in insane persons of advancing years.
Turning now to the form of mental disorder, we find that
the cases in the table are divisible as follows :—
General paralysis ... ... ... 22
Melancholia (acute) . 3
„ (chronic). 2
Mental stupor ,, 1
Epilepsy (with mania)... ... ... 1
Chronic mania ... ... ... ... 4
Chronic mania with demen tia... ... 2
Dementia (secondary). 4
„ (senile) . ... 3
* This was the figure in the year 1885.
lI'V J JL ? ' Jed". V ' ‘ " *
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512
On Hcemorrhages and False Membranes , [Jan.,
Two facts are apparent from this analysis—first, that
hematoma of the cerebral meninges * is more common in
general paralysis than in all other forms of insanity put
together; secondly, that it occurs in the immense majority
| of instances in cases in which the mental disease has been of
I some standing; for in only three of the cases given in the
( table was the insanity of less than three months’ duration,
and these three cases were all examples of melancholia. Of
the 42 cases of hseraatoma given in the table 23 were males
and 19 females ; this gives us a percentage of 11*79 on the
total number of male cases examined, and one of 9*26 on the
whole series of females.
( These figures indicate that haematoma is more common in
males than in females. This result is due to the excess of
I male general paralytics over female ; for if we exclude general
paralysis altogether we find that the percentage of cases of
hsematoma on the total number of males remaining (115) is
6*08 ; whilst the percentage on the total number of female
non-general paralytics (166) is 7*83, a balance on the side of
the female. If, on the other hand, we take cases of general
paralysis only, we find that out of 80 males there were 16
cases of haematoma—a percentage of 20*00; whilst out of 39
females 6 cases occurred—a percentage of 15*38 ; so that it
( would appear from this that male general paralytics are more
liable to the affection than female.
I The condition of the subdural space in the 42 cases given
in the table may be briefly summed up as follows:—In one
i case mention is made of fl uid b lood only; in sev£n others
l fluid blood, wa^xionibiued with rece nt clot; in all the rest
1 there was more or less o? a membrane present; but in no
less than 15 of these the membrane, which was attached
more or less loosely to the inner surface of the dura mater,
had all the appearance of coagulated blood, and was
described as such in the notes. In the remaining cases, the
membrane, whilst still frequently exhibiting by its colour
more or less of a haemorrhagic element, was described in
such terms as a whitish or pinkish thin gelatinous lamina,
a thick fibrinous laminated membrane, etc.
The actual conditions met with in each case are given in
detail in the table.
* It is necessary, for the sake of brevity, to make use of a term which will
Btand for the conditions of the subdural space described in the table, but im¬
possible to obtain one which does not connote a pathological theory, the proof
or disproof of which has yet to follow.
Digitized by t^ooQle
1888.]
by JoSEl’H WjGLESWORTH, M.D. 0V0
Now, in seeking to discover the pathological process
which is at the root of the above phenomena it is, I think,
a very suggestive fact to note that in no less than seven of
the cases—one-sixth of the whole—fluid blood, or this com¬
bined with recent blood clot, was found in the subdural
space, without the presence of any trace of membrane on the
inner surface of the dura mater. The advocates of the
pachymeningitic view assert that the blood which is so fre¬
quently met with, and of which they are compelled to give
an account, is extravasated through the rupture of delicate,
thin-walled vessels ramifying in a membrane wl,iich has pre¬
viously formed on the inner surface of the dura mater. But
if, as the above cases prove, blood may be found in consider¬
able quantity without the presence of any trace of such a
membrane, why is it necessary to call in the aid of a mem¬
brane to account for it in any case? It may, of course, be
argued that these cases of fluid or clotted blood only should
not be included in the same category as those in which a dis¬
tinct membrane is present; but to this it may be replied
that the two conditions occur in just the same class of cases,
and there is such a very gradual transition from one to the
other that the conclusion is strongly suggested that the
me mbrane is formed from the blood, and not the blood from
the membrane.
This opinion is reinforced by the structure of the mem¬
brane itself, whether this have the haemorrhagic or the
fibrinous form; for in the former case it has all the appear¬
ance, both to the naked eye and to the microscope, of a
recent thrombus, and in the latter it closely resembles in its
intimate structure the laminated fibrinous clots met with in
veins when coagulation in them is of old date. And just as
in the case of a recent thrombus, the clot is at first but very
loosely attached to the wall of the vessel, but becomes more
firmly united with it as time goes one, though still for some
time capable of being readily separated ; so is it in the case
of the membranes under consideration, which though becom¬
ing more firmly adherent to the inner surface of the dura
mater as their age increases, are nevertheless almost always
capable of being easily peeled off from this.
The microscopical appearances of the membrane will vary
with its age. Thus in Case No. 27jitbe membrane was com¬
posed of more or less structureless^iooking bands of imper¬
fectly formed fibrous tissue, between which were contained
considerable collections of red blood globules, the relative
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514 On llcemorrhages and False Membranes , [Jan.,
proportions of these two elements varying in different parts;
whilst in Case No. 19i the fibrous tissue was more fully
developed, with oval nuclei, and red blood globules were
not met with in the portion examined, but there were
numerous leucocytes scattered about. In both cases delicate
capillary vessels were observed in the membrane, and plenti¬
ful collections of hasmatoidin granules. The membrane, in
fact, resembles in structure an organizing or organized
thrombus.
If the structure of the membrane itself gives no support to
a supposed inflammatory origin, what is to be said as to the
condition of the^ura mater from which it is presumed to
be derived ? OnewouIcT expect at least to find evidence of
inflammation here. But, to the naked eye at any rate, such
evidence is not apparent. The dura mater is, as a rule,
| either not^ thickened at all or only very slightly so, and the
membrane, which is almost ^ilway*T loosely adherent to its
inner surface, can be stripped off with ease, leaving this
inner surface smooth and shining in the great majority of
, cases. It is true that to microscopic examination the dura
7 mater may present appearances indicative of slight inflam-
l matory change. Thus in Case No. 19 there was a tendency
’ to accumulation of leucocytes in the inner layers of the dura
. mater, and the nuclei of the fibrous bundles were abnormally
' distinct. But such changes may fairly be considered to be
( secondary to the irritation of the adjacent clot, and to be in
all respects comparable to the processes which go on in the
wall of a vein when coagulation has occurred within it. A
thrombus in a vein sets up irritation in the wall of this
( vessel, with effusion of leucocytes; and it is through the
f agency of these migratory cells that the clot becomes
, | adherent to the vessel, and subsequently undergoes organiza-
* t tion. Now, the inner surface of the dura mater might be
compared to the inner wall of a vein within which coagula-
1 tion has occurred; and I w’ould submit that the fibrinous
membranes found beneath the dura mater are merely clots
] which have become converted into imperfect fibrous tissue—
organized, in fact—by means of leucocytes which have
j migrated from the dura mater in response to the irritation
' set up by these clots. It is fair to assume that if these
j membranes were the product of a primary inflammation of
, the dura mater it would not be necessary to have recourse to
the microscope for the demonstration of this process.
. f-vv J »'-v .'& *" *
<r' //Wv /L ^
1888.]
by Joseph Wioleswobth, M.D.
515
An additional argument in favour of the hgR jpprrhflg m.
origin of these subdural membranes i§ furnished by the fact
that the membrane is sometimes presented to us in its most
typical form in subjects who have at some period or other of
their insanity exhibited symptoms of considerable cerebral
haemorrhage. This was so in Case No. 27, in which a thick
fibrinous laminated membrane was found after death coating
the whole of the inner surface of the dura mater. This patient
just nine months before her death fell off her chair one morn¬
ing in a fit; two hours after this she presented all the symp¬
toms of a copious haemorrhage. She was profoundly comatose,
and lay on her back breathing stertorously; all the limbs were
absolutely paralyzed and completely flaccid, and the plantar
reflexes were totally abolished; the temperature was lowered ,
being reduced to 95’5°. The patient remained comatose with
lowered temperature for some hours, but the coma and
paralysis gradually passed off, and by the following day she
had recovered Fer usual maniacal condition, the temperature
at the same time rising to the normal. It is necessary to
insist here on the lowered temperature as a diagnostic sign
of cerebral haemorrhage, as in the apoplectiform seizures of
general paralysis the temperature always rises rapidly if the
attack is one of any severity. The inference is, that in the
attack thus briefly described the patient had a very free
haemorrhage into the subdural space, which gradually became
organized, and constituted the fibrinous membrane found at
the autopsy. I may add that no signs of haemorrhage,
either recent or remote, were discovered in the interior of
the brain of this patient.
Further evidence of an important kind is furnished by
Cases Nos. 20 and 36 in the table.
In both these cases there was an ante-mortem thrombus of
some standing blocking up the longitudinal sinus through¬
out the whole, or a great portion, of its length. It is
clear that in these cases there must have been great disten¬
sion of the venous system which has its terminus in the
longitudinal sinus, and consequent great liability to rupture
of venous radicles or capillaries. That such rupture had
actually taken place is proved by the fact that in both these
cases a number of small haemorrhages from the size of a pin’s
head to that of a hemp-seed had occurred into the cerebral
cortex. The inference seems irresistible that the gelatinous
red lamina met with in each of these cases was produced in
a similar manner. Yet these cases were examples—No. 20
xxxm. 34 f
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On Haemorrhages and False Membranes , [Jan.,
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in particular being quite a typical one—of the so-called
pachymeningitis interna hemorrhagica , in an early stage. If,
then, an appearance exactly resembling this latter condition
can be produced by haemorrhage simply (and I submit that
these two cases prove that this may be so), why is it necessary
to call in the aid of inflammation as a factor in the produc¬
tion of similar phenomena in other cases ?
A further point which seems worth noting is that the
affection is by no means always bilateral, although it is so in
the majority of cases. In a littl e under half t he cases given
in the table the bilateral c haracter was well marked, whilst
in the remainder t he affection was either unilateral o r main ly
so; it was wholly unilateral in 15 c> ses of the series—rather
more than one-third of the whole. Without attaching too
much importance to this point, one would nevertheless
expect to find an inflammatory affection more constantly
bilateral.
Briefly, then, to sum up the argument so far as this has
proceeded. We noted that blood was frequently found in
the subdural space without trace of membrane, and the
inference that the membrane was formed from the blood
was supported by its occurrence in the same class of cases as
that in which simple haemorrhage occurred, and by the
gradual transition to be observed from one to the other.
The structure of the membrane itself resembled that of clot
in its different stages, and it was sometimes met with in its
most typical form in subjects who had presented during life
all the signs of cerebral haemorrhage. That a gelatinous
red lamina adherent to the inner surface of the dura mater
might be produced by haemorrhage was shown by its associa¬
tion with haemorrhages into the cortex in cases of thrombosis
of the cerebral sinuses. Furthermore ail signs of inflamma¬
tion were absent from the dura mater (at least to naked eye
examination), and the affection was more often entirely
unilateral than might have been expected did it have an
inflammatory origin.
But if the different forms of membrane met with in the
subdural space are to be looked on simply as the result of
haemorrhage, slight or severe, which has taken place into
this region, how are we to account for the frequent occur¬
rence of this process in cases of insanity ? The answer to
this question is to be found in twa of the physical conditions
which, singly or combined, occur in most cases of insanity,
viz., wasting of the hemispheres, and general or localized
>* v v :>
.
1888.]
by Joseph Wiglesworth, M.D.
517
congestion of the meninges. The brain being in a closed box
the atrophy of the convolutions which we so commonly meet
with in insanity must be compensated for by the effusion of
fluid. Usually the fluid thus effused to supply the lost brain
substance is serum, and its occurrence under these condi¬
tions is usually well understood. But it does not seem to be
recognized that blood may be a compensatory fluid as well as
the serum which is derived from it; nevertheless there does
not seem any valid reason for doubting that this may be so
under certain conditions.
The atrophy of the convolutions must tend to remove a
good deal of support from the exterior of the meningeal
vessels, and thus create a tendency to congestion and rupture,
which is usually prevented from occurring on account of the
lost support being supplied by the effused serum. But it is
easy to suppose that under certain conditions, such as very
great or very rapid wasting, especially if accompanied with
weakness of the walls of the vessels from degeneration, the
required support might not be afforded efficiently, and hence
that rupture of vessels with escape of their contents might
occur. It is not, however, necessary to assume that actual
rupture of the vessel-wall takes place in all cases, although
doubtless this is so when the haemorrhage is at all extensive,
but minor degrees of effusion may be produced by escape of
the vessel contents through the walls by diapedesis when the
internal pressure is high. Effusion of blood in one or other
of these ways is, I submit, what actually occurs. It is
obvious that if general or localized congestion of the
meninges co-exists with loss of external support from
atrophy of the gyri the tendency to rupture will be much
enhanced.
Evidence in favour of this view is afforded by a study of
the conditions under which these hsematomata beneath the
dura mater are found. The so-called pachymeningitis (the
phenomena presented by which I have above endeavoured to
prove to be the result of haemorrhage alone) is more fre¬
quently found in general paralysis than in any other form of
insanity. This is the usually accepted opinion, and it is one
which is fully borne out by the cases given in the table, for
out of these 42 cases no less than 22 were examples of
general paralysis. Now it is just in this disease that the
conditions above indicated, viz., great and rapid wasting and
general or localized congestions of the meninges, occur with
the greatest frequency and intensity.
a * f e \rC y y
jt <cr»— ^
518
On Haemorrhages and False Membranes., [Jan.,
K,
4 !
v.r
There is no need to lay stress on the large amount of brain
wasting which is the invariable concomitant of general
paralysis when the case has been of any duration; the fre¬
quent congestion of the meninges, more especially of the
pia mater, is a fact equally capable of proof. When death
has occurred in this disease after a series of epileptiform or
apoplectiform attacks it is common enough to find consider¬
able diffused congestion of the pia mater. But I have fre¬
quently also seen under these circumstances localized
irregular-shaped patches of extreme congestion, which do
not necessarily occur over the motor region. In such cases
the pia mater over a variable area may be so intensely con¬
gested as actually to resemble an ecehymosis, without, how¬
ever, any blood having escaped on the free surface. It is
manifest, nevertheless, that the conditions here must be
highly favourable to actual rupture, and I doubt not that
this frequently occurs.
Such localized congestions are not, however, confined to
general paralysis, as is shown by Case No. 42 in the table—a
typical example—but they are by far most frequent in this
disease.
It is not intended to be implied by the above allusion to
epileptiform attacks that these latter are caused by effusion
of blood beneath the dura mater. Though this may be so
in a few cases it is certainly not so in the majority, for daily
observation shows us that epileptiform attacks may frequently
occur without any haemorrhage having taken place. The
more correct interpretation would seem to be that the
epileptiform attacks are produced, in many cases at least, by
the meningeal congestions, and that rupture of a vessel from
one of these ecchymotic-looking patches is a complication
that may, or may not, occur. The localized congestions may
themselves be the result of loss of support from rapid
wasting.
It seems worthy of note that phthisis is put down as the
cause, or a part cause, of death, in a number of the cases
given in the table, as in these cases the wasting produced by
the cerebral disease would tend to be distinctly reinforced
by the pulmonary affection.
Further evidence in the same direction is furnished by the
age at which these hsematomata are usually met with, for.
as was previously shown, the affection is distinctly one of
advancing years. This is the case even in insanity, where
the mental affection usually tends to produce a premature
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1888.]
by Joseph Wiglesworth, M.D.
519
senility, and it is probably still more marked in sane people,
for in them, when non-traumatic subdural haemorrhage
takes place, as it sometimes does, it is met with almost
exclusively in old age. We recall here the fact that a cer¬
tain amount of brain-wasting may almost be looked upon as
a normal accompaniment of old age, and if to this we add
the very frequent association of senility with degenerated
vessels we have another powerful factor introduced.
Indeed, I think it may be said that wasting is most liable
to occur in those whose vessels are most diseased, and hence
these two factors, both tending to produce a rupture on the
surface of the brain, are often combined.
A further highly significant point remains to be noted.
When the hsematoma is entirely unilateral the hemisphere of
the side on which this has occurred seems to be generally the
lighter of the two. This was so in the great majority of the
unilateral cases given in the table, where each hemisphere
had been separately weighed after being denuded of its
membranes.
Further observations on this head would be desirable since
hemispheres vary normally in weight, but the fact that in
almost every case in which this point was noted the condi¬
tions above-mentioned existed could hardly have been a
matter of accident. In some cases the difference in the
weight of the hemispheres was decided, amounting to as
much as 20 grammes. It is obvious that if loss of support
from atrophy of convolutions is a factor in the production of
haemorrhage, such haemorrhage is most likely to occur on the
side on which the loss of support has been the greatest.
We have yet to inquire into the clinical significance of
hsematoma of the cerebral meninges, and to trace out, as far
as possible, the symptoms it occasions. It must at once be
admitted that in the majority of cases no symptoms capable
of recognition are produced. Occurring for the most part in
demented patients, often towards the close of life, and in the
majority of cases to an inconsiderable extent, this is only,
perhaps, what might have been anticipated. Occasionally
in a chronic dement the development of unusual mental
torpor, gradually deepening into coma, may give the needed
clue, and atr times, as in the case of general paralysis before
quoted (No. 27), signs of copious haemorrhage have been
noted during life. But these are exceptional instances, and
it is not uncommon, especially in general paralysis, to find a
thick, fibrinous lamina covering the whoje extent of the dura
^ V /I CWW C f v : * *■ i " v " f'**'^'* i < <? 1
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On Tlrcmorr/iages and False Membranes, [Jan.,
mater, the presence of which has not even been suspected
during life. The explanation of this, probably, is that the
haemorrhage which has taken place has simply filled up the
vacuum that would otherwise have been occasioned by the
wasting of the brain substance, and has done neither more
nor less.
Incidentally one might here remark that this very absence
of symptoms points to the compensatory nature of the affec¬
tion, for inflammatory products are no respecters of space,
and the encroachment of these on the surface of the brain
could hardly fail to produce symptoms of irritation and
pressure, even in a demented patient.
But there are other cases, chiefly of acute insanity, in
which the haemorrhage seems to do more than merely fill up
a vacuum, and appears to introduce a complication which
may actually be the cause, or a part cause, of the death of
the patient.
In illustration of this I will very briefly relate three cases
of recent melancholia which have been under my observation.
They are numbered 5, 8, and 11 in the table.
No. 5.—Alice S., eet. 50, was admitted suffering from her second
attack of insanity, which was then of two weeks’ duration. She
had an expression of alarm, frequently screamed, and at other
times made a sort of moaning noise. She was very taciturn, and
could with difficulty be got to give her name. These symptoms
increased. She lay in bed, making a sort of moaning noise at
times, and took no notice of any questions put. She often moved
her hands about restlessly. The urine was retained, necessitating
the use of the catheter. The temperature was normal up to the
day before death, when it rose to 100 o, 4. She gradually passed
into a semi-comatose condition, and died seventeen days after
admission.
As regards the autopsy, besides the details given in the
table, it is sufficient to state that both lungs were very con¬
gested and cedematous, and there was some patchy consoli¬
dation along the posterior borders of each.
No. 8.—Harriet B., set. 48, was admitted suffering from her first
attack of melancholia, of two weeks’ duration. It was stated in
the order of admission that the only answer she could make to
questions was that she was ruined. She was admitted in a very
weak state. She lay on her back in bed taking no notice of her
surroundings; could not be got to give any replies to questions,
but muttered to herself at times; arms and legs were kept very
rigid when attempts were made to move them ; temperature varied
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1888.] by Joseph Wigleswobth, M.D.
from 99*°4 to 102°. She had a little diarrhoea, and gradually sank
and died five days after admission.
There was nothing noted at the autopsy which would account
for death beyond the haemorrhage into the subdural space.
No. 11.—Elizabeth W., eet. 52. This was her first attack of
melancholia, which was said to be of six days’ duration. When
admitted she was very fretful and depressed, and cried a good deal.
A few days after this she resisted taking her food, and constantly
made a sort of groaning noise. Three weeks after admission she
lay in bed, scarcely speaking at all, and could with difficulty be
got to answer the most simple questions, but she made almost
constantly a low moaning sound. The physical and constitutional
signs of pulmonary gangrene now set in, and patient died thirty
days after admission. The temperature during the last week was
only once below 102°, and reached to 103°*4.
In reviewing these three cases several points suggest them¬
selves for consideration. What was the cause of the haemor¬
rhage beneath the dura mater ? At what period of the case
did it occur? How far did it influence the symptoms, and
what connection had it with the death of the patients ? To
these questions it is difficult, in fact impossible, to return
satisfactory replies. I would, however, suggest the following
as a probable interpretation:—The cases commenced as
ordinary attacks of melancholia. Without discussing the
pathology of this condition, it will, I think, be conceded that
even in recent cases there is some amount of wasting of the
convolutions. Such wasting would tend to remove support
from the vessels of the pia mater and render them liable to
rupture, as previously noted. It is no argument against this
view to say that such rupture does not occur in the majority
of cases, for the conditions may not have been exactly
similar. In the cases under consideration degeneration of
vessel walls may, considering the ages of the patients, have
been an additional factor. Rupture of a vessel having once
occurred, the amount of blood effused would depend upon
various circumstances ; it is manifest that effusion of blood is
less under control, so to speak, than effusion of serum, and it
might tend, in certain cases, not only to fill up any vacuum
occasioned by loss of brain substance, but to spread further;
the more recent the case and the less the amount of wasting,
the more likelihood would there seem to be of this taking
place. But, under these circumstances, effusion of blood would
be very liable to set up active irritation. That such irritation
existed in the cases detailed may, I think, be legitimately in¬
ferred from some of the symptoms. Thus the constant or
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522
On Hemorrhages and False Membranes , [Jan.,
frequent utterance of a low moaning noise was a prominent
symptom in at least two of the cases; and restless move¬
ments of the hands, or rigidity of limbs, was likewise noted.
But, in connection with the symptomatology, it will be well
to give a short account of another case, which was not in¬
cluded in the above, because not a recent case of insanity,
but which, nevertheless, is worthy of note. It is case No. 42
in the Table.
Mary Ann W., set 33 at death, had been an inmate of the asylum
for eight years. Her mental condition was peculiar. She suffered
from mental stupor of an unusual type, and would remain for
weeks or months huddled up in a corner with her head strongly
bent on the thorax; she exhibited at times a tendency to catalepsy,
and was only partially amenable to external suggestion. After a
long but uncertain period of this lethargy she would brighten up
and be for a time fairly rational, but in the course of a few days
she would relapse into her former state, w T hich was well-nigh
habitual to her. The patient, whilst apparently in her usual
health, was seized one night with a sharp attack of diarrhoea,
being freely purged three or four times ; this ceased and w r as not
renewed, but on the afternoon of the following day her pulse
(whilst lying in bed) was 140, and her temperature 102*°8.
Physical examination of chest, negative. Mental condition w r as
an aggravation of her usual state of semi-stupor. Her pulse and
temperature continued raised for the next few days, and there was
considerable difficulty in administering food. She then passed
into a very restless condition, continually tossing about in bed,
throwing her arms about, and constantly moaning; when moved
she resisted and screamed loudly as if in pain. She gradually got
weaker, and died ten days after the transient attack of diarrhoea,
which appeared to usher in the illness. At the autopsy, besides
the subdural haemorrhage, there w'as found considerable congestion
of the lower lobes of both lungs, but nothing else w r orthy of note.
In this case, as in some of the others, there were continual
restless movements of the arms, occasional screams, and the
frequent utterance of a low moaniDg sound. The restless
movements and the moanings appear to have been the most
constant symptoms noted. Turning to the immediate cause
of death, it will not have escaped notice that in three out of
the four cases more or less disease of the lungs of recent date
was present; in connection with which matter we may recall
the well-known association of pulmonary affections with,
cerebral diseases.
One further point remains for consideration. I stated to¬
wards the commencement of this paper that cases of severe
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1888.] by Joseph Wiolesworth, M.D.
head-injury, such as those associated with fracture of the
skull, had been excluded altogether. It has not, however,
been feasible to exclude entirely the possible agency of a
minor degree of traumatism. Case No. 8 (above described)
presented, when admitted, a good deal of ecchymosis of the
face, chiefly on the left side; and Case No. 26 sustained a
considerable ecchymosis around the right eye, and died a
week afterwards of pneumonia. Did the injury in these two
cases cause the haemorrhage into the subdural space ? In
neither case did it appear sufficient to have done so in a
healthy person; but, given the conditions previously com¬
mented on, as predisposing to haemorrhage, it is clear that
we have in traumatism, even though of a slight nature, an
additional agency, which might be sufficient to turn the
balance in favour of a haemorrhagic effusion, which might
not otherwise have occurred.
Conclusions .—It will be convenient here briefly to sum up
the main conclusions which the foregoing considerations
appear to justify :—
(1) The morbid conditions described under the term pachy¬
meningitis interna hcemorrhagica are not the result of inflam¬
mation at all, but are solely due to the effusion of blood
beneath the dura-mater; the haematomata thus formed be¬
coming organized and eventually converted into fibrinous
membranes.
(2) Such effusions of blood are especially liable to occur in
the insane by reason of the loss of support sustained by the
meningeal vessels, on account of the convolutional atrophy
which is so marked a concomitant of insanity; assisted as
this condition so frequently is by transitory or more per¬
manent congestions.
(3) It is because these conditions are most perfectly ful¬
filled in general paralysis that haematomata are more often
met with in this disease than in any other form of insanity.
(4) Whilst subdural haemorrhage occurs by far the most
frequently in chronic cases of insanity, it is also met with in
a small minority of acute cases, chiefly, if not solely, when
the symptoms have been of a melancholic character; and in
these cases the haemorrhage may introduce a complication
which may actually be the cause of the death of the patient.
(5) Whilst in the great majority of cases traumatism may
be confidently excluded, there seems reason for believing
that, under favourable predisposing conditions, a slight injury
may start a haemorrhage which may prove fatal.
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524
CLINICAL NOTES AND CASES.
Folie du Doute. By P. J. Kowalewskt, Professor of Psychi¬
atry and Neurology at the University of Kharcov.
(Concluded from p. 218 .)
I shall now allow myself to mention a case in my own
practice.
Mrs. Sch., aged 27, wife of a physician. Her father is a healthy,
vigorous man. Her mother a sickly woman. Her cousin (related
to the two families, the father and uncle of the patient having
married two sisters) has attacks of epilepsy. The brothers and
sisters of the patient are in good health. The patient was
nervous from her childhood. She was married five years ago.
Soon after her marriage her husband went to the war, and this
made a strong impression on the young lady. During her preg¬
nancy a mole showed itself, followed by violent haemorrhages. All
these causes—haemorrhages, pains, and mental commotion—highly
affected the health of the patient. She became anaemic, suspicious,
and anxious about the state of her health. She began to entertain
fears that the genitals, but no other part of her body, would
take cold, and in consequence of these fears she wrapped, even in
summer, the lower part of the abdomen, legs, and sexual parts in
flannels. On one occasion, whilst making an injection, the mid¬
wife accidentally broke the glass bottle which contained the liquid.
This brought on a dreadful fit of terror, the patient fearing that
the broken pieces would enter the genitals. She had a throttling
sensation in the throat, her arms and legs trembled, and she burst
into tears. This acute attack did not last long, but the doubts
remained, and from this moment she suffered dreadful torments.
She feared that the pieces of glass would fall on her dress, petti¬
coat, or shift, and from thence enter the genitals, and in order to
avoid this misfortune, she used to examine, hundreds of times a
day, her dress and underclothing, and as soon as this examination
was finished doubts again arose in her mind whether pieces of
glass had, after all, not remained concealed in her dress. She
allowed nobody to make her bed, examining herself minutely every
part of it, and frequently when already in bed she used to jump
out suddenly and again recommence examining and shaking out
the bed clothes. The linen was always washed under her own
personal supervision and dried in her own room, as if left out of
doors someone might throw glass on it. But even in her own
room the linen used to dry either in her presence or with the doors
locked. She could not look at objects made of glass, and there¬
fore glasses, lamps, &c., were banished from her house. The
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Clinical Notes and Cases.
525
window panes were her great tyrants as she could not do other¬
wise than put up with them. She could exist as long as nothing
was broken in the house, but when she heard the sound of glass
breaking in the house she shrieked, groaned, and was in a state
of terror. It is a noteworthy fact that she could eat and drink
quietly without fearing that the pieces of glass would enter into
her mouth, but she was always terrified at the thought that they
could come into contact with the sexual organs. She dreaded going
into the street, full of fear of coming on pieces of glass. When,
unfortunately, she saw a piece of glass, she made a wide circuit
round it, but this did not save her from the necessity of examining
and shaking out her dress, &c. When the patient looked out of
her window into the yard, and someone broke a glass or anything
else in an adjoining yard, she had for days long no peace of mind.
She was terrified when she had to take medicine out of a glass
bottle. She kept examining it to see that it was not cracked, and
if a crack did exist it caused her endless terror. Another mis¬
fortune soon added itself to the first. The patient began to be
afraid of needles. She fancied that the end of the needle would
break, fall on her dress, and thence enter the sexual organs. In
consequence, before making use of the needle, she used to examine
it frequently, and, after having ascertained that the needle was
whole, she nevertheless examined her dress and underclothing. In
the summer of 1881 she went to Tatta, but this journey, instead
of quieting her, made her only worse. Added to all this, the
patient was anaemic and heard noises in her ears. Antiflexio uteri
et catarrhus colli uteri.
We pointed out that neurasthenia could engender many
neuroses and psychoses. These neuroses and psychoses may
appear alone or in various forms in combination with each
other, and we have many clinical cases of such a combina¬
tion. Under the denomination Onomatomania, Prof. Charcot
and Dr. Magnan* have given an excellent description of
pathophobia and uncontrollable obsessions combined. R6gisf
described emotional delirium with anxietas pnecordialis
combined. A. TakovlewJ described a case of pathophobia
accompanied by “ impulsive ” acts. Roussell§ showed the con¬
nection between epilepsy and uncontrollable obsessions.
Gnauck,|| Sovetow,^ Platouow,** and others demonstrated
the combination of delusion of persecution with epilepsy.
* Prof. Charcot and Magnan, “ Archive de Neurologic,’* No. 29.
t Btgis, “ I/Encephale,” 1885, No. 6.
X A. A. Takovlew, “Arch. Psychiatric,” Vol. vii., 2.
§ Boossell, “ The.British Medical Journal,” 1879.
|| Gnanck, “ Arch. f. Psychiatric,” B. xii., No. 2.
if Sovetow, “ Arch. f. Psychiatrie,” Vol: i., 2.
** Platonow, “Arch. f. Psychiatrie,” Vol. xii., No. 1:
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526 Clinical Notes and Cases . [Jan.,
Will© mentions a case where hereditary ideas changed into
“ Griibelsucht. Folie du doute/’ &c. We could quote a great
many instances of similar combinations.
We can state that a degenerative psychosis can also appear
as a combination of different varieties of delusion. Thus, we
can meet delusion of persecution combined with hypochon¬
dria, delusion of doubt with hypochondria, or with delirium
of persecution. We shall here describe a case where folly of
doubt was combined with delusion of persecution.
Countess A. K., twenty-six years old, granddaughter of General
K., one of the heroes of 1812. Her father was a very cruel and
impetuous man; her father’s brother had epileptic fits. The
patient’s mother is also eccentric. During her lifetime she was
suspicious and distrustful. She had lost her husband fifteen years
ago, and since his death she had been constantly wandering from
place to place—Petersburg, Nice, Biarritz, Moscow, Kharkow,
Kiew, &c. The servants could not stay in the house. She at first
liked and caressed them, but they soon were out of favour. She
at first suspected and soon after dismissed them. When living in
her own house, where she always had three doorkeepers and a
great many servants, the old countess used every day, before
going to bed, to examine herself the whole house, after which
mother and daughter locked themselves up in their rooms. The
old countess frequently got up in the middle of the night and went
all over the rooms, fearing that someone was hidden in the house.
The distrust of the old countess showed itself specially in conver¬
sation on serious subjects. At every new idea that was started
she used invariably to put the question—“ What does it mean ? ”
and at any news she heard—“ Why should it be so ? ”
The patient had six brothers, of whom one died of general
paralysis of the insane. Another, a very nervous man, died in a
state of lunacy. A third involved himself in speculations by
which he ruined himself and his family. Two others are so stout
that, when driving in a carriage, they have to sit opposite each
other. The brothers are, notwithstanding, clever, intelligent, and
practical men. The patient always lived with her mother, and
after the death of her father seldom with the other members of her
family. Speaking of her brothers, she used to say—“ We are very
fond of each other, but when we are together w'e always quarrel.”
From her early childhood she was nervous and impressionable.
Educated by a nervous and suspicious mother, she naturally took
after her. In childhood her affections underwent sudden changes.
The patient writes in her autobiography—“ At times she became
pensive, serious thoughts arose in her mind, her heart beat vio¬
lently, her eyes filled with tears, and their expression ceased to be
that of a child, and became melancholy. This state did not, how¬
ever, last long, and used to end suddenly by some childish frolic
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1888.]
Clinical Notes and Cases .
527
and by an unrestrainable fit of laughter.” During her childhood
the patient suffered from many complaints, especially those of the
digestive organs. Until her sixteenth year she was a thin, pale,
sickly-looking and nervous young girl, but from that time she
rapidly recovered, and developed herself. She had twice hit her
head, once on the sinciput and another time on the occiput. Men-
struse showed themselves in her sixteenth year, and continued
regularly without any morbid phenomena except some irritation.
The patient was well brought up, and notwithstanding the frivo¬
lous, aristocratical life which she led, she found time for serious
reading. From some of her writings, which 1 had occasion to see,
it is evident that she interested herself in particular in the relation
of man to God, as well as to nature, and in all its surroundings. The
problem of existence troubled her. She did not follow religious
rites, but her mind was absorbed in religious thoughts, and she
endeavoured to study the thoughts of others. She suffered very
much morally, and sought for consolation and peace either in God
or in nature. By her own writings or by the extracts which she
made from books, it can be seen that she suffered mentally, was
dissatisfied, and was seeking for peace of mind. She began the
history of her life as follows :—“ The life of man is an enigma,
the possibility of happiness is given to everyone, but fatality often
ruins the career of man, and that which could have been will never
recur again. There are natures that can love with all their heart,
for whom love is as necessary as air and light, and fbr whom life
without love is reduced to a state of vegetation.”
This melancholy, despairing state of the mind in search of con¬
solation is to be traced throughout all the writings of the patient.
She was not of an even temper. She sometimes felt affection for
a friend and confided to her her innermost thoughts and secrets,
and then suddenly, without any or for the most futile cause, she
broke off all relations with her and considered her henceforth as
her enemy and as a dangerous person. These ruptures grieved
her intensely, and rendered her suspicious and disenchanted of
people. The same used to occur with servants, whom she at first
treated as friends and afterwards as enemies, spies, &c. It is a
noteworthy fact that the mother as well as the daughter, if they
quarrelled with anybody, each transferred at once her affections
to some other person. When, for instance, they quarrelled with
one of the brothers, they used to transfer at once their attentions
and affection to another brother, a servant, &c. The brothers were
quite aware of this, and knew that the same fate awaited the
beloved of the moment.
From her earliest years the patient admired the beauties of
nature and art. Travelling in Italy, Tyrol, France, &c., she
used to take long walks contemplating the views. Whilst at
Munich she often went to the gallery of paintings, spending
there many hours. All this contributed to make her pensive,
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528 Clinical Notes and Cases . [Jan.,
and seek for solitude. She liked to bury herself in her own
thoughts.
Suffering from a chronic inflammation of the digestive organs,
the patient frequently complained of feeling ill and languid. Her
relations say that she became hypochondriac. Being of a loving
and warm disposition, she fell in love four years ago with a young
man who reciprocated her love; but the suspicious character of
mother and daughter caused a rupture. It seemed to both women
that the bridegroom did not love his bride sufficiently; that he
wished to marry only for the sake of her money; that he had a
mistress, &c. All this was pure invention, but the young man
was rejected. The mental sorrows of the patient were somewhat
soothed by constant travelling, but she became still more suspicious
and distrustful, and at the same time superstitious. She fancied
that she was “ clairvoyante.” The following circumstance was
what brought this on. She saw as a vision a gentleman acquain¬
tance riding on horseback; that the horse reared and threw him
off, and that he hurt his forehead. The fall from the horse and the
sight of the gentleman’s face covered with blood caused a great
fright to the patient, who shrieked. Her mother succeeded in
quieting her, but the day and hour when the patient had this vision
were noted, and soon after they learned from the sister of the
gentleman in question that he had had a fall from his horse pre¬
cisely on the same day and at the same hour. From this time the
patient became convinced that she was. “ clairvoyante.” She
believed in fortune-tellings, chiromancy, &c., and was in despair
when her forecastings were unfavourable.
In the meantime revolutionary movements had commenced in
Russia, and amongst its victims were several of the patient's
friends and relations. She became still more suspicious and
exceedingly irritable. This was a year and a half before she
became completely insane, and she got worse and worse every
day. The patient suspected that the floor had been made double
for some evil purposes by enemies, and that the servants put poison
in her mother’s bed. She feared to lie on the sofa, as she said
that there was something wrong. She was particularly suspicious
of her sister-in-law, who was a very amiable young lady, who did
everything she could to please her. The sister-in-law accompanied
the patient and her mother to Kiew, where they frequented very
much society. The sister-in-law invited young men to her house,
and endeavoured to find amongst them a husband for the patient,
and in this she succeeded. A young gentleman made to the
patient a proposal of marriage, and he was accepted by her. But
very soon suspicions arose. Her sister-in-law was young and
beautiful, and the young men used to pay their court to her. The
patient fancied that she wanted to prevent the marriage, and
angry words passed between her and her sister-in-law. The
mother and daughter fancied that thcii relations were in the •
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529
1888.] Clinical Notes and Cases.
plot. The bridegroom was rejected, and fche patient grew much
worse.
At this time the patient began to write a novel under the title
“ Lost Happiness,” wherein she describes herself; but, unfortu¬
nately, in consequence of her illness, the novel stops where the
heroine’s childhood is described.
During the last years appeared the symptoms of the delusion of
doubt. The patient used to rise several times to lock a door, and
after having repeatedly ascertained that the door was locked, she
nevertheless again had doubts of its being locked, and again
rose. She could neither eat nor drink without fancying that the
food was either of bad quality or was poisoned. She frequently
had doubts of her having paid the tradesmen’s bills, and used to
go over and over to inquire. The patient was very fond of read¬
ing, and was in the habit of making marginal notes in the books
which she read. She began to fancy that persons touched her
books, which annoyed her, and caused her to wash her hands.
Soon after she got into the habit of washing her hands on touching
any object. When she took up anything she examined it for some
time with disgust, and then either kept it in her hand with a feeling
of restraint or threw it away in disgust. Whilst eating or taking
anything in her hand she would always ask what it meant, or
what it would lead to afterwards. As these symptoms only
showed themselves at intervals they w r ere not considered as
pathological symptoms, and were attributed to extravagance and
to her being spoilt. At the same time, the patient considered
herself to be very ill, and drank a great deal of milk, and tried to
get better, although she had an excellent constitution and was
fairly stout. She complained of oppression on the chest and of
retchings.
After having rejected her bridegroom in Kiew, the patient and
her mother seem to have lost their presence of mind, and did not
know what to do. They took several decisions without, however,
carrying any of them out. They decided to go to Moscow, to the
Crimea, to Nice, Petersburg, and came to Kharcow. Having a
beautiful house in St. Petersburg, they hired rich apartments in
Kiew, which they left to go into an hotel, and finally they set off
travelling.
All these decisions were communicated to the brothers, who
were requested to forward the ladies’ effects to various places, and
it thus happened that umbrellas were sent to Tatta, shoes to
Moscow, a fur cloak to Petersburg, money to Nice, whilst the
patient and her mother finally went to Kharcow. During the
journey frow Kiew to Kharcow the illness developed itself into an
acute shape. When they entered the railway carriage the patient
grew suddenly alarmed, and called out, “No, no! we shall not be
well here, it is a bad carriage.” They changed carriages, on
which the patient exclaimed again, “We should have remained in
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530
Clinical Notes and Cases .
[Jan.,
the first carriage, which was good. This is a bad one.” The
patient was agitated during all the time that the journey lasted.
“ There is a noise in the carriage. They meant to do something to
ns.” She begged her mother at every station not to proceed any
further as they were running to their perdition. During the
journey she refused to take any nourishment, as everything was
poisoned; so was the air, and every object surrounding her. She
must not touch anything, nor must anybody touch her. There
w r as something peculiar about the train which was specially
destined to torture them.
They arrived at Kharcow. On their way from the station the
mother related that the patient complained of everybody they met
turning their heads aw’ay and looking angrily at them. On enter¬
ing the room of a w r ell-known hotel the patient complained that it
was bad, and that there was a peculiar smell in it, and that it was
poisoned, and that she must go into another room. In the same
hotel lodged Count K., the patient’s uncle, who offered to give up
his own room, but she found that this room was also bad. Some
misfortune or other must happen to them. She feared that she was
going to die, and asked to see a doctor. Finally, I was called in.
On my examining the patient, I found the young woman to be
tall, well-formed, fair, of a good constitution, and 29 years old.
She did not remain quiet for an instant, -walked about the room,
and talked in a loud and agitated voice. She spoke abruptly, and
repeated one and the same phrase, for instance : “ What will
become of us ? what will become of us ? what will become of us ?
What do you want, doctor ? -what do you want, doctor ? Mother,
do not leave me ! mother, do not leave me! ” &c. Sometimes
these sentences were pronounced in a singing tone, sometimes
they sounded like shrieks.
From the general aspect of the patient it was evident
that she was in a very excited state of mind, proceeding
partly from ideas of persecution and partly from an unac¬
countable torturing feeling of anguish. The patient was
convinced that she, her mother, and her two brothers were
threatened with some dreadful misfortune; they were first
to be all tortured and then murdered. She ran every instant
to her mother, looked into her eyes, kissed her hands, asked
for her blessing as if they were going to be parted and she
was ready to die. Everybody was plotting against them,
everybody was a wretch and a persecutor. The carriages
driving and the men moving about, even a dog crossing the
street, implied something mysterious connected with her
fate. Every movement, every look of bystanders had a
peculiar meaning which the patient commented on, and
which brought on an attack of fear. Since several days the
Digitized by t^ooQle
631
1888.] Clinical Notes and Cases .
patient had not drunk anything, and she was tormented by
thirst.
She took up with avidity a tumbler of water, held it in her
hand for half-an-hour, hut dared not drink, thereby aggravating
the tortures of thirst. “ The water is poisoned.” The patient’s
tongue and lips are parched; a drop of water tastes bad to the
patient, which confirms her in her idea that the water is poisoned.
She eats nothing herself, and gives nothing to her mother to eat.
She has not slept for several nights, and is constantly waking up
her mother, as she is afraid that if they go to sleep they will
never wake up again. The mother could not leave her for an
instant. The functions of the intestinal canal had ceased since
several days; she had retchings and nauseas. The urine passed
seldom, and only in small quantities. It was of a high specific
gravity and acid. The organs of senses were in a state of hyperaes-
thesia. The patient could hear a whisper at a great distance, and
paid great attention when anything was whispered, and at the
same time she did not seem to hear what was said in a loud voice
close to her. The slightest contact with any object, such as a
hair or a feather, excited the patient. Suspiciousness and dis¬
trustfulness on the part of the patient reached their extreme
limits. The train of ideas was in a disordered state—abrupt, and
void of any system. The patient frequently looked at herself in
the glass, and always found some changes in her hair, eyes, &c.
She examined her hands, and found them also changed. She
sometimes remembered certain events in her life and attributed to
them a special meaning. She used to throw herself on her
mother’s things and on her own, hold them tight in her hands, as
if she feared that somebody would take them away from her or
that they were sacred objects. The pulse was feeble, 112 pulsa¬
tions a minute ; no fever. Menstruation appeared four days later
than its usual time.
She grew still more agitated during the night. The following
day she was troubled with the same fears, despair, and unaccount¬
able ideas of persecution, the same dread of death, and of some
dreadful event; the same doubts and fear of dirt and of touching
anything, the indescribable state of anguish, which drove the
patient into despair and made her burst into tears. The phenomena
were the same, but had become more acute. During one of these
paroxysms the patient put half her body out of the window, and
screamed, “ Help! There are women in the room No. 4 being
murdered.” At the same time she broke the lower panes, and it
was with difficulty that she was removed from the window.
The next day the excitement of the patient had somewhat
calmed down, but the delusion of doubt showed itself in a very
marked and clear manner. All that she undertook to do she left
undone twenty times, to begin over again twenty times. “ Bring
xxxin. 35
Digitized by t^ooQle
532 Clinical Notes and Cases . [Jan.,
me some milk,” she said ; “ I shall take it in bed.” The milk is
brought to her. u No, put it on the table.” She walks up to the
table. “ Ah ! why have I come here ? I ought to have taken the
milk in bed.” She goes to the bed. “No, I must have the milk
on the table,” and so on. She takes a bath, puts in her right leg.
“ No, I must put in my left leg.” She puts in her left leg. “ No,
I must put in my right leg,” and so on twenty or thirty times
over and over again. I went out driving with her in a carriage;
she sat on the right and I on the left. “ No,” she said, “ I shall sit
on the right.” We changed places. “No,” she said; “why
should you sit to the right and I to the left ? ” We again changed
places, and so it went on. With all this, the patient suffered,
trembled, cried, and is seized with fear that she did so and not so.
It was only in my presence that those who surrounded her in¬
spired her with a certain amount of confidence ; it was only from
me that she accepted any food. I fell ill, and for five consecutive
days she refused to take any food; and it was only when my
assistant threatened to feed her by force that she. consented to
eat, but until I recovered it was only from my assistant that she
accepted any food. The delusion of doubt, which at times showed
itself very clearly, gradually disappeared altogether, and was
succeeded by a state of simple w ant of self-confidence, and a
dread of every object and apparition. When she was calm she
recognized the absurdity of her fears, but a moment after the
same fears reappeared.
This state lasted nearly three months. Under the influence
of a calming treatment appeared “ intervalum lucidum” After a
year I met her at Reichenhalle, and found her in the same state,
but in which the “ folie du dotite” showed itself under a more
acute form.
I allow myself from all that precedes to draw the following
conclusions:—
1. That neurasthenia engenders neurosis in various forms
and degenerative psychosis.
2. That in many cases the disease is limited to neurasthenia,
hut that in some, neurasthenia enters into a second stage,
i.e. 9 elementary mental disorders.
3. That these elementary disorders either have a happy
issue or enter the third stage—organized neurosis and
psychosis.
4. That in exceptional cases, neurasthenia can engender
pathophobia, which, in connection with uncontrollable obses¬
sions, can degenerate into u folie du doute”
5. The delusion of doubt may appear in its pure form or
in connection with other forms of degenerative psychosis,
hypochondriacal delusions, &c.
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Digitized by L^ooQle
Clinical Notes and Cases .
533
1888.]
Case of Multiple Sarcomata of the Cerebrum . By F. St. John
Bullen, M.R.C.S., L.S.A., Pathologist and Assistant-
Medical Officer, West Riding Asylum. (With Plate.)
W. K., aet. 52, admitted into West Riding Asylum, Feb. 12th,
1887, died March 14th, 1887.
I am indebted to his medical attendant for the following
details:—
History. —Patient’s general health has shown signs of failing for
some time. In October, 1886, he was treated for catarrhal pneu¬
monia ; in the course of a fortnight complete infraclavicular dul-
ness on the right side was noticed, with absence of breath sounds.
An exploratory puncture gave a negative result. In November,
pain, cramp, and numbness in the right arm, the former shooting
up the neck, were superadded to the preceding, and these
symptoms were held to justify the diagnosis of tumour. In
January, symptoms of mental derangement were observed, he
became drowsy, depressed, irritable, wandered about aimlessly,
and developed delusions. He suffered from frontal and occipital
headache and neuralgia, w r ith occasional attacks of giddiness.
He had been a very intemperate beer-drinker.
Family History. —Phthisis and cancer said to have existed in his
family. No insanity.
Mental state on admission. —Patient was very drowsy and
apathetic, and required much rousing before he could be made to
answer questions. He did not recognize his surroundings, nor did
he manifest any desire to do so. He >vas unable to give his age,
the date, his home, address, or to render any account of his illness.
He was aw r are of his failure of memory, and said that he did not
sleep well. There was no evidence of hallucinations.
Physical condition. —Obese and flabby, head large, fairly well¬
shaped, face rather cyanosed, bloated, with enlarged capillaries,
pupils equal, reactions sluggish but present, patellar reflexes very
exaggerated, the superficial reflexes present.
Thoracic examination. —Breathing laboured, at intervals pa¬
roxysmal attacks of coughing, which left him much cyanosed and
twitching about the face. The cough accompanied by mucous
rales, but no expectoration.
Distinct dulness existed over front and upper part of chest, to
the right of the sternum, shading off gradually about its middle.
Breath sounds harsh, expiration everywhere prolonged, vocal
resonance somewhat diminished, heart sounds feeble, otherwise
normal, extensive engorgement of the veins of the neck and front
of chest, urine normal.
Progress of case .—During the next week there was but little
change beyond slight aggravation of the foregoing symptoms. It
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534 Clinical Notes and Cases. [Jan.,
was suspected that there was a greatly thickened pleura and
enlargement of the bronchial glands.
A week later the dulness had extended towards the back of the
thorax, and aegophony was observed below and in front. Dry
rales and rlionchi were present.
In the course of the following fortnight patient grew worse.
Over the right front of the chest the skin was very oedematous,
The dulness was absolute over the whole right side. Heart-sounds
scarcely audible. He was restless, and slept but little. Cyanosis
increased; he grew rapidly feeble and passed into a semi-uncon¬
scious state, twitched about the face, and died asphyxiated.
Throughout his temperature was normal, and he was able to
sleep on either side. On two occasions an exploratory puncture
w r as made, but only about a drachm of slightly turbid fluid was
withdrawn.
Post-mortem, the following was observed :—Considerable oedema
of right upper extremity, and of head and neck. Adherent to the
upper part of the pericardium w T as a mass of tumour, about two
inches in diameter, through the centre of which one of the pul¬
monary veins passed.
The heart showed no morbid change, save much dilatation of
the tricuspid orifice. A large cyst existed at the lower part of the
right pleural sac, holding about twenty-four ounces of purulent
fluid, solidified pus, and gelatinous material. The pleura was
greatly thickened, and there were strong adhesions between it and
the lung.
At the upper and inner part of the right lung, and extending
up by the side of the trachea to rather above the level of the first
rib, was a morbid grow'th, lobulated, soft, and in the larger masses
diffluent at the centre. Portions were deeply pigmented.
The tumour on section presented an almost creamy-white
appearance, with a slight pinkish tinge. Portions having similar
characters, but firmer, extended into the interior of the lung about
the root. The lung was everywhere dark, and showed some fibrosis
and a portion of consolidation, the result of catarrhal pneumonia;
it was compressed so as to be almost devoid of air. Left lung
slightly congested and oedematous ; early cirrhosis of liver; other
viscera normal.
The skull-cap was rather thin, but dense; the dura mater
slightly morbidly adherent. The sinuses contained a little black
clot; the veins were somewhat distended. Inner meninges showed
thickening, toughening, and opacity, and an excess of serous fluid
was held in their meshes—most abundant over the convolutions
immediately bounding the longitudinal fissure. No disease of
vessels. The brain was of good size and consistence, and its gyri
of fair complexity and arrangement. Scattered over the surface
of the hemispheres were many small fungoid growths, varying in
size from a pin’s head to a large pea. They were placed alike on
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1888 .]
Clinical Notes and Cases .
535
the summits of the convolutions and in the sulci between, the
smaller generally occupying the latter position, the larger the
former. These were the more numerous. They were raised from
one to three lines above the level of the gyrus; their margins were
bevelled, their summits flat, except in the sulci, where they were
rounded. The surface of the majority was abraded by the removal
of the membranes, and here their margins were often everted
and lipped. Their number appeared about equal on the two
sides of the brain. They were most numerous over the frontal
are®.
Where the brain matter had been unavoidably lacerated in re¬
moving the membranes, owing to the intimacy of their adhesion
to the summits of the tumours, an irregular excavation of the
following characters was left : It was limited to the gyrus de¬
stroyed, not implicating the convolutions in its vicinity. The
margins, floor, and walls of it were alike ill-defined, pulpy, and
flocculent. From the latter numerous fibrinous shreds hung. A
general rusty tint, significant of minute haemorrhages into the
brain-substance, was present. The surface of each tumour where
the covering of cortical matter had been removed was soft, fluffy,
and streaked, often radiately, by delicate vessels, so numerous as
to contribute a general red, rusty tint to the whole. On section
of a convolution the growth appeared to have commenced in and
to have involved chiefly the medullary matter; the grey cortex,
somewhat thinned, was spread out over it.
Microscopic examination .—The thoracic tumour appeared to
consist exclusively of small, round cells, occasionally somewhat
irregular, packed together without obvious stroma, and containing
one or more nuclei. Numerous vessels traversed the mass; they
were but channels, their walls being composed of cells similar to
those constituting the bulk of the tumour; in only a few cases did
connective tissue aid in their formation.
The cerebral tumour was composed of small, round, nucleated
cells, imbedded in the meshes of a fine, web-like reticulum, the
fibres of which appeared to penetrate between the individual cells.
A few of the latter scattered through the section were of greater
size, triangular shaped, with large nucleus, and having processes
continued into the reticulate stroma. In parts, the structure more
closely resembled that of the thoracic growth, the cell elements
being massed together and the reticulum not obvious. Many of
the vessels presented signs of rupture and extravasation of their
contents.
This case is of interest as exemplifying the possibility of
tumours affecting the cortex without any symptoms obviously
denoting them.
The mental symptoms which the patient exhibited were
easily explicable as due to the intense venous congestion
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536 Clinical Notes and Cases . [Jan.,
produced by the thoracic tumour, as well as to his previous
intemperate habits.
I have extracted from the pathological records of the
asylum four other cases of cerebral tumour worthy of group¬
ing with the preceding. In none of these did any symptoms
exist apart from the mental disorder, which itself was not
indicative of the growth of a tumour. Briefly abstracted,
they were the following :—
Case I.— A tumour, the size of a hen’s egg, involving the orbital
lobule of the frontal lobe.
Case II.—Two rounded growths (sarcomatous), one and a half
and one and a quarter inches in diameter respectively, occupying
the white matter of the temporo-sphenpidal and frontal lobes of
the left hemisphere, the smaller ones the frontal region of the
right.
Case III.—A tumour, about the size of a pigeon’s egg, in the
centrum ovale of each hemisphere, immediately overlying the roof
of the lateral ventricle, of the nature of angioma.
Case IY.—A growth involving the outer division of the
lenticular nucleus of the left side, the external capsule, claustrum,
medullary, and grey matter of the Island of Reil.
Case of M . R.—A Medico-Legal Study. By Richard J.
Kinkead, M.D., Lecturer on Medical Jurisprudence,
Queen’s College, Galway.*
The following case would prove interesting merely as a
medico-legal record ; but, decided as it was on the mental
condition of the prisoner, as it raised the question of insanity
and crime—as fine distinctions were drawn as to the legal
difference between drunkenness and disease of the mind pro¬
duced by drink, and, again, between voluntary, or involuntary,
or accidental, drunkenness, and the criminal responsibility
connected therewith—I venture to submit it to the Psycholo¬
gical Section.
M. R. was committed to Her Majesty’s Prison, Galway, on the
23rd April, and tried before Chief Baron Palles and a common jury
on the 20th July, 1887, for the wilful murder of M. D.
Evidence for the Crown was given by the mother, sister-in-law,
and brother of the deceased, the servant man, the sister-in-law’s
father, a neighbour, Dr. Dalton, who had attended him dining life,
* Read in the Psychology Section of the British Medical Association, at the
Dublin Meeting, August, 1S87.
Digitized by AjOOQle
1888 .]
Clinical Notes and Cases .
537
and Dr. Nally, who assisted Dr. Dalton to examine the body after
death.
Professors Pye and Kinkead were examined by the defence.
The witnesses produced by the Crown showed, that D. had been
suffering from typhus fever; that the prisoner was engaged as
nurse on the 15th April, and from that day till the night of Friday,
the 22nd, or early in the morning of the 23rd, she had been nurs¬
ing him night and day; that the doctor last saw him on the Wed¬
nesday (20th April) before his death ; that he was then very weak,
apparently sinking, and the doctor told the relatives that he did
not expect him to recover.
That about half-past nine or ten o’clock on the night of the 22nd,
the sister-in-law gave a glass of whisky each to her husband and
the servant man; took half a glass herself, gave half a glass to the
nurse, and left the bottle, still containing five glasses, on the dresser
in the kitchen.
That the family then went to bed, leaving the mother and nurse
iii charge of the dying man. The mother, worn out by previous
watching, went into her daughter-in-law’s room about ten o’clock
and fell asleep (this room was separated from that of deceased by
the kitchen or living-room, which occupied the entire centre part
of the house). How long she slept she did not know, but 44 some¬
where abbut an hour before dawn ” she was awakened by the nurse's
screams. On going to the door of the room she saw her son’s dead
body on the floor of the kitchen surrounded by fire ; his clothes, two
shirts, and a pair of drawers, were all consumed, save portions on
the legs and arms; the nurse screaming and dancing about, having
a brush in one hand, a pair of tongs in the other. The mother swore
that not only did the nurse throw fire at her to keep her out of the
kitchen, but threw a 44 pot lid full of coals ” on the deceased;
witness then fainted, or, as she described it, 44 became weak; ” on
coming to herself she succeeded in getting in.
She described the nurse as at times supporting herself by the
walls, at others dragging her legs after her, as being very excited.
Could not say whether she was drunk or mad.
The daughter-in-law was also awakened by the nurse’s screams.
Saw her 44 hopping on the floor ; ” corroborated the mother’s testi¬
mony, except that she did not see any fire thrown.
The other witnesses confirmed the account as to position of
body, <fec., but the servant added that the prisoner asked him for a
drink, and said u She’d soon have the devil burnt, and M. D.
back again.” While the father-in-law deposed that the head
and chest were “ dark scorched,” and the hair burnt off, that he
asked the prisoner 44 What have you done ? ” or 44 Why did you do
it ? ” and that she replied, 44 1 done that—I burnt him. That’s the
divil I burnt, instead of Michael.” In his opinion she was either
drunk or crazy.
The medical evidence was to the effect that the body was burnt
Digitized by AjOOQle
538
Clinical Notes and Cases.
[Jan.,
from head to foot; the burns on the head and chest black and
charred; on the neck and under arms red; those on the back not so
marked, mere scorches; some of the burns were red. Some had a
red line round them, and there were blisters. That some were
inflicted before and some after death, and that death was caused by
burning.
None of the organs of the body had been examined. In fact no
post-mortem examination, in the ordinary acceptation of the term,
had beem made; conclusion as to cause of death was come, to from
extent of burns; the red line and blisters were evidence of their
being inflicted during life. Burns inflicted immediately before,
could be distinguished from those made immediately after death.
The contents of blisters had not been examined. No marks of
violence were found on unbumt portions of body.
For the defence medical evidence was given to the effect that
burns made, roughly speaking, within fifteen minutes before, could
not be distinguished from those produced within fifteen minutes
after death; that the contents of post-mortem burn blisters were
watery, while a life one was rich in albumen; that the charring
of flesh might take place during life, yet it indicated that the tissues
acted on had been first killed by the burn and then charred.
The presumption of the prosecution was that the prisoner had
J ra &g ei d deceased from his bed and burnt him. f
But the entire absence of motive— the man was dying, and the
prisoner was a stranger to him, never having met him until engaged
to nurse him—together 'with the horrible mode of killing, also raised
the presumption that she was insane or drunk.
In support of the latter, although there was no direct evidence
of her having taken more than the half glass of whisky, yet it
was proved that the bottle containing five glasses was put on the
dresser, that it was afterwards found empty, that the mother had
taken none, and that there was no other person who could have
consumed it with the exception of the deceased.
I was directed to examine the prisoner and report as to her
sanity.
I first saw her about 12 o’clock on the 24th April; although the
exact time of the transaction could not be accurately fixed, as the
burning might have taken place any time between 11 p.m. on the
22nd and about two hours before dawn on the morning of the
23rd, yet the time of my examination was within thirty to thirty-
six hours of the occurrence.
She was very nervous and jerky; her pulse 120; temperature
103; tongue foul. She complained of headache, pains in the
bones, shivering, and looked very ill. As she had been nursing a
case of typhus, I thought it probable she might have contracted
the contagion, and isolated her, but as the symptoms passed off in
a couple of days I attributed them to drink, excitement, and the
exhaustion of eight days and nights’ continuous nursing.
Digitized by t^ooQle
Clinical Notes and Cases .
539
1888 .]
Having given evidence to tliis effect, and that she was perfectly
sane both on the 24th of April and 20th of July, I was asked
by the Judge was it possible for a person suffering from delirium
tremens to get well in thirty-six or forty-eight hours.
I replied No; but that I had frequently seen prisoners, com¬
mitted in what I might call the first stage, some of whom suffered
from delusions, get over it in the time specified.
Explaining that though drunkenness was no defence to a criminal
charge, while disease of the mind produced by it was, the Judge
asked were there not conditions of degradation of the blood in
which drink would cause not so much drunkenness but a disease
of the mind ? Supposing, for instance, a week’s watching both
day and night of a fever patient, would not that be likely to pro¬
duce such depravation of the blood that stimulant would take an
unexpected effect and cause disease of the mind ?
I said that much depended on the neurotic constitution and
bodily condition, but given a nervous person, exhausted by such a
watch, if she received a severe shock or great fright, that of itself,
and quite independent of the question of stimulants, might pro¬
duce insanity, either temporary or permanent. Also, depending on
the person’s temperament, there were bodily conditions which
would cause stimulant, taken in less quantities than would at other
times do so, to produce such intoxication as would prevent the
person knowing the nature and quality of his acts.
The case, as put to the jury both by the defence and the Judge,
was —
(1) Did the nurse take the man out of his bed and bum him to
death ?
(2) If so, was he alive when she did it ? If he was, then she
was guilty, but if not, then the burning of the dead body was not
a criminal offence.
The Chief Baron said, that, to establish the charge, the Crown
must prove conclusively that the man w r as alive when burnt; if
there was a reasonable doubt the prisoner should get the benefit,
and he expressed his opinion that it had not been proved that the
man was alive.
If the jury came to the conclusion that he was alive, then they
should consider—
(3) Was she drunk ? or
(4) Was she insane ?
Having explained at length the law with regard to crimes com¬
mitted by the insane, the Judge directed the jury that, drunken¬
ness being a voluntary act, the law rightly held persons responsible
for acts done in a condition voluntarily produced, although when
in that condition they did not know the nature and quality of their
acts, and expressed his emphatic dissent from Mr. Justice Day’s
ruling in Reg. v. Baines. But that if a person, from any cause, say,
long watching, want of sleep, or depravation of blood, was reduced
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540
Clinical Notes and Cases .
[Jan.,
to such a condition that a smaller quantity of stimulant would
make him drunk than would produce such a state if he were in
health, then neither law nor common sense could hold him respon¬
sible for his acts, inasmuch as they were not voluntary but pro¬
duced by disease. It appeared from the evidence that the nurse
was under the delusion that her patient had been turned into a
devil, that the proper course was to burn the devil, and thus bring
back the patient; was that delusion the result of drunkenness or
disease of the mind ?
The jury found the prisoner guilty of manslaughter, but insane
at the time of committing it, and she was ordered to be confined in
a lunatic asylum during the Lord Lieutenant’s pleasure.
To account for the horrible actions done, and the words spoken
by the prisoner, it was suggested that a popular superstition gave
rise to the drunken or insane delusion; but no such superstition
was proved, nor am I aware that any exists to the effect that a
dying man is changed into a devil, that the latter can be purgated
by fire, and the former thereby restored; nor would it be consis¬
tent with the logical cunning of a lunatic to endeavour to drive out
a spirit by the very element in which he is supposed to live and
move habitually.
No doubt there is a prevalent, superstition as to changelings, but
I believe such transformations are confined to children, and the
power of working them strictly limited to “the good people” or
fairies.
The real solution, as it appears to me, was not put forward
at all.
It is not unusual that, to a person dying of fever, there
should come a sudden accession of strength—-the last flicker
of the flitting flame—sufficient to enable him to leave his bed
and walk.
I believe this happened in this case; that he did get up;
got as far as the kitchen, and fell into the fire; it is more
probable than not that he fell into it dead—the exertion
exhausting the last remnant of vital force.
The nurse and mother being asleep, there is no evidence as
to how long the body lay there, but from the charred con¬
dition of the head and chest, and the almost total consump¬
tion of the clothes, it must have lain a considerable time.
When the nurse awoke she saw her patient lying in the
fire and rushed to pull him out; in doing so, the fire being
a turf one, “ on the hearth,” a considerable quantity of the
coals must have been dragged out along with the body—
* hence the statement as to the fire surrounding it.
It is not surprising that an ignorant woman, suddenly
aroused from sleep, her nervous system excited from eight
Digitized by t^ooQle
Clinical Notes cmd Cases.
541
1888.]
days and nights of watching, startled at the sight, and pro¬
bably drunk, on turning over the body and seeing a black
face, head, and chest, instead of her patient's features, should
imagine that what she saw was the devil, and arrive at the
idea that she could call back the patient by continuing to
heap coals of fire on the devil's head.
Nor is this view inconsistent with her words, for even sup¬
posing that she knew what she was saying, which is doubtful,
they would imply no more than a consciousness that the catas¬
trophe was caused by her negligence, and that she was doing
her best to remedy the mischief. That not a single witness
testified to the house being filled with smoke, is, however,
inconsistent with the theory propounded that she burnt
deceased in the middle of the kitchen floor.
Medically, it makes no difference as to the fact of a man's
being temporarily insane, whether the poison producing the
insanity has been consumed, or generated within his body.
Legally the difference is very decided, for the one may be
hung for murder, and the other may not; although Mr.
Justice Day said in Reg. v. Baines—“I have ruled that if a
man were in such a state of intoxication that he did not know
the nature of his act, or that his act was wrongful, his act
would be excusable." Yet there is no doubt but that the
majority of the judges would concur with the Chief Baron
that a man was criminally responsible for his acts when
drunk. But the distinction drawn by the Chief Baron be¬
tween voluntary and involuntary drunkenness has not been
always acted on, moreover it opens up a very wide field.
If criminal consequences do not attach when intoxication
is involuntary in the sense of being unexpected, it follows
when involuntary in its true sense—that is, when the will
cannot control the craving arising from habitual excess;
when from some inherited neurotic constitution, or acquired
nervous defect, or exhaustion, the will-power is weakened and
a systemic demand for stimulant springs up—that drunken¬
ness becomes a valid plea. Hence there is imported into such
investigations questions as to those neurotic and physical con¬
ditions, either inherited or acquired, which predispose to, and
often compel, excessive drinking.
The problem is thus rendered even more complicated than
a Chinese puzzle, and involves a number of unknown quanti¬
ties, so that it may be unsolvable, or its solution mere guess¬
work ; and thus justice, instead of acting on fixed and rational
principles, becomes fallacious and uncertain.
Digitized by C^ooQle
542 Clinical Notes and Cases . [Jan.,
This must be so as long as the law (1) fails to recognize all
insanity as disease, and that the acts springing from disease
can’t be controlled, nor the disease cured by punishment; (2)
while it fails to recognize that mental alienation from alco¬
holic poisoning is a true insanity; and (3) while it fails to
recognize the production of this insanity as an offence, and
only connotes crime to the acts resulting therefrom.
Can the question be solved, save in very exceptional cases,
as to how much was due to insanity, i.e., perverted nervous
action caused by functional or organic derangement arising
from within, and how much was due to drink, t.e., perverted
nervous action produced by alcohol ?
Again, when does drunkenness cease to be simply drunken¬
ness and become a disease of the mind ?
Mr. Justice Manisty in Reg. v . McGowan, ruled “ that a
state of disease brought on by a person’s own act— e.g.> deli¬
rium tremens, caused by excessive drinking—was no excuse for
committing a crime unless the disease so produced was per¬
manent.” Chief Baron Palles distinctly charged that while
drunkenness was no defence, disease produced by drunken¬
ness was.
Whether the craving for excessive stimulation be the result
of inherited defects or acquired nervous disabilities, or created
by habit, once established it is a disease, and my experience
leads me to conclude that not one in a hundred can control
the craving. Drinking with such persons is therefore in¬
voluntary, and I concur that it is not common sense, whatever
may be the law, to punish such persons for acts committed in
a condition which they can’t help getting into, and which,
moreover, the law does nothing to prevent; but it does seem
inconsistent that, while those who, by their own acts, have
established a diseased condition, should escape punishment,
the man who has only taken one or two steps on the down¬
ward road should be punished, not for having entered on the
incline, but for acts which he could neither control, nor know
the nature and quality of.
It would be intolerable that men should be permitted to
get drunk and commit criminal acts with impunity, but it is
just as intolerable to permit them to get drunk with impunity
and then try them for their lives, aye, and hang them too, for
acts done in the insane condition which the law allows them
to produce, and which the Legislature declines to prevent or
remedy.
Digitized by L^ooQle
1888.] Clinical Notes and Cases . 643
Hysteria in Men . By Francis W. Clark, Assistant Medical
Officer to the Croydon Infirmary.
The subject of hysteria is one which must always demand
attention from the practical physician, owing to the infinite
variety of the phases under which the disease may present
itself, the aptitude with which it simulates other diseases of
a purely organic na/ture, and, lastly, the frequent association
of organic lesions with symptoms of a purely psychical
origin.
The evident loss of self-control, or “ will-power/’ as it has
been termed, which lies at the root of all the symptoms of
this strange disease, appears, perhaps, in stronger contrast
w r hen occurring in men, from the fact that more or less
deficiency in this respect is looked upon as one of the special
characteristics of the weaker sex.
Many have been the theories mooted with the object of
throwing some light upon the pathology of hysteria, and I
will, with your permission, venture to mention one or two of
the more feasible of these hypotheses.
It will be obvious that the numerous aspects under which
the disease may present itself point clearly to a central
rather than to a peripheral origin, and hence it is that the
various theories centre round some abnormal condition of
the cerebral hemispheres. The two theories most in vogue
at the present day may best be described as the vascular and
the molecular theories. According to the former, the symp¬
toms of the disease, hysteria, depend for the most part upon
an altered blood-supply to the ganglionic centres of the
cerebral cortex. This theory gains considerable support
from the fact that fasting, anaemia, and all sources of pro¬
longed physical and mental exhaustion are potent causes of
certain forms of hysteria, mostly of a convulsive type, and
moreover that stimulants and a generous dietary will, in such
cases, frequently modify or prevent an impending attack.
The other theory, which I have named the molecular
theory, and which claims, perhaps, more adherents than the
foregoing, is to the effect that certain molecular changes
occur in the cortex of the cerebral hemispheres, disturbing
for the time being the due relation between central and
peripheral nerve-strands. This theory has been aptly illus¬
trated by Dr. Russell Reynolds, who compared the relation
existing between a healthy and a hysterical brain to that
existing between a magnetized and a de-magnetized iron
Digitized by t^ooQle
544 Clinical litotes and Cases. [Jan.,
bar. We all know that a physical shock will so disturb the
molecular composition of a magnetized iron bar as to deprive
it of its magnetism, and in a similar manner may we not
imagine that such a shock may suffice, in certain constitu¬
tions, to so alter the molecular composition of the cerebral
cortex as to deprive the subject, for a time, of his power of
self-control? There is, however, this great difference
between the de-magnetized iron-bar and the hysterical
brain, that the former, being inert, can never spontaneously
regain its magnetism, whereas the latter, being a living,
growing body, may, in time, regain its wonted stability.
With reference to the treatment of this disease, 1 have
found that the removal of the patient from the influence of
all injudicious sympathy, coupled with a plain but ample
dietary, and, where the patient has faith in drugs, some
simple placebo, will lead to a marked improvement in the
symptoms, if not to a complete cure.
The three cases which I wish to detail to you have come
under my care at the Croydon Infirmary during the past
eighteen months, and are all well-marked examples of the
disease.
Case I.—The first case is that of J. C., a potman, aged 27, a tall
and well-developed man, who came under my care first in June of
last year (1886), with a history that, some few years previously
he had been bitten by a dog. No after consequences occurred at
the time, but for about twelve months previous to the time at which
he came under my care he had been suffering from frequent fits of
an epileptiform nature, during which he foamed at the mouth and
barked like a dog, occasionally passing his urine under him.
These fits varied in duration from a quarter of an hour to an hour,
and during the fit there was marked opisthotonos, and the patient
w*as very violent, though he rarely did himself any injury, and
never bit his tongue during a fit. If any remarks were passed by
onlookers during a fit the patient invariably remembered what
had been said, and moreover it was found that when suggestions
as to any heroic form of treatment (such as a cold douche) were
made in his presence he came round far more rapidly than would
otherwise have been the case. The patient was a man of most
violent temper, and it was observed that he always had a fit when
anything occurred to displease Lim, or which threatened to inter¬
fere with his personal comfort.
In the intervals between these fits he complained of absolute
loss of power in all four limbs, with some occasional and slight
anaesthesia, but there w r as no wasting of any of the muscles, the
reflexes were normal, and the sphincters unaffected. This apparent
paraplegia had lasted for several months.
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1888.]
Ctvrvicat Notes and Cases .
645
In common with many hysterical patients he was unable to
control his laughter when amused, and he would frequently con¬
tinue laughing for an hour or more over some trivial occurrence
which had pleased him.
His intellect was, however, clear, and he took great pleasure in
reading aloud to other patients, doing so with considerable fluency.
Before coming under my care he had been treated with large
doses of bromide of potassium, and setons had been applied behind
his ears, but the fits and the paraplegia still remained.
He was, therefore, placed under the care of a male atten¬
dant, and was given a plain but ample dietary, and it was found
that he gradually convalesced, and at the end of some six months
he was able to walk easily with crutches. He is now, I may add,
earning his own living by working upon a railway-line, although
he still, I hear, makes some use of his crutches, though more
apparently from habit than from necessity. I might mention that
1 have, on more than one occasion, found the greatest difficulty in
inducing patients convalescent from hysterical paraplegia to dis¬
card their crutches when they no longer required them.
One incident, which is extremely characteristic of the disease,
occurred during the time that this patient was paraplegic, namely,
that he was one day intensely annoyed with the nurse for refusing
to turn over for him the newspaper which he was reading. After
roundly abusing the nurse, and having completely lost his temper,
he turned over the paper for himself, this being the first time that
he had moved his arms voluntarily for some months. After this
incident the paralysis of the upper limbs rapidly disappeared, but
the paralysis of the legs remained for some time afterwards.
I would suggest that in this case, which is the most severe one
that I have ever met with, the fear of hydrophobia excited by the
bite of the dog had so unsettled the patient’s mind that he, for a
time, completely lost the power of self-control, and having in his
mind the idea that “ fits ” and paralysis were the ordinary symp¬
toms of hydrophobia, he accordingly gave way to the “ fits ” and
firmly believed himself to be paralyzed.
Case II.—The second case is that of G. M., aged 38, a short,
healthy-looking man, who is subject to periodical attacks of
paralysis of the lower extremities, lasting for from a few days to
two or three weeks. The patient has suffered from these attacks
for the past nine years, and during each attack he is gloomy and
morose, scarcely speaking to anyone, and will refuse food for days.
At other times he is of an exceptionally merry disposition, will
read and talk with fluency, and can walk or run with ease.
Accompanying the paraplegia, the patient suffers from enormous
tympanitic distension of the abdomen, the belly-wall being fre¬
quently as prominent as in a pregnant woman at full term. I can
only compare this condition of the abdomen to that occurring
occasionally in women, under the name of spurious pregnancy,
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646
Clinical Notes and Cases .
[Jan.,
and its cause I believe to be in botb cases an hysterical paralysis
of the muscular walls of the intestine, and abdominal parietes.
This patient has a marked lateral curvature of the spine, with
the convexity towards the left side, and this, he states, he has had
as long as he can remember. There is, however, no tenderness of
the spine, the muscles of the lower limbs are not wasted, and the
reflexes are normal.
This patient has also much improved under similar treatment,
the attacks having become less frequent and of much shorter dura¬
tion during the past twelve months.
In this case, as in the following one, we find associated symp¬
toms of an undoubtedly hysterical origin, with true organic disease,
and it is, of course, in such cases that the greatest care is requisite
in separating the symptoms due to the organic lesions from those
which are of a purely psychical origin.
Cask III.—The third case is that of J. W., aged 63, a spare and
neurotic-looking man, who has suffered from paralysis of the
lower extremities, with tingling sensations and other symptoms of
a subjective nature, for the past four years.
The reflexes are normal, and there is no anaesthesia, no wasting
of the muscles, and no affection of the sphincters, nor was there
any tendency to the formation of bed-sores after the patient had
been bed-ridden for some years. In this case also, strange to
relate, there is a slight lateral curvature of the spine, and the
patient is, moreover, a confirmed masturbator.
All the subjective symptoms were, for some months, completely
cured by small doses of very dilute Aq. Rosae, the patient remark¬
ing, however, on several occasions that the medicine was rather
too strong, and sometimes got into his head. This patient ha s
certainly improved to the extent that he now gets up every day,
whereas formerly he was bed-ridden, but the paralysis of the
low r er extremities has not yet disappeared, and I must confess
that, while admitting hysteria to be responsible for the majority
of the symptoms, I am yet inclined to consider this patient an
inveterate malingerer, who, so long as his friends will support him,
has no desire to regain the pow r er to walk.
Digitized by AjOOQle
1888.]
547
OCCASIONAL NOTES OF THE QUARTER.
“ Not more than Seven Clear Days ”
There is, we are informed, a wide-spread doubt among
medical men accustomed to sign lunacy certificates, and also
among the superintendents of asylums, as to the meaning of
the formula “not more than seven clear days/ 5 The importance
of a correct interpretation is obvious, seeing that unnecessary
delay and expense in obtaining fresh certificates may be in¬
curred in some instances if the period does not lapse so soon
as some suppose, and seeing, moreover, that an asylum super¬
intendent may subject himself to serious legal consequences
if he admits a patient within a period which he believes to
be seven clear days from the date of the medical examination,
but finds when the point is contested that the judges do not
support him in his reading of the phrase. When the Lunacy
Act Amendment Bill was first introduced, the Parliamentary
Committee of the Association requested, among other things,
that this term should be defined, but the Lord Chancellor
did not comply with the request.
The well-known clause in which the law is laid down is
found in 16 and 17 Viet., c. 96, s. 4, and 16 and 17 Viet., c.
97,s.74 —
“No person, not a pauper, shall be received into any
asylum . . . without the medical certificate ... of two
persons . . . each of whom shall separately from the other
have personally examined the person to whom it relates, not
more than seven clear days previously to the reception of
such person into such asylum. . . . And every person who
receives any person, not a pauper, into any asylum, save
under the provisions herein contained, shall be guilty of a
misdemeanour.”
Suppose, for example, a medical man examines a patient
on February 1, how long is his certificate valid ? On what
day subsequently would a superintendent be guilty of a mis¬
demeanour if he admitted him into his asylum ? Some reply
that the certificate is valid until February 8, and no longer;
others until February 9. If the former be correct, it is
obvious that a superintendent who admits the patient on the
9th, subjects himself to the risk of a penalty and great
annoyance.
The Lunacy Commissioners, it is well known, hold that
xxxxii. 36
/
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548 Occasional Notes of the Quarter . [Jan.,
“ seven clear days ” cover a period of nine days. Thus they
would accept as legal the admission of a patient into an
asylum on the 9th of February whose examination bore date
February 1st. It must be remembered, however, that
although the presumption is that they are perfectly right,
they are merely the interpreters, not the makers, of the law,
and that a judge might decide otherwise and so rule that a
medical superintendent against whom a patient had brought
an action had acted illegally. We are assured by counsel
that the result of such an action would be extremely doubt¬
ful—depending on the particular judge who gave judgment—
and that to adduce the sanction of the Lunacy Commis¬
sioners would not avail the unfortunate asylum superin¬
tendent. As on referring to the late Mr. Archbold’s “ Lunacy
Acts ” we failed to find any commentary elucidating the
point at issue, we addressed ourselves to his editors, Messrs.
Glen, barristers, and received from Mr. Alexander Glen the
following:—
" The meaning of ‘ so many days at least ’ was considered
in the case ‘ Reg. v. Shropshire JJ.,’ noted at p. 258 of
our edition of ‘ Archbold’s Lunacy Acts.’ The meaning is
the same as that of ‘ so many clear days ’ or f not less than so
many days ’ before or after an event; that is, there must be
the specified number of complete days after the day of the
first event and before the day of the second event. Now,
the expressions used in the Lunacy Acts 6 within so many
clear days,’ ‘ not more than so many clear days/ 6 not beyoud
the period of so many clear days,’ must be construed on the
same principle, and, in these cases, there must not be the
specified number of complete days between the days on
which the two events happen. Thus the 9th February is
‘ not less than seven clear days after ’ the 1st February, and
therefore it is not c within seven clear days after ’ the 1st
February.”
The Commissioners in Lunacy leave no room to doubt in
their official documents that in their opinion the meaning of
the words of the Act above quoted, “ not more than seven
clear days,” is precisely the same as “ within seven clear
days.” Thus in their “ Instructions ” in regard to “ single
patients” issued in 1877, and still in force, they state “a
certificate becomes invalid and useless if the reception does
not take place, or if the order is not signed, within seven clear
days from the day of the medical examination on which the
certificate is grounded.” Again, under “ Directions to
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1888.]
549
Occasional Notes of the Quarter .
Medical Men/ 5 the instruction is repeated in the words:—
“ The patient must be examined within seven clear days
prior to admission.”
The same words occur in the circular entitled “ Lunacy-
Medical Certificates Instructions,” signed by the Secretary,
Mr. Perceval.
In justification of the statement that “not more than
seven clear days ” is equivalent to “ within seven clear days,”
it may be noted that Mr. Dauby P. Fry, at p. 69 of his
“Lunacy Acts” (last edition), inverts the statement con¬
tained in the Act, and holds that it is right to say that the
examination must be “ within ” seven days of admission.* If,
however, it he right to substitute the expression “ within ”
for “ not more than,” it does not appear to be safe to admit
a patient on the 9th February who was examined on the 1st.
Observe, that after the day of admission we have the 2nd, 3rd,
4th, 5th, 6th, 7th, and 8th days of February—“ seven clear
days ”—within which the patient must be admitted. This
would seem a common sense, and, we believe, legal view to
take of “ within seven clear days/” but, then, there is no
judicial sanction for the assumption that “ within ” is equiva¬
lent to “not more than.”
The judgment of Coleridge, J., in 1842 (not in a lunacy
case, but one in which a similar question was raised, namely,
in “Liffen v. Pitcher ”),f favours the contention that there
would not be “ more than seven clear days ” between the
examination on the 1st and the admission on the 9th, and,
if so, the Act would have been complied with.J But the
judge did not commit himself to the opinion that “ not more
than ” is correctly paraphrased by “ within,” but only laid it
down that “ clear ” days are distinguished from “ ordinary ”
days by the exclusion of the first and last day.
If, then, we need not follow the Commissioners in regarding
“ not more than ” as synonymous with “ rvithin ” seven days,
and if the terminal days—the days of examination and admis¬
sion—are to be excluded, it may be argued that if a patient
be examined on the first of the month and be admitted on the
* To avoid burdening the main argument with a minor point, we relegate to
a note the fact that Mr. Fry thinks the word “ clear ” is scarcely necessary here,
the days so referred to being natural or ordinary days. The word is wanted in
a negative or exclusive proposition, but not in an affirmative or inclusive one.
f Vide “ Dowling’s Reports on Points of Practice,” Vol. i., N.S., p. 767.
J In connection with this question, “ Rex v. Justices of Herefordshire,” 3 B.
and Aid. 681, should also be referred to. We have already noted “ Reg. v.
Justices of Shropshire,” 8 Ad. and El. 173.
Digitized by t^ooQle
550 Occasional Notes of the Quarter . [Jan.,
ninth, such examination was made, as the Act directs, “ not
more than seven clear days previously. 55
The difficulty of arriving at an indispntably clear conclusion
on this important point ia confirmed by an observation of
Lord Mansfield : “ Probably no question has more exercised
the minds of judges in former times than the question as to
the proper mode of computing time. 55 Unfortunately we
labour under this exercise of mind at the present day.
It need hardly be added that the broad and not the narrow
interpretation is the one we should desire to be correct,
as the time is often inconveniently short between the
examination and admission. All we wish is to have the law
unmistakably clear, lest by pursuing the broad way some un¬
happy asylum physician find that in his own experience it
but too surely leads to destruction.
Provision for Indigent Idiots and Imbeciles .
All who are acquainted with the demands made upon the
Public Charities by families which have the misfortune to
have an idiot child, know how utterly inadequate is the pro¬
vision made for this class in Englaud. In the first place,
there is a great mass of pauper idiocy. Undoubtedly,
counties and boroughs are obliged by law to admit cases of
idiocy and imbecility into workhouses and asylums in the
same way as lunatics. It is not, however, necessary to prove
that it is highly undesirable to mix this class with the in¬
sane in county asylums, or to retain them in workhouse
infirmaries. It would be possible, indeed, to erect separate
buildings exclusively for idiots on the grounds of the asylum,
and this course may be adopted if no distinct provision for
the training and care of idiots be provided, as was proposed
a few years ago by the Charity Organization Society. We
will, however, assume that such provision will be made for
pauper idiots as shall meet the objection of mixing them
with the insane, and that they shall receive the special
kind of education which they require. There still remains a
not inconsiderable number of idiots who belong to a class
socially above a very poor and strictly pauper class. In many
instances a small weekly payment could be made, and,
indeed, nothing would be more painful to the parents of
such a child than to have to seek relief and ask for the
Digitized by t^ooQle
1888.]
Occasional Notes of the Quarter .
551
admission of their child into a pauper asylum through the
relieving officer. For persons in this social grade, the
charitable Institutions, Earlswood, the Koyal Albert
Asylum, Star Cross, &c., provide, but only to a very small
extent, and everyone knows the extreme difficulty of obtain¬
ing votes by canvassing in order to procure admission. In
short, the supply falls ridiculously short of the demand.
We are brought, therefore, to the conclusion that increased
efforts must be made to provide for the idiot children of non¬
pauper parents who can contribute a small sum towards
their maintenance and training. In some instances, no
doubt, it would be difficult to pay anything, although it
would not be fitting that the child should be treated as a
pauper. For the corresponding class of the insane, much
larger provision, although still inadequate, has been made.
Will the benevolent public come forward to increase the
number of institutions like Earlswood, and free from the
objectionable system of canvassing? It is time that an
effort was made in this direction. It must not be done by
making exaggerated statements as to the educability of
idiots, or by making sensational appeals founded on pro¬
mises of substituting able-bodied and able-minded workers
for those who cumber the ground, but by taking the
position that idiots must be removed from the families of
the poor in the interests of themselves and their families,
that they can be improved up to a certain point, can be
rendered cleanly in their habits, and in some instances even
able to earn a modest livelihood.
An effort has been recently made to obtain funds for the
above-mentioned object under the City of London Parochial
Charities Act, 1883. Section 14 appears to warrant the
application for a grant of the surplus funds so far as the
inhabitants of London are concerned, for it refers to
u the promoting the education of the poorer inhabitants of
the Metropolis; ” and after enumerating various other objects,
including convalescent hospitals, the section proceeds to
state: “And generally to the improving, by the above or
by any other means which to the Commissioners may seem
good, the physical, social, and moral condition of the poorer
inhabitants of the Metropolis ; 99 that is to say an area in¬
clusive of the whole Metropolitan police district, viz., fifteen
miles out. A formal application to the Charity Commis¬
sioners for England and Wales under the above Act was
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Google
552 Occasional Notes of the Quarter. [Jan.,
made in October, and subsequently a deputation waited upon
Mr. Anstie, at their office, in order to urge the claims of
idiots upon the above-mentioned surplus funds. Sir Edmund
Currie, who introduced the deputation, made a lucid state¬
ment of the reasons which induced those who attended to
make the application. The application was courteously and
carefully considered. Mr. Anstie, however, expressed the
opinion that the application would be more likely to succeed
if funds were already obtained for the erection of an insti¬
tution designed for the object in view. Without committing
himself or his colleagues, he pointed out that the application
might possibly be acceded to if they were asked to aid
rather than initiate such a movement. We hope that this
suggestion may prove the starting point of a resolute attempt
to make increased provision for idiots and imbeciles of the
indigent but non-pauper class of the Metropolitan district.
In this connection we should like to see schools established
for intermediate cases of mental feebleness.
At the Congress of German Teachers held at Gotha in 1887,
a most interesting address on such auxiliary schools was
delivered by Herr Kielhorn, of whose own at Brunswick, wo
can speak very highly from a visit paid thereto in 1886.
In Germany, schools of this kind have been established in
several of the more important towns, viz., at Dresden, Leipsic,
Gera, Halberstadt, Cologne, Brunswick, and others. Into
these schools those children are drafted who have shown
themselves quite unable to follow the instruction given in
class at the national schools. This incapacity, evidenced
during a period of at least two years, is suggested by Herr
Keilhorn as a test or as a definition of weakmindedness.
Having entered the auxiliary schools, they there receive in¬
struction adapted to their powers of reception by teachers who
have gained experience in the methods required to call out
the faculties of these children. All the children being, so
to speak, at the same level, it is possible to instruct them in
class. At the same time, however, the demands of each child
upon the teacher are much greater than in ordinary schools,
and this very arduous form of teaching will scarcely permit
of a class of more than twenty children for each instructor.
Herr Kielhorn advocates his cause with great force and
earnestness, and certainly carries conviction with him. There
can be no doubt of the value of these schools, for there can
be no doubt that children of the class we are considering can¬
not be taught together with the relatively keener witted
Digitized by i^ooQle
553
1888.] Occasional Notes of the Quarter.
i
children who congregate in our public schools. The extra
care and patience which the former would require could not
possibly be given by the master, and if given would only
prove so much energy withdrawn from those nobler spirits,
who, by-the-bye, would so much rather be fly-catching or
preparing uncomfortable seats for confiding comrades than
marching with Cyrus, or camping with Csesar, or following
Ulysses in his devious wanderings.
The author of the paper dwelt on the many points which
mark the weakminded child, and on the many dangers which
await him if let out into the world unprepared. He also
points to the risks society itself runs from the uninstructed
feebleminded, who add so largely to the criminal classes.
On this point he refers to the words of Dr. Kind—“ Which
costs more (in hard cash), to instruct the idiot or to neglect
him ?” And he truly says that this holds equally for the
weakminded, i.e ., short of idiocy. The special treatment of
the bodily defects of the weakminded is insisted on by Herr
Kielhorn, and the importance of patient instruction in skilled
manual work, in order that, being unable to train their in¬
tellects above a certain level, their quick fingers may make
up for their slow and deficient mental processes.
We trust these observations may serve to awaken interest
in a movement which we shall soon, it is to be hoped, our¬
selves enter upon. It is a movement that must come.
PART II.—REVIEWS.
The forty-first Report of the Commissioners in Lunacy. 31 st
March, 1887.
The total number of persons returned to the office of the
Commissioners in Lunacy as of unsound mind on the 1st
January, 1887, was 80,891, showing an increase on the
previous year of 735. These were exclusive of 249 lunatics,
so found by inquisition, living in the immediate charge of
their committees, and 69 male insane prisoners detained in
convict prisons.
Their distribution was as tabulated on p. 554.
While private patients have increased by 15 and paupers by
780 during the year, a diminution in the number of criminal
patients has brought the nett increase in patients of all
classes to 735; the average annual increase of the last ten
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Summary of Insane Patients, 1 si January, 1887
Total . 3,973 3,834 7,807 182,155 40,288, 72,443 1 481 1G0 641 136,609 41,282 80,891
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555
years having been 1,591. This, tinder any circumstances,
would have been a remarkable decrease, but it assumes
additional importance as following upon a similar decline
in the figures of 1885, showing a drop in the two years of *34
per 10,000 of the entire population.
As the Commissioners remark, the returns of two years do
not in themselves afford a sufficient basis upon which to
form an opinion as to the causes of this apparently favourable
record, and the decline may indeed prove, by further ex¬
perience, to be rather temporary than permanent.
It is, however, at least curious that this sudden and very
considerable drop should have been coincident with a dis¬
tinctly marked and widely-spread disinclination on the part
of medical men to certify to the insanity of both private and
pauper patients.
If the two sets of facts have a direct relation to each
other, as they certainly seem to have, it must be obvious that
numerous cases of insanity are probably occurring which are
not brought under official supervision. And if this is so,
where do they go ? How are they disposed of? Either,
under normal circumstances, many patients are sent to
asylums who do not need to be placed under care, or there
must be a large amount of clandestine lunacy, which is not
receiving the treatment it requires, and will lead to an ac¬
cumulation of chronic cases whose chance of successful treat¬
ment will have passed away. This is a point which it behoves
the Commissioners and the public carefully to consider.
The ratio of admissions to population, which in 1876 was
5*27 per 10,000, had sunk in 1886 to 4*87. The percentage
of total lunatics to population had increased in the same
period from 26*98 to 28*64 per 10,000, or from 1 in every 370
to 1 in every 349. The increase, which had been a gradually
progressive one previously, has been arrested for the last
three years, as is shown in the following table:—
Year.
1878
1879
1880
1881
1882
1883
1884
1885
1886
1887
Total lunatics to total population.
1 in every 365
it
363
a a
it it
it It
»?
it it
it it
ii ii
tt it
361
356
352
348
345
345
347
349
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Is this arrested increase to be attributed to the cause
already referred to, or has it also some close relationship to
the pressure of hard times and the cutting off of the drink
supply? The problem is not uninteresting, either in its
psychological or its social aspect.
The recovery and death rates of the year under review
appear not to have varied greatly from those of previous
years. The death rate generally and the recovery rate for
females have somewhat exceeded the ten years average.
The following table gives the percentages of recoveries and
deaths in the different classes of asylums and in private
care, after transfers and admissions into idiot asylums have
been excluded:—
Proportion per cent,
of recoveries to
admissions.
Proportion per cent,
of deaths to the
average numbers
resident.
M.
F.
T.
M.
F.
T.
County and Borough Asylums
3501
46*53
40-91
12*61
8-62
10*42
Registered Hospitals .
37*54
55*02
47*50
8*60
5*16
6*70
Metropolitan Licensed Houses
3507
43*46
39*14
15*50
10*48
12-76
Provincial Licensed Houses ...
31*41
44*66
38*95
8*33
6-73
7*39
Private Single Patients
5*00
17*30
11*95
5*14
4-79
4*93
The average proportion of stated recoveries to admissions
in the various classes of asylums and in single care was 41*16
per cent.; that of deaths to the average numbers resident
10*03 per cent.
Of these deaths 19 were from suicide; 17 in County and
Borough Asylums; one in a registered hospital; and one in
a Metropolitan licensed house.
The causes of death in 72*2 per cent, of the total number
were verified by post-mortem examinations. This is a distinct
advance upon the records of previous years, and is quoted
~ ; th approval by the Commissioners.
wen cases of deaths in County Asylums this result
"ently due to suffocation during epileptic fits.
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1888.]
The Commissioners express a general approbation of the
condition and the care and treatment of the patients in all
classes of asylums under their supervision, and their entries
on the occasions of their periodical visits fully bear out this
general commendation.
It is greatly to be hoped that this fact will not be over¬
looked when any new scheme for county government is under
consideration, lest by any radical change in their manage¬
ment a disastrous blow be struck at a system which evidently
works well, and to the benefit both of the patients and of
those who have to provide the means for their care and
maintenance.
The average weekly cost of maintenance of patients in
County and Borough Asylums is again diminished, as the
following comparative statement will show :—
1886.
1885.
s. d.
s.
d.
In County Asylums.
8 7§ ..
,. 8
X1 8
In Borough Asylums
9 7i ..
.. 9
In both taken together ...
8 9i
.. 9
Of
The Commissioners devote considerable space in their
report to observations upon the employment, exercise, and
amusement of the insane, which may very fitly be quoted at
length in this place.
In the treatment of the insane gre&t importance should be
attached to the subject of their useful employment. Our aim
constantly is to encourage the efforts of superintendents to devise
suitable occupations, and to induce their patients to engage in
them, and with the view of ascertaining as nearly as we can the
extent to which such efforts have been successful, we have insti¬
tuted a comparison of the results attained in the years 1877 and
1886 respectively.
It is our practice at our visitation of County and Borough
Asylums to inquire, and note in our entries, the number of
patients of each sex who are at such times usefully employed,
with the nature of their employment, and from the notes thus
made we are able to arrive, very approximately, at the proportions
which the employed in the above-mentioned years bore to the total
numbers of patients in all the asylums.
We find then that in 1877 the numbers usefully employed at
the time of our visits to all the County and Borough Asylums bore
to the total number of patients the proportion of 56*65 per cent.;
while in the year 1886 the proportion was 61*87 per cent. There
has thus in 10 years been an increase of 5*22 per cent.
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This advance is, we consider, a very satisfactory feature in the
present management of the asylums; but we cannot rest satisfied
with it, believing that considerable further progress is both prac¬
ticable and desirable.
We are led to this conclusion by observing the great difference
which now exists in the proportions of the employed in different
asylums. To a certain extent this difference may be traced to the
differing amount of labour which each superintendent considers
sufficient to warrant him in classifying a patient as a worker.
This consideration, however, would scarcely afford a complete
explanation of the differences observed. In some asylums we find
the proportion as low as 45 or 46 per cent., while in others it
reaches 76 or 78 per cent.; and though circumstances vary, there
is not, in our opinion, so much difference in them as would reason¬
ably account for the variance, or constitute a valid excuse for the
very low proportions which we have mentioned.
To devise suitable work, and effective inducements to engage in
it, requires much thought, trouble, and ingenuity, as well as
favourable circumstances of locality and surroundings; but,
believing, as we do, that superintendents generally are fully
alive to the importance of the subject, we look with confidence
for a progressive and substantial increase in the proportions of the
usefully employed of asylum patients.
Not much less important than employment is regular, sufficient,
and varied exercise for insane patients. In this matter, too, we are
glad to be able to report improvement. It is now the rule much
more than formerly to arrange for giving extended walks, rather
than confine patients wholly to the airing courts, where they
saunter about in a listless manner or crouch in corners ; but there is
still ample scope for further progress.
A third branch of treatment -is the amusement of the insane.
Here also we find progress. In all, or almost all institutions
visited by us, there are, beside the provision of games, musical
instruments, and books and newspapers in the wards, frequent
meetings of the patients who are capable of enjoying them, to
witness musical or theatrical entertainments, or to dance ; while in
the summer, outdoor games and amusements are organized and
encouraged.
The three subjects we have thus touched upon, are, each in its
place and degree, very valuable agents in promoting the cure of
such patients as are curable, or the comfort and amelioration of
those whose recovery is improbable, and who unhappily form the
vast majority of asylum inmates. They are consequently, in our
opinion, subjects worthy of the most careful attention of all who
are charged with the care of the insane.
The Commissioners conclude an able, practical, and useful
report by the following summary of the changes which have
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occurred in the constitution of the Board since the date of
the last annual report:—
Pursuant to the powers of the Act 8 and 9 Yict. c. 100, Mr.
Thomas Salt, M.P., one of the unpaid Commissioners, was, on 21st
December, 1886, elected as permanent Chairman of this Com¬
mission, in the room of the late Lord Shaftesbury.
Mr. Francis Barlow, for many years one of the Masters in
Lunacy, and the last of the Commissioners named in the Act 8 and
9 Viet. c. 100, resigned his appointment (which was unsalaried) in
April last. Being much occupied by the duties of the mastership,
Mr. Barlow had never been able to devote much time to the affairs
of this Commission.
On 1st May, 1886, the Lord Chancellor Herschell was pleased to
appoint Viscount Emlyn to he a Commissioner in the room of Mr.
Barlow.
We have to record, with sincere regret, the death on 5th
November, 1886, of our colleague, Dr. Robert Nairne.
His services to the public, as a paid Commissioner in Lunacy,
extended over 27 years, his appointment dating from 1856. In
1883 he resigned his office, but was immediately made an honorary
Commissioner, in which capacity he continued to afford us the
advantage of his long experience.
Twenty-ninth Annual Report of the General Board of Com¬
missioners in Lunacy for Scotland. Edinburgh, 1887.
The report of the Commissioners in Lunacy for Scotland
for 1886 is an unusually favourable one. It commends
highly the treatment of, and the accommodation provided
for, all classes of the insane, whether in asylums or in private
dwellings. It shows also that the whole increase of the
number of pauper lunatics maintained in asylums and other
establishments, during the year, is only 18.
During the year, the whole number of registered lunatics
increased from 10,895 to 11,025, thus giving an increase of
130, of whom 30 were private and 100 were pauper patients.
The number of individuals in the Lunatic Department of
the General Prison, and in the Training Schools for Imbeciles
diminished from 62 and 230 respectively, to 56 and 228.
In the manner of distribution of the insane the following
changes have occurred during the year :—
In Royal and District asylums there has been an increase
of 31 private patients and a decrease of two pauper patients.
In private asylums there has been a decrease of 11 private
patients. In parochial asylums there has been a decrease of
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one pauper patient. In private dwellings there has been an
increase of 10 private and 82 pauper patients.
The total increase of private patients in asylums has been
17, and the increase of registered pauper lunatics in asylums
and other establishments has been 18. This increase of 18
in the number of pauper patients is less than those of the
years 1885 and 1886, which were 96 and 74 respectively, and
also below the average annual increase for the five years
1880-84, which was 140.
From the table showing the number of admissions into
establishments each year, after deducting transfers, it is found
(1)—that the number of private patients admitted during last
year was 443, being four less than during the preceding
year, and seven less than the average for the quinquenniad
1880-1884; and (2)—that the number of pauper patients
admitted was 1,997, being 63 less than the number during
the preceding year, which was the same as the average for
the quinquenniad 1880-84.
During the year 49 voluntary patients were admitted into
asylums, and the number resident on 1st January, 1887, was
44. Referring to these admissions, the Commissioners say :
— u We have for some years been able to state that nothing
has occurred to indicate any difficulty or disadvantage trace¬
able to the presence of this class of patients in asylums;
and we continue to be of opinion that it is a useful provision
of the law which permits persons who desire to place them¬
selves under care in an asylum to do so in a way which is not
attended with troublesome or disagreeable forms, but which
nevertheless affords sufficient guarantee against abuse.”
There were 177 private, and 961 pauper patients discharged
recovered during the year. The following table shows the
recoveries per cent, of admissions :—
Classes of Establishments.
Recoveries per cent, of Admissions.
1880 to 1884.
1885.
1886.
In Boyal and District Asylums .
41
37
42
„ Private Asylums.
38
50
26
„ Parochial Asylums .
42
41
41
„ Lunatic Wards of Poorhouses .
6
7
6
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Of private patients 131, and of pauper patients 458 were
discharged unrecovered.
The deaths in establishments during the year numbered
99 private, and 576 pauper patients. The following table
shows the death-rate for private and pauper patients in
establishments per cent, of the average number resident in
the years 1885 and 1886, and the corresponding average
death rates for the quinquenniad 1880-84 :—
Classes of Patients.
Death-rates in all Classes of Es¬
tablishments per cent, of the
Number Resident.
1880-84.
1885.
1886.
Private Patients ....
70
80
67
Panper Patients .
81
81
79
With respect to the discharge of patients on statutory
probation, the Commissioners again urge its more extended
adoption. In the following paragraph the statistics of its
use during the past year are given :—“ At 1st January, 1886,
58 patients were absent from asylums on probation. Of
these 26 have been finally discharged as recovered, two were
sent back, and 30 remain under the care of friends. In the
course of 1886, 101 patients were discharged on probation.
Of these 27 have been finally discharged as recovered, nine
remain under the care of friends, 11 have been returned to
asylums, one died, and 53 are still on probation.”
From this it appears that of the 58 patients absent from
asylums on the 1st January, 1886, 30 remained under the
care of their friends, but whether as discharged relieved, or
unimproved, or as still on probation, is not stated. Surely,
to extend a period of probation over more than twelve
months is unfair to both the patient and the authorities of
the asylum who are responsible for him.
The whole number of changes among attendants during
1886 is 429, which is 52 less than the number for the
previous year, and 51 less than the average for the last ten
years.
During the year 228 patients escaped, of whom 22 were
not brought back during the currency of the Sheriff’s order.
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or the certificate of emergency on the authority of which
they had been detained. Two of these last were removed
from the registers as recovered, 12 as relieved, and four as
not improved. Three were found drowned, and one died
from exposure.
Of accidents occurring in asylums 115 were reported, of
which 15 ended fatally. In six of these cases the death
was suicidal.
On the present condition of the various establishments for
the insane the Commissioners report very favourably, and,
as in previous reports, they note with approval the discharge
from asylums of patients who have ceased to benefit by
their detention there, thus providing accommodation for
more urgent cases without the increase of costly asylum
buildings.
While there is ample asylum accommodation for private
patients belonging to the more opulent classes of the com¬
munity in Scotland, there is at present very inadequate
provision for those whose circumstances permit of a rate of
board being paid for them equal to the rates charged for
pauper patients, but not so much above them as to obtain
accommodation in the best class of private asylums. Re¬
ferring to this, the Commissioners say :—“ In our last
Report (p. xlvi.) we gave a statement showing for 1st
January, 1886, that 1,053 patients were maintained out of
private means at rates under 21s. a week. Of these 912
were maintained as private patients, 774 in Royal Asylums,
and 138 in District Asylums. The rest, 141, were in the
position of paupers, 22 being in Royal Asylums, 108 in
District Asylums, and 11 in Parochial Asylums. In pro¬
viding for the 774 patients, the Royal Asylums were, as we
have said, performing to that extent a most charitable and
most useful work. The position of the 138 patients who
were inmates of District Asylums cannot, however, he
regarded as satisfactory, for they are liable to be discharged
whenever the accommodation which they occupy is required
for paupers, and there are obvious objections to the placing
of persons maintained out of private means in institutions
specially intended for the accommodation of paupers. It
may, however, be held that the placing of private patients
in District Asylums is so far suitable that it does not involve
classing the patients as actual paupers; but it admits of no
doubt that it is a great hardship, if not an injustice, to
oblige the 141 persons who are not admitted as private
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patients, but sent into asylums at the instance of inspectors
of poor, to be registered and treated as actual paupers when
their maintenance is entirely defrayed from private sources.
It is important to keep in view, in regard to this class of
cases, which actually come upon the poor law records, that
the present position of the matter must in many instances
lead to the actual pauperizing of persons who *might under
other circumstances be saved from it. Efforts are frequently
made by relatives and friends to keep a patient from becom¬
ing a burden on the rates if they can thereby save him
from the stigma of pauperism. If, however, the patient is
forced into the position of pauperism notwithstanding that
these relatives or friends defray all the cost of his main¬
tenance, there is an obvious inducement to them to avail
themselves of the benefits of the position as they have to
submit to the degradation. We have given full recognition
to the degree to which the managers and directors of Royal
Asylums have endeavoured to meet the wants of this class
of private patients with scanty resources. But we think
that they will not have done all that ought to be done, nor
all that can be done, if public attention is intelligently
directed to the matter, until all patients for whom rates of
board of not more than £25 a year can be paid are provided
for in these institutions as private patients.”
The average daily cost of maintenance of pauper patients
in the various classes of establishments has been Is. 3fd.,
which is the same as that for the previous two years.
With regard to the condition of patients residing in
private dwellings, in addition to the reports of the Deputy-
Commissioners, Dr. Sibbald reports on the condition of
these patients in the county of Midlothian. The number
of patients visited in that county was 179, of whom 53 were
private and 126 pauper patients ; and, except in a few cases
where improvements were suggested and at once carried into
effect, all were found suitably provided for.
Speaking of this mode of providing for patients, Dr.
Sibbald says :—“And here it may be well to allude to a
misapprehension which seems sometimes to exist. It
appears sometimes to be supposed that the providing for
pauper lunatics in private dwellings in Scotland is a result
of recent administration. A glance at the table on page
107 will show that this is a mistake. The fact is, that the
number of persons provided for in this way does not bear so
large a proportion to the population of the country now as
xxxm. 37
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it did when the present lunacy system came into operation.
The number has, indeed, increased from 1,877 in the year
1859 to 2,140 in 1887; but this is more than 300 short of
what would have been accounted for by the increased popu¬
lation of the country.”
If, however, instead of contrasting the figures for 1859
and 1887, as suggested by Dr. Sibbald, the figures for 1878
and 1887 be contrasted, it will be seen that since 1878 there
has been a very rapid increase in the number of pauper
lunatics in private dwellings. In 1878 they numbered 1,385,
in 1887 they numbered 2,140. Again, from 1859 to 1876
there was a regular annual decrease, the decrease for the
period being 492. There are thus two periods, the first from
1859 to 1876, during which patients were removed from
private dwellings to asylums; the second from 1876 to
1887, during which patients were removed from asylums
to private dwellings. These figures, while they show that
the system of boarding pauper lunatics in private dwellings
was not introduced by the Board, appear to point to an
alteration in the policy of administration of the Board,
dating from about the year 1876.
The following paragraph from Dr. Sibbald’s report is
interesting, containing as it does his view of the policy of
the Board with regard to the system. He says a The
position of the pauper lunatics in private dwellings has,
however, been altered in important respects by the adminis¬
tration of the Board. During the earlier years the efforts
of the Board were directed mainly to the sending to asylums
of patients who were unsuitable for treatment in private
dwellings, and to the amelioration of the condition of those
who, though suitable for such treatment, were inadequately
provided for. In pursuance of this course, the number of
pauper lunatics in private dwellings was considerably
diminished. But it was prevented from diminishing so
much as it would otherwise have done by the fact that a
large number of persons previously unreported, who were
suitable for care in private dwellings, were during the same
period brought under the supervision of the Board. It was
recognized by the Board, from an early period of their
administration, that the providing for a certain number of
pauper lunatics in private dwellings was one of the elements
of a proper system of lunacy administration. The Board
have not, it will be seen, introduced a new mode of pro¬
viding for pauper lunatics. They have only endeavoured to
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1888.]
place under proper regulation a mode of provision which
has always existed in Scotland, and which, indeed, has
always existed in every country. The difference between
the system which they have been enabled to establish and
that of other countries consists in the fact that the patients
so provided for are under the supervision of a central
authority, which requires to be satisfied that they are
suitable for such treatment, and that they will receive it
in a satisfactory manner; while, in most other countries,
those who are so provided for may be said to be merely
left outside of the general lunacy administration.”
Dr. Fraser has this year adopted a new form of report.
He deals with his district as if it were a large asylum.
From the statistics he furnishes, it appears that during the
year the number of pauper patients in his district has
increased from 996 to 1,091, and that the number located
there for the first time in 1886 was 225. In Ayrshire alone
60 new cases have been boarded in private dwellings. In
Forfarshire there have been 27 new cases, in Lanarkshire 23,
and in Stirlingshire 28.
The number of discharges of all kinds from the district
was 151, of which 26 were recoveries, 11 were removals
from the poor roll, 50 were removals to establishments, and
64 were deaths. Of the 64 deaths, eight resulted from
cerebral and spinal affections, 31 from thoracic affections,
11 from abdominal affections, 13 from other natural causes,
and one from accidental burning, caused by the patient's
clothes becoming ignited while standing near the fire. Six
other accidents of a trifling nature are recorded as having
occurred among the whole population of 1,177 insane in
the district. In one case an imbecile girl became pregnant,
but inquiry showed that she must have been in that con¬
dition when she came under the jurisdiction of the Board.
Dr. Fraser is to be congratulated on the altered form of
his report. Its arrangement renders it easy to refer to, and
the additions in the shape of a table of the causes of death,
and statistics relating to accidents make it much more
valuable and complete. By freely publishing such details
the Board do much towards establishing confidence in the
system which they have adopted for providing for so many
comparatively helpless beings.
Dr. Lawson, in his report, deals with each county sepa¬
rately, but furnishes a table showing the admissions and
discharges for the whole of his district. The admissions
/
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number 171, the discharges 134, giving an increase for the
district of 37. Of the patients discharged, 60 died, 14 re¬
covered, 52 were removed to asylums, and eight were removed
from the roll. In Eifeshire only has there been any con¬
siderable increase in the number of patients in private
dwellings, and these were sent from Dundee, the City of
Edinburgh, and St. Cuthberts. In 1884 there were visited
in Fifeshire 156 pauper lunatics in private dwellings; in
1886, 265 were visited.
Speaking of the large number of these patients collected
together in and around the parish of Kenoway, Dr. Lawson
takes occasion to point out that in no way do they render
themselves obnoxious to the general public. He reports
that he has made special inquiry into the matter in the
village itself, and that the result of frequent conversations
with some residents there on the matter has been to confirm
him in this opinion. He says:—“ It would be quite possible
for anyone to walk through the village, from end to end and
top to bottom, without knowing that there was a single
pauper lunatic boarded in it. At the present time there are
about sixty such. When I am making my inspection I
occasionally meet one, whom I know to be a patient, walk¬
ing slowly along, but not looking or behaving in such a way
as to attract notice. Some will be found to be working
steadily and quietly in the fields, the gardens, or the byres.
Others will be seen helping their guardians at housework,
and the aged or infirm will be found quietly sitting or lying
indoors.”
It is to be regretted that Dr. Lawson does not furnish
statistics relating to accidents, escapes, or causes of death.
Although the number of insane in private dwellings has
again considerably increased, it appears from the report
that the system continues to work most satisfactorily. The
patients themselves are described as being much happier,
their guardians are benefited by keeping them, the erection
of costly asylum buildings is avoided, and at the same time
the patients are more cheaply maintained. Such being the
case, it is to be hoped and confidently expected that the
system will soon be much more fully adopted throughout
the whole of Scotland.
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Thirty-Sixth Report of the Inspectors of Irish Lunatic Asylums.
Dublin, 1887.
The Report of the Inspectors of Irish Asylums differs but
little from that of the preceding year, either in volume or
matter.
The total number of the insane under Government super¬
vision, and their location, as compared with the return given
in the thirty-fifth report is as follows:— S
On 31st December, 1885.
On 31st December, 1886.
Males.
Females.
Total.
Males.
Females.
Total.
In District Asylums ...
5402
4470
9872
5493
4584
10077
„ Private „
243
389
632
233
369
602
„ Gaols.
■
—
—
1
—
1
„ Palmers town House
6
9
3
6
9
„ Criminal Asylums ...
29
173
139
33
172
„ Poorhouses .
2233
3733
1532
2309
3841
Total .
7292
7127
14419
7401
7301
14702
These returns show an increase on the year of 283, and,
according to the Inspectors, from the decreasing population
of the country, there is evidence that the ratio of the insane
to the sane in Ireland becomes larger from year to year.
The increase for the year 1885 amounted to 143, that for
1884 to 188, and that for 1883 to 266. Taking the population
of Ireland to be five millions, the ratio would be one insane
person to 340 of the general population. Looking back to
the Blue Book for Ireland for 1885, we find the ratio given
by the Inspectors to be one individual more or less mentally
affected in every 350 of the population.
The Inspectors point out that the inmates of public and
private asylums are regarded as belonging to the lunatic
class proper, that is, to individuals who at one period of
their existence were possessed of intellectual faculties, and
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even now have clear reasoning powers. In poorhouses, on
the other hand, a very large proportion of the insane is con¬
stituted of idiots and demented persons. Independent of
these, there exists an unknown amount of congenital idiocy
in the lower strata of society. This classification certainly
possesses the beauty of simplicity, and if it could be accu¬
rately adhered to would save endless trouble. But in Irish
asylums are there no dements, imbeciles or epileptics? In
poorhouses are there no cases of mania and melancholia?
Does all congenital idiocy belong to the lower strata of
society ? Is it not found amongst the children of the well-
to-do farmers and shopkeepers ? The number of the latter
class are considered to be few, for two reasons (1st), from
the small number of idiot children, 85 under 12 years of age,
now in workhouses ; (2nd), from the evidence given by local
authorities that idiocy has much decreased. During the
present year the Inspectors will apply to the Local Govern¬
ment Board for further information on the subject.
As regards the mental condition of the 10,077 patients,
the probably curable are estimated as 2,228, and the in¬
curable as 7,779, each class needing equal professional care
and domestic supervision, as those who are innocuous and
tranquil when properly attended to become dangerous and
unmanageable when neglected.
Such being the case, the Inspectors point out that it should
not be a matter of surprise that for its own protection and
that of the public this innocent community should be
deprived of its freedom, and that owing to improved treat¬
ment their longevity should be increased, and, therefore,
that additional accommodation should be required for them.
Twelve years ago the accommodation iu Irish asylums was
7,000 beds, it has since been increased by 2,600, and still
there is a marked deficiency. During the past year the
admissions to the 22 district asylums have been 2,746—1,531
males and 1,215 females. Of these 2,140 were cases of first
attack, and 606 relapses.
Amongst the admissions were a few cases of soldiers
becoming insane whilst on active service. The question of
the erection of a separate institution for the military
stationed in Ireland having been submitted to the Inspectors,
they recommended, in lieu thereof, that on a soldier being
duly certified to be a lunatic he should be transferred, under
certain conditions and rules approved by the Lord Lieuten¬
ant, to the asylum of the district in which he happened to
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be quartered for a period of three months, his maintenance
to be defrayed by the War Office at Is. 6d. per day. If he
recovered during that time he should be sent back to his
regiment, or at the end of three months be removed to the
place to which he was chargeable on enlistment, the expenses
of his transfer being repayable to the asylum.
As regards the different forms of admission to public
asylums, 1,831 cases were sent through magistrates’
warrants under the provision of the 30th and 31st Vic., c.
118, as dangerous lunatics ; 698 were received by the asylum
physician as urgent; whilst 83 were authorized at the meet¬
ings of governors. The Inspectors express strong disappro¬
bation of the Dangerous Lunatic Act, as they consider that
its effect is to mar the utility of public asylums, for four
reasons: 1st. No reliable information is supplied for the
guidance of the asylum physician further than the offence
committed, or the assumption of an intention to commit a
crime. The Inspectors, however, do not state why the
history of the case should not be obtained, if so desired, in
the ordinary way. 2nd. Strangers are occasionally made
chargeable to districts with which they had no previous con¬
nection. Persons committed under the Dangerous Lunatic
Act are made chargeable to the district in which the alleged
offence was committed. 3rd. Under this Act, lunatics, male
and female, young and old, are conveyed long distances
under police escort. This objection is certainly a most
proper one. It is deplorable to think that the statute,
almost universally used in Ireland, should be so opposed to
all ideas of civilization as to convert the insane into criminals,
and cause them to be looked on as such. 4th. The statute
leads to magisterial oversights, causing constant illegal com¬
mittals, necessitating the constant return of warrants to the
justices for correction. It is, however, to be feared that
under the most perfect form of order of committal, magis¬
terial errors will occur.
To obviate the unsatisfactory arrangements under this Act,
the Inspectors propose to amend it so as to impose on the
relieving officer the duty of reporting in all cases of insanity,
so that the lunatic may be visited by a medical man and
then taken charge of in the poorhouse until remitted in due
form to the asylum of the district. No suggestion is, how¬
ever, made as to the form of order on which the transfer
should take place, or who should be responsible for the re¬
moval. That every insane person should first have to pass
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through the union before obtaining admission to an asylum
appears rather a retrograde idea with regard to the early
treatment of insanity. A few' years ago an attempt was
made by Mr. E. Litton to extend to Ireland certain sections
of Act 16 and 17 Vic., c. 97, in so far as they related to the
care and protection of pauper lunatics. This would have
been, indeed, a boon, as it would have simplified the diffi¬
culties at present existing of obtaining admission to public
asylums in Ireland.
The mortality was higher in Irish public asylums during
1886 than during the preceding year, without any epidemic
to account for it, as the sanitary condition of the twenty-
three district asylums is considered by the Inspectors to be
satisfactory, that is to say if the small number of deaths
the result of bad sanitary arrangements be taken as a proof
of the excellency of the condition of the ventilation and
drainage. Only seven cases of typhus fever and twenty-six
of dysentery occurred in these establishments. The argu¬
ment that because epidemics do not occur that, therefore,
the sanitary arrangements must be good, has been used so
often to oppose every improvement in sanitation that it
cannot be received as an unquestionable argument of the
condition of Irish asylums. However, the Blue Book goes
on to state that the drainage of the Carlow and Mary¬
borough Asylums had to be thoroughly remodelled, whilst
the unsatisfactory condition of the drainage of the Rich¬
mond Asylum, which the Inspectors state was reported on a
few years back by the late resident physician, Dr. Lalor, has
again been brought under public notice, and has been re¬
ferred to Sir C. Cameron for advice, and it is hoped will, in
due course, be remodelled. Further on the Inspectors state
that serious apprehension existed as to the water supply in
other asylums, particularly Armagh, Killamey, Down, and
Carlow. At Mullingar the scarcity of water is so great as
to prevent the required additions to the building from being
carried out. Under these circumstances, we may be allowed
to consider the sanitary condition of public asylums in
Ireland as not as yet perfect.
As to the predisposing causes of insanity (table 15) amongst
the admissions, 517 were said to arise from moral causes
and 788 from physical influences; 561 cases were referable to
hereditary tendency, and 880 are set down as unknown.
1,641 patients were discharged from public asylums. Of
these 1,172 were recovered, 380 improved, and 89 removed.
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not improved. 894 deaths occurred, all except eight being
from natural causes ; three were from accident, and five from
suicide. Of these no details are given, except that inquests
were held, resulting in each case in a verdict exculpating
the officials from blame.
Pulmonary disease is stated to have been the cause of
death in 294 cases, cerebral affection in 244, debility and old
age in 169, disease of the heart in 37, abdominal derange¬
ments, including 26 cases of dysentery, in 83 ; the remaining
deaths are stated to have been due to “ febrile , scrofulous , and
cutaneous maladies of no marked description.”
We cannot congratulate the superintendents of Irish
public asylums on the scientific accuracy displayed in the
return of the causes of death; nor can we understand how
febrile, scrofulous, and cutaneous maladies could be of no
marked description and still prove fatal. No mention is
made of the number of post-mortems held in these estab¬
lishments, nor do the Inspectors express any opinion of the
importance of these examinations in order to obtain some
more accurate record of the causes of the mortality occurring
amongst the inmates.
Taking the percentage of recoveries on the admissions, as
usually adopted in Parliamentary Reports, forty-three per
cent, would be the average in Irish asylums. The Inspectors,
however, consider that tins is a flattering but rather fallacious
theory, insomuch as the recoveries do not all belong to the
annual admissions. The more intelligible calculation as to
the utility of public asylums on the score of recoveries should
be based on a daily annual average, which should give a
percentage of 8f.
Taking annual expenditure for the two years 1885 and
1886, the cost per head for the first year amounted to
£21 19s. 5d. on a daily average of 9,684, and in the second
to £20 19s. 8d. calculated on 9,999, the average number for
the latter year.
Prom inquiry, the insane in workhouses are supposed to
cost something less than four shillings per week; if so,
their total maintenance amounted to £40,000 a year. This,
added to the cost of district asylums, £216,802 5s. 5d., with
cost of criminal lunatics at Dundrum, £6,327, cost of
Government patients at Palmerstown House, £280, would
represent in round numbers £259,323 as the sum obtained
last year from all sources for supporting the insane poor in
Ireland.
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In the 33rd Report (1884) the outlay incurred in the
erection of Irish asylums was given in detail; since then
many improvements have been carried out by the Commis¬
sioners of Control. At present the balance due by Ireland,
on account of public asylums, to the Treasury, amounts to
£219,582 17s. 4d., to be repaid by the four provinces as
follows :—By Ulster, £88,185 15s. 8cL ; by Connaught,
£26,883 17s. 4d.; by Leinster, £42,840 9s. 4d.; by Munster,
£61,672 15s. The exact sum chargeable on the 25th of last
March to the various counties and boroughs belonging to
each province is given in appendix G of the Blue Book for
this year.
The management of District Asylums, as heretofore,
meets with the full approbation of the Inspectors thanks to
the liberal control of Local Boards, the judicious manage¬
ment of medical superintendents, and the efficiency of officials
and attendants attached to them. Against the latter few
charges of a serious nature have been made during the year,
but the services of the most efficient have been frequently
lost in consequence of insufficient wages. Under the Statute
19 and 20 Yic., c. 34, any increase of wages has formally to
be applied for to the Lord Lieutenant, and much delay
thereby results. The Inspectors suggest that a maximum
and minimum scale should be recognized, within which a
discretionary power might be exercised by the Local Boards.
The domestic arrangements, also, of these institutions
meet with the commendation of the Inspectors; their in¬
mates are well clad and well fed, animal food being supplied
in the great majority six times a week at dinner. (Table
28, giving the dietary of the district asylums, shows that in
six out of the twenty-two asylums meat is given six times a
week, the average amount of animal food being 22 oz. per
week, exclusive of bone.) In most asylums there are large
refectories, serving also as recreation halls. The dormitories
are lofty and well ventilated, well kept, and supplied with
excellent bedding. Means of amusement are on the increase,
excursions to the country and to the seaside frequently take
place, tending, if not to the recovery, at least to the quietude
of the patients, doing away with restraint or confinement
under any form. As regards domestic furniture as com¬
pared with England, the Irish institutions are, perhaps, not
so showy; but if the original habits of life of the occupants
be taken into comparison the difference between the two
would, perhaps, not be so great. As a rule Irish lunatic
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institutions present interiorly a cheerful, and, in fact, a
decorated appearance, while exteriorly the grounds are neatly
maintained.
Nothing could be more gratifying than these laudatory
remarks, showing that at least the Inspectors are completely
satisfied with the whole working of the institutions under
their charge. In addition, they wind up their remarks on
public asylums with the remarkable sentence : “ In our de¬
partment of the public service, however, there exists no
more gratifying characteristics than the utter absence of
unkindly or sectarian feelings, as is evidenced by the una¬
nimity of all parties in fostering a cordial relationship, and
the tranquillizing influence of religious observances.” This
statement is also a subject for sincere congratulation,
although it is not quite plain who they are who exercise
this unsectarian spirit and foster cordial relationship and the
tranquillizing influences of religious observances. No one
would have supposed for a moment that any other feelings
would have actuated the Inspectors themselves in their
official dealings.
During the past year the following changes have occurred
amongst the medical officers of Irish public asylums. Owing
to the death of Dr. Eames, the popular Medical Superinten¬
dent of Cork, Dr. Dwyer was moved from Mullingar and
appointed his successor; Dr. Finnegan, Medical Superin¬
tendent of Castlebar, was moved to Mullingar; and Dr.
O’Neil, for seven years Assistant Medical Officer at the Rich¬
mond Asylum, was appointed to Castlebar. On the death
of Dr. Lalor, of the Richmond Asylum, whose name is
associated with the establishment of schools for the insane,
Mr. Conolly Norman, of the Monaghan Asylum, was selected
to succeed him; and the vacancy thus made was filled up by
the appointment of Dr. Taylor, who had been for nearly
eight years Assistant Physician at the Dundrum Criminal
Asylum. On the resignation of Dr. McKinstry, of Armagh,
Dr. Graham, Assistant Medical Officer at Belfast Asylum,
got the appointment.
On January 1st, 1886, the Dundrum Criminal Asylum
contained 144 men and 29 females. The admissions were
19 men and six women; 22 were discharged—eight recovered
and 14 improved—four died, leaving at the beginning of the
year 139 males and 33 females under treatment. No escape
or accident of any sort occurred, but three dangerous as¬
saults were made, one of a very aggravated character, on the
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resident physician, whose life was imperilled, though, provi¬
dentially, he escaped unhurt. The Inspectors point out the
difficulties and dangers of dealing with many of the inmates,
some of whom are malingerers, others on the border-land
between sanity and insanity, who give much trouble by
exciting others to insubordination. Last summer a cabal
was got up by these to waylay and murder two of the
attendants. Latterly four strong cells with prison-like ap¬
pearance have been constructed for these dangerous cases,
the knowledge of which fact is said to have a useful effect.
Connected with the subject of criminal lunatics, the
Inspectors call attention to the fact that when a prisoner is
acquitted on the ground of insanity the antecedents of the
case are not further inquired into at the time, no testi¬
mony is brought forward to elucidate the occurrence, the
prisoner is confined at pleasure, and may be detained in¬
definitely for want of information to guide the Executive.
The Inspectors advise, when the plea of insanity is put
forward, that the act itself should be investigated before the
jury. It is, however, difficult to understand why the Govern¬
ment should not always be able to obtain the records of the
crime, or what object would be gained by continuing a trial
where insanity was proved, unless it is proposed that the
Judge should fix the length of time during which the
lunatic was to be kept in confinement.
Little change is stated to have taken place in the con¬
dition of the insane in workhouses ; the number of lunatics
under care continues almost the same from year to year. In
the great majority of cases the forms of mental derange¬
ment found in these institutions are considered by the
Inspectors not to require asylum treatment however much
their condition might be benefited by a more liberal atten¬
tion to personal comforts. They, however, become violent,
and are transferred to asylums. This the Inspectors object
to, as they take up room which should be reserved for acute
cases; hence asylums become overcrowded and the public
rates are increased. This does not present itself so forcibly,
as the support of asylums and poorhouses is derived from
different sources. The Government rate in aid is also
applicable to the one and not to the other. “ That lunatics,
properly speaking, should stand in a different category from
the imbecile, idiotic, and demented in poorhouses is now
fully recognized, and justly so.” This may be perfectly
true, but it is difficult to understand why the lunatic in a
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workhouse should be denied the care and treatment of an
asylum if he requires it; nor is it evident why the State
should make a distinction between one form of lunacy and
another.
The Inspectors, however, advocate the provision of ac¬
commodation in one or more of the unions in each district
for idiots, confirmed imbeciles, and the utterly demented,
who would thus be supported out of the rates.
Since 1884 they have been advising this plan to the
Guardians of the Dublin Unions, to erect a plain pile of
buildings as a receptacle for their insane inmates, who at
present enjoy very imperfect and painfully restricted accom¬
modation.
No change has taken place in the number of private
asylums, licensed under 5 and 6 Vic., cap. 123, during the
past year, but the number of patients located in them has
fallen off. In 1885 the number was 632, whilst at the end
of 1886 it was only 602. We may here remark that this
decrease in the number of patients in private asylums in
Ireland has been going on from year to year. Thus at the
end of 1882 the number was 650, whilst at the end of 1883
the number was only 636.
Only one case of suicide is reported in these institutions
during the year. This was the case of a lady, who had
been long supposed to have been free from any suicidal
tendency, and afforded an example of the impulsive and
uncertain action of a person mentally affected.
The Inspectors consider that the power vested in them
of allowing patients out on trial for definite periods has
proved beneficial, though a few cases required to be brought
back.
With reference to the domestic management of private
licensed houses, they complain that in some there is much
room for improvement, so as to raise them at least to a level
with the best organized for the insane poor. The depressed
condition of the country, and the irregular system of pay¬
ment, they consider some excuse for these deficiencies,
particularly as no provision has been made for the reception
of lunatics of humble circumstances, except in district
asylums, which are already filled by the insane poor.
With the general sanitary condition and the profes¬
sional care bestowed on the inmates the Inspectors have
little cause of complaint; and while they advert to some
private asylums as inferior, they state that others are con-
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[Jan.,
ducted in a highly creditable manner, and afford every
means of comfort to their inmates.
The appendices are stated to supply information con¬
nected with the department under various headings, a few
tables of a solely professional nature being omitted by desire
of the Government, otherwise they would have been intro¬
duced. The Inspectors are, however, to be congratulated on
the introduction of Table No. 15, giving the causes of mental
disease of those admitted to district asylums during the
year; and it is to be hoped that, in spite of the opposition
of a Government, who take so little interest in the progress
of psychological medicine as to place obstacles in the way of
further research, that in time the Irish Blue Book will equal
those of the other parts of the United Kingdom in the
compilation of statistics, and that we may obtain that great*
desideratum so long looked for—a compilation of tables
giving similar statistics on insanity in the three divisions of
the United Kingdom. On this point we shall continue “to
peg away” until the desired end is attained.
Legons sur les Maladies du Systems Nerveux faites a la
Salpetriere 9 par J. M. Charcot.
(First Notice.)
We are pleased to welcome another instalment of Pro¬
fessor Charcot’s lectures. His previous works have been
made familiar to the profession by the translations under¬
taken through the agency of the New Sydenham Society.
The present work is in no way inferior to those which pre¬
ceded it, and, indeed, in some respects it has a fascination
and a charm of its own. We trust that the New Sydenham
Society will once more bring the great French master’s
labours before the profession in an English dress, although
we cannot but feel that however competent the translator
may be. it will be impossible to reproduce the peculiarly
eloquent and picturesque style for which the author is so
justly famous.
The work before us deals with a variety of subjects; but
the greater bulk is devoted to the subject of hysteria, and
incidentally to that of hypnotism and the effects of sugges¬
tion.
The investigations which Professor Charcot has been
carrying on for years into these matters are familiar to alL
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1888.]
The present volumes, therefore, will be of special interest,
as giving a more detailed account of his labours in this
direction than has hitherto been presented in book-form.
The work before us possesses that remarkable suggestiveness
for which all the author’s contributions are so renowned.
No one now alive has done more than M. Charcot to foster
the spirit of research into the obscure problems of the
nervous system. Several of the younger workers at La
Salpetriere have given their aid in compiling these lectures,
and their assistance is suitably acknowledged on the title-
page, and on many occasions in the text. The names of
these collaborateur8 are Fere, Babinski, Bernard, Guinon,
Marie, and Gilles de la Tourette.
In this review we propose to give briefly an outline of the
contents of each lecture, though it must be confessed that
an abridged account such as this will convey but an imper¬
fect idea of the author's views.
The first lecture is introductory, and in part historical.
The author alludes to his past efforts to make the Hospital
of La Salpetriere a regularly organized institution for the
teaching of nervous diseases. His struggles have at last
succeeded, and the French Government arid the Municipal
Council of Paris have removed all obstacles. The out¬
patient department has been entirely re-modelled, and in
the Hospital itself there are now a museum and laboratories
for various purposes; and, indeed, everything has been done
to make La Salpetriere an institution perfectly adapted for
treatment, for clinical teaching, and for original research.
The author proceeds briefly to point out that specialism in
medicine has become absolutely necessary, and that we must
accept it because we cannot avoid it. The field of research
in nervous diseases is so vast that little or no apology is
required for its specialization. The chapter ends with some
general remarks on the methods of investigation to be
adopted, on the difficulties to be encountered, and with
some practical observations on the simulation of disease,
especially with reference to the cataleptic state.
The second lecture treats of the muscular wasting which
sometimes supervenes in joint-affections, especially when
dependent on traumatic causes. The paralysis is most
obvious in the extensor muscles, and is accompanied by
atrophy. The muscles affected show simple diminution of
excitability to both the constant and the induced current; in
other words, there is a quantitative change in the reactions,
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not qualitative, as seen in muscular atrophy dependent on
degeneration of the nerves or motor cells. It is curious
that there is no necessary relation between the intensity of
the joint affection and the degree of paralysis and muscular
atrophy. The articular lesion is often slight, and it has to
be remembered that the muscular affection may persist long
after the primary cause has disappeared. The author dis¬
cusses the various theories which have been put forward in
explanation, but he rejects them all. According to him, the
most probable hypothesis is that there ensues a dynamic
spinal lesion. The spinal motor cells become inert by reflex
influence, but they undergo no degenerative change such as
occurs in acute poliomyelitis. The prognosis in these cases
is favourable, and it would appear that statical electricity
has a marked influence in hastening the cure.
In the third lecture the author discusses the influence of
traumatism in the production of contractures. He points
out that rigidity of an extremity sometimes occurs suddenly
after an injury, often of slight degree, and that the con¬
tracture thus determined may be the first manifestation of
the hysterical diathesis. One of the most characteristic
features of hysterical contracture is its sudden onset, thus
differing from the late rigidity observed in destructive lesions
of the pyramidal tract.
In the fourth lecture the author treats of muscular atrophy
consecutive to chronic articular rheumatism. He observes
that in these cases, as in those articular affections arising
from injury, the extensor muscles are mainly involved.
The muscles become weak and atrophied, and present quan¬
titative changes in their electrical reactions. In some cases
the tendon reflexes become exaggerated, and ankle-clonus
may be present. He remarks that occasionally this condi¬
tion is so striking that even competent observers have been
led to look upon the spinal condition as the primary factor,
the arthropathy being secondary. But an attentive study of
the evolution of the phenomena will show that the contrary
is really the case. In some articular affections of rheumatic
nature, the most striking condition is not muscular atrophy,
but spasmodic contracture. Here, again, the extensors
mainly suffer. The state of spasm is involuntary, and in
all probability of reflex nature, as Hilton has pointed out.
In the fifth lecture the discussion of reflex amyotrophies
and contracture is continued. In certain instances spas¬
modic contracture of articular origin is not limited to the
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muscles around the affected joint, but becomes more or less
generalized, so that an entire extremity may become affected.
The subjects in whom this occurs are usually hysterical.
The deformities of chronic articular rheumatism are
originally dependent on spasmodic muscular contracture of
reflex nature. The hands are usually pronated and slightly
flexed, and there is a general deviation towards the ulnar
side. According to the position of the phalanges, the defor¬
mities may be classed under two heads: (a) the type of ex¬
tension, resembling the hand in athetosis; (b) the type of
flexion, similar to the attitude of the digits in paralysis
agitans.
The remainder of the fifth lecture is devoted to certain
symptoms which are occasionally but rarely observed in the
early stages of general paralysis of the insane. The author
has seen three or four cases in which ophthalmic megrim,
having the usual characters, has supervened in the initial
stage of general paralysis, and has appeared to have some
relation with the onset of the disease.
The sixth, seventh, and eighth lectures are devoted almost
entirely to the consideration of certain phases of hysteria.
In the first place attention is drawn to functional visual dis¬
orders. When hemiansesthesia is present there is usually
some defect of vision on the same side. Often a very
marked contraction of the visual field is present, and this
contraction exists on both sides when there is general anaes¬
thesia. Accompanying this condition there is, as a rule, dimi¬
nution in the visual acuity. The author dwells particularly
on the diminution or even absolute loss of colour perception
occurring in hysteria (dyschromatopsia and achromatopsia).
Under normal conditions the visual field is more extensive
for blue than for yellow, and for yellow than red; then
follow green and violet, the latter being perceived by the
most central parts of the retina only. In hysterical
amblyopia there is general contraction of the colour-field,
violet disappearing first, then green and red. Yellow and
blue alone often remain, but sometimes these are lost, and
then there is complete loss of colour-perception, all objects
appearing grey.
To the law just enunciated there is an exception, very
frequent both in males and females. The contraction of
the circles representing the colour-fields is not always con¬
centric. The circle for red is frequently greater than that
for blue, and this peculiarity is, in the author’s opinion,
xxxiii. 38
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[Jan.,
characteristic of hysteria. A case in which this peculiar
feature existed has lately come under our own observation,
and the subsequent history of the patient (a man) fully
corroborated the hysterical nature of the affection.
The author calls attention to the so-called hysterogenic
zones, and he points out that they are often found at certain
definite spots on the surface of the trunk and head. On the
limbs these zones are said not to exist, but in a. footnote
allusion is made to some recent researches by Pitres and
Gaube, which indicate that hypersesthetic areas may be pre¬
sent on the extremities, and that they differ in no respect
from those found on the body and head.
As regards the frequency of hysteria in the male, an obser¬
vation by Briquet is quoted, which gives the proportion as
one male to twenty females. Although this is probably an
exaggerated proportion, it indicates that male hysteria is far
from being so rare as is usually supposed. In boys, hysteria
is most common about the age of twelve or thirteen, and in
adult males, according to the observations of Klein (a pupil
of Ollivier), about the age of twenty-four. This practically
coincides with the statement of Bussell Reynolds that in
adult males hysteria is most frequent between the ages of
twenty and thirty. Taking hysteria, occurring both in
males and females, hereditary influence is present in about
thirty per cent.; but it must be borne in mind that the
hereditary taint may exist in the progenitors not solely as
hysteria. It is well known that epilepsy, insanity, and
other affections of the nervous system in the ancestors may
come out in the offspring in the form of hysteria.
Professor Charcot illustrates by clinical cases the well-
known fact that contractures of a hysterical nature may be
present when convulsions, globus, and other classical features
are quite absent. In such cases anaesthesia may be dis¬
covered, or hysterogenic zones, and then the diagnosis is
well-nigh certain.
An interesting case of contracture of the left hand follow¬
ing a slight injury to one finger is described and discussed.
It is shown that exactly the same deformity can be produced
in a hystero-epileptic woman with hemianaesthesia by elec¬
trical stimulation of the ulnar nerve. A very ingenious
method is described by which hysterical contracture, or the
cataleptic state, can be absolutely diagnosed from malinger¬
ing.
In the ninth lecture a remarkable series of symptoms
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following an injury to the sciatic nerve is narrated. After a
contusion of the left buttock severe pains were felt in the
course of the great sciatic nerve, and then there gradually en¬
sued weakness, with atrophy of both lower limbs, but mainly
of the left. The glutei muscles were chiefly affected. Sen¬
sation everywhere was perfect. Disorders of the bladder
and rectum were present. Indeed, the clinical features
of the case pointed to the existence of a lesion of the spinal
motor cells. As the tendon reflexes were markedly ex¬
aggerated, certain of the motor cells were in a condition of
hyperexcitability; but the muscular atrophy indicated that
other cells had undergone more profound changes, possibly
of a destructive nature.
In the tenth lecture double sciatica is discussed, and the
conditions under which it arises are enumerated. It is not
uncommon in diabetes, and in certain spinal affections, such
as locomotor ataxy and meningo-myelitis. In the case
which forms the author's text, the sciatic pains were depen¬
dent on new-growth involving the vertebrae and the nerve
trunks. Most often, perhaps, the growth is secondary to
carcinoma of the breast, as in the instance narrated. It
must be remembered, however, that vertebral cancer may
give rise to spasmodic paraplegia, quite unaccompanied by
pains in the course of nerve trunks.
In the second part of this lecture a case of hypertrophic
cervical pachymeningitis is discussed, in which the flexion
of the lower limbs was overcome by surgical means, and a
practical cure effected. It is pointed out that the spinal
affection may undergo resolution, and that the deformity
of the legs may be the only obstacle to the upright posture
and to walking.
In the eleventh lecture a case of word-blindness is very
fully narrated, and in the succeeding lecture the subject is
discussed from a clinical and pathological standpoint. Pro¬
fessor Charcot gives a brief analysis of sixteen recorded
cases. Usually the onset is sudden, and there is a certain
degree of right hemiplegia, which may rapidly disappear.
In the early stages there exists frequently some motor
aphasia, which gradually passes away. It has to be remem¬
bered that word-blindness may exist alone, uncomplicated
by hemiplegia. Visual disorders may be present, and in
two cases hemianopsia was observed. In three out of the
sixteen cases a curious fact was noted. When the patient
tried to read he wrote the words, or traced the characters in
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space with his index finger. The notions thus furnished by
muscular movement may in some measure supplement or aid
the vague ideas conveyed by the visual images. Treatment
based on this fact was adopted in two cases, and in one (a
patient at La Salp6tri&re) the result was very encouraging.
From tbe few autopsies that have been made in this affec¬
tion, it would appear that the disease is situated in the
inferior parietal lobule.
In the thirteenth lecture a very complete account is given
of a case in which there was sudden loss of the faculty of
mental vision (Galton’s mental imagery). The patient had
previously been gifted with a most remarkable faculty for
reproducing mentally the forms and colours of objects.
After the onset of the disease he was unable to recall
mentally the features of his wife and children, or the
streets and houses in his own town with which he had been
perfectly familiar.
An interesting discussion follows on verbal amnesia, and
its complex nature is fully described.
The subject of muscular atrophy has long passed into a
critical stage, and hence we welcome Professor Charcot’s
attempt to bring the various forms of amyotrophy into some
classification, provisional though it may be.
The fourteenth lecture is one of the most interesting in
the entire work, and will prove of great service to those
practically engaged in the diagnosis and treatment of nervous
diseases. It is only of late that the condition of the muscles
and nerves has received from the pathologist the attention
which, on a priori grounds, might be expected.
M. Charcot is inclined to believe that pseudo-hypertrophic
paralysis, the juvenile forms of progressive muscular atrophy
described by Erb and Duchenne, and Leyden’s hereditary
form, are really varieties of one morbid entity —primary pro¬
gressive myopathy . Under this same heading may be classed
those cases of muscular paresis or paralysis in which there
is no change in the bulk of the muscles—neither atrophy
nor hypertrophy.
In the fifteenth lecture the subject of tremors and chorei¬
form movements is discussed. It is pointed out that
although the tremors of disseminated sclerosis and paralysis
agitans differ in some very important characters, they have
one feature in common, and that is that the oscillations are
slow, four or five in a second. In this respect the tremors
differ essentially from those seen in alcoholism, chronic mer-
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curial poisoning, general paralysis, and exophthalmic goitre,
in all of which the tremblings are vibratory, and occur
eight or nine times in the second. In addition to these two
varieties there is a form seen in hysteria which holds an in¬
termediate position, the oscillations being five to seven per
second.
After a brief account of the movements observed in
ordinary chorea, and some remarks on their essential
features, other affections are discussed, such as prse- and
post-hemiplegic chorea and athetosis. It is then pointed
out that in rhythmical chorea, which is very often allied to
hysteria, the movements pursue a regular course, and are
co-ordinated, thus differing fundamentally from common
chorea. The cases which are given by way of illustration
are full of interest, and are accompanied by drawings repre¬
senting the grotesque attitudes which are sometimes seen in
saltatory chorea.
The remainder of the work, which comprises ten lectures,
is entirely devoted to the author’s favourite subject, hysteria.
With this we shall deal in our concluding notice.
Les DSmoniaques dans L’Art. J. M. Charcot (de l’lnstitut)
et Paul Richer, avec 67 Figures Intercalees dans le
Texte. Paris: Adrien Delahaye et Emile Lecrosnier,
1887.
We have already drawn attention to this joint production
of MM. Charcot and Richer.
A fresh interest attaches itself to certain works of Art of
the old masters when they are regarded from the neurolo¬
gist’s point of view. Paintings which have been seen number¬
less times and admired for their artistic merit, but nothing
more, are found to possess striking points of attraction when
brought into relation with those forms of nervous disorders
which have received such a large amount of study in recent
times, and upon which such a flood of light has been thrown
by the scientific study of the functional disturbance of the ner¬
vous system by the practice of hypnotism. It will no doubt
be felt by some that sentiment as embodied in Art is in
danger of being, to some extent, destroyed by the relentless
manner in which the frigid hand of medical science draws
aside the veil which the mediaeval artist throws over his pro-
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584 Reviews . [Jan,,
ductions. But this is only the common fate of the mysteries
of life when dissected by the scalpel of the anatomist.
No one, at any rate, could leave the wards of the Salp£tri5re
and proceed to visit the picture galleries of the old masters,
of the churches where Art has been employed to represent
the miraculous scenes of ecclesiastical history, without being
struck with the accuracy with which the painters have de¬
lineated those convulsions and nervous distortions which may
be seen in so concentrated a form in the great Paris Hospital,
always celebrated, but rendered more famous than ever by
the genius of M. Charcot.
We take, almost at random, by way of illustration of the
commentaries made by our authors on the pictures to which
they refer, a scene of possession painted by Matteo Rosselli in
the Church of the Annunziata, at Florence (p. 46). It is not
an instance of exorcism. No priest is present, and there is
nothing in the gestures of those who stand by to indicate, as
in many other paintings, an attempt to expel the demon.
Notwithstanding, three imps are represented as escaping in
the curtains of the bed upon which the possessed lies in her
clothes, the violence of her convulsions being shown by the
presence of two men who have to hold her. A fifth assis¬
tant, a female, arrives on the scene, carrying some linen,
apparently intended as the means of restraint. The dress of
the possessed is partly unfastened, the legs are semi-flexed,
the arms separated from the body, and held by the anterior
part of the shoulder and the arm, while she gesticulates
wildly, the body being flexed forward as described by MM.
Charcot and Richer as occurring in the hysteric crisis
under the name of “ Mouvements de Salutation.” In spite
of the smallness of the copy made of the picture, it is suffi¬
ciently clear that the mouth is open, while the eyes are
raised spasmodically upwards, and the whole face is slightly
swollen. All these traits belong, it is pointed out, to the
second stage of the “ grande attaque hyst^rique,” or period
of clownism. We have, in fact, happened to choose one of the
smaller and more meagre pictures commented upon by the
authors of this work, but it is all the more striking to see
how cleverly and accurately they read the design of the
artist, and make instructive inferences where the ordinary
observer would pass them by almost or altogether un¬
noticed.
We would fain pass on to describe and interpret, with the
assistance of MM. Charcot and Richer, other works of art in
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1888.]
which demoniacal possession is represented, but we must
content ourselves with quoting the concluding observations
on the ecstatics.
In order to render all the varied expressions of those represented
in a state of ecstasy, the artists have been able to find invaluable
models in hysterical subjects. This assertion will not appear rash
or exaggerated to any who like ourselves have seen hysterical
patients, even women among the poor, in a certain phase of the
great attack. When under the influence of religious hallucinations
they assume the attitudes of so true and intense an expression that
the most consummate actors could not do better, and indeed the
greatest artists could not find models more worthy of their brush.
To paint an ecstatic, the artist has, then, sought to express a
thought, a sentiment. Everything is done by rule, and presents
the figure in a reasonable manner; all the traits, all the move¬
ments, have a common object—the expression. We judge of the
value of the artist’s work according as the object is attained, and
the qualities of the expression of the figure are pure, true, and
well rendered. In the figures of demoniacs it is no longer the
same. We are, then, in the presence of extraordinary attitudes,
strange contortions, and deformities of features, which do not
respond to any idea or sentiment. It is the period of the “ grande
attaque,” represented under the name of the stage of “ attitudes
illogiques,” in contrast to that which follows and is the stage of
“ attitudes passionnelles.”
Every resource fails the artist, sculptor, and actor in the absence
of the exact observation of nature. For it is not sufficient to pro¬
duce deformities merely at pleasure, and to produce strange effects
at will; there is under this apparent incoherence a hidden reason
which arises out of a morbid process, while in the nature of the
deformities of parts, or the contortions of the whole, as well as in
the mode of succession and grouping of all the phenomena, one
finds, as our studies of the works of the old and modern masters
demonstrate, the indisputable marks of a pre-established order,
and all the constancy and inflexibility of a scientific law.
The illustrations which accompany the text are beautifully
executed, and render the work one of great artistic value as
well as scientific interest.
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La Physionomie , chez Vhomme et chez les animaux , dans ses
rapports. Avec Vexpression dcs Smotions et des sentiments .
Par S. Schack, Major deTarme danoise. Paris : Librai-
rie J. B. Bailliere et Fils.
There have been so many fruitless efforts made to estab¬
lish a system of rules whereby to estimate the moral and
mental qualities by bodily characteristics, and we have been
obliged to reject as useless so many “ pseudo-sciences 99 (as
Dr. 0. W. Holmes calls them) which as phrenology, pal¬
mistry, and graphology, etc., have one by one claimed atten¬
tion, that at first we were tempted to throw this book aside
as but another attempt of the same kind. An inspection of
the clever drawings deterred us, however, and we are glad to
draw attention to a series of observations, which, if not
aspiring to establish infallible laws, at least contain many
interesting, and in many cases valuable, suggestions.
A difficulty which meets us at the outset in establishing a
science of expression, lies in the fact that everyone must be
his own physiognomist.
In other sciences and in the arts many men may use ODe
instrument. A dozen chemists may use the same scales and
test-tubes, and there is a recognized system of weights and
measures, but the weights and measures of feeling and
opinion have no fixed scale ; every man must use his own set
of instruments and must make allowance for the u personal
equation 99 in his estimate of the dispositions of his fellow-
men. “ Le caract^re personel de Tobservateur et ses setfti-
ments ont une influence des plus grandes sur sa fa<jon de
comprendre et de juger le caractere et la physionomie d’autrui.
. . . nous serons toujours portes a preter tr&s volontiers, a
l’homme qui ressemble & notre ennemi, les m&mes faiblesses
qu* a ce dernier, si nous ne mettons soigneusement de cot6
tout esprit de passion et d’amertume.” The face, according
to M. Schack, is a register of the dispositions, not of the indi¬
vidual only, but of his ancestors:—“ Or si l’on songe que non
seulement les traits au repos se refletent dans la physiono¬
mie de l’enfant, mais que ^expression meme se transmet par
Fh6redite, on comprendra facilement que les penchants, les
tendances, les facultes en harraonie avec ces expressions se
transmettent 6galement des parents aux enfants.” He seems
to look on the face as the moulding and solidifying of col¬
lective ancestral expressions, saturated with ancestral emo¬
tions, modified by each individual, and passed on in relentless
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sequence to the next generation. M. Schack attaches to
every form of every feature, and to every combination of
these, some particular quality of the moral or intellectual
nature inherited or acquired. For, in contemplating the late-
realized force of heredity, we are not to lose sight of the part
that each generation plays, and the modifications to which
each individual is subject. As some insects change in colour
with the changing colour of their food, and as some flowers
are altered by a difference in soil, so every man changes in
feature, or expression, or voice, or in all of these, with a
change of thought, habit, and circumstance. Eyes, mouth,
ears, are, as it were, tinged with their food.
“Such as are thy habitual thoughts, such will be the
character of thy mind, for the soul is dyed by the thoughts,”
says Marcus Aurelius, and “ Such as is the character of thy
mind, so will be thy face, for the face is modelled by the
mind,” says M. Schack, in effect.
But who shall interpret the subtle minglings of many
troubled generations of men which we see blended in one
face now? In general this is impossible, admits M. Schack.
“ Aussi ne sera—ce que chez les individus fortement carac-
terises . . . que nous pourrous poursuivre nos recherches;
. . . 1’immense majority des hommes echapperait a toutes
les regies de notre physionomonie.” Many faces would not
repay the study, as M. Schack says elsewhere —“ There are
many insignificant faces, because there are many silly souls.”
The physiognomist must not occupy himself at first with
ordinary men, but study extreme forms, and “ il ne faut pas
qu’il evite Thom me per vers sous le pretexte, futile ici, qu’il
aime mieux le commerce de l’homme sage et bon, son role
lui impose, tout au contraire la fr^quentation continue des
hommes les plus divers.”
After elaborate examination of every feature and of acts,
such as walking, handshaking, and bowing, M. Schack brings
us to the characteristic part of the book, which owes its value
in great part to the fact that its illustrations are all either
drawn from historical characters, whose portraits are more
or less familiar to us, or from sketches of individuals drawn
by the author himself. The stories accompanying the sketches
are often very instructive, and the likeness between the person
and the animal whose physiognomy M. Schack claims for
him or her is sometimes very striking. This part of the
book, however, must be read to be appreciated, for the im¬
pression of the drawings cannot be fairly conveyed in words.
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A third part of the hook is devoted to the influence of here¬
dity on the physiognomy.
M. Schack’s cautions about indiscriminate and ignorant
applications of his rules are probably needed. Cruel mis-
judgments might be carelessly made by ignoring counter¬
balancing traits ; and in any case definite rules winch human
nature tends to lead us to apply to others while making
favourable exceptions for ourselves cannot be too carefully
adopted. In a multitude of observers there might be found
no two to agree in all points, so we may say with Socrates,
€i In our present condition we ought not to give ourselves
airs, for even on the most important subjects we are always
changing our minds, and what a state of education does that
imply.”
Lwnacy in Many Lands . By G. A. Tucker, Sydney, 1887.
If the time-honoured proverb that “ a great book is a
great evil ” be true, the work before us ought to be very
evil indeed, seeing that there are nearly 1,600 pages. A
report of the inspection of a very large number of asylums
in both hemispheres of the globe must necessarily occupy a
large amount of space, and it may, on the whole, be more
convenient to comprise it within two covers. Mr. Tucker
had, for six years prior to 1865, an interest in a private
asylum at Melbourne. Having parted with it, he established
at Sydney the asylum called Bay View House, the proprietor¬
ship of which he held until 1886. In 1881, his health having
failed, and having speculated with great success, Mr. Tucker
resolved to collect together facts from all the principal
institutions for the insane in the world and report upon
them to the Government of New South Wales. Before
setting out upon his travels he applied for and obtained an
introduction from the Colonial Secretary, who stated that he
was about to visit such institutions “ in the interest of his
business.” This is certainly rather an unusual way of
describing the mission of a man who considered that his
report would be “ of benefit to the Colony,” and who desired
to place his facts “ in the shape of a report before the
Government.” We think that the divergence between these
modes of regarding the object of the journey has led to
considerable misunderstanding, and was probably the means
of placing the traveller in an ambiguous position. The mis-
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589
1888.]
understanding referred to would have been avoided had it
been made perfectly clear that while a Colonial Secretary
besought those to whom Mr. Tucker might apply for in¬
formation to pay him every attention, he was not in any
sense deputed by the Government. Be this as it may, Mr.
Tucker has visited all the States of the German Empire,
Austria, Bussia, Denmark, Norway, Sweden, Holland,
Belgium, France, Switzerland, Italy, Corsica, Spain, Great
Britain, and Ireland, as well as Tunis and Algiers. Prior to
this he had visited Victoria, South Australia, Tasmania,
New Zealand, and Honululu, whence he crossed the
Pacific and inspected all the institutions of the United
States and Canada. The number of asylums visited exceeds
400. Altogether he has travelled 140,000 miles.
The work contains a general summary extending over
about eighteen pages. The great mass of the volume is
occupied with the reports of individual asylums. There will,
no doubt, be many who will dissent from the correctness of
Mr. Tucker’s statements and conclusions, and it is impossible
for us to decide with whom the truth lies without personal
knowledge. We are bound to say that in some instances in
which we possess this knowledge, the report made by the
author appears to us to be very misleading. In these
instances, however, the impression left by our traveller’s
report would not be disputed by those having charge of the
asylums, for our criticism arises from Mr. Tucker having
failed to discover flagrant abuses and grievous defects.
Such being the case, it is not unnatural that we should look
with some degree of suspicion on the reports of those
asylums with which we have no means of being acquainted.
In spite of this mistrust, and in spite of communications
having reached us commenting on the incorrectness of many
of the statements made relative to certain asylums in our
own country, we are of opinion that the returns obtained
from superintendents of asylums and their comments are
of considerable value, and will continue for some time useful
for reference by those who require information of this kind.
It is not to be denied that the author has spent a great deal
of time, labour, and money in this investigation ; indeed, he
calculates the latter at no less than ±3,000. We believe
the work has been sent to public institutions and the libraries
of those who make the care and provision of the insane their
special study. They will find this volume useful, if too much
is not expected of it. For the present, at any rate, it will
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[Jan.,
excite fresh interest in asylums, and if those who are aware
of inaccuracies of statement will make the necessary correc¬
tions publicly known, the mischief arising from the errors
into which Mr. Tucker has fallen will be prevented.
We are open to receive any communications of this nature,
provided they are signed by the writers.
Pharmacology and Therapeutics . By Dr. Lauder Brunton.
Macmillan and Co., 1887.
It is quite impossible to do justice to a work of the magni¬
tude and importance of Dr. Brunton’s within the short space
at our disposal—it is much more possible to do injustice.
We will not attempt to do more than just indicate the plan
and aims of the work. It is divided into six sections, the
four last of which treat of materia medica, as it is generally
understood, the two first of general pharmacology and thera¬
peutics, and of general pharmacy. It is needless to say that
so distinguished a physiologist as Dr. Brunton has put his
chief strength into Section I., and it is this part which marks
the book as a special book. Herein we find the most careful
analysis of the problems of physiology pursued back into the
domains of chemistry and physics. From this analysis con¬
clusions are drawn, which, marshalled, are led to the conquest
of new territories in the region of therapeutics. The whole
aim and object of Dr. Brunton's work is to build therapeu¬
tics on sure foundations. Need we say that these same are
physiologic P Now, without committing ourselves to judg¬
ment on the matter, we would yet point to the extreme com¬
plexity of the problems of therapy and to the uncertain sound
emitted on the part of physiology. There is a suspicion
within us which hints, Are we ripe for this method, which is,
strictly speaking, that of applied physiology? Can we discard
the method of Hippocrates—the method of Sydenham ? We
venture these remarks from a very careful consideration of
the subject, a consideration which the admirable introduction
to Trousseau and Pidoux's work on therapeutics has not a little
helped in forming. We sincerely recommend Dr. Brunton’s
work to the consideration of all who have therapy at heart,
which should include us all, for we shall fail to grasp the
situation if we fail to perceive the physiologic tendencies of
medicine and the claims which are put forth in this direction.
We recommend the work, but we recommend it for most
careful weighing.
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Reviews.
591
Mental Affections of Childhood and Youth . By Dr. Langdon
Down. Churchill.
This small book of 300 pages is really the result of a re¬
quest by the Medical Society of London that Dr. Langdon
Down should give the Lettsomian Lectures. These lectures
were highly appreciated, and a further request was made that
they might be published, and, in compliance with this desire,
they appear in this form with several other papers added,
which had appeared in various medical periodicals, and
had not been brought together before. The consequence
is that within the cover we have rather a mixed set of
essays on diseases of childhood and youth. We have not
only idiocy treated more or less systematically, and from
the point of classification, but also an essay on the result of
consanguineous marriages, and another on the relationship
of idiocy and tuberculosis. We advise our readers to study
the volume for themselves, as it is the result of the observa¬
tions of a very busy man, who has had more opportunities
of watching than recording. Success in our profession is
often the destroyer of good original work, and this seems to
have to some extent affected our author, for these lectures
but enlarge on the idea of some 20 or more years ago, and
do not, to our thinking, add many facts nor elucidate more
fully the theories of the younger physician. Dr. Langdon
Down will ever be remembered as having started the idea that
among idiots were to be seen failures in development which
were to be looked upon as parallels of certain other races of
men who were not highly developed; that, in fact, they
were survivals or vestiges. This appealed to everyone at the
time when Darwinism was at the very greatest point of its
power, but it was seen that many other things beyond ex¬
ternal resemblance must be taken to make up the picture of
the survival or the relapse in race type. We hoped to find
these or some of these links in the volume before us, but we
find a repetition of the belief without any more real strength
derived from facts.
With this criticism we end our fault-finding, and would
fully acknowledge the thoroughly practical way in which
the book is put together. Dr. Langdon Down’s oppor¬
tunities have been many for observing the children who are
the links between the idiot and the lunatic, those children of
neurotic parents who break down as soon as any vital strain
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[Jan.,
is placed on them, and his comments on such cases are note¬
worthy.
There are reports of cases of imperfect corpus callosum
and fornix, which might be of use in the discussion on the
uses of the corpus callosum, though Dr. Down owns that it
is very rare to find such commissural defects among idiots.
A paper which is specially interesting, from the various
ways in which its results have been received, is that on the
condition of the mouth in idiocy. The united experience of
those practising among idiots and of dentists is, that with
degenerating stock there is a marked narrowing and vault¬
ing of the palate. This does not mean that all idiots have
high palates, nor that all with high palates are idiots. A
paper from the London Hospital Reports of 1864 is reprinted
on so-called polysarcia and its treatment. This is a little
outside the scope of this book, we think. The reprint
about the result of marriages of consanguinity is interest¬
ing, and Dr. Down is one of those who is convinced that
the union of blood-relations has some influence in the
deterioration of the species. There are essays on classifica¬
tion, the obstetrical aspects of idiocy, and reports of several
interesting cases of nervous disease, such as pseudo-hyper¬
trophic paralysis, deserving consideration; and, on the
whole, though not a great work as the result of such vast
and extended observation, we must be grateful for its appear¬
ance.
How to care for the Insane. By Dr. W. D. Granger, Buffalo
State Asylum. Putnam, NYY.
With each development of teaching there must arise a
demand for some fresh series of text books; so it is in
America with the science and art of nursing. In England
we have not got so far, we are content to teach our nurses
to use their hands and acquire as much from common sense
as possible. But on the other side of the Atlantic a great
movement has been begun, and we would warn our younger
physicians to be on their guard lest they too will have to
protect their rights against women. It appeared to us when
in America that the nurses already have to do too much of
the practical work, and the doctors, though beads, are not
so highly informed as heads should be ; that is, we think that
just as the head must be served by the hand as part of the
same body, so the medical head is best when it has been
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1888 .]
served by its own hand, not that of another. The American
men seem inclined to neglect the use of their legs, and if
they do not take care they will too soon fulfil the prophecy
of the future man, who was to be all head, “ sans legs, sans
teeth, sans everything ”—but brain. But to return to the
book under review. Institutions for the training of mental
nurses being established, it is well they should have handy
text books on the subjects of simple anatomy, physiology,
and natural science. Dr. Granger has written a primer of
this sort which we have already passed into onr wards as a
stimulus to further knowledge, and as the book is simple
and cheap we would suggest that it should be bought, and
it will hold its own, at least, beside the u rules and regula¬
tions ” which have hitherto occupied the mind of the English
asylum physician.
The Nursing and Care of the Nervous and the Insane. By
Charles K. Mills, M.D., Professor of Diseases of the
Mind and Nervous System in the Philadelphia Poly¬
clinic. Philadelphia: J. B. Lippincott Company, 1887.
The number of handbooks recently published in America
treating on the care and nursing of the insane indicates that
much attention is being bestowed on this subject by American
alienists. The work under review is one of a series of hand¬
books on nursing, issued by Messrs. Lippincott, and has
been published, according to the author, in response to fre¬
quent requests from nurses, that they might possess some
information, in a compact form, as to the care of those
nervously affected. This is the only book with which we are
acquainted which treats of the nursing of that ever-increas¬
ing class—those affected with functional nervous derange¬
ments not necessarily insane, although on the borderland of
insanity. The nursing and care of the insane forms the last
chapter, and comprises only 35 pages, or a little less than
one-fourth of the entire work. The other chapters deal with
such subjects as massage—the present fashionable remedy
in many functional nervous disorders—and electricity, with
its various modes of application. We think that the author
has devoted too much time and labour to the technicalities
of electricity, especially when we consider for whom the book
is intended; and he has consequently had to curtail the more
important, because practical, sections of his book. In the
chapter on the care of the insane he deprecates the teaching
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of elementary anatomy and physiology to attendants. Prom
some little experience in lecturing to attendants we have
found that such information as may be obtained from
Huxley’s “ Physiology ” or other rudimentary works proves
of great interest, and enables attendants to grasp the sub¬
stance of future lectures with a greater degree of intelligence.
We can heartily recommend this work as a useful hand¬
book, not only to nurses in general hospitals and those
especially engaged in the care of private neurotic cases, but
also to asylum-attendants.
The few illustrations it contains are excellently executed,
the book is neatly got up, and, as is the case with most
American publications, it compares most favourably with
any work of its kind published in this country.
T. D. G.
Gehirn (Anatomisch ). By Prof. Mendel, Berlin.
This small pamphlet of 60 pages is a reprint of the article
by the author in the tc Encyclopedia of General Medicine,”
edited by Dr. Eulenburg. It is handy and complete, and
has very good illustrations. In saying it is complete we
would not imply that it contains all the anatomy of the brain
as developed and divided by the Germans, but it contains
the best accepted facts as to the development of the brain,
the simplest methods of dividing the brain, the finer and
coarser structure and arrangement, as well as the histology
general and special. The chemistry of the brain is also given
in brief, and the blood and lymphatic systems are described.
The ganglia at the base are studied both in relation to their
development and their connections.
The cranial nerves with their origins are given, and Dr.
Mendel has some original opinions on the nuclei of the
seventh.
We should recommend those working at neurological
subjects to have this small brochure as a very convenient
book of reference. Dr. Mendel has given the weight of the
brain and its parts careful consideration, and his experience
shows that women—German women too—have not only
absolutely but relatively less brain than man, and that
this deficiency is marked even at birth. He shows, too, that
there is no direct relationship between weight or height
of body and mass of brain. In man the maximum weight is
reached between 20 and 30 years of age, but in woman the
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maximum is reached at 20. It declines sooner, too, in woman
than in man. As the brain has many other functions
besides those of mind to perform, its size does not bear
direct relationship to the mental power of the individual.
As might be expected, we find all data as to specific gravity,
reaction, &c., set forth. The localization of function is
accepted, and the irradiation from centres also given, and
though this is a German book, Ferrier has at least the
credit of being referred to without any jealous qualifications.
A very careful description of the minute arrangement of the
cortex is given, with a. series of parallel sections of different
areas. These are diagrammatic, but will be found to be
useful, but from what has already been said it will be seen
that a useful addition to anatomy, physiology, and neuro¬
logy has been made, and we welcome the work.
Die Gesundheitspflege in der Mittelschule , Hygiene des Kdrpers
nebst heilaujigen BemerTcungen . Von Dr. Leo Burgee-
stein. Alfred Holder, Vienna, 1887, pp. 140.
We can recommend this book to all interested in the impor¬
tant subject with which it deals. After a few pages to the old
Greek and English methods of education, the author considers
the arrangements which should be made to prevent study in¬
juring the health, and the necessity of inquiring into the
capabilities and deficiencies of the pupils. Dr. Burgerstein
has a good chapter upon gymnastics and bodily exercises. He
gives us much information about the health of children at
school-ages; but he does not treat the question of over¬
pressure with the fulness which its importance demands.
He points out what he considers Austro-Hungary might
learn from the educational systems of other countries, and
gives especial praise to the English public schools. He thinks
that if it were possible to combine the German striving after
ideal culture and the German scientific spirit with the
English formation of character, the ideal of education would
be reached. There are some things in our upper class
English schools which are only suffered because they are
old, and which no new establishment could venture to adopt.
Boys are sent often to these high-class schools more through
the social ambition of the parents than from the hope of
getting a good education. At the same time, our new
educational institutions bring evil as well as good along
with them,
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Dr. Burgerstein remarks that in some English schools
about which he has information there is scarcely one-fifth of
the amount of shortsightedness seen in German ones. This
shortsightedness was greatest in the higher schools. In
Austria only one per cent, of the pupils in the village schools
is found to be shortsighted, in the gymnasia 30 to 35 per
cent. In a middle school in Vienna with 406 pupils, only
one-third had normal vision; in the lower under-gymnasium
more than a third, 39*1 per cent.; in the upper-gymnasium
more than 50 per cent, were shortsighted. Dr. Burgerstein
quotes the words of Virchow: “ First health then education/’
and gives as his opinion that six hours daily study is enough.
This may be quite true, but in this age of competitive ex¬
amination it is the inspectors and examiners who regulate
the educational pressure, and they think little or nothing of
the ill-health’ they may cause by over-exertion. Medical
men now and then preach about the folly of injuring the
health by too great study, but nowhere do we see more
mental effort thrown away in useless directions than in
medical curricula and medical examinations, carried on in
great part by college examiners, who pull this way and that
way till the unfortunate candidate is tortured, as on the
rack, to learn what he will cast to the winds when the happy
moment arrives that he escapes from their grasp.
Zur Oeschichte der Psychiatrie in der 2 ten Halfte des Vorigen
Jahrhunderts. Dr. H. Laehr. Berlin, 1887.
Dr. Laehr has done a useful work in preparing a sketch of
the history of the reforms in the treatment of the insane
during the second half of the eighteenth century. No one
is more familiar with the names of those who fill a prominent
place in this history. We have already noticed in a former
number his calendar of everything relating to lunacy in
every civilized country; the present paper is a fitting
pendant to it, and is, we think, of more utility. One is sur¬
prised that no similar sketch has appeared in Germany
before. It does not admit of quotation, so that all we can
do is to refer our readers to the article itself for reference.
We may, however, cite the concluding paragraph.
In every country, independently of one another, have occurred
similar reforms in psychiatry, because the development of the original
soil of Medicine has carried along with it the development of each
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branch of the medical art, the latter not being able to develop inde¬
pendently ; and because the education of the nation has established
the means requisite for its practical application. Philanthropists and
physicians can thence surpass antiquity with the inspiration, power,
and perseverance, necessary in a reform, and break new ground.
Dev Hypnotismus. Yon Prof. Heinrich Obersteiner. Wien,
1885.
Prof. Obersteiner, of Vienna, has given a sketch in this
pamphlet of 46 pages (reprinted from the “ Monatsblattem
des Wissenschaftlichen ” Club in Vienna) of the past history
of hypnotism. He frequently refers to Heidenhain, to whom
Germany owea its present interest in the subject. A Ger¬
man physician has recently stated that the Dane Hansen,
eight years ago, knew more about hypnotism than all the
German doctors put together! It is not necessary to notice
this short essay at further length.
The Asclepiad. Third Quarter, 1887, Vol. iv., No. 15.
This journal, altogether written by Doctor Benjamin
Ward Richardson, is conducted with as much spirit as ever,
and bears as a motto on the title-page Terar dum prosim.
Another motto might appear on Dr. Richardson’s periodical,
from Horace, Omne capax movet urna nomen , for the capacious
Richardsonian urn sends forth every name in turn. In
this number we have presented to us “ Medicine under
Queen Victoria,” and the well-known Dr. John Snow, a
native of York, is selected as the representative of medical
science and art of the Victorian era. An excellent portrait
accompanies the sketch. Of more immediate interest to the
readers of the “Journal of Mental Science” is the first
chapter of the epitome of the advancement of medicine
under our Queen. The subject is “ The Treatment of the
Insane.” A copy of the well-known engraving of William
Norris, who was chained in the days of Haslam to an
upright bar in a cell in Bedlam, is given. The only recom¬
pense accorded this unhappy American has been the
notoriety of his case wherever the history of the past treat¬
ment of the insane has been related. The print having been
a familiar sight as long as we can remember, we were not
aware that it was extremely rare. Haslam seems to have
had no advanced views in regard to the management of the
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insane, and he could not conceive it possible that the system
which had been for years in operation at the York Retreat,
when he gave his evidence before the House of Commons in
1815, was really carried out in that institution. Dr. Richard¬
son describes the treatment of patients in old times by
causing them to revolve on a wheel. When we visited an
asylum on the Rhine in 1853 a large box in the form of a
wheel, capacious enough to admit an excited patient, had
been disused only three years. And we have recently seen it
exhibited in that institution as a curiosity, useful in remind¬
ing the world of the change that has taken place in all
civilized countries in the treatment of the insane. The use
of such a machine is now restricted to dogs, which are made
to revolve by Fiirstner and others, for enormous periods of
time, in order to ascertain whether they can produce general
paralysis of the insane. Had such experiments been made
in order to deter the superintendents of asylums from
adopting the revolving-wheel treatment, by showing its
effects in producing general paralysis, the motive would
have been intelligible. As, however, no one is now bar¬
barous enough to employ this apparatus in lunatic asylums,
there does not seem any occasion to confirm by experiments
on animals the conviction of the ill-effects likely to follow
from such a mode of treatment. Unhappy dogs!
Dr. Richardson gives a rapid but excellent sketch of the
reform in the treatment of lunatics. “ For some time pre¬
vious to the Victorian era there had been a few good and
humane efforts to relieve the insane of a certain amount of
the oppression to which they were subjected. Three names
in connection with this effort deserve especial mention—
Pinel, of the Bic&tre in Paris; the elder Tuke, in the Retreat
at York; and Dr. Charlesworth, in the City of Lincoln
Lunatic Hospital, in which institution the grand final and
triumphant experiment of entire freedom of the insane was
carried out.”
A description of the treatment pursued at the Lincoln
Asylum follows, and due credit is given to Charlesworth and
Hill. Of the latter Dr. Richardson speaks from personal
knowledge: “I was with Gardiner Hill in his last hours,
and told him once again, as I had often told him aforetime,
that he had not lived in vain, and that some day the world
would recognize him as one of its greatest benefactors. He
could not speak, for his speech was paralyzed, but his close
grasp of my hand conveyed to me, with all the eloquence of
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death, how the hope cheered him in the valley of the
shadow.”
Then comes Dr. Conolly, with “ unexampled opportunities
equalled only by unexampled zeal and industry, who showed
at Hanwell how grand an advance was secured.”
It is a compliment to our department of medicine, for
which we thank Dr. Richardson, that he has put “ the treat¬
ment of the insane” as the most prominent and important
instance of progress in his epitome of the good work done
during the Victorian era.
An Address to Asylum Attendants “ Off Duty ”—“ Invalided .”
By the Reverend Henry Hawkins, Chaplain of the
Middlesex Asylum, Oolney Hatch.
The above has been printed this year, and is characterized
by the same qualities as the tracts for attendants which
have preceded it. As in everything else, so does it hold
good, unfortunately, in the sphere of asylums for the insane
—there are chaplains and chaplains; those who hold their
office for no higher purpose than to make a livelihood, and
those who, like Mr. Hawkins, perform their duties as a
labour of love.
We take the opportunity of drawing attention, not only
to the tractate above mentioned, but to those which have
been in circulation for some time. They are as follows :—
“Work in the Wards by Asylum Attendants,” “Made
Whole, a parting Address to Convalescents on Leaving an
Asylum,” “Friendly Talk with a New Patient,” “Visiting
Day at the Asylum.” It must be gratifying to Mr. Hawkins
to observe the increasing interest which is felt in the welfare
of asylum attendants. Nothing can be more certain than that
the well-being of an asylum depends upon no one circum¬
stance more than the status of those who are placed hour
after hour in the immediate charge of patients. Much is
necessarily left to their honour and unseen conscientiousness.
Everything, therefore, which is being done at the present
day to raise the standard of this class of well-deserving
officers merits cordial support and encouragement. There
may be two opinions as to how far it is desirable to proceed
in the direction of teaching special subjects, including a
quasi-medical knowledge of insanity; indeed, we think
mistakes may easily be made in this way. But there can
be no question as to the desirableness of levelling upwards
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as regards the influence which is brought to bear upon
attendants. We are aware that many superintendents
have a strong prejudice against taking into their service
those who have been trained in other institutions. It is
difficult, however, to see why there should not be the same
gain from thoroughly well-trained mental attendants as is
universally acknowledged to be the case from hospital nurses.
Dr. Cowles, the excellent Superintendent of the McLean
Asylum, Boston, Mass., has sent us a composite photograph
taken from a class of fifteen nurses in that asylum, and
whether we look at them singly or compositely, we are
charmed with the features, expression, and dress of those
whom Dr. Cowles is moulding for such noble purposes.
They seem to be a guarantee of the care, attention, and
kindness which they will pay to those who have the good
fortune to be placed under their charge; and we are much
mistaken if there are more than a very few superintendents
in British asylums who, seeing this pleasing group, could
carry their prejudices so far as to refuse to take into their
service any one of this intelligent and modest company.
Great credit must be given to the physician who has done
so much to train them in the way they should go. We
have every hope of their not departing from it when they
are old, and, what is much more important, when they are
young.
We take this opportunity of noticing a useful and. un¬
pretending periodical, entitled “ Nursing News,” published
monthly. The sixth number is before us, and among the
articles is one entitled “ Notes on Nursing the Insane,” by
Miss Swain. In it she makes some practical remarks on
the duties of nurses. We are glad to see any indication
like this of increased interest on the part of ladies in the
nursing of the insane. We trust this publication has as
large a circulation as it deserves to have.
On the Diagnosis of Diseases of the Brain , Spinal Cord ,
and Nerves . By C. W. Suckling, M.D.Lond., M.R.C.P.
H. K. Lewis. London : 1887.
This little book is obviously intended to be only an
elementary treatise, and the author himself regards it as an
introduction to the standard works of Ross, Gowers, &c. It
is the outcome of post-graduate lectures at Queen’s College,
Birmingham, on the “ Diagnosis of Diseases of the Nervous
System.” There are a number of woodcuts. If the book is
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taken for what it professes to be, the practitioner will not be
disappointed in it. He will find it useful to have presented
to him, in a small compass, the characteristic features of the
diseases of the nervous system, which he is sure to meet with.
Mental physicians require some book of the kind, and in the
absence of more detailed treatises they will derive assistance
from the lectures of Dr. Suckling. We may point out that
under “ Agoraphobia ” the author only speaks of vertigo as
causing the difficulty experienced by phobists of this kind,
whereas persons suffering from this malady may have a
nervous horror of crossing a wide space without having any
vertigo. There is a useful table of the reflexes.
Psychiatrie , Ein Kurzes Lehrbuch fur Studirende und Aerzte .
Yon Dr. Emil Kraepelin, Professor in Dorpat.
Zweite, griindlich umgearbeitete Auflage. Leipzig:
Yerlag yon Ambr. Abel. 1887.
A favourable notice of the first edition of this work will
be found in this Journal, July, 1886, p. 254, and an abstract of
its contents appeared in the Retrospect of the same number.
The new edition has grown in bulk, extending now to 532
pages instead of 377. In the interval the author has been
promoted to a professorship at Dorpat, Russia. One is
reminded by the terms of the dedication of a melancholy
event which has also happened, for whereas the first edition
was dedicated to Dr. B. V. Gudden, then the director of the
Munich Asylum, the second edition is dedicated to his
memory. We can do no more than repeat our commenda¬
tion of Dr. Kraepelin’s work. An English student of
German psychiatry who desires to have it presented to him
in a small compass, and with a lucidity which some people
fail to discover in most German books, will find the present
volume of the greatest use.
A Dictionary of Terms used in Medicine and the Collateral
Sciences . By the late Richard D. Hoblyn, M.A.Oxon,
11th Edition. Revised throughout, with numerous addi¬
tions by John A. P. Price, B.A., M.D.Oxon. London :
Whitaker and Co., Paternoster Row; George Bell and
Sons, York Street, Covent Garden. 1887.
Hoblyn’s Dictionary has always been a favourite, and we
are glad to see a new—the eleventh—edition called for. The
book is brought up to date, aud Dr. Price has spared no
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[Jan.,
effort to make it worthy of the support of medical men.
When the Dictionary of the Sydenham Society is completed
it will, no doubt, be the most complete work of the kind
issued, but even then a small dictionary like Dr. Hoblyn’s
will be required. The danger is that the former will be too *
elaborate, and to some extent defeat the end the Sydenham
Society had in view. However that may be we commend
the lesser book to our readers. No medical library ought
to be without it.
Lehrbuch der Psychiatric fur Aerzte und Studirende. Von Dr.
Rudolf Arndt. Wien and Leipzig: Urban and Schwar-
zenberg. 1883.
Die Neumstlienie ( Nervenschwdche) y ihr Wesen , Hire Bedeutuny
und Behandlung vom Anatomisch-physiologischen Stand -
punkte fur Aerzte und Studirende , bearbeitet von Dr.
Rudolf Arndt, Professor der Psychiatrie, und Director
der Psychiatrischen Klinik an der Universitat, Greifs-
wald. Wien und Leipzig : Urban and Schwarzenberg.
1885.
Der Verlauf Der Psychosen . Von Dr. Rudolf Arndt und
Dr. August Dohm, Weiland Assistentarzt der Letzteren.
Mit 21, theilweise farbigen Curventafeln. Wien und
Leipzig: Urban and Schwarzenberg. 1887.
Our space will not allow of an analysis of these works,
but Dr. Arndt has already obtained so high a reputation by
his writings that it is unnecessary to do much more than to
endorse the verdict of his countrymen.
The earliest of the above works, published in 1883, is a
systematic work on mental disorders arranged on thoroughly
physiological principles, while the author shows his thorough
acquaintance with the pathology of insanity. The work has
taken a high position, and does not require our recommenda¬
tion to increase its reputation. It may be observed that the
observations on paranoia are especially complete, and this
before the attention of alienists was more particularly drawn
to its character.
The second work on the list enters fully into the nature,
importance, and treatment of that morbid condition of the
nervous system which had a special name given to it five
years before by Dr. Beard, but which had long been known
by the Germans under the name of “ Nervenschwache.”
The work shows great research, and it is surprising to see
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1888.]
what an amount of matter results from the suggestion of a
term. It seems to enable observers and writers to bring into
a focus all that they know about a certain group of symptoms
which are by no means new, or recently discovered, and
which are like iron filings attracted to one point when a
magnet is introduced. As one of the symptoms of neuras¬
thenia, some remarks are made on intoxicating beverages in
relation to treatment, to which we would refer our readers.
The third work is devoted to the course of the psychoses,
and is a joint production. It contains some carefully pre¬
pared pulse-tracings (coloured), each case being accompanied
by a chart. The work does not admit of analysis, and as it
only extends to 47 pages it should be procured by those who
wish to possess a series of tracings made with great care in
typical forms of insanity. The tracings in cases of mental
stupor are especially interesting. One taken during a con¬
dition of great excitement, laughing, singing, &c., is very
characteristic (Case 7).
Those who know Professor Arndt personally cannot fail to
be struck with his great ability, powers of exact observation,
and the clear expression of his views on psychological ques¬
tions. His writings possess all these characteristics, and we
can confidently recommend them to students of Psychological
Medicine.
PART III-PSYCHOLOGICAL RETROSPECT.
1. English Retrospect.
Asylum Reports , 1886-7.
(Continuedfrom p. 455.)
Argyll and Bute , 1886-7.—The weekly charge to parishes has
been reduced from 8s. 8d. to 7s. 8d. per patient for the ensuing
year. The actual cost for last year was 8s. 0£d. It is to be re¬
gretted that in many asylums the rate of maintenance should so
nearly approach that in workhouses.
We are much pleased to find that, even now, the occurrence of
preventable deaths is leading to the introduction of improved night
supervision. In the report by Dr. Mitchell we read:—
The unfortunate deaths of P. M. J. and A. B. have led to an examination of
all the locks of the Asylum, which are now understood to be in good order, and
also to the employment of two night attendants on the male side, and to the
placing of epileptics during night in circumstances which admit of a more
careful and constant supervision.
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604 Psychological Retrospect . [Jan.,
Various structural improvements have been effected, but it is
noted that the hospital accommodation is insufficient.
Dundee Royal Asylum , 1886-7.—It is most pleasing to learn
that this asylum is gradually escaping from its financial diffi¬
culties.
The following paragraphs refer to subjects which might pro¬
fitably engage the attention of several superintendents. Such
work is truly in the right direction, and cannot fail to do good:—
The classes and lectures referred to in last report were resumed on an ex¬
tended basis during the winter evenings, and with satisfactory results. A
class for writing and arithmetic was opened early in the season, and was
attended by both patients and attendants, the number averaging 19 of the
former and 18 of the latter. Progress was tested by competitive examinations,
and book-prizes awarded to those who showed greatest proficiency, and also to
those who had made greatest progress during the session.
The Rev. Mr. Wilson also gave a regular course of lessons in music on the
tonic sol-fa notation, which was much appreciated, the average evening attend¬
ance being about 20, and including both patients and employes,
A course of lectures was again delivered to the nurses, attendants, and
servants, but on a much more extended scale than that of last year. To make
this as efficient as possible, attendance was here compulsory, all those em¬
ployed in the service of the asylum being divided into two classes so as to suit
convenience of attendants. Seven lectures were delivered to each, or fourteen
in all, and embraced not only the duties required of all in their dealings with
the patients, but also included elementary instruction in physiological
anatomy and mental science. Copies of a synopsis of each lecture were also
provided for those attending. From the interest and attention shown, this
system of imparting a thorough knowledge of their duties to those in the em¬
ployment of the Asylum cannot fail to be beneficial.
A considerable portion of Dr. Rorie’s report is devoted to the
consideration of the removal of patients to the lunatic wards of
workhouses.
Essex .—The Committee have accepted a tender for the erection
of a new block of buildings for 450 patients. The estimated cost
is £63,873. The enlargement of the laundry is included in this
contract. The building of a new chapel is under consideration.
Much progress has been made with al terations in the drainage,
and it is hoped that soon all will have been completed in accord¬
ance with the most efficient sanitary requirements.
Dr. Amsden has not found the sending of chronic harmless
cases to workhouses successful. He has found that, with few ex¬
ceptions, they have been sent back as unsuitable for workhouses
with the existing accommodation and means of supervision.
Fife and Kinross , 1886-7.—Fourteen chronic cases were boarded
out during the year. Additional precautions have been adopted to
protect the building from fire.
The following paragraph from Dr. Turnbull's report touches on
a subject too often overlooked by those talking and writing about
the treatment of the insane :—
Three of the male cases illustrate very well the fact that the number of
admissions to the asylum is not a matter of mental disorder, pore and simple.
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Asylum. Reports.
but that extraneous circumstances have a great influence on it. The patients
in question were respectively 51, 41, and 35 years of age; in all of them the
insanity had existed and been recognized from childhood, and they all had lived
for years under the charge of their relatives. There was no special change in
their mental state last year to render asylum control more necessary than
before—they were in that respect practically the same as they had been for
many years before, but their domestic circumstances had changed, depriving
them of their former guardians. In one case the sister who took care of the
patient was leaving home to be married; in another the frailty of advancing
years made the mother nnable any longer to manage her insane son; and in
the third the relatives were negligent of their duty to the patient. Thus all
the three had to be placed temporarily in the asylum. A residence of some
months there was distinctly beneficial in each case in improving the bodily
health and in training the patient to more orderly and steady habits; then
suitable homes were found for them elsewhere, and the three were duly
boarded out.
Glasgow District , 1886-7.—In reproducing the following passage
from Dr. Clark’s report, we would venture to say that we hope
that his anticipations of a recovery-rate of 60 per cent, may be
realized, though we feel certain that he is doomed to disappointment.
His cases show the beneficial results of direct treatment, but they
do not differ in any respect from those to be met with in any good
asylum where definite medical treatment is adopted.
I believe a recovery-rate of 60 per cent, is possible in a district like ours,
where insanity is rarely the development of a mere mental idiosyncrasy, where
it is often rather an accident of physical disease, and therefore amenable to
direct treatment.
Many gratifying illustrations of the result of individualizing treatment
might be quoted, and I am forced by the logic of fact to admit that patients
long deemed hopeless have recovered because of persistent attention and care
on the part of some sanguine and resolute nurse. A well-equipped medical
and nursing staff would extract a more searching and complete history of each
case, and many hitherto unknown symptoms when brought to light would
stimulate the hope of recovery or amendment [or the reverse— Eds.]. Un¬
doubtedly, also, many wretched hospital cases owe their recovery to patient,
intelligent nursing, and liberal dietetic treatment.
As examples of cases open to the influence of direct medical treatment, I
may quote (1) the case of a woman admitted in a state of acute depression.
Buffering from most intractable scrofulous sores, which wero only finally healed
up after eighteen months of persistent treatment. She was then discharged
recovered. (2) A young woman in a very reduced condition, admitted in a
state of acute maniacal excitement. She was fed by the stomach pump four
times daily for seven weeks, and for a long time continued in a very reduced
physical state. After a year and nine months’ persistent care she recovered.
(3) A young man was admitted in a state of acute delirious mania, suffering
from severe scalp wound, inflammation of shin bone, and peritonitis. Local
treatment was impossible without the use of frequent hypodermic injections of
a hypnotic. After two weeks the mental furore ceased, the wound took on a
healthy action, and the peritonitis began to disappear. He was discharged
after thirteen months’ residence. (4) The case of a man in a state of
delirious excitement, from the brain-anaemia of heart disease. He was subject
to curious sensations; sometimes he felt his bed going up and down like a
hoist, and at other times thought himself going round like a paddle-wheel.
Under appropriate treatment he improved physically, and was recovered
mentally after five weeks’ residence. These are only four of several of last
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Psychological Retrospect.
[Jan.,
year’s eases; they show a very small fraotion of our hospital work, and they
illustrate more forcibly than any words of mine how mnoh scope there is in
each an asylum as ours for the best resources that we oan command.
Isle of Man. —Dr. Richardson reports that in some cases in
which it was considered judicious, and under proper regulations
adapted to each case, patients have been allowed to visit their
friends at home. In several instances in which, from various
reasons, they had not been visited for some time it is believed a
consideration of this kind has had the effect of removing any wish
to escape.
Montrose , 1886-7.—We are much pleased to learn that in the
dispute between the Managers and the District Board the former
have been successful. The General Board of Lunacy decided that
the rate of maintenance charged by the Managers was a fair and
reasonable one.
Dr. Howden records an outbreak of pneumonia, such as has been
observed from time to time in various asylums. In our present
state of ignorance, these outbursts are inexplicable, and appear
mysterious; but they are deserving of very close study.
On the 10th of March the temperature fell, and strong north winds set in,
the weather being in marked contrast to the end of February and the first
week of March ; e.g ., on the 24th February, with a balmy S.W. wind, the lowest
the thermometer registered was 46 deg. F., while on the 12th March, with a
bitter north wind, it went down to 21 deg.
I do not affirm that the lung disease, which appeared with something like an
epidemic character in the middle of March, was due purely to the sudden fall
in temperature, because many were seized who were protected from cold both
by day and night; besides, I am not aware that either in Montrose and district
or in other parts of Scotland, though subjected to the same low temperature,
was the prevalence of pneumonia unusual. There oan be little doubt, however,
that the sudden cold, added to some unknown condition, was an important
factor in the production of lung disease. On the 13th March, the day after the
lowest temperature, a patient who suffered from fibroid phthisis was seized with
bronchitis and died in eight days. On the 17th a man was seized with pleuro¬
pneumonia, and died in three days. On the 19th another man took pneumonia,
from which he recovered. On the 21st two men took pneumonia; one died
next day, the other recovered. On the 23rd a strong, healthy young woman
was attacked with the same disease, and died on the 4th of April. On the
24th a strong man, who worked on the farm, took ill. On the 25th a man and
two women were seized with pneumonia, and a woman with pleurisy. The
man and one of the women died, while two of the women recovered. On the
27th a man took pneumonia, and died in four days. On the 28th two men were
seized; one died on the 30th, and the other on the 1st April. On the 30th an
attendant, a strong young man, took pleuro-pneumonia, from which he ultimately
recovered. On the 31st one woman took pneumonia and another pleurisy; the
first died on the 4th April, the other recovered. So much for the death-roll of
March. On 4th April a case of pleurisy occurred, on the 8th a case of pneu¬
monia, and on the 10th a case of pneumonia; the case of pneumonia on the 8th
died, the other two recovered. On the 15th an old woman was seized with
pleuro-pneumonia, and died next day. Thus, between 20th March and 16th
April we had no fewer than 12 deaths from acute lung disease.
A somewhat similar outbreak occurred in the winter of 1878-9.
Newcastle-upon-Tyne .—The following extract from the Visitors’
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report contains a truth which should be laid to heart by more than
one asylum officer:—
They (the Visitors) have not hesitated to call additional skilled counsel when
they considered that special knowledge was requisite. Their experience in
connection with the main building has taught them that by taking the opinion
of a responsible person during the progress of particular works considerable
sums of public money may ultimately be saved.
In his report, Dr. Wickham returns to the relation of intemper¬
ance and insanity, and we have pleasure in reproducing his re¬
marks :—
Exception was taken by a reviewer to some remarks in my last report, in
which, while giving it as my opinion that it would probably always be a
vexed question whether the intemperate habits were the canse of the insanity
or the insanity the canse of the intemperate habits, I had said that ° in the
great majority of the particular cases which have come under my own notice
the evidence is in favour of the conclusion that the insanity causes the intem¬
perate habits,” and it was urged that if my observations were correct “we
are and have been totally wrong in our treatment of such cases. Instead of
drunkards being taken to a police-court, they should be committed to an
asylum as dangerous to themselves. As a necessary consequence our asylums
must be multiplied at least ten-fold.’*
I am glad to acknowledge the courtesy which I have always received from
the review in question, but I venture to remind the critic that his alarm that
if my views are correct we must, so to speak, begin at the beginning again,
has nothing to do with the truth or otherwise of them. And I take this oppor¬
tunity of stating that my remarks have been applied more promiscuously than
was intended, and, if I may say so, than their words will bear. I did not
mean to imply that all drunkards were insane, and that insanity caused the
intemperate habits of all such persons. I was speaking only of those cases whioh
had come before myself, in which insanity and intemperate habits had been
concomitant, and I remarked that I had interested myself for many years in an
attempt to place them in their proper sequence in each case, with the result
that an insane neurosis was generally found to have preceded the intemperate
habits. Every year strengthens my conviction that if we only search care¬
fully enough we shall find one constitutional taint or another in those who, as
we are apt to think at first, have been rendered insane by intemperance. And
so long as it is permitted to perpetuate this taint by unsuitable marriages, it is
of little consequence that it is nurtured by intemperance and kindred vices,
for the commonwealth must continue to pay the penalty of not trying to stamp
out the taint itself. To try and check it at the other end is like raising a bank
and trying to stop a current without taking notice of the stream which con¬
tinually feeds it; and it is to be hoped that society will, some day or other,
reach such a wholesome state of education in this respect that the intermarriage
of the consumptive, for instance, will be regarded with as much repugnancy
as is extended now to wedlock within the prohibited degrees of consanguinity.
Northampton .—It is reported by the Visitors that during 1886
a sub-committee was appointed to take into consideration the best
method of making provision for the idiot children in the county.
This sub-committee, accompanied by the clerk to the Visitors
and medical superintendent, visited four idiot asylums and one
county asylum where a block has been built for the treatment of
idiots. The result of these inspections and deliberations was em¬
bodied in a report to the General Committee, the purport of which
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[Jan.,
was that a block for 48 idiot children should be erected in the
west corner of the asylum. Plans for this have been prepared,
and will be shortly forwarded to the Commissioners in Lunacy, two
of whom have already approved of the site and of the scheme
generally.
Mr. Greene reports that the hospital for infectious diseases has
been handed over by the contractors. It consists of three blocks.
One block contains the dormitory for men, with a day-room, single
room, two nurses’ rooms, store-rooms, lavatories, and bath-room.
Another block has the corresponding rooms for women, and the
third block, placed at the rear of the others, consists of the
kitchen, laundry, two bedrooms for domestic servants, disinfecting
room, boiler house, and mortuary. The hospital will accommodate
14 patients, allowing two thousand cubic feet of space to each
patient.
St. Andrew's Hospital .—It is very satisfactory to learn that this
great hospital is free from debt. We find nothing in the report
calling for special notice, though we are glad to find that Mr.
Bayley continues to employ his male patients in garden and farm
work.
Northumberland .—The extensive additions to this asylum seem to
be nearly complete.
Since the ventilation of the wards and dormitories was improved
there has been a marked diminution in the number of deaths from
phthisis.
As to out-door exercise, Dr. M’Dowall reports :—
In order that everything may be done to promote bodily health, increased
attention has been paid to the patients exercising beyond the airing-coarts.
Although for many years almost none of the female patients have used the
airing-courts, but have walked beyond them twice a day, this health-giving
exercise was enjoyed only in the afternoon by the men. Since the spring,
however, they also have walked out every forenoon. Of course, all cannot go—
the lame, feeble, and wildly excited must be left behind, but, with these excep¬
tions, every male patient, not usefully employed, walks in or beyond the grounds
twice every day, weather permitting. This arrangement has been followed by
good results ; the patients have been improved in body and mind, and the
attendants have necessarily been called upon to devote increased attention to
those placed under their charge.
Norwich .—The Commissioners begin their report by saying:—
In an asylum where so much is done by the Committee to render the manage¬
ment as good as possible, we regret to find that there is, as yet, no assistant
medical officer, and we desire at the commencement of our report to state our
conviction that no asylum, even with fewer numbers than are received here,
can be adequately supervised by only one medical officer, however zealous he
may be, and we hope that the post of assistant medical officer will shortly be
filled. We ought, perhaps, to say that this is the only asylum within the
limits of our official knowledge which has not such an officer.
Have the Commissioners forgotten the York Lunatic Hospital ?
Although this strongly expressed recommendation was made in
April, we do not find that it has been adopted, and it is not even
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1888.] Asylum Reports.
referred to by the Visitors in their annual report, nor by Dr.
Harris. We hope that he will not fail to urge this most
strongly on the attention of his Visitors, because we believe that
it is an official error and a personal injury for a man to attempt to
direct such an asylum single-handed.
Nottingham (Borough ).—Plans have been prepared for the en¬
largement of this asylum, and the estate has been increased by the
addition of 20 acres.
It is remarkable to find that of 60 women admitted last year no
fewer than seven were general paralytics.
Nottingham {County). —Although great allowances must be made
for such an old building as this, one is surprised to read that “ a
new drain has been laid under F. 1.” No doubt every pre¬
caution will have been taken to prevent the escape of sewer gas;
but at the very best the presence of a drain under a room must
be a constant anxiety and a possible source of danger.
Nottingham Lunatic Hospital. —We are much pleased to learn
that an assistant medical officer has been appointed.
The Committee have sanctioned the reception of patients at an
initial rate of 25s. weekly. It is, therefore, expected that the un¬
occupied beds will soon be filled, as the Commissioners do not
think it would be easy to find as good accommodation at so low a
rate.
Oxford. —The Visitors report that they had the salaries of the
attendants under consideration, but that no material alterations
had been thought requisite.
We find that the ordinary attendants receive wages varying
from £23 to £35 per annum. Without venturing a definite
opinion, it is our impression that these payments are below the
average in county asylums. The Visitors should remember that
the first requisite in asylum management is a thoroughly efficient
staff of attendants, and that to secure suitable men the wages
should err towards liberality.
The Committee have settled a dietary table for the attendants
and servants and ordered its publication in the wards. Why in
the wards ?
The Commissioners report :—
As regards exercise, we should like to see a regular system of daily walking
exercise beyond the airing courts, but on the asylum estate, instead of such
exercise being afforded ouly once or twice a week as at present. But improve¬
ment in these matters can hardly be accomplished without a stronger staff of
attendants. Here the proportion of attendants to patients is smaller than
commonly prevails in connty asylums, and is, in the male division (including
in the 16 day attendants a tailor attendant and a shoemaker attendant), one
to 13i ; but in the female division (where the day attendants are also 16) one
to 17 only.
It must be admitted that the staff is numerically weak.
Perth District Asylum , 1886-7.—An evening class for elementary
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6l0 Psychological PetrospecU [Jan.,
education has been formed, and an evening Sunday school meets
during the winter months.
On account of overcrowding it has been necessary to enforce the
removal of patients not bona-fide paupers.
The estate has been extended by leasing between 13 and 14
acres for a term of 19 years.
Portsmouth .—A detached hospital has been built and many
minor alterations effected during the year.
The Commissioners recommend the formation of a walk round
the estate. If this were made probably many of the 283 patients
now taking exorcise only in the airing courts would no longer be
obliged to be so restricted.
Roxburgh , ^c., 1885-6.—The main building has been divided
into sections, the division walls carried through the roofs, and iron
doors fitted up so that all communication between the various
sections can be cut off in the case of fire. This is a most judicious
precaution.
It is very sad to think that Dr. Grierson, a man for whom his
many friends have the sincerest regard, has been compelled to
resign his appointment on account of bad health. In all his
relations he is a highly admirable man, and of quite unusual
culture.
Roxburgh , (J-c., 1886-7.—The appointment of Dr. J. Carlyle
Johnstone as medical superintendent is notified, and Dr. Grierson
is retained as consulting physician.
Steady efforts continue to be made to board out such inoffensive unrecovered
cases as no longer require asylum treatment, and it is gratifying to note that
these efforts meet with the hearty approval and support of most of the
Parochial Boards of the District, though Inspectors of Poor still experience
considerable difficulty in procuring suitable homes and guardians for their
patients. It is now pretty generally understood that the detention in an
asylum of a lunatic who does not require asylum treatment is at the same
time an injustice to the lunatic and the most expensive method of dealing
with him.
Salop and Montgomery .—A very severe outbreak of typhoid
occurred. The following extracts from Dr. Strange’s report
contain matters of interest relating thereto :—
In my monthly report for May I had to record that there had occurred
lately several cases of diarrhoea of a severe type, and also stated my belief
that they were due to the well water being contaminated with sewage. I
reported that drains in the immediate vicinity of the well had been found
leaking, and that the drains were defective and badly laid. In June I had to
report that a severe ontbreak of typhoid fever had occurred, due, in my
opinion, to the well becoming polluted with sewage. The outbreak occurred
after the heavy storms in May, and at that time a considerable amount of land
water, evidently impregnated with sewage, was discovered to be flowing into
the well.
It is worthy of note that the earlier pollution of the well, which was pro¬
bably caused by sewage, gave rise to a severe type of diarrhoea, and that no
case of typhoid appeared until after the second pollution caused by the heavy
rains (after the drain supposed to have been at fault had been taken away),
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and when the pollution was surface water driven through soil previously im¬
pregnated with sewage.
The epidemic lasted 11 weeks, 38 were attacked, many of the oases were of
a very severe type, and some were rapidly fatal. Eight persons succumbed.
Coincident with the epidemic were several cases of diarrhoea of a severe
type.
The whole of the sanitary arrangements have been examined by
Mr. Field, who condemns the whole of the drainage.
Somerset and Bath .—For scalding a patient to death an atten¬
dant was sentenced to 12 months’ imprisonment—a punishment
he richly deserved.
Dr. Wade thinks that the passion for dress which prevails
amongst asylum nurses, and in which they are too often en¬
couraged by local tradesmen, frequently leads them into debt,
and it is, he fears, to get away from debts which they cannot meet
that in many cases they move from place to place.
The Commissioners commend an arrangement by which the
names of the outdoor working men are called over every morning
by the Assistant Medical Officer before they leave their wards, so
that the due medical supervision of this class may be secured.
Staffordshire. Bumtwood .—The estate has been enlarged by the
purchase of some adjoining land, and the erection of the new
dining and recreation hall is progressing.
The Commissioners note as a valuable improvement, and one to
be applied throughout, the alteration of the locks on single
room doors so as to allow of the doors being opened from the out¬
side without using the key, and consequently without noise. This
must obviously tend to the comfort of the patients occupying the
rooms.
Although the following paragraph from Dr. Spence’s report
contains no original truth, it refers to a most important subject,
one, indeed, at the very basis of successful asylum management:—
The record of work done during the year is a satisfactory one, and employ¬
ment has been found for over seventy per cent, of the men and as favourable
a proportion of the female patients. To induce so large a number of the
inmates of a lunatic asylum to engage in useful work involves the expenditure
of no small amount of tact and trouble on the part of those who are in direct
authority over them, and especially do the charge attendants merit commenda¬
tion for the thorough and intelligent interest which they take in this important
part of their duty, and for the assiduity manifested by them in pressing on
the attention of those under them the great benefit to be derived from
properly regulated and suitable employment, outdoor as far as practicable, in
the treatment of those mentally afflicted. Plenty of walking exercise is the
only substitute we have for outdoor work in the case of the women, but this is
carried out in a thoroughly systematic manner, so that no female patient who
is physically fit to leave the wards and airing courts is debarred from joining
the walking parties.
Staffordshire. Stafford .—We regret to find that serious ill-health
prevented Mr. Pator writing his annual report.
The number of attendants in some of the wards appears to be
smaller than it should be.
XXXIII.
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612
Psychological Retrospect,
[Jan
j
Suffolk .—Extensive alterations and improvements are still «n
progress ; and it would appear as if the Visitors had awakened to
the necessity of bringing the asylum up to modern requirements.
Mr. Eager reviews his work during the past ten years and its
results. It is quite evident that he has laboured under many
difficulties and discouragements, and he is to be congratulated
that his efforts have not been fruitless, but promise to be more
productive in future.
The following extiacts from Mr. Eager’s report are somewhat
long, but as they refer to the maintenance of an efficient staff of
nurses and attendants, we think that they are worthy of attention.
He is not quite correct in saying that shortening of the hours on
duty has never been suggested; it is in practice in some asylums.
We are especially pleased to find him recommending that the
nursing staff should be changed every eight hours. We have
urged the same reform for a number of years, and feel quite sure
that in this direction lies the most urgent reform in asylum
management. We are strongly of opinion, also, that no attendant
or nurse who has left one asylum should be engaged in another.
Such an arrangement would not have beneficial results :—
The difficulty of obtaining and retaining the services of suitable persons to
act as attendants and nurses does not abate. Some, who, entering on their
duties with scant possessions in a carpet bag, work well and honestly for a
time, become independent, careless, and neglectful of their duties when they
have had time to pull themselves together and become possessors of a trunk
and a fair wardrobe. Some, I am sorry to be compelled to believe,
leave us in order to avoid the payment of debts which they have been
unwisely permitted to run up at the shops in the neighbourhood. For
the most part inconsistent in their demands and ever seeking for that El
Dorado where no work and all the luxuries of life can be obtained, they give
notice on the least reprimand being given them, even though it may be for
dereliction of duty, often of the most flagrant kind. As a rule I refuse all
attendants who have held posts in other asylums, from experience looking upon
them as wanderers not easily satisfied and frequently ungrateful. It is
common to receive applications from attendants who, having passed through *
four or five asylums, are willing to commence at the first step of the ladder
here, and who, if they had remained contentedly in their first post, might
have been a good many pounds a year better off with the better prospect of a
pension. As I have frequently stated, I believe this unrest to be due to a
great extent to the fact that these people are perfectly well aware that if they
leave one asylum they will bo able without much difficulty to obtain a post in
another, as it is well known amoncrst them that at many of these institutions
the authorities seem only too anxious to pick up anyone who has had a few
months’ knowledge of a lunatic. The authorities of the asylums where this
course is adopted do not seem, however, to benefit much if I may judge from
the frequent applications I get for the characters of those who have left or who
are leaving us. Whilst insisting on the folly as far as they are concerned of the
constant movement of our attendants, and on the bad effects upon our patients
of the frequent changes in the staff and the consequent influx of new and untried
hands, it must not be supposed that I do not fully recognize the trying and
arduous nature of an attendant’s duties—indeed, none but those who are
constantly amongst the insane can be fully cognizant either of the irksomeness
of the daily routine or of the responsibility, and the constant exposure to
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1888.]
613
Asylum Reports.
danger and liability to injury, which these duties impose; and those who per¬
form their duties faithfully deserve indeed from all the greatest consideration.
Higher wages, an improved dietary, the provision of rooms fitted up with
every requisite for amusement, such as pianos, billiard and bagatelle tables,
&c., where attendants may associate during their days and evenings off duty,
more comfortable private sleeping-rooms—all these have been provided daring
the past few years in many asylums with the view of making the asylum
service more acceptable, though, I fear, not with a very good result.
No shortening of the hours on duty has, however, as far as I am aware, ever
been suggested, and yet I think that, considering the harassing and monotonous
nature of the duties to be performed, it can scarcely be expected that an
attendant can continue to act conscientiously and actively for twelve or thirteen
hours daily, even in wards where the least troublesome class of cases are
located. Much less, then, can the imposition of such hours be defended where
their duties compel them to be constantly in close contact with the most
demented, filthy, and often impulsive persons, and where they must of necessity
have much to do which is exceedingly unpleasant and revolting.
If, then, we are to provide for our patients that amount of undivided atten¬
tion, careful tenderness, and active supervision which is absolutely necessary
for their proper care and treatment, if the improvement of their condition is
desired and accidents are to be prevented, I believe the nursing stuff should be
changed at least thrice in twenty-four hours, and that when off duty attendants
and nurses should be enabled to get right away from both wards and patients.
This can only be done by providing considerable accommodation in a distant
part of the grounds, to which should be attached a pleasure garden, where
tennis, croquet, and such like games might be engaged in. 1 am surprised
that in those asylums where, owing to the treatment of large numbers together,
the maintenance cost has fallen so much below the average, no reduction in the
hours of the attendants’ duties has ever been attempted with the object of
remedying the evil of frequent changes, and of securing a better and more
responsible nursing system.
A good and varied dietary, comfortable quarters away from the scenes of
their daily labour, less duty and more means of healthy amusement and occu¬
pation—these combined are in my opinion the only means by which we shall
be able to secure and retain the sort of persons we require for asylum service.
Surrey . Wandsworth .—Gratuities from the Benevolent Fund
were presented to 40 patients on being discharged recovered.
Sums amounting to no less than £150 were given to those atten¬
dants who, by long and efficient service, deserved them.
Many patients complained to the Commissioners that they never
saw the Committee of Visitors. The Commissioners rightly think
that every patient ought to have opportunity of making known
his complaints to the Visitors at each time of their meeting, and
that it is especially desirable that the working patients should be
able to do so, as it is for the most part patients who do useful
work who are the most likely to be soon fit for trial or discharge.
The amount of restraint is unusual for an English asylum,
Surrey. Cane Hill .—The visitors note that a memorial is being
adopted by some of the Boards of Guardians in the county for pre¬
sentation to Quarter Sessions, suggesting that represen tat ions may
be made to Her Majesty’s Government with the view of getting
the Parliamentary grant now made towards the cost of the main¬
tenance of pauper lunatics in county asylums extended so as to
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Psychological Retrospect.
[Jan.,
include all pauper lunatics whether they are in workhouses or
asylums. The visitors concur in the prayer of the memorial, and
think that the proposed extension, if adopted, might have the
effect of inducing the Guardians to provide special accommodation
for more of the old harmless imbeciles.
With a view to retain the asylum for those patients only who
had acquired a legal settlement or who were properly chargeable
to Unions in the county, the visitors caused an inquiry to be made
with regard to several who had formerly been inmates of Bethleni
Hospital and who had been removed to the asylum by officers of
the St. Saviour’s Union. The result was that out of 24 test cases
nearly all of them were found to have settlements in Unions in
other counties.
The visitors think that the present law should be amended so as
to give the county authority or the Committee of Visitors of an
asylum the same powder to obtain orders of adjudication as is now
possessed by a Board of Guardians.
Surrey . Brookwood .—Concerning general paralysis Dr. Barton
reports:—
On going carefully through the previous admissions I find there has been a
steady decrease in the number of cases suffering from this fatal disease for
some years past. This is very marked on comparing the numbers admitted
during the previous ten years. I find the proportion of general paralysis to
the admissions during the first half of the decade was nearly 13 per cent.,
while for the latter half it was only barely 6 per cent. To what cause this
decrease may be due I am not prepared to say, but I am inclined to hold with
the theory that the existence of general paralysis amongst the pauper classes
has been influenced by the prolonged depression of trade and privation conse¬
quent thereon, which precludes indulgence in the same degree as formerly in
dissipation and drink.
A post-mortem examination was made in every case.
Sussex .—The following paragraphs from Dr. Williams’s report
refer to an important matter which has, so far as we know,
received little or no attention :—
During the last year or two there has been a marked increase in the use of
Section lxviii. of 16 and 17 Vic., c. 97, by the provisions of which a lunatic,
not a pauper, not under proper care and control, can be sent to an asylum on
the order of two justices.
Many of the cases so sent, however, have been paupers, or the fact of their
having become insane has pauperized them. Nevertheless, the word pauper
was often struck out of the magistrates* “ order,” although the Relieving
Officer certified in the “ statement ” on the same sheet of paper that the lunatio
is chargeable to such and such an Union. If the alleged lunatic is not a pauper
it is doubtless necessary to proceed under this section, but if a pauper, to pro¬
ceed under it would appear to be unnecessary. Formerly this section was only
used occasionally, and in cases of great emergency, such as when a lunatic at
large was rendering himself obnoxious or dangerous to the public and the
friends would not interfere, and the spirit of the section would seem to show
that it was specially framed to meet 6uch cases.
There is, however, considerable hardship in the working of this section, as
will be seen from the following record of a case which is by no means an
isolated one. A gentleman of considerable independent means, well educated
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1888.]
615
Asylum Reports.
and refined, becomes insane, and has strong homicidal and snioidal impulses.
He is dangerous both to himself and others, and becomes aggressive in the
public thoroughfares. His relations, from various reasons, refrain to take the
necessary steps to place him in safety. He falls into the hands of the police;
is brought before two justices, who call to their assistance a medical man.
He is undoubtedly insane and a danger to the public. They sign an order for
his removal to the County Lunatic Asylum, where he has to associate with and
be treated exactly in the same way as the pauper lunatics. There he must
remain as long as he is insane unless the friends or relations come forward and
undertake to be responsible for him, or unless he is made a Chancery lunatic,
which takes months, possibly years, to accomplish. To remedy this injustice
the Act would seem to require to be amended so as to give the justices power
to compel the nearest of kin to take the necessary steps for the lunatic's safe
custody, or else to order his removal to some asylum or place where the
accommodation will be commensurate with his means and education.
Warwick .—This asylum is now no longer capable of receiving
all the patients belonging to the county. In order to postpone
the necessity of building the required accommodation a contract
has been entered into with the Birmingham asylums for five years
for the reception of not more than 100 patients.
Dr. Sankey points out that general paralysis is greatly on the
increase in Warwickshire.
Males.
Females. Total deaths.
1872-76
... 17
1 18
1877-81
... 29
4 33
1882-86
... 40
10 50
Arrangements have been made for providing a suitable Divine
service for Roman Catholic patients. This is much to be com¬
mended, and is worthy of imitation in many asylums.
Wilts .—The following paragraph from Dr. Bowes’s report records
an unusual form of death in asylums :—
Accidents in asylums have occurred and deaths been caused by eating yew
and other poisonous shrubB, but there appears to be no recorded instance of
lunatics confined in an asylum eating and dying from taking poisonous fungi,
and the following casualty is therefore unique:—On August 28th 130 female
patients, in charge of 10 nurses, spent the afternoon and had tea under the
trees in the cricket ground. Nothing unusual was noticed until the next morn¬
ing, when two of the patients were seized with pain in the stomach and violent
retching; they presented all the symptoms of irritant poisoning. The cause, by
the confession of one of the sufferers, became known, and the usual treatment
was adopted, with, in the case of the healthy and strong patient, a good result,
but the other, who was delicate and diseased (suffering from fatty degenera¬
tion of organs), succumbed after forty-eight hours' suffering.
Wonford House .—A considerable number of structural altera¬
tions and improvements, including the remodelling of the drainage
and sanitary arrangements, were effected during the year.
It is very gratifying to find that at the end of the year no fewer
than 65 patients were maintained at rates below the actual cost.
The seaside house at Dawlish is found of increasing service.
Two carriages are now used for the patients, and are a source of
much pleasure and benefit.
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Dr. Deas submits a number of improvements to be undertake
when opportunity offers. They would, no doubt, add much frifte
efficiency of the hospital.
Worcester. —A new chapel has been opened and an excellent
organ provided. The building accommodates 720 persons.
The Commissioners say:—**
We were gratified to hear that the Committee here not only visit the wards
frequently, but give to every patient an opportunity of their bringing forward
any grievance, ticking off the name of each patient on the list so that he or she
has that face-to-faco interview with a magistrate, which contents so many.
In too many asylums, we fear, the Visitors avoid the visits to
the patients as much as possible, and do not devote that time
which this most important, though disagreeable, duty demands.
Yorkshire. East Riding. —A fever hospital has been erected, at
a cost of £1,300.
Dr. Macleod’s home was entirely destroyed by fire, but has been
rebuilt. It is highly creditable to the discipline of the establish¬
ment that during the fire there was no vestige of panic.
Yorkshire. North Riding. —Occupation, the best form of treat¬
ment, seems to be judiciously pursued at this asylum. Mr.
Hingston says:—
Occupation of a varied nature has thus been provided for the patients, and
the benefits accruing to them thereby are very great. The attendants are
always instructed that the patients who are working under them are employed,
not so much for the value of their work, which is sometimes less than worth¬
less, but for the good they derive from the exercise and occupation. Compara¬
tively few of the men are ever idle, the very worst, comprising those too
dangerous to be allowed to handle tools, being provided with work of some
kind, such as rolling the lawns or cricket ground, wheeling soil, &c., and in
many instances the fresh air and healthy exercise thus obtained have proved
most beneficial, and have led to good results.
West Riding. Wakefield. —In spite of all that bas been done to
bring this building up to modem requirements some of the wards
must be dismal in the extreme, seeing that the Commissioners
note the fact that at the time of their visit (November) it was
necessary to light the gas at mid-day. They very properly con¬
clude that this state of the wards must have a prejudicial effect
on the patients.
As many as 250 men and 100 women are entirely confined to the
airing courts for exercise.
Many improvements continue to be effected. These include a
new mortuary, constructed upon the most approved principles.
Dr. Bevan Lewis is to be congratulated on having reduced the
hours of his nursing staff. He says :—
In April last, the question of long hours on duty having been brought before
the Committee for consideration, I was authorized to introduce certain changes in
the organization of our nursing staff, such as would practically abolish evening
duty after 8.30 p.m. It was considered that the time on duty was unneces¬
sarily prolonged in the case of the day attendants, and that such a concession
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1888.] Asylum Reports.
would be both reasonable and beneficial. The change was first tried on the
male side, and, having worked satisfactorily, was subsequently adopted on the
female side. I can now report in very favourable terms of the new departure
which has been highly appreciated by the nursing staff, in whose interest .it
was made.
Yorkshire . South .—The Committee have sanctioned some reduc¬
tion of the working hours of the male attendants, and a necessary
increase of the staff to admit of this being carried into effect. It
is to be hoped that this arrangement will be extended to the
nurses as speedily as possible.
At the urgent recommendation of the Commissioners the Com¬
mittee decided to grant to patients discharged on trial a weekly
sum equivalent to the cost of their maintenance in the asylum.
Dr. Mitchell hopes that such beneficial results will justify this
plan of assisting patients at & most critical time, as are stated to
have followed its adoption elsewhere.
York Retreat .—This institution shows signs of continued success.
A Convalescent Home has been opened at Scarborough for ten
lady patients, and also for those patients who every summer visit
the sea side. From personal inspection we can speak highly of the
arrangements made to secure the comfort and the safety of its
inmates.
York Lunatic Asylum .—This asylum has been vastly improved
by the alterations recently made under Dr. Hitchcock’s super¬
vision. An excellent bowling alley has been added. The improve¬
ment in the appearance of the asylum is quite surprising to any
one acquainted with it in former years.
2. Scandinavian Retrospect .
(i Continued from p. 432.)
II. Medical Gymnastics or Movement Cure .
By Ellen F. White, Certificated by the Royal Gymnastic Central
Institute at Stockholm.
The term “ Medical Gymnastics ” is used to express the treat¬
ment of disease by movements. Ling, an officer in the Swedish
Army, and the originator of this system, received his first inspira¬
tion on the subject by finding that fencing cured the lameness in
his own arm. From this simple fact he was drawn on to think,
why should not other affections be also cured by means of move¬
ments. So he went through a complete course of anatomy,
physiology, and pathology, and gradually evolved the whole of his
system, which embraces, not only medical, but also military and
hygienic or educational gymnastics. The object of hygienic
gymnastics is to preserve the balance of power in the body; that
of medical gymnastics is to restore the balance when it has been
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Psychological Retrospect.
[Jan.,
disturbed by loss of proportion between the parts. The blood is the
carrier of life and of disease. If the stream to any part be above
or below the normal supply, disease is the result. Can the flow and
the actual quality of the blood be regulated by gymnastics ? The
experienced gymnast at once answers “ Yes.” The very fact that
the hands and feet become warm through exercise shows that the
sluggish circulation has been quickened, and that more and fresh
blood has been brought to them from some other part which has
in consequence become poorer, perhaps to its own benefit. Ling,
by his marvellously clear insight into anatomy and physiology, was
able to think out and arrange movements for all parts of the body,
by means of which the supply might be decreased or increased, or
the nutritive quality improved, all according to the exigencies of
the case. Nor is the control of the circulation the only weapon in
the hand of the gymnast. By constant pressure the form and
direction of the parts may be changed, and swellings caused by
accumulation of matter may be reduced and absorbed.
Movements are of two kinds—active and passive. The active
movements may be “ free,” that is without any extraneous help ;
or “ compound,” that is with the assistance of the operator. The
nature and the amount of required assistance varies with the
strength and capacity of the patient. In “ free ” movements the
patient has only himself to depend on, and unless he has already
had some gymnastic training the result will be a wavering, un¬
certain exercise, lacking form and concentration. The touch of a
practised hand giving support or resistance where, and only where
and when actually needed, at once guides the refractory limb in
the right direction; and firm and decided movement is the result.
Slow and quick movements act differently, and the operator can
regulate the time and strength of a movement by the way in
which he weighs, lengthens, or shortens the natural levers in the
body. Take, for instance, “ double plane-arm bending.” The
patient’s arms are stretched forwards, with the hands the same
height as the shoulders, and rather more than shoulder breadth
apart. The movement to be executed is to move the arms in the
same plane, without bending the arms, as far back as they w'ill go
without bringing the shoulders forward. The gymnast places his
hands behind the wrists of the patient, giving more or less resis¬
tance. By placing the hands behind the patient’s fingers the
force required for the movement is much increased.
Apparatus also is used, chiefly as the means of isolating the
movements to a certain part of the body ; or as the means of
obtaining complete relaxation of the muscles under a passive
movement.
Passive movements are described as absorbent in their effects,
and belong peculiarly to medical gymnastics. In these the patient
must not contract his muscles at all, but let himself be perfectly
“limp.” For most people this is not at all easy. At the first
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Scandinavian Retrospect.
619
touch the muscles contract, building up a barrier between the
operator and his work, rendering the operation far more difficult,
and sometimes nullifying entirely the effect to be produced.
“ Massage ” forms one part of the passive treatment. It is given
on the bare skin, and is resorted to chiefly for rheumatism and for
swellings of all kinds, in conjunction with active and other
passive movements for increasing the circulation. Important as
massage is, it forms only a part of the passive treatment. Other
passive movements are percussions, vibrations, frictions, slapping,
kneading, &c., with nerve and vein and artery pressures. Most of
these have a stimulating effect on the nerves. I saw one little girl
who had no power of dorsal flexion in her right wrist. As the
doctor pressed firmly upon the radial nerve the hand lifted itself
for a few moments and then sank back to its former position, lift¬
ing itself again under renewed pressure. The doctor told me that
when she first came to him the lifting of the hand had been very
feeble. She had how begun to lift it herself a little after each
nerve pressure, and he hoped to effect a complete cure after a few
months.
Compression of the jugular vein is sometimes used for head¬
aches. By pressure on the pneumogastric nerve palpitation of the
heart may be checked. Percussion is given either with the half-
closed fist as “ sacral ” percussion, or with the ulnar side of the
hand, as on the head or spine.
In the treatment of the patient the whole system is considered,
and not only the local evil. Thus headaches would be treated by
specific movements, but also by movements directed at the root of
the evil, whatever it may be. The health of the whole body
depending on the blood, the organs concerned in preparing the
blood for use, and for regulating its circulation, are first to be con¬
sidered. Each prescription begins with a respiratory movement
to increase the amount of air inspired, and consequently the
quantity of oxygen in the blood. Hence it is important that the
air to be inspired should be as pure as possible. Then comes a
movement for the circulation, bringing all the muscles of the body
into play. Then the local disease is attended to ; and, lastly, the
digestive organs, to stimulate secretion and absorption in the ali¬
mentary canal, and to strengthen the action of the bowels. By
different positions and- points of support, an infinite variety of
movements may be produced suitable to all ages and all degrees
of strength. The same movements may be taken standing, sitting,
reclining, lying, or kneeling. And even these five fundamental
positions may be very much modified and varied. In most cases
the simpler the movement the better, for the action is then more
concentrated, and the form is more easy to watch.
Indigestion is most effectually cured bj gymnastics; it is one
of the diseases most frequently handled in the gymnasium. Dr.
Classon, Professor of Anatomy in Upsala, says, in relation to this
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Psychological Retrospect.
[Jan.,
subject :—“ It is from the digestive and other mucous membranes
and glands that the blood supply to the working muscles is ob¬
tained. Gymnastics can also be made, in the sense alluded to, to
regulate the blood quantity and the function of these organs. The
increased waste and repair in the working muscles afford means of
reacting on the digestive apparatus. It has been said that in
gymnastics is to be found the only true stomachic we possess. This
expression becomes more correct, nay, almost literally true, if we
take into consideration the muscular coat of the stpinach and
intestines. An increased activity in the voluntary muscles pro¬
duces, for example, a similar activity, and consequently greater
development, in the involuntary muscles.”*
Many patients with obstinate constipation have been effectually
cured, as well as those with diarrhoea, a fact which might be of
some value as a preventive in cholera, but only, perhaps, if
given immediately upon the appearance of any premonitory
symptoms. I am told that Mr. Bampfield, who was a Navy
surgeon in the early part of this century, had great opportunities
of observing the symptoms of Asiatic cholera in Calcutta, and he
found that the cramps attending its attack could always be entirely
relieved by pressure; by which, also, he used to cure ordinary
cramps.
Patients with disease of the heart apply frequently for relief,
which can be given in almost all cases. Of course, where there is
organic disease of long standing cure cannot be expected; but
great relief may be given, especially where the movements can be
repeated many times a day.
Hypertrophy of the heart and the nervous palpitations so
frequently following general debility are almost without exception
cured by gymnastics. The movements are “ derivative,” thus
lessening the pressure on the heart. “ Derivative ” or “ Abstrac¬
tive ” movements are those which conduct the blood away from
any part. Thus foot rotation is a derivative for the head, arm
movements for the chest, especially if they be passive and do not
increase the action of the heart. Vibrations, percussions, and
passive movements with feet and under arm, and very gentle res¬
piratory movements are the chief exercises used in such cases, the
operator keeping very strict watch that the action of the heart
is not increased.
We have now a little girl under treatment for valvular insuffi¬
ciency, caused by rheumatic fever, and curvature of the spine.
After every trunk exercise a “ derivative ” movement is given to
quiet the action of the heart. The peculiar w r histling sound is
now scarcely audible, and her back is nearly straight. [During
the four or five weeks since the foregoing w r as w ? ritten a complete
cure has been effected. The girl has been again examined by her
# From “ Kinetic Jottings,” by Professor Georgii (p. 252).
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1888.]
Scandinavian Retrospect .
621
father, Dr. Sodermark, and he declares that he cannot now trace
any sign of valvular insufficiency or other disease in her heart.]
In the early stages of consumption a complete cure may he
effected. In this disease great pains are taken to widen the chest
and to improve the digestion and circulation. A gentleman of
consumptive tendency after six months’ treatment had gained
three inches in width across the chest, with a corresponding im¬
provement in health. He now hopes to be able to settle down at
home instead of wandering about the Continent in search of
health.
Something ought now to be said about spinal complaints. In
cases of acute inflammation no active movements can be even
attempted; and where the bones have grown together the back
oannot be straightened again. But the chest can be widened, the
general health improved, and the patient enabled to hold himself
up instead of depending on artificial support.
The treatment for curvatures, where there is no complication
with inflammation, has for its object to make the muscles contract
on the convex side, thereby stretching the too strongly contracted
muscles on the concave side. The exercises must be most carefully
watched, and should never be taken save with bare back, so that
the operator can see the effect of each exercise and watch the
progress made from day to day. There is a very great variety of
movements for this deformity and all its complications.
In his Fothergillian Prize Essay on the spine Mr. Bampfield
gives movements, both active and passive, with and without the
aid of the elaborate mechanical contrivances then in use for the
cure of curvature by the active exercise of the muscles. The
movements were to be continued “till fatigue be produced,” which
was to be succeeded by an interval of complete rest in the
horizontal position.
By the use of stays and other supports the back may be held
straight, but no strength can be given by them to the weakened
muscles, which grow weaker day by day from disuse. The length
of time necessary to effect a cure depends very much upon the
strength and capacity of the patient, and also on his degree of
stiffness. Two or three months are often enough to strengthen
the back if the curvature be slight, and the patient bring his will
to help in maintaining a good position out of the gymnasium. It
is better to give milder movements twice or three times a day
than to tire-out the patient with strong movements once a day.
Here, also, attention must be paid to the general health and the
style of the clothing. The female clothing is quite as inconvenient
in Sweden as in England, with stays and improvers, buttons,
bands, and strings almost endless, and the dress tight across the
chest. One little girl now under treatment for a double curvature
was told to make her things fasten down the back to facilitate
exposing the spine to view under the exercises. She simply turned
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622 Psychological Retrospect. [Jan.,
them round and pnt them on, hind-before, thns giving at the same
time more room for her chest.
Rhenmatism, sprains, and stiff joints and swellings of all kinds
are treated by massage in conjunction with active and other
passive movements, given w r hile the muscles are pliable from the
massage, thus slowly accustoming them to contract freely.
Sprains may be cured very quickly. The manipulation should
begin at once, and should be repeated twice or three times a day.
For stiffness after a fall the remedy is rapid. I was calling one
day at a friend’s house and found the little boy on the sofa, very
unwilling to move. He had slipped on the polished floor and
bruised his leg, so that it was painful to walk. Much against his
will, I began to rub him, and in a quarter of an hour sent him
back to play in the nursery, much to the amazement of his father.
In disorders of the thumb, arising very often from writing and
from various mechanical pursuits, massage is used with active
and passive movements, rotations, bendings, and stretchings for
the whole arm and for each individual joint. This being a local
affection of the muscles, they require strengthening by improving
the circulation and action of the nerves.
Adhesions, whether with rheumatism or otherwise, are broken
up with more or less powerful massage, succeeded by a forcible
bending of the joint as far back as possible. A cure is thus
effected by slow degrees, depending very much upon the nature
of the case, its cause, and the length of its duration.
Hip disease in like manner is very successfully treated even
when the abscesses have formed and are actually open, improve¬
ment often being visible almost from day to day.
In nervous twitchings and convulsions very great benefit is
derived from the movement cure. In this case the muscles are
gradually brought under the perfect control of the will.
Hyphochondria, hysteria, and other nervous affections are
frequently treated in this manner with good result. Under such
rational occupation, and exercise of the mind in conjunction with
the body, the mind also recovers its balance, its health improving
with that of the body.
In cases of insanity, on the other hand, the body often seems to re¬
tain its healthy condition. But seeing how seriously in many persons
the state of the optic nerve, for example, is said to be affected by a
slight disturbance of the spinal balance or other condition from so
apparently trivial a cause as that of wearing liigh-heeled boots, it
would be but reasonable to expect that some other of the brain-
nerves also may be brought into a healthy condition by operating
upon the spinal system through properly directed movements.
How far the other sensory nerves may be influenced by spinal
action remains yet to be investigated ; but other brain-nerves
which are connected with the internal organs of respiration,
circulation, and digestion, and w T ith certain muscles also, may in
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Scandinavian Retrospect .
628
any case be influenced by improved spinal action through the aid
of properly directed movements.
We must always keep in mind, and here especially, that the use
of gymnastics, whether hygienic or medical, is not to develop or
strengthen the muscles or the muscular system, but to preserve, or
it may be to restore, the proper balance between all the vital
functions of the body. When these are in proper order the pro¬
portionate strength of the muscles is a natural consequence.
Unless the movements are perfectly passive they involve a
systematic expenditure of brain power in order to execute the
movements correctly. This expenditure must be specially and
carefully provided against. An ill-directed energy of the brain
may be then guided to other more wholesome channels, as one
might set a child with a so-called “mischievous tendency’* to
some manual labour to prevent its spending its energies in doing
mischief.
Nervous irritability is often a precursor of settled madness. But
the effects of gymnastics on insanity, arising from organic disease
of the brain, have been, as yet, but little studied. It is unlikely
that any relief in such disease would be afforded by working upon
the cerebral nerves. Where, however, the insanity is known
to have arisen from pressure, from impei'fect circulation, or
from derangement of some other parts which may be reached and
handled by gymnastics, a cure is often effected, the madness dis¬
appearing with the removal of the physical derangement ; the
quieting effects of the movements on the nerves assisting the cure.
There is evidently a rich field open for investigation in both these
directions, with the prospect of great results, if taken up as a
special branch of the system. The same may be said as to the ap¬
plication of gymnastics to specially female disorders, which is, as
yet, much questioned by the medical faculty. Still, there are some
gymnasts who make this branch their speciality with more or less
success.
Chronic diseases are those which come, at present, more
frequently under treatment, but the practice of treating acute
cases by gymnastics is gaining ground. It is expected that in
course of time medical gymnastics will be almost entirely under
medical control.
Young medical students are encouraged to go through the course
of instruction given at the Institute. Students are not admitted
under 20 or over 30 years of age. The qualifications required of
all students who apply for admittance to the Institute are : (1) A
certificate of health and freedom from organic disease and de¬
formity, flat foot, or other defect. (2) A good school certificate;
and, for native candidates (3) A certificate of confirmation, or
failing that, as in the case of some foreigners, a personal recom¬
mendation from some clergyman. A foreigner must, of course,
have mastered the language to enable him to follow the given
course of instruction readily and accurately.
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Psychological Retrospect . [Jan.,
Sweden is now over-run with so-called gymnasts who have been
a few months, or it may be a few weeks, under some teacher, and
who then begin to practice on their own account, bringing great
discredit on the whole system by their faulty and inefficient work.
It is to be hoped that in a short time no one will be allowed to
practice without a diploma.
On leaving the Institute the student has acquired a certain
amount of practical as well as theoretical knowledge. But he (or
she) still lacks the requisite experience, and it becomes advisable
for him to work for a year or more under some able gymnast be¬
fore depending entirely on himself.
In medical gymnastics the brunt of the work falls upon the
hands and arms, and a large firm hand is a great advantage.
Delicate, tapering, flexible fingers are quite the reverse. Height
also is an advantage if strength be in proportion. A short gymnast
has some difficulty in handling a large and heavy patient. The
eye also must be trained to watch accurately the effect of the
movements, and, in conjunction with the hand, to detect the
slightest deviation from the correct form.
Anatomy and physiology are needed for the educational branch.
How much more so are they required for the medical. Some little
knowledge of pathology also is imparted, but more careful instruc¬
tion is given in the treatment of diseases. The diagnosis is
commonly given by a physician, the treatment then being
prescribed by the gymnast. The more expert and experienced
gymnasts often draw up their own diagnosis. If trained assistants
having no theoretical knowledge are employed very careful super¬
vision is necessary.
A certain amount of apparatus is requisite, but this need be neither
elaborate nor expensive. Two wooden stools, a bench, over which
the patient can sit astride, a couch with a hinged back, which can
be placed at any angle, or lowered to a level with the seat, and a
horizontal bar, w r hich can be raised or lowered to any height, are
all that are really required in ordinary cases. The usual furniture
of a room, a sofa, music stool, &c., can all be used if the gymnas¬
tics are given in the patient’s home.
It w r ould be impossible in such a cursory sketch as this to go
into further details. But I w r ould add that Professor Georgii’s
u Kinetic Jottings ” will be found to contain much interesting
matter on the subject of the “ Movement Cure.” I have but in¬
dicated some few of the many w r ays in which the system may be
applied. It will be seen from what has been said that the course
of instruction must be tolerably severe, and indeed I was cautioned
seriously against attempting it. The requisite Skill of hand and
accuracy of eye can be acquired only after long and persevering
practice. It is not until after a year spent in daily practice upon
one another that students are allowed to help with patients. The
daily practice in educational gymnastics is of great assistance in
training the eye to take in different forms with accuracy.
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Scandinavian Retrospect .
625
A great future, I hope, is before us in England if only the lead¬
ing members of the profession can be led to look carefully and
fully into the working of the system, and to test its true value by
their own observation of its results. I have shown what is
required of those who come to learn. Should there be any who
are disposed by similar training in this Institution to devote them¬
selves to the relief of those many cases of bodily suffering which
cannot be reached so readily or effectually by the ordinary modes
of medical treatment, I cannot but commend to their notice the
farewell words addressed by Professor Torngren to myself:
“ Should any other countryw oman of yours feel inclined to come
she would be most heartily welcomed.”
Some apology may seem due for my thus venturing to urge this
subject so strongly upon the notice of medical men and women in
England. I am quite aware that massage has been much used,
and with great success. I am aware that something has been
done in the way of medical direction of movements for the restora¬
tion of the action of the muscles in cases of rheumatism, adhesions,
or injury; and there is now in London an institution for giving
passive movements by mechanism. But I believe that, com¬
paratively speaking, few have knowm at all of gymnastics hitherto
as more than a mere series of stereotyped exercises, given by
persons absolutely without medical qualification or any proper
anatomical or physiological knowledge, and given for the exercise
of the limbs and the development of the muscles, often it may be
to the detriment of the general health, and almost certainly to
failure in the case of any special ailment. But impressed as I
have been with a deep sense of the value of the system as carried
on in the Institute at Stockholm, I would with much deference
invite inquiry into its merits, being most anxious that its highly
scientific nature should be investigated, and that the true reasons
for its highly scientific study should be pointed out, and more
generally known and understood.
P.S.—Since the foregoing was written the practice of medical
gymnastics has been placed under strict medical supervision, and
the course of instruction is becoming more severe. Young medical
men taking it up will now have to give two years to the prepara¬
tory course, and then one year to the medical. They that have
obtained their certificate are now entitled to the prefix (not as it
would be in England the suffix) of “ Gymnastik Director.”
No one may now practice without the certificate of the Royal
Central Institute, and no patient may be treated without a declara¬
tion or recommendation .from a physician that the patient may
receive medico-gymnastic treatment. The first offence will be
punishable as “ quackery,” the second will be visited with a pro¬
hibition to practice, which will be a deprivation of the benefits of
that certificate. So that they who attempt to take patients with-
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626 Psychological Retrospect. [Jan.,
out a doctor’s declaration, as well as they who have not passed the
examination, are alike restricted. The propriety of this must be
apparent to all who have made themselves acquainted with the
system, for they will see that great and irremediable mischief may
be done by an ill-advised application of this mode of cure.
3. French Retrospect .
By D. Hack Tukb, F.R.C.P.
Reports on the administration of the departments for Epileptics and for
Idiots and Imbecile Children at the Bicetre .
We regret that a notice of these admirable Reports which have
appeared yearly under the auspices of the Progres Medical, has not
found a place before now in our Journal. With a limited space at our
command, and an unlimited material making demands upon that space,
we are compelled to omit much of which the intrinsic merit calls for
notice.
The reports consist each of two parts, the first of which deals with
the history of the development of the above-named departments, and
in particular records the patient, untiring endeavours which the chefs
de service have brought to the improvement of the administration of
these departments, including the formation of a separate department
for the treatment of children who are weakminded and idiots. This
part has, of course, a special interest for the great People whom it con¬
cerns, and it will suffice for us to express our hearty sympathy with
the movement and our pleasure at the progress made. To us as
Englishmen it is most gratifying to find that our own institutions of
Earlswood and Darenth have such commendation from our neighbours.
The second part is clinical, and contains much that interests the
specialist in nervous diseases, much that interests the worker in general
medicine. An exhaustive critique of this part would take us beyond
the limits assigned, but we may select here and there from the 1885
volume. The records of twenty-one cases of epilepsy treated by means
of curare are given. The treatment was by subcutaneous injection,
and was maintained for periods of three and six months. The con¬
clusions are that the drug is not amongst those serviceable in epilepsy.
Of the twenty-one cases one only was distinctly benefited. With
these results, it is scarcely worth while giving details as to doses, etc.
Twelve cases of epilepsy treated with sclerotic acid, either by the
mouth or subcutaneously, derived benefit in five cases. Four of these
cases were under treatment more than a year. The results are de¬
scribed as “ peu encourageants,” which probably means that, in the
cases benefited, the benefit was not striking. A foot-note points out
that these negative results accord with the experience of Dr. Gowers
as to the uselessness of sclerotic acid in epilepsy.
An outbreak of rotheln at the Bicetre furnished the materials for an
inquiry into the nature of this specific exanthem. It is pointed out that
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1888.]
the affinities of this affection are with measles and not with scarlet
fever. The likeness to measles they would make to be that, not of
twin-sisters, but of half-sisters. u Non deux soeurs jumelles, mais &
un certain degr6, demi-soeurs.” They further suggest that the like¬
ness is something of the kind which obtains between variola and vari¬
cella ! We are tempted to ask what is that likeness ? That no real
advance has been made in this vexed question will become apparent,
we think, if inquirers will turn to p. 107 and consult the “ diagnostic.”
We must confess to some malice in having picked up this apple of
discord grown on arriere soil. A case of some interest of congenital
idiocy with horse-shoe kidney is detailed. There was a very marked
phimosis in this case, which apart from its interest in relation to mal¬
formation of other parts, presents this further suggestion that it, and
not the horse-shoe kidney, with its anteriorly-placed ureters was the
cause of the micturition trouble observed.
Some admirable plates illustrate an interesting case of epilepsy with
cerebral haemorrhage.
These few selections may illustrate the kind of work which the
Bicetre reports undertake. It is clearly the kind of work which large
institutions alone can undertake. We heartily commend the great
zeal, which must lead to the accumulation of a most valuable materiel
of clinical and pathological results. H. S.
VAutomatisme Somnambulique devant les Tribunaux . Par Dr. Paul
Garnier. Paris : J. B. Bailliere et Fils, 1887.
La Psyckologie du Raisonnement; Recherches Experimental par
VHypnotisme . Par Alfred Binet. Paris: Felix Alcan,
Editeur, 1886.
Animal Magnetism. By Alfred Binet and Charles Fere. London:
Kegan Paul, Trench and Co., 1887. (The International Scientific
Series.)
We are glad to see the subject here treated of placed in such trust¬
worthy hands, and only regret the title of the book. It is a pity
to retain this misleading term, especially when “ hypnotism ” is now in
general use. We hope to return to this work in our next number, in
the meantime recommending our readers to obtain the volume.
Le Langage Interieur et les Diversea Formes de L'Aphaaie. Par
Gilbert Ballet. Paris : Felix Alcan, Editeur, 1886.
Les Phenomenes Affectifs et les Lois de leur Apparition . Par Fr.
Paulhan. Paris: Felix Alcan, Editeur, 1887.
The number of works on hypnotism and allied subjects which have
appeared in France during the last two or three years is so great- that
it is difficult for the reviewer to keep pace with them. They show the
extraordinary interest which hypnotism has excited, and how its bear¬
ing upon psychology, both in its pure and medical aspect, has become
evident to French physicians. Dr. Garnier is well qualified to express
an opinion on somnambulism, from his position in connection with the
xxxiii. 41
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Psychological Retrospect.
[Jan.,
special infirmary for the insane who come under the notice of the Paris
police. He more especially regards the subject of hypnotism in its
legal aspects. Blind impulses due to somnambulism are obviously of
extreme importance, the subject being totally unconscious of the acts
he has committed. He reports the case of & young man charged
with theft.*
M. Binet has written a book in a scientific spirit, in which psycho¬
logical questions are viewed in their relations to hypnotism, not by any
means exclusively, but as a help to other methods of inquiry. His
theory attempts to explain the process of reasoning by means of images
and sensations, and by these properties alone. Nothing intervenes;
hence, strictly speaking, the expression, M I reason,” is not correct.
" It is incorrect to say that a judgment is the act by which the mind
compares. It is as if I said that chemical combination is the act by
which chemistry reunites two bodies. As the combination of bodies
directly results from their properties, so mental combinations, and
especially reason, result directly from the properties of images ” (p.
161 ).
M. Ballet’s book is written in a very clear style, and the title is
happily chosen as representing the extraordinary phenomena so little
realized by the world in general, which occur in consequence of sub¬
jective conditions which form a world of their own. The work bears
more especially upon the different forms of aphasia. The condition
known as word-deafness and that of word-blindness are described
lucidly, assisted by the diagram or scheme of M. Charcot. Thus, with
the infant acquiring the idea of such an object as a bell, this sounds in
its ear, the vibrations are transmitted by means of the auditory nerve
as far as the common auditory centre, that is to say that portion of the
cortex whose function it is to perceive sounds; the vibration and
commotion are preserved by the cerebral cells, which henceforth are
differentiated. The sound of the bell will become part of the “ de¬
posits/’ so to speak, of the brain, and the deposit will be persistent
and durable according to the frequency with which the differentiated
cells perceive the vibrations of the bell. The infant who experiences
the sensation and remembers the sound has not yet the idea of the
bell. This presupposes, in effect, the association of different memories
and images resulting from many sensorial impressions—the visual
impression which will reveal to the subject the general form of the
~ object, its relief, its colour, and the tactile relation which will serve to
render the form more precise, and give the notion of the consistency
of the bell. In short, the infant will have a complete idea of the bell
only at the moment when the intelligence will associate the various
auditory, visual, and tactile images with one another.
Manuel Pratique de Medecine Menlale; par M. R£gis. Avec me
Prejace } par M. Benjamin Ball. Paris : Octave Doin. 1885.
Too long a time has been allowed to elapse between the appearance
* A report of this interesting case will appear in onr next number.—E ds.
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1888.]
French Retrospect .
629
of this work and onr notice of it. We commend this Manual for what
it professes to be—a practical guide to mental medicine in a portable
form. It is not necessary to analyze the book. A few words may be
said on the section on “ manie suraigue” or delire aigu. Mental
physicians in England are but too familiar with Acute Delirious Mania
and its most serious character. M. Regis’ description of the symp¬
toms would seem, however, to mark a more intensely fatal condition of
the system than the form which usually presents itself to us in
England. He observes that the correct way of regarding it is to
admit a state of hyper-acute mania, sometimes simple , consequently
without any lesion, and sometimes associated with other morbid con¬
ditions, as general paralysis and alcoholism, in which there are certain
morbid changes. Then follows the description:—“ Delire aigu is
almost always preceded by a stage of premonitory depression, which
in certain cases leads one to suppose that the patient labours under an
attack of melancholia. Shortly agitation supervenes, and in a few
days, sometimes in a few hours, it reaches its highest point of acute¬
ness. The tongue becomes dry, fever is lit up, the pulse exceeds 120,
the temperature rapidly rises to between 103*5 and 105 ; the head is
hot, the eyes haggard, the skin covered with greasy perspiration. The
patient looks terrified, he is a prey to extreme agitation ; he utters
incessant cries, constantly spits, or the saliva runs from his mouth ;
he has a horror of food, and sometimes approaches a condition of
hydrophobia. At this moment cure is still possible, but the disorder
is much more likely to end in death, which happens between the fifth
and the tenth day. Then the fever increases ; a comatose condition
succeeds to the agitation; the pulse becomes more frequent and
weaker; the tongue and the lips become covered with sordes, the breath
is foetid, the breathing oppressed ; the excretions are passed involun¬
tarily; there is persistent insomnia; twitchings, convulsions, general
or partial, occur ; typhoid symptoms follow ; there is diarrhoea, the
pulse is imperceptible, the coma becomes more and more profound;
lastly, fainting-fits occur, and the patient dies, either suddenly during
syncope or slowly from nervous exhaustion.” It will be seen from the
above, that the description of acute delirious mania would be incom¬
plete, according to English experience, were so intense a form as this
to be the only one presented to the student. A series of cases occur,
doubtless requiring the greatest possible care and treatment, marked
by delirium and prostration, and usually with some rise of temperature;
but the majority of cases recover if placed promptly under care. We
should like to know from French alienists whether they are not familiar
with cases of this kind as well as the extreme form described by M.
R^gis. The Manual commences with a brief, but useful historical
sketch of the insane in ancient times. The book is very well got up.
Le cerveau et Vactivite cerebrals an point de vue Psycho-physiologique .
Par Alexandbe Hebzen. Paris : J. B. Balliere, 1887.
We are obliged to defer a notice of this able work to our next
number.
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Notes and News,
[Jan.,
PART IV.-NOTES AND NEWS.
THE MEDICO-PSYCHOLOGIGAL ASSOCIATION.
The Quarterly Meeting of the Medico-Psychological Association was held at
Bethlem Hospital, on November 11th. The chair was occupied by Dr. F. Need¬
ham, and there were also present Drs. Robert Baker, Fletcher Beach, David
Bower, G. F. Blandford, Edward East, J. E. M. Finch, Robert Jones, H. Rooke
Ley, A. McLean, W. J. Mickle, J. D. Mortimer, J. G. McDowall, H. Hayes
Newington, J. H. Panl, H. Rayner, H. Sutherland, Alonzo H. Stocker, R. G.
Smith, R. Percy Smith, D. Hack Tuke, T. S. Tnke, C. M. Tuke, D. G. Thom¬
son. Samuel Wilks, J. F. Woods, Ernest W. White, T. Outterson Wood, Ac.
Dr. D. Hack Tuke, after referring to the gift of £1,000 which had been made
by Mrs. Holland, the sister of the late Mr. Gaskell, the inteiestof which is
devoted to an annual prize, announced that he had recently received from Mrs.
Holland a letter, saying that her sister and nieces desired to make some
addition to the testimonial to her late brother, and enclosing a cheque for £340,
the amount having been contributed as follows:—
£
Mrs. Robson, Lymm, Cheshire
.200
Miss Gaskell, Manchester
. 65
Miss J. Gaskell, Manchester.
. 25
Mtb. W. Grey, Wilmslow, Manchester
. 25
Miss Gaskell, Weymouth .
. 25
£340
The cheque had been duly paid into the bank, and it now remained for the
Treasurer, Dr. Paul, to have the amount invested when the proper time should
arrive, and it would also be included in the trust deed. This additional donation
was very welcome.
The President said that this was very satisfactory news, and he felt sure
that the Association would wish to convey their thanks to the ladies who had
so generously supplemented the former act of benevolence, for which they were
indebted to Mrs. Holland (applause).
The following gentlemen were elected members of the Association, viz.
E. G. Thomas, M.B.Ed., of Caterham Asylum, Surrey; Theo. B. Hyslop,
M.B.Ed., Glasgow District Asylum, Bothwell; W. Habgood, L.R.C.P., Ass. Med.
Off., Banstead Asylum, Surrey; Eric Sinclair, M.D. Glasgow, Med. Supt.
Gladesville Asylum, New South Wales ; Chisholm Ross, M.B.Ed., M.D., Sydney,
Ass. Med. Off., Gladesville Asylum, New South Wales; Herbert Blaxland,
M.R C.S., Med. Supt., Callan Park Asylum, New South Wales; Leslie Earle,
M.D.Edin., Melbourne, Royston, Herts j G. F. Fitzgerald, M.B., B.C. Cantab.,
County Asylum, Cane Hill, Surrey; Graham A. Reynolds, M.B., C.M., Rarn-
wood House, Gloucester; J. F. G. Paterson, M.R.C.S., Camberwell House, S-E.;
W. A. Anderson, County Asylum, Banning Heath, Kent.
Dr. Percy Smith showed the brain of a patient who died recently in
Bethlem Hospital, exhibiting the following condition:—Lying between the dura
mater and arachnoid, and slightly adherent to the former, wag found at the
post-mortem examination, extensive haemorrhagic pachymeningitis.
This condition is roughly symmetrical, and extends over the whole of the upper
surface of the brain as exposed by removal of the calvaria, reaching from
the anterior edge of the frontal lobe on the left side as far back as the
parieto-occipital fissure, while on the right side it extends to the back of the
hemisphere. The new membrane also dips for a short distance into the fissure
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Notes and News,
631
1888 .]
between the two hemispheres. In front the membrane desoends beneath the
frontal lobes, passing across from one to the other, and terminating on the left
side at the posterior edge of the anterior fossa of the skull; while on the right
side it descends partly over, the anterior extremity of the temporo-sphenoidal
lobe, thus partly lining the middle fossa. Lying in the left middle fossa, and
covering the under surface of the left temporo-sphenoidal lobe, was a separate
pachymeningitic sac, forming a sort of pad, the posterior end of which lay on
the upper surface of the tentorium oerebelli. The membrane was everywhere
found to form a closed sac, resembling the pleura in- arrangement, and on the
right side it was torn in process of removing the skull-cap, and some serous
and bloody fluid escaped. Numerous Bmall and large hromorrhagio patches are
scattered throughout the membrane.
The pia mater can be easily raised from the convolutions; these are nowhere
wasted, but on the left side slightly flattened. There are no naked-eye changes
in the cerebral arteries, and there is no sign of descending changes in the
motor tract or Bpinal cord.
The whole brain is small, and weighs only 36 ounces, but appears to be normal
in structure.
Clinical Notes of the Case .—Allan J., rot. 18, admitted into Bethlem
Hospital January 1st, 1887.
Family History .—Father was formerly a patient in Bethlem, having been
admitted in July, 1874, suffering from general paralysis. He was discharged
after sixteen months 7 stay in the hospital, and subsequently died elsewhere. Of
the father's immediate relatives a sister had died of phthisis, and a brother of
hydrocephalus, while a maternal uncle had died insane.
As far as could be learnt of the previous history of our patient, he had
always been of a happy, sensitive, and emotional disposition, and was able to
learn easily and remember well; he had been to Bchool abroad, and could speak
German almost perfectly. After leaving school his mother had kept him at
home, doing nothing for some months, and eventually he went as a clerk in an
office. His illness began early in 1886 with depression of spirits and loss of
memory, and from this time he became steadily worse, and on admission to
Bethlem he was quite unable to take care of himself. He could not converse, in
fact he only repeated the word “ see ** in answer to any question, and, even
when sitting still, would constantly use tlie same word. He was dirty in habits,
restless and troublesome about his food, in fact was completely demented.
His circulation was extremely feeble, his hands being always blue and flabby,
but no disease of heart or lungs could be detected. His pupils were equal
and acted to light, and his knee-jerks were very brisk.
There w as no sign of any ocular or other paralysis. His gait was fairly steady,
but he walked with knees and back rather bent. He was not known to mastur¬
bate. He became progressively weaker physically, and eventually became
unable to walk, and had to sit by the fire in an arm-chair all day. His legs gra¬
dually became more and more flexed, he was always moving his hands restlessly,
fidgeting with his clothes. He never appeared to be in pain, though his eyebrows
were generally drawn up and corrugated. In August it was noticed that his
right arm was becoming flexed and rigid, and this condition prevailed more and
more till his death; and even after death it was not possible to straighten it;
his left arm became slightly flexed and drawn across his body, but was not
rigid. He had no convulsions or vomiting. The eyes were examined as recently
as the day before his death, and no optic neuritis was found. He died rather
suddenly from pneumonia and syncope.
Dr. Fletcher Beach inquired whether there was any history of syphilis. He
had had a case some time back with very similar symptoms. It was a child of
nine or ten years of age, and the father had been under the care of a physician
for syphilis.
Dr. Percy Smith said that in his case there was no history of syphilis so far
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632
Notes and News.
[Jan.,
aa he knew. There was only one other ohild in the family. One of the children
was born five years before the appearance of general paralysis in the father,
and the other three years before it.
Dr. Savage said that he felt a special interest in this case from the fact of
the very marked pachymeningitis at a very early age. For the last month or
two the patient had all the appearance of a person suffering from general
paralysis. He had seen the father at Bethlem, and he had also seen the sister,
who was perfectly healthy. There was no history to be got at of syphilis in the
father, and the boy had no signs of it. Unfortunately, he had no record of the
father’s post-mortem, but there was the fact that the father died of general
paralysis and the son of progressive dementia with pachymeningitis at the
age of nineteen.
Dr. Wilks referred to the effusion of blood, saying that in general paralysis
there were often distinot apoplectic attacks which might correspond to those
special effusions. The condition disclosed was apparently reoent, and he
apprehended that there had been distinct attacks of effusion in this case.
Dr. Ratner said he had never seen a case of the sort so early in life.
Dr. Percy Smith said that as to a distinct attack at the onset they only
knew that the boy had got progressively weaker. He had no convulsive
attacks. When he died he had a sort of faint more than anything else—no
convulsion— and he had pneumonia, and at the same time he got more anaemic
and cachectic. With respect to the effusion the membrane at the post-mortem
did not seem to be independent of the dura mater. There was a distinot saoon
each side. Between the outer and the inner layer was lying some remains of
the clot. The separate pouch seemed to be a distinct sac, which, when it was
first opened, contained some fluid. It would be rather difficult to say that it
did not originate from some effusion.
Dr. Hack Tukr said that in the Prize Essay by Dr. Wiglesworth, which
would appear in the next number of the Journal, the true nature of the false
membrane in pachymeningitis was fully considered.
Dr. White read a paper on “ Athetosis connected with Insanity,” communi¬
cated by Dr. Greenlees, Assistant Medical Officer at the City of London Asylum
at Stone.
Dr. Fletcher Beach said that as regards the case alluded to, which he had
described in the “ British Medical Journal,” he had at first thought that it
might be a case of athetosis, but he now thought that it could not be so
on account of the character of the movements.
Dr. Mickle said that he thought the cases referred to often followed upon
extensive lesions of the cortex from various causes. He had a case at that time
of a boy whose history was imperfect, but who was demented and imbecile, and
had been for many years subject to epileptiform convulsions. He had never
himself yet seen the boy in a convulsion, but they appeared to be of a usual
type, and he entertained no doubt that they were what were very properly
called epileptiform convulsions. In that case some critical brain damage had
occurred which led to secondary degeneration descending to the cord. The
patient had been in a state of stationary hemiplegia evidently of long duration.
The limbs affected had undergone an inconsiderable amount of atrophic
shortening and distortion, the foot affected being, when comparatively at rest,
somewhat in the talipes varus position, and there were athetosio movements of
the side affected, chiefly in the upper limb, but also seen in the lower. The
movements were of typical form, and the case, so far, resembled that brought
before them. In the majority of cases of athetosis no doubt the movements
were post-hemiplogio. In the case he mentioned the paralysis was marked.
The boy had been growing worse in some respects, and if the case should un¬
fortunately come to a necropsy it would be an interesting one in which to
determine the relation of lesions to the symptoms mentioned.
Dr. Raynkr said that he also had seen a case of athetosis on one aide in
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Notes and News.
633
1888 .]
which there was the history of injury with lose of brain snhstanoe. He did
not see the end of that case, so could not quote the post-mortem appearances,
but the fact went to bear out what Dr. Mickle had said, viz., that the condition
might be due to cortical injury, and not to fibres lower down in the brain.
Dr. White remarked that it was an interesting thing that the left forearm
and the right foot were the most athetoBic in the case referred to.
Dr. Savage read the following paper on “ Notes on the International Congress
in Washington ”:—
Mr. President and Gentlemen,—The first question asked on both
sides of the Atlantic after the meeting of the Medical Congress at
Washington was as to whether it had been a success.
It is not for me to say whether the whole Congress was all that
its well-wishers could have desired, but I can truly say that as far
as our special section was concerned it was a success. Ihe meet¬
ings were constantly well-attended, and the papers were interest¬
ing and fairly well discussed. The papers and discussions were
held in French, German, and English, and so the section deserved
to be called International. I shall leave to others the task of
telling what they saw in American asylums and similar institu¬
tions, while I chiefly concern myself with the papers read in the
section itself.
I think it only right to say that the reporting in our section was
exceptionally good, being done by Dr. McGarr, Assistant Physician
at Utica Asylum, who was able to report in shorthand, and thus
to save a very great deal of trouble to the speakers.
Our section was honoured by the selection of Ur. Blandford to
give one of the general addresses, and though the notice given to
Ur. Blandford was of the shortest, yet he was able to give a most
interesting address on the treatment of recent cases of insanity in
asylums and in private houses. The audience was large and
appreciative.
X)r. Andrews (of Buffalo), the President of the section, gave a
very good address of the kind which was expected from him, as it
was full of facts specially interesting both to strangers and to
Americans, allowing the latter to take stock of their advance and
of their dangers at the same time that strangers were enabled to
compare their own condition with that of their hosts. Ur. Andrews
first paid well-merited praise to the late Ur. Gray, of Utica, who
was to have been President. Next he dealt boldly with the
statistics of the insane in America. He showed how the numbers
of those in asylums was rapidly increasing, and that the increase
was greatest in the more settled and established parts; thus in
the New England States there is one insane person to 359 of the
population, whereas there is only one to 1,263 in the Western New
States ; and in the South this is also apparent, for on the Seaboard
States there is one to 610, and in the extreme South one to 935.
Among the negroes insanity is said to occur only in one to 1,097,
but the President pointed out that among this race the increase of
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634
Notes and News .
[Jan.,
insanity is at present greater than among any other class of the
inhabitants. The rapid increase in the number of asylums is
shown by the fact that fifteen new asylums have been built since
1880. Other speakers will refer to some of these, and to their
special advantages or defects. In America one is more struck
than elsewhere with the separate State Laws of Lunacy, and it
seems that sooner or later more uniformity must be established.
There are but two States without asylums of their own, and there
are but two in which special provision is made for criminal
lunatics. New York alone has an asylum for the chronic insane.
It was pointed out that at present the block-system of architecture
modified in one way or another is the most popular, and that
electric lighting has made great progress. The systems of heat¬
ing differ, as the President pointed out, from ours in the use of
metal radiators, and the ventilation depends either on fans for
driving in or for extracting air. Assistant medical officers in
some States have to pass examinations before the confirmation of
their appointment, and Dr. Andrews said that the wicked system
of political appointments is nearly, if not entirely, abolished. As
might be expected, our American President spoke more openly of
some modes of treatment than we are in the habit of doing. I
doubt whether anyone in English asylums would talk of oopho¬
rectomy or castration as “ accepted modes of treatment.”
The address was thoroughly practical, and followed as it was by
one from Dr. Hack Tuke on the various modes of providing for the
insane and idiots in the United States and Great Britain, it was
very suitable to begin the work of the section with.
Dr. Tuke, being an Englishman, he will pardon my passing
over his paper, which was fully appreciated, with the remark that
the only point which was really discussed was that of non¬
restraint, and it seems to me that we are very much at one with
the majority of the American alienists, but that they having been
accused of being behind their cousins have resented the impeach¬
ment, and are consistent in defending their action in this
respect. There can be no doubt that restraint is very rarely used
in the best asylums, but the feeling which actuates the two nations
seems to differ. With us the latter has grown into a fully-organized
feeling of humanity above law, but with the Americans it seems
to be the result of their law-abiding and not organized humane
feeling.
Dr. Hurd (of Pontiac) gave a carefully-studied paper on the
various relations of religious delusions and their association with
other morbid states of mind'and body. It seems to us that he has
got as far as the collecting stage, but not yet to that of the
philosopher. The deep altruistic relations which connect religion
and sexual desire deserve fuller study.
Dr. Spitzka (of New York) exhibited two very interesting
specimens, the most interesting being the nervous tissues of a
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1888.]
Notes and News.
635
girl of 24, who had lost both father and brother with similar
obscure nervous symptoms. The symptoms had begun when she
was about 14, and had very closely resembled those of insular
sclerosis. There was scanning speech, tremors, progressive in¬
ability to control her limbs, dropping of small things from the
hands, with finally coma and death. Post-mortem : the disease was
found to be spread through the brain and cord in the form of very
numerous miliary aneurismal sacs. These were present in both
white and grey matter. The dilatations were most numerous in
the brain, but largest in the cord.
This case seems to merit special consideration, and it is well
that it should be recorded. As Spitzka said, “ First it illustrates
how a multiple affection not involving coarse tissue change may
ape the clinical picture of disseminated sclerosis to a certain
extent; second, it shows how an apparent family type of nervous
disease may be in reality but a manifestation of the tendency to
degeneration of that system which is as profoundly under the con¬
trol of hereditary influences as any other—I mean the vascular.”
A very incomprehensible paper was read by Dr. Clark (of
Toronto) on remissions and intermissions in insanity and on
chemical, psychic, and vital forces, but it appeared to be a hazy
semi-spiritualistic paper which, as far as I could learn, no one
understood.
Drs. H. Wardner and Bower (of Bedford) read papers on
occupation of the insane, and though interesting as showing what
can be done on a small scale, I still think they have not solved
the problem of employment for the larger hospitals where patients
of the middle classes are received.
In a paper by Dr. Fisher (of Boston), “Monomania” was
discussed, and, though nothing new was brought forward, reasons
were given for retaining the old word and not accepting in full
the German term, paranoia. As time pressed, no discussion took
place on this paper; and here I may say that the real difficulty
of this, as with most Congresses, was that the subjects were too
many and too diffuse to allow of fair, let alone full, discussion.
No Congress would be complete without attempts to classify,
and this one was marked by two elaborate attempts to arrange the
disorders of the mind into more or less natural groups by Drs.
Channing and Hughes (of St. Louis).
I do not think that any good will result from giving you the
details of the suggested classifications, for they, like the rest, do
not get beyond the market gardener’s stage, and certainly do not
approach nearer than other forms of arrangement—the natural
orders of the botanist. Dr. Hughes did not do justice to himself
or to his subject by the ill-arranged way in which his paper was
brought before the section.
Dr. Hughes pointed out the unsatisfactory method of looking
upon all idiots as alike, though the causes and conditions of arrested
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mental growth may vary almost infinitely. This is true, but, in
classifying, we have in the first place the ruin to examine and not
the causes of the disease.
Dr. Mendel (of Berlin), who by his genial presence did much to
make our section attractive, read a paper on the origin of the
facial nerve, giving a new or hardly described root; his paper was
in German, and most of those present felt that justice could not be
done to it without studying it in extenso .
Dr. Homans (of Helsingfors) read a very interesting paper on
the result on the nervous system in dogs, of amputations of the
several limbs at different parts, so that the different degrees of
secondary wasting could be traced.
Dr. Homans thinks he has discovered a special set of sensory
cells. He gave interesting details of the peripheral degeneration
as seen in the divided nerves, and these are of great importance in
tracing the so-called secondary changes and seeing whether they
are direct transmissions of degenerations or if they are simultaneous
changes occurring in the two ends of the nerve chain.
Dr. Otto read a description, in German, of his method of staining
with aniline dyes. The three last papers were illustrated by
specimens and photographs.
Dr. Langdon Down presented a short paper on the meaning of
the prow-shaped skull and its relations to the neurotic type of
mind.
Dr. Bishop (of Chicago) read a very interesting paper on a
subject which deserves more special study from our point of view.
He looks upon hay-fever as a true neurosis, and not as depending
on pollen. For years past I have taught that this affection is most
common in members of neurotic families, and, again, that it may
alternate with neuroses, a patient when insane not having hay
asthma ; but though this is true it does not follow that it is to be
looked upon as a neurosis. I believe that the experience of some
who discussed the paper is not uncommon—that hay-fever may be
developed in later years, and under conditions of nervous weakness.
In this case it may, if you like, be called an acquired or inherited
nervous weakness.
A paper, not needing notice here, was read by Dr. G. Eliot on
“ The Treatment of Neuralgia in Private Practice.”
The next paper, on “ Border-Land, Early Symptoms, and Early
Treatment of Insanity,” by Dr. Russell, was chiefly interesting
from the very vigorous protest raised by Dr. Gundry against
assuming insanity in every case where a single symptom, which
may be associated in some cases with insanity, has occurred in
the lives of great men. He ridicules the evidence of insanity in
Caesar and Napoleon, and also does not think there is evidence of
insane hallucinations in Luther. We are quite in accord with him
in thinking that the border-land has been too much used. There
is a border-land which patients may pass through in going into or
out of an attack of insanity, and there is a border-land in which
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687
some neurotic people always dwell, but there are many symptoms
which occur with insanity which do not necessarily point to iip
presence in any individual case by their presence alone.
Special attention is called to the interest of the paper by Dr.
Cowles (of the McLean Asylum, near Boston) on “Nursing
Reform for the Insane.” This paper deserves very careful study,
but, as Dr. Blandford will probably refer to the whole system of
the training of nurses as followed by the officers of the McLean
Asylum, I shall say no more.
Dr. Mendel read a short paper in which he objected to the term
moral insanity, and thought that all cases of moral insanity so-
called might better be classified under the heads of paranoia or
weakmindedness. The general feeling, however, was that till we
had a complete system of classification, we must be content to use
terips which bear a fairly definite relation to groups of cases. I
had the honour of reading papers and maintaining a discussion on
the relationships of insanity with syphilis, in which I was ably
assisted by contributions [from Drs. Shuttleworth, Beach, Wigles-
worth, Mitchell, Warner, and others.
This discussion would occupy too much time and space to be
reconsidered here, but I trust when the full report of the Congress
appears it may not prove altogether unworthy as representing
English psychiatric study.
One rather strange example of the uses of the section may here
be given. A man suffering with loco-motor ataxic symptoms made
application to the President of the Congress (Dr. Davies) to
have his case examined and finally settled. The President sent
the patient to our section, and our President deputed Dr. Mickle
and me to examine and report on him. This we did, with what
result I know not.
Dr. Mendel showed some dogs’ brains in which adhesions be¬
tween brain and membranes had occurred. These were from
Portugal, and we had- not full details, but they were said to have
been caused by constant rotatory movements which were conveyed
to these dogs. I must say without further observation I am not
prepared to accept these brains; and so my task is done. We
who went had hearty welcome, much good fellowship, and we
believe that our time was well spent. I need not enter into the
subject of dinners, receptions, and other entertainments which did
so much to contribute to our pleasure and to the upsetting of our
digestion.
The President said that it was very gratifying to find that their own section
of the Congress had been so successful.
Dr. Blandford said he fully endorsed all that had been said as to the
success of the psychological section of the Congress, and would add (that the
gentleman who contributed chiefly to the success of that section was Dr.
Savage himself.
The speaker then read the following paper:—
I have been asked to give you my experience of American
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Notes and News .
[Jan.,
Asylums, and, although this is very small, I do so with pleasure
if only to bring back the memory of the warm welcome with which
I was received at those institutions. I must commence by saying
that I did not visit them with any idea of making a complete
inspection, neither did I make any notes with the view of writing
on the subject. The whole number visited was only six, my time
in America being but brief. My companions not being psycho¬
logists I was not so free as if I had been travelling alone. I
greatly regret that I was not able to visit more asylums, to many
of which I had invitations from the superintendents to which I
should have been glad to respond. Now, of the six asylums
visited four were for paying patients, answering to our hospitals,
such as Bara wood House and those at Northampton, Cheadle, Ac.
These were the Bloomingdale Asylum at New York, the
Pennsylvania Hospital for the Insane at Philadelphia, the
Friends’ Asylum for the Insane at Philadelphia and the McLean
Asylum at Boston, which is a branch of the Massachusetts General
Hospital—as the Bloomingdale is a branch of the New York
Hospital, and the Pennsylvania a branch of the Pennsylvania
Hospital. The two for the lower classes were those at Washington
and at South Boston, which is the asylum for the city of Boston. It
is to be noted that three of these were under orders to move
further away from the cities near which they are situated, though
I did not hear that there was any prospect of these changes
being immediately carried out. As with us, such moves are
talked about for some time before they are brought into effect.
From this it will be seen that the asylums I saw were for the most
part of somewhat ancient date and built on the one block or
conjugate plan, with a central administration building and wings;
but in addition to this several of them had detached buildings or
villas in the grounds for quiet patients and for those wishing
better accommodation than the asylum-wards. I was greatly
pleased with a house lately erected at the Bloomingdale Asylum
for such patients by Dr. Nichols. There is one also at the McLean
Asylum, and one is being built at the Pennsylvania Hospital, and
at many hospitals which I did not personally visit. I read that
the system of detached blocks, connected by corridors, is being
adopted. At the fine asylum at Washington, so ably presided over
by Dr. Godding, the main building is supplemented by various
detached blocks, some of which have been built economically for
the reception of quiet patients; one is for people of colour, of
which there are great numbers at Washington, and one is
for working patients who are to live by themselves and go
to and come from their work without disturbing others.
When we enter the wards, we find that they consist for the most
part of long corridors or galleries, with dormitories opening out of
them on both sides. The light comes from the end or ends of the
room, and the result is that there is not much of it. We all
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1888.]
recollect asylums built on this plan in our own country. A dark
room in America, however, is not such an unmixed disadvantage as it 1
is with us. You must remember that they have a summer in which
the heat is almost tropical. To every window throughout the
country are shutters to shut out the sun and render the room dark.
Every house has its verandah, or, as it is called, piazza, to afford
shade. Not only have they shutters to keep out the sun, they are
obliged to have wire doors and wire windows to keep out the
flies, mosquitos, and other winged abominations which infest their
country. So that when we are inclined to condemn their rooms as
dark we should remember that light connotes heat and flies, while
darkness gives coolness and rest. The end window of the gallery
is frequently partitioned off by a wire trellis work so that the
patients cannot approach the glass, and this interval is often filled
by plants, birds, and the like. In the older asylums we meet with
metal window-frames, and windows are much guarded by wire-
work such as was in vogue here in former times. Each gallery or
ward is complete in itself ; the patients live there, eat there, sleep
there, wash and bathe there. Each has its dining-room, and I
found the table neatly laid for its occupants, probably twelve to
twenty in number, the service suited to the class of patients, and
often flowers to brighten the whole. I did not see a common
dining hall, so far as I remember, in any asylum. Now, this method
of administration, like most things, has its advantages and dis¬
advantages. A small number of patients is mpre easily looked
after than a large, and the eating of each individual can be better
noted. But the monotony of the perpetual life in one ward is not
relieved by the change to a common dining hall, which is a dis¬
advantage. The distribution of food, too, is an important matter,
but the Americans are so clever in all mechanical details with
their tunnels, tramways, elevators, dumb waiters, and the like,
that this seems to them no difficulty, and each ward receives its
food in due order from the kitchen department. Yet I find in a
paper by Dr. Seip, of the Danville State Hospital, giving an
account of a visit to European asylums, that he approves of the
system of associated dining rooms. He says that the patients
march to the hall, and the meal, effectually supervised, having
been served, they return to the wards; the working staff go to
their places, and the full complement of attendants are left to
occupy the patients instead of spending never less than two hours
after a meal in dish-washing, as is the rule in such asylums with
ward dining-rooms. He applies the same argument to baths. In
the American asylums each ward has its bath, lavatory, and
closets. Dr. Seip thinks that time is wasted by this method, and
says that five or six hours are spent on a bath-day in a ward of
thirty patients, and that this amount of time is largely reduced
by the wholesale treatment in a large bath-room. For the class
of patients I saw, a bath-room in the ward appears to me far more
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comfortable, and it is not necessary that the whole number should
bathe on the same day. The system of baths and the snpply of
hot and cold water are very good, as is everything mechanical.
The same remark applies to the ventilation and warming. Yon
will recollect that after one of their almost tropical summers they
have to endure all the rigour of an almost arctic winter, a winter
such as we at our worst never experience, with the thermometer at
20° below zero, and deep snow lying in their grounds perhaps for
months. Such cold necessitates apparatus for warming beyond
anything we require, and in every asylum we find a system of
steam boilers, engines, and machinery on a very costly scale. For
in the asylums, and, in fact, throughout the country, the tempera¬
ture indoors is maintained at not less than 75° F., which we should
consider very high, in fact, oppressive, but which may be beneficial
to some melancholic and demented patients. You will, moreover,
understand that it is difficult to take patients out of such an
atmosphere into intense cold when all the place is covered with
snow, and I gathered that they go out very little in the winter,
and are, in point of fact, very much confined to the house. So that
what with the great cold and the great heat, when it is too hot to
be out of doors, patients are much less in the grounds than they
are in our asylums, where we can keep them often almost all day
in the open air. The Americans are not fond of out-door exercise
or of going for a walk in the sense of a constitutional. In-door
amusements and occupations were well promoted. There are good
recreation halls, which are sometimes used as chapels. Here
entertainments, drill, calisthenics, and music are liberally pro¬
vided by the asylum staff, and tea parties are given by the
matrons frequently. I gathered, however, that there is not
much social meeting of the two sexes of patients, and that of this
there is probably less than with us. Of officers, certainly of
medical officers, I should say the supply exceeds that of our own.
At the Pennsylvania Hospital for the Insane, where the daily
average was last year 393, there are five medical officers ; at the
McLean Asylum, where they average 169 patients, there are three;
at the State Hospital at Norristown, Philadelphia, where the
average is 1,426, there are three gentlemen physicians for the
male department and three ladies for the female, besides a lady
who is the resident pathologist, and a gentleman ophthalmologist;
at the Danville State Hospital, averaging 798, there are four
medical officers, all gentlemen. I mention these because I am
able to give the numbers. I have not the statistics of others
which I know to be as well officered. The number of attendants
also seemed to be liberal, especially at night. Thus at the McLean
Asylum, which, as I have said, numbers 169, there are fifteen
attendants, seven men and eight women, on night duty. This is
the asylum which has a training school for attendants, where
either men or women can have a two years’ course of training in
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1888.]
general nursing, with special reference to the care of cases of
nervous and mental disease. They are employed as assistants in
the wards of the asylum, they attend lectures and demonstrations
given by the medical staff, the superintendent of nurses, and head
nurses. They receive during the first year, the women £30 and
the men £55; during the second year the women get about £36
and the men £60; while, after graduating, the women are paid
some £60 per annmn and the men can rise to upwards of £70.
These seem high wages to us, but the cost of labour, as you know, is
very high in the States compared with England. At the Pennsyl¬
vania Hospital lectures are given to the attendants on anatomy,
chemistry, physiology, hygiene, and on their special duties. Dr.
Andrews told us at the Congress that “ in the State of New York,
attendants and all employes in public asylums have been placed upon
the Civil Service List, and are subject to examination before a Board
organized for the purpose. This makes them State appointments,
and renders them entirely independent of political influence both
in appointment and continuance in place.” And he goes on to
say that “ an extension of this system would do away with the
present evil existing in some States which arises from the positions
of attendants being considered places of patronage for the party in
power.” Out superintendents would be much aggrieved were
they to lose their old attendants on a change of the Ministry.
Passing from officers and attendants we come to the patients.
These appeared to me to be much the same as any that we should
meet with of the same rank in life in our own asylums. Not more
seemed excited, not more demented. I saw some recent and acute
cases, some, not many, restrained by means of a strait waistcoat;
and this brings me to the question of mechanical restraint, one
which has been truly a “burning” question in America as in
England. I believe that in America mechanical restraint has
greatly decreased within the last ten years in the best asylums,
and is decreasing; probably in such asylums there is less than we
should find on the continent of Europe. Our President at the
Congress said that he believed that the opinion in England and
America was practically the same, viz., that restraint might occa¬
sionally be necessary, but that non-restraint should be the rule,
restraint the exception. I have but one remark to make on the
subject. In no asylum that I visited did I find a padded room, and
Dr. Tuke, I think, only found one. There seems to be an objection
to them, an objection, I cannot help thinking, founded considerably
on sentiment, as is a great deal of the objection to mechanical
restraint in that extreme view taken of it here to which the name
of Conollyism has been given. There seemed to be an objection to
placing a patient in solitary confinement such as a padded-room
or seclusion-room, and I saw several in restraint in the wards, who,
in my opinion, would have been better if alone, or alone with an
attendant, and not exciting other patients or excited by them. In
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Notes and News.
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the leading American asylums I believe mechanical restraint to be
now used but little, but I have no doubt that it is used far more in
the poorhouses and almshouses which exist in large numbers
throughout the States, and contain large numbers of the insane.
The patients, however, are being gradually removed, at any rate in
some States, to the State Hospitals. In this respect they are going
through much the same experience as befell us here when County
Asylums were first established for the reception of the pauper
classes. As regards treatment, I found that all the best known
drugs were freely used in the asylums I visited—hyoscine and
hyoscyamine, paraldehyde, chloral, the bromides, and morphia. I
did not find that treatment by means of baths was carried out,
whether by the prolonged warm bath or by shower baths. The
latter I did not see anywhere, and I believe that they do not exist.
The pathology of insanity and brain disease is not neglected in
America. At the Washington Asylum there is a most excellent
pathological laboratory, fitted up with every convenience for post¬
mortem examination and for illustrating the histology and morbid
anatomy of the brain. Not only here, but in other asylums is there
a special pathologist, and the reports generally show that this
department is not neglected.
Dr. Mickle said that he saw very little indeed of the American institutions
daring this trip, having arrived at Washington in a very dilapidated state and
with a very severe sore throat. The place was then in intense heat. He was
very much interested in the pathological museum. There were to be seen there
a number of skulls of soldiers dying of their wounds in the civil war, and
among them some of very special interest, in which bullets, striking the head,
had not damaged the external table of the skull, but, although externally the
sknll appeared to be intact, its internal table was fractured opposite the point of
impact of the bullet, and the fragments in some cases were driven into the
meninges and brain. Among other objects of interest he saw there was the
spinal column of John Wilkes Booth (the murderer of President Lincoln), who
was shot in the spinal cord by one of the soldiers pursuing him. Then, as
illustrating the perpetuation of errorfrom generation to generation for lack of in¬
dependent original investigation, and therefore of some psychologic interest, was a
manikin which, for many generations, had served to demonstrate anatomy in
Japan, and among other peculiar arrangements of that specimen was this—that
the lungs were carefully wrapped round the stomach to keep it warm ! By the
kindness of Dr. Godding he, like others, went to the Washington Asylum and
was much interested in what he saw there. One thing which particularly struck
him was the very large number of different races found among the patients—
patients from all quarters of the globe, including the native red man and the
semi-naturalized negro. The Washington Asylum was splendidly situated, com¬
manding a fine panorama of the surrounding country for many miles. The
pathologist of the institution exhibited a number of brains prepared according
to a method of his own. The brains, after being placed for a short time either
in alcohol or in a solution of chromic acid or of chromates, were placed in a
chloroformic solution of Japan wax, and the result was very good, the outlines
being in a number of cases preserved very well. The pathologist, who evidently
is one of whom the profession will hear again, also exhibited a number of
microscopical slides. Dr. Witmer, another of the assistant-physicians there,
had devoted an enormous amount of time to promoting the convenience, com¬
fort, and interests of the foreign members of the Congress, and personally be
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Notes and News.
(343
was much indebted to him in this respect, and he was indebted to Dr. Witmer
for seeing a case which had been one of ear disease with mania, and in which
the patient, after mental recovery, remained perfectly deaf, but was able to
understand every word uttered by those she knew by watching the motion of
the lips. Dr. Savage had not said much about the entertainments, but it might
be said that the proceedings of the psychological section of the Congress wound
up with a very enjoyable banquet given to the foreign members by the American
members of the section, and at that banquet not only was there a most recherchS
bill of fare, but, the labours of the section being closed, there was a feeling of
lightheartedness among the members, which was the very soul of conviviality.
Dr. Boweb corroborated what had been said by Dr. Savage and the other
members who attended the Congress.
Dr. Savage, in reply, said that one or two things had struck him in the
course of the discussion. One moot point had been that of an observation ward
for suicidal cases, and he had seen something of that sort particularly novel in
the asylum at Worcester. At the end of each wing there was built out a large
circular building with just one entrance from the main ward. This was the
case on two floors—day-room on the ground floor and bedroom on the upper
floor—and in that very large circular chamber the one attendant was able to sit
near the door, and the whole of the building would be under his eye at once.
It was splendidly lighted up, and the attendant was provided with a lamp which
could be used as a reflector. He believed he had urged objections to observa¬
tion galleries, but that one large chamber was as nearly free from danger as
anything could be. As regards airing-courts, unquestionably they saw none,
or scarcely any. Probably the explanation given by Dr. Blandford was a true
one. The Americans seemed developing at such a rate that they would soon be
without feet or hair or teeth. Dr. Hack Tuke had, in his book on his own
American trip, mentioned “ night medical officers ” being employed as well as
night attendants, so that one assistant medical officer would be on duty the
whole night. It was rather onerous work, no doubt, but had its advantages.
Another point which suggested itself was—What is the relative value of the
female medical officers ? He was 6orry to say that when he put this query in
America the answer always was: “ Well, do not introduce them into England.
You know they are very kind and very sympathetic, but we do not get such an
equivalent of work out of them as was expected.” I said, “ But my friend, Dr.
Tuke, is disposed to look upon them as presenting some advantages” The
answer was, “ Well, yes, Dr. Tuke is very kind and sympathetic, but he has not
to work with an assistant medical officer who is a lady ! ”
Dr. Savage, in reply to Mr. C. M. Tuke asking when the members of
the Association would have an opportunity of reading some of the papers
considered at the Congress, said that the papers were really the pro¬
perty of the Congress. The whole of the papers would be published within
twelve months. He believed that their own section would be extremely well
edited, because the secretary of the section was the editor of an American
journal. He thought, from what he heard, that it was likely that the sectional
meetings would be published separately, but he might state that the American
journal published at Utica contained a very good resumS of the proceedings
of the Congress, and the superintendent of that asylum was rather anxious that
members of the Association should know this, and if gentlemen wishing to have
copies of the American journal would send in their names through him, copies
should be ordered for them.
Dr. Hack Tuke said he should like to express his obligations to Drs. Savage,
Blandford, and Mickle for the very interesting accounts they had given of the
Washington Congress, which had been more especially so to himself, as he had
visited America three years ago, and reported upon asylums there. The result
of more recent inquiries seemed to be upon the whole very satisfactory. During
the past three years it was evident that still further development had been made
in the direction which he had indicated in his book, of having either entirely
xxxui. 42
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644 Notes and News . [Jan.,
separate buildings, or blocks connected by corridors with the main asylum, so as
to break up more and more that congregate system which had been so long in
use in American asylums. In regard to mechanical restraint, it appeared that
even less was now used than a few years ago. As regards the training of
mental nurses, he had been very much interested in that matter when he was in
America. Dr. Cowles was, so far as he knew, the only superintendent in America
who strongly advocated having female attendants on the male side of the
asylum, considering that it had an enormous influence in promoting refinement
and self-control among the patients. The employment of female attendants in
this way was one thing, their training for their own sex another—the former was
beset with difficulties, but the latter was no doubt a most valuable thing. As he
had remarked to Dr. Cowles, when writing to acknowledge the photographic
group of bis nurses, the difficulty would be to retain fifteen nurses in service who
were so good looking. As regards lady physicians, he was well aware there were
two sides to the question, and had spoken of their employment as an experiment.
Dr. Savage exhibited a machine called “ The Allen Surgical Pump ” (Truax
and Co., New York), and explained its manipulation. The inventor claimed for
this pump that it could be used to aspirate and to inject, also as a stomach
pump, uterine dilator, urethral dilator, and tampon, for litholapaxy, embalming,
direct transfusion, transfusion of defibrinated blood, and as a syringe or douche.
If the opening of the tube should become clogged a backward turn of the crank
would free it. As an aspirator, it was stated to be superior in several ways;
thus, there were no connections requiring air-tight joints, and no bottles to
empty. In the common aspirator the air was exhausted from the bottle, the
connection opened, and a force often excited which would draw in the tissue.
With the apparatus exhibited just the force required was exerted. If the pus
should be thick and flow slowly, a powerful force would be got, while if the pus
was lighter, flowing freely and fast, it would supply the tube, and the force
would be proportionally less. In rinsing the bladder the force could be
regulated by the operator by a slow motion of the crank. The apparatus was at
the same time a force and vacuum pump.
Among other exhibits were photographs of nurses and probationers at the
McLean Asylum in Boston, and the spinal cord from a case of acute general
paralysis of the insane, showing bony plates in arachnoid.
SCOTTISH MEETING.
A Quarterly Meeting of the Medico-Psychological Association was held in the
Hall of the Royal College of Physicians, Edinburgh, on the 10th Nov., 1887.
Dr. Howden was called to the chair; the other members present being Drs.
Blair, C. M. Campbell, J. A. Campbell, Clouston, Ireland, Carlyle Johnstone,
Keay, Macdowall, Maclaren, R. B. Mitchell, G. M. Robertson, Ronaldson, Rorie,
Turnbull, Batty Tuke, Urquhart, Watson, and Yellowlees.
The minutes of last meeting were read, approved of, and signed.
Frank Lang Collie, M.B., C.M.Aberd., Clinical Assistant Medical Officer,
Perth District Asylum, was elected a member of the Association.
Dr. Howden showed the plans of the proposed detached infirmary building for
Montrose Royal Asylum. It has been designed to accommodate 100 patients, 50
male and 50 female, at an average cost of from £130 to £140 per bed. Pro¬
vision was made for a section with all necessary appliances, capable of being
entirely cut off from the general sick-rooms, and intended for use in specially
repellent cases, such as gangrene, &c. The plan of independent ventilation
for each department has been adopted.
Dr. Rorie read a paper on “The Present State of Lunacy Legislation in
Scotland.’*
Dr. Clouston said he was sure they were all obliged to Dr. Rorie for his
historical review of lunacy legislation and practice in Scotland. In 1857 they
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Notes and N&ivs.
645
really had only English experience to guide them. Our Act was largely founded
on the English Act. Following the lines that experience pointed out, the Scotch
Lunacy Law and the Scotch lunacy system had become greatly changed. He
thought that Dr. Rorie, perhaps, meant his paper as a flag of warning against
certain dangers. The tone of his communication was in some way rather ad¬
verse to the present practice in Scotland. There was no doubt whatever that
some things had been carried out neither in accordance with the Act nor with
common sense. Different districts carried out different practices, and this had
advantages and disadvantages. Dr. Rorie showed in his paper that the general
Board of Lunacy and the Parochial Boards have been undergoing a process of
education. The Parochial Boards are taking, on the whole, a larger and more
enlightened view of their duties in regard to the insane than they did in and
after 1857. He did not think that asylum superintendents could take a line
antagonistic to the local authorities having a certain amount of control over
the incurable insane. It was natural that they should feel a little hurt that,
while having control in other matters, a line of demarcation should be drawn
against them in the matter of lunacy. He thought it was necessary that they
should look at this matter from the Board’s point of view as well as their own.
He was quite prepared to homologate what has been done with regard to licensed
houses for boarding-out patients and poor-houses. And looking to their present
experience of the best method for providing for pauper insane of the different
classes, he did not think there was anything better than the three methods in
use—the asylum for the curable, the dangerous, and the troublesome, the
lunatic ward of the poor-house for the easily managed incurable, and the board¬
ing-out for, those still more quiet and more fit for family life. When these three
methods had been carried out, under proper conditions, the problem of dealing
with the insane had been very successful. Dr. Rorie would agree with him that
the weak point in the Scottish system is the selection of the patients for these
various modes of treatment. By devising a practical scheme for deciding how
these patients are to be allocated, this weakness would be removed. At present
they were in a mass of confusion. If the Parochial Boards will accept the con¬
trol of the incurable and those easily managed, every one of them should help
those Boards to make a suitable selection. They claim that the medical officers
of asylums should be the sole judges in this matter, and that it is not for laymen
to say who are and who are not fit for the asylum, or for the poor-house, or for
boarding-out. What they have to make provision for is, who shall be the
authority in selecting these patients. What he did by way of compromise in the
Royal Edinburgh Asylum, after years of trial, was to select and recommend out
of the patients those whom he thought suitable for the poor-house or to be
boarded-out. Parochial Boards do something more than this, they sometimes
send those whom they think quiet and manageable to be boarded-out without
sufficient consideration, and not by medical authority, and hence some of the
failures of the system. He would say that they must take the members of the
Parochial Boards along with them in this matter. He did not think that they
could take the position that the Parochial Boards are to have absolutely nothing
to do with the selection. He thought that if the powers of the three authorities,
the asylum doctors, the Parochial Board, and the General Board, w*ere defined in
this matter, they might get a good workable system. He did not quite agree
with the tone of Dr. Rorie’s paper. It was right that the question of economy
should be one main question in the treatment of a chronic incurable lunatic. He
thought the ratepayer must have a great deal to say as to it, for such a patient,
though his general management and treatment should be founded on medical
principles, commonly needed no active medical treatment. Regarding Dr.
Rorie’8 contention that as a lunatic was only deprived of his liberty because he
was dangerous, therefore we should discharge him from an asylum when he
ceased to be so—that would never hold water. The lunatic is not sent to us
under common law because he is dangerous, but by the Sheriff under statutory
law. He did not think that they had to do with the question of danger. He
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646
Notes and News .
[Jan.
thought that the old notion of the common law would be altered by-and-bye.
It did not represent fact as regards lunacy, and the lawyers themselves will no
doubt give up contesting that danger is the only ground for deprivation of
liberty quoad lunacy.
Dr. Watson, continuing the discussion, said—As one of the medical officers
of the much-derided so-called parochial asylums, he begged to draw attention to
one or two points that Dr. Rorie and subsequent speakers must have misappre¬
hended. In the selection of patients it was his invariable experience that the
Parochial Board is entirely guided by the medical officers in the selection of
patients for the lunatic wards of the poor-houses, and also for boarding-out. So
much was this the case that it was impossible for the Parochial Board, at its
own hand, to board out any patients. The superintendent, according to a regu¬
lation of the Board of Lunacy, must take the opinion of the medical officer of
the asylum, and be guided by him ; and he cannot discharge the patient unless
the medical officer signs the minute—the latter having complete control. [This
view gave rise to a short general discussion, several members expressing their
dissent.] Dr. Watson, continuing, said there was no reason why the Parochial
Board should not be represented in the government of a chartered asylum. With
regard to the instability of the Parochial Board, he found in his own district
that out of the 33 members they had in 1880 no less than 13 were still remain¬
ing. It wasonly the members that were not of great consequence that shifted
about.
Ur. Yellowlees said that he had not noticed in Dr. Rorie’s paper any
reference to asylums for the chronic insane of the pauper class. He believed
that a better, healthier, and happier home could be made for the chronic pauper
insane in an asylum of this kind than in the wards of poor-houses, and at an
expense very little greater. He had hoped to find this question solved at the
Willard Asylum, in the State of New York, an asylum specially intended for
chronic patients, which he had lately visited, but had been disappointed. It was
an admirable institution in every respect except the vital one of economic main¬
tenance. While economy was not the main thing, it certainly came next in
importance to the welfare of the patients. He thought that the Parochial
Boards were only doing their duty to the ratepayers in seeking the least expen¬
sive mode of providing for their incurable cases, and were therefore entitled to
our co-operation. In practice he had not found the Parochial Boards unreason¬
able, and had had no difficulty as to the selection of patients whether for poor-
houses or for boarding-out. He felt it his duty to point out suitable cases, and
frequently parted with useful patients rather than keep them in the asylum at
needless cost. There was a certain limited class of patients—those who had seen
better days, and had a better education than the others—who deemed the poor-
house a terrible degradation, and who were able fully to appreciate the amenities
of an asylum. He bad alw ays held out firmly against such cases being relegated
to a poor-house. Speaking from a limited experience, he bad not found the
boarding-out of pauper patients satisfactory, although, when both patients and
guardians were carefully selected, he believed it often answered well.
Dr. J. A. Campbell, of Carlisle, as one of the two English asylum physicians
present, thanked Dr. Rorie for his interesting paper, and hoped it would shortly
appear in the Journal, more especially the portion which gave a tabular state¬
ment concerning the positions of the insane in asylums, workhouses, and
boarded with relatives or others. So far as he could gather from the paper,
there were few’er boarded-out now than in 1859. The boarding-out system in
Scotland has been nmch eulogized. A calm and judicial history of its working
so far, its merits, its difficulties, its defects, dealing both with patients and the
public and touching on the pecuniary question, would he interesting and useful.
The opinion that “ a boarded-out dement ik better off than an asylum patient
or a British working man ” is open at least to doubt; and the weekly expendi¬
ture shown by Dr. Lawson in the 26th Report of the Commissioners in Lunacy
for Scotland of a boarded-out lunatic who lived with his sister, and whose cost
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Notes and News.
647
1888.]
for everything was 3s. 1 Jd. a week, and who had only }lb. of animal food a
week, would make one fear that he was undergoing a process of slow starvation.
Enthusiastic and glowing descriptions which avoid mention of all drawbacks
tend only to engender distrust, and are far too common in new developments
of modes of treatment of the insane. In the lately proposed new legislation
for England it was suggested to follow certain of the Scotch procedures, notably
an expiry at a given date of order of detention. I should like to hear the
opinion of members on this point. I think that the provision of expiry of
order is merely a mode of increasing the duties of the superintendent without
in any way benefiting the patient. In any future Scotch legislation Sec. 90 of
cap. 71 of Victoria 20 and 21 should be omitted. It gives a Justice power, on
the sworn evidence of any credible witness, to grant a warrant for the detention
of any alleged lunatic and his transmission to the nearest town for examination.
The power of treating patients for insanity for six months without any for¬
mality should, in my opinion, also be altered. I think it is open to much doubt
whether it is a good plan to allow one of the medical certificates which consign
a patient to an asylum to be given by one of the medical staff of that asylum. I
am of opinion that more power in dealing with insane in private dwellings who
are not under certificates should be given to the Commissioners in Lunacy. A
perusal of Sir A. Mitchell’s book on the insane in private dwellings clearly shows
the need of this. I quote : “ Indeed, in one remarkable case which I shall
presently detail, all the efforts of the Board to liberate the patient were without
success.” So far as I can find, no further powers have been given to this Board
since this book was written. In England the law provides distinctly that any
lunatic not properly looked after, be he rich or poor, shall be dealt with by the
Relieving Officer, under penalties if he neglects his duty.
Dr. Howden agreed with Dr. Clouston and Dr. Yellowlees that it was
beneficial to the insane poor that they should be provided for in various ways.
Curable asylums, lunatic wards, or chronic asylums, and private dwellings had
each their advantages according to the requirements of the lunatics. He had
not found any difficulty in working with Parochial Boards under the present
system, and found them always glad to be advised as to the suitability of cases
to be transferred to lunatic wards or private dwellings. He thought that the
discharge of uncured patients was justified by the result; and in support of
this view stated that of 124 uncured pauper patients discharged during five
years from the Montrose Asplum only 17, or 13*7 per cent., had been returned.
During the same period 176 patients were discharged recovered, of whom 42, or
23*8 per cent., had been returned. In Forfarshire the boarding-out system
appeared to be on the increase. From the parish of Dundee alone the number
of pauper lunatics boarded in private dwellings had risen from 29 in January,
1885, to 88 at the present date. They were much indebted to Dr. Rorie for his
paper, and would take his hint to keep their eyes open as regards future legis¬
lation. He did not see any practical way by which Parochial Boards could be
represented on the Boards of chartered asylums. At the same time, if they
were, he was not satisfied that their representation would be injurious to the
interests of the asylums. .
Dr. Tuhnbull considered that an essential point m lunacy legislation should
be elasticity. Different cases of insanity required different methods of pro¬
cedure in dealing with them ; and the nearer our Rystem comes to providing
the varied requirements for all the different cases the better it would be. All
cases do not need to be in asylums ; and, therefore, care under private guardian¬
ship, or boarding-out, should be a recognized part of our lunacy system, and
should be suitably provided for in our legislation. Similarly, an asylum for
chronic cases, and the lunatic wards of a poorhouse, supply suitable care for a
certain class; and in moving patients to them from the ordinary asylum the •
procedure should be simple and expeditious, and not hampered by unnecessary
restrictions. He thought the responsibility of the removal of unrecovered
patients from asylums should not be entirely in the hands of the medical
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648
Notes and News ,
[Jan.,
attendant; and the present system, he thought, could be made to work quite
smoothly. K the friends of an insane patient are willing to care for him, we
have no right to insist on parochial relief being accepted by the friends, and on
the patient being placed in an asylum. Similarly with patients already in
asylums, if the friends are willing to undertake their care they ought, under due
restrictions, to have the power of doing so, and must, of course, take the re¬
sponsibility. The medical authorities should advise what they think is best in
the interests of the patient, but are not entitled to enforce continued detention
in the asylum unless there is a distinct reason for it, such as the patient being
dangerous. This latter emergency is already provided for in our lunacy statutes.
In a recent case the Parochial Board had referred the matter to him; and he
advised very strongly against the patient’s removal, but could not prohibit it.
The friends persisted in removing the patient, with the result that in four days
they had to bring him back to the asylum again. He thought the friends would
in that way be thoroughly convinced that asylum control was necessary for the
patient, and was not urged by the medical officer merely as a fad of his own.
He considered that in the case of pauper patients it was unobjectionable and
often convenient that one of the certificates might be signed by the medical
officer of the asylum. With regard to the renewal certificate on the expiry of
the Sheriffs order, he thought the certificate served a very good purpose, and
ought to be kept in force.
Dr. Yellowlees observed that he found Parochial Boards only too ready to
accept the statements of friends regarding their ability to provide for patients;
and only too ready to take the view that, if a patient w’as not “ dangerous,’* he
might be safely removed. From the medical point of view, it was not primarily
a question of saving the rates, but the lunacy of a pauper and the curability of
his disease.
Dr. J. A. Campbell said that if the friends of a pauper in England wished to
take him out of the asylum they can make him a private patient, and so remove
him. Before the patient can be withdrawn, however, the friends must sign an
obligation that they are willing to maintain him ; but he will not be discharged
if he is dangerous or suicidal. -
Dr. Me Dow ALL said that in Northumberland the parochial authorities are io
the habit of keeping patients in the wards of the workhouse, and then sending
them to the asylum when they become troublesome. He would be glad if
future legislation would make this illegal. y
Dr. Ireland concluded the discussion on Dr. Rorie’s paper by urging the
necessity of lunatics being provided with proper medical care. The happy results
were seen in the number of patients who had recovered as shown by Dr.
Rorie. He would regret to think that pauper lunatics in workhouses should be
deprived of such aid, and there could be no doubt that in many cases they were
subject to more restraint than in ordinary district asylums.
Dr. Keay read the next paper on “ A Case of Insanity of Adolescence.”
Dr. Yellowlees said he did not like to permit so interesting and important
a case to pass without comment. He was not quite sure if it was a case of
insanity of adolescence. Dr. Keay had pointed out the difference between it and
other cases, and mentioned constant and invariable depression as one of Die
symptoms. He (Dr. Yellowlees) had found a prominent symptom of insanity
of adolescence to he unceasing mischief-making, as if for the mere pleasure of
giving trouble. He could not in too strong language say how injurious it was
to a patient of this character to be engaged in a constant struggle with
attendants, especially if he succeeded in escaping. If there ever was an occasion
for locked doors and rigid seclusion this was one.
Dr. Ireland followed. He asked what was the insanity of adolescence ? He
• was not favourable to the multiplication of technical terms, but they should be
strictly defined. He had noticed the question asked in an examination paper
set by Dr. Clouston for the new certificate of the Association. He (Dr. Ireland)
had put the question to a prominent member of the Society, but he did not seem
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1888.]
Notes and News.
649
to know. Dr. Kea/s case was that of a man who had inflammation in the
glandular system, which ended in blood poisoning. Now, adolescence is a mark
of health, and he could not see that in the matter of clearness anything was
gained by the term “ insanity of adolescence.”
Dr. Robertson read a paper on “ Reflex Action of Automatic Speech.”
Dr. Turnbull expressed the thanks of the meeting to Dr. Robertson for his
paper.
The members dined together at the Edinburgh Hotel after the meeting.
The next Scottish Quarterly Meeting will be held on the second Thursday of
March, 1888, in Glasgow.
IRISH MEETING.
The Quarterly Meeting of the Medico-Psychological Association was held in
the Richmond Asylum, Dublin, on December 1st, 1887. There were present:
Dr. Duncan (in the chair), Dr. Patton (Dublin), Dr. J. Molony, Conolly Norman,
F.R.C.S.I., Dr. Myles, Dr. Cope, E. M. Courtenay, M.B.
William Thornley Stokes, Esq., M.D., Visiting Surgeon, Swift’s Hospital, pro¬
posed by Conolly Norman, F.R.C.S.I., seconded by John Molont, M.D., was
duly elected a member of the Association.
Dr. Courtenay stated that, having at the last annual meeting handed in his
resignation of the post of Irish Secretary, he was requested to continue in office
until an appointment could be made. He was then directed to obtain the sense
of the Irish members as to the name of the candidate they would select to be
laid before the general meeting for appointment. He, therefore, proposed Mr.
Conolly Norman as the most fitting selection, if for no higher reason as the
superintendent of the largest Irish asylum, and as living in the Metropolis.
Dr. Patton seconded the resolution, which was agreed to.
Dr. Courtenay begged to call the attention of the meeting to the Bill intro¬
duced during the last Parliamentary Session to amend the Superannuation Act
at present in force in Irish asylums. The Bill had not only been introduced,
but had passed through the House of Commons, and had only been stopped by
having no seconder in the House of Lords. The object was to introduce a
scheme of superannuation very much in conformity with that in force in
English County Asylums, and to this no one could object, except in so far that
the pension given was so large, and the period of service so short, that in
England, where it was necessary that pensions should be ratified at Quarter
Sessions, the award made by Asylum Committees was nearly always sent back to
them, and the unfortunate pensioner was satisfied to take a very small part of
what he was entitled by law. But what he had to object to, and what was the
interest of every one connected with Irish lunatic asylums to oppose, was a
clause stating that pensions should be granted at the will of Boards of Asylum
Governors, “ and not otherwise.” It was unnecessary for him to point out, with¬
out going into any political discussion, that the management of asylums would
undoubtedly in a few years be thrown into the hands of men of very different
feelings to those who at present are appointed governors of asylums, and that it
would undoubtedly occur that men holding office in asylums would at the end
of their years be thrown out, without being granted the pension they had looked
forward to as the support of their old age. He, therefore, considered that this
was a subject of importance to every Irish superintendent. He had attempted
to have it opposed in every way in his power in the Commons, in which he was
ably supported by Dr. Nugent; but the passing of the Bill was kept so quiet
that it had only been heard of before the third reading, and was only thrown
out of the House of Lords as it had no seconder. He, therefore, considered that
some action should be taken to amend the Bill during the next Session.
Mr. Conolly Norman concurred with Dr. Courtenay. In his
opinion the clauses of the proposed Bill absolutely excluded men in the
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650 Notes and News. [Jan.,
position of medical superintendents from any chance of pension. The very fact
of so large an amount as two-thirds of their pay, and allowance being allowed
them after fifteen years’ service, would cause Boards of Governors at once to
reject any claim to pension in their case. An attendant might by chance be
given £40 a year on retirement, but the chances of a physician obtaining £400
from a board, constituted as public asylum board, would be, after a few years,
if the power of refusing was left to them, simply hopeless.
Dr. Duncan suggested that a petition be drawn up to the Chief Secretary,
praying that the Bill be taken into consideration by the Government as to
whether they would not insist on retaining the power of having some voice in
the superannuation of their own officers.
Dr. Courtenay seconded the proposition, which was agreed to.
PELLAGRA.
In the neurological Section of the annual gathering of German Naturalists
and Physicians, held at Wiesbaden, Sept., 1887, Dr. Tuczek, of Marburg, pre¬
sented an able and elaborate report on the nervous disturbances witnessed in
Pellagra, of which we hope to make further use, but in the meantime it may be
stated that Dr. Tuczek based his report on a study of Pellagra in northern Italy,
which he had made during the months of April and May, 1887. About three
hundred and fifty patients had come under his notice, and eight autopsies.
Amongst the psychoses observed in Pellagra, melancholia stood first, and in par¬
ticular the variety named melancholia with stupor. In respect of other cerebral
symptoms, e.g., vertiginous attacks and twitchings, like those seen in cortical
epilepsy. Dr. Tuczek was able to confirm the statements made by numerous
Italian writers on Pellagra. He was also able to confirm the observations on
cord symptoms, viz., parsesthesias, motor and sensory palsies, vaso-motor dis¬
turbances. Of three hundred cases he found the knee-jerk exaggerated in two-
thirds of the number ; the exaggeration amounted to the most intense form of
patella clonus in some of the cases. In twenty-three of these cases there was
ankle-clonus as well, and in general, exaggeration of the tendon reflexes of the
upper limbs, also more or less distinct of the other symptoms of spastic spinal
paralysis. In seven cases the knee-jerk was wanting; in none of these cases
was there ataxy. In the remaining cases there was either diminution, or no
essential change in the tendon reflexes. Difference in the liveliness of the knee-
jerk on the two sides was frequently observed. The author showed in photo¬
graphs the chief types of psychosis in Pellagra, also the skin-affections. He
showed, by means of preparations, the trophic lesions of the tongue: and he then
discussed the post-mortem appearances in Pellagra. In all eight cases there
were degenerative affections of the spinal cord, in two eases of the posterior
columns only ; in the other cases combined disease of the posterior columns,
and of the hinder portions of the lateral columns. Preparations were shown.
The clinical and anatomical investigations speak in favour of the toxio theory,
which points to the prolonged use of diseased maize. Dr. Tuczek drew atten¬
tion to the analogous toxaemias, Ergotism and Lathyrism, and laid stress on the
point that, as in other forms of toxaimia, so in “ Maidismus ” or the “ Maldic
psycho-neurosis” the nervous disturbances were not exactly progressive.
AMERICAN PROBLEMS OF PSYCHIATRY.
[Having admitted Dr. Kiernan’s'paper into our Journal (July, 1887), we con¬
sider it only fair to place the following criticism on record which appears in Mr.
Wines’s “ International Record of Charities and Correction.” Audi alteram
j ' partem .—Eds.]
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Notes and News.
651
1888.]
** The * Journal of Mental Science ’ for July publishes an article, by Dr. J. G.
Kiernan, on ‘ Amerioan Problems in Psychiatry,’ illustrated by a study of
Cook county insanity statistics. It is a strange mixture of truth and exaggera¬
tion, or misstatement, and characteristic of its author. It is a matter of regret
to us, as we presume it will be to the neurologists of the United States gener¬
ally, that the Cook County Hospital, which has been managed by a Committee
of the County Board, of which several of the members and the warden of this
hospital appointed by that Committee are under indictment for corruption in
office, should have been selected as a typical American institution, to be held
up to the view of English readers in the year which witnesses the meeting of
the International Medical Congress in oar national capital. The degree of
conscientious adhesion to truth exhibited by Dr. Kiernan in his allegations
may be judged by his quotations, as where he represents the Illinois Commis¬
sioners, for instance, as having said that * Dr. Spray deserves credit for having
entirely dispensed with the use of restraint,’ when they said *almost entirely;’
or where he charges that ‘ the Illinois county insane are to-day chained,
naked, and filthy, in dungeons with only an opening in the door-top for air,
light, and heat, through which food is pitched as to a dog,’ giving the State
Board of Charities as his authority. This charge, which was never true of the
insane of Illinois as a class, but only in exceptional instances, is not true * to¬
day ’ of any insane man or woman in any county poorhouse in the State. But
the subject deserves no farther notice at our hands. His slurs upon the
Illinois Board of Charities were fully refuted in oar issue of July, 1886.”
FORGING CERTIFICATES OF CHARACTER.
Edwin Jones, late porter in the employment of the Worksop Poor Law
Guardians, was charged with having on the 6th of October offered his services
to the Guardians on the production of a forged certificate of character.—The
Clerk to the Guardians (J. S. Whall) prosecuted, and said that the prisoner,
among other applicants, presented one from Dr. Jepson, Medical Superintendent
of the City of London Asylum. He produced documents which he said were
original ones. Dr. Jepson was present, and would give evidence before their
worships that he had never written such a certificate in his life, and that the
man, instead of being in the asylum four years, had only been in it six weeks,
and instead of leaving of his own accord, he was discharged for abstained leave.
The following was the certificate produced :—
City of London Asylum, January 15th, 1886.
I herewith beg to state that Edwin Jones lias been here four years. He is an excellent
attendant, kind to the patients, steady, sober, intelligent, and trustworthy; and not afraid
of work. He leaves of his own accord, and I am sorry to lose him.
Octavius Jkpson, M.D.
Dr. Jepson swore that he never wrote the letter or any portion of it.—Mr.
Beevor : It appears you have attempted a gTeat fraud upon the Guardians of the
Worksop Union. You will have to pay a fine of £10 and costs, or in default of
payment go to prison for two months.
PENSIONS OF MEDICAL SUPERINTENDENTS.
On the 9th December a meeting was held at the County Hall, Derby, of the
representatives of nine out of 16 Boards of Guardians in the County, in order to
discuss with the Visiting Justices of the County Asylum the question of the cost
of maintenance of the patients. The meeting originated in the action of Chester¬
field, the largest Union in Derbyshire. Dr. Murray Lindsay was present, and
was able to show that the cost of patients in the asylum, so far from being
excessive, as alleged, was a halfpenny per week less than the average of all the
asylums (8) of nearly equal size. The maintenance charge has been reduced
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652
Notes and News.
[Jan.,
three times in less than two years—3d. per week on each occasion. It now
stands at 9s. 6d., improvements having been effected at the same time by addi¬
tions to the day and night attendants; also better diet. Under cover of a dis¬
cussion on the maintenance charge, an attack was made on the salaries of
medical superintendents and their pensions, which are regarded as excessive.
The Chairman of the largest Union objected to pensions altogether, on the
ground that the large salaries now paid were amply sufficient. One gentleman
said that he would rather a larger salary was paid than that a pension should
be given. It is probable that Magistrates are becoming more influenced by the
objections raised by Guardians than many suppose, and it is by no means
improbable that in the near future the pensions of county superintendents will
participate in the general reduction of income in this country, and the depres¬
sion of trade and agriculture. It may, indeed, be said that the tide has already
turned. The Pension Committee of the Association will, of course, do all in
their power in the interests of the medical superintendents of county asylums.
These will, no doubt, be fully alive to the importance of united action in support¬
ing this Committee in the course it thinks best to pursue, whatever that may be.
We append the following list prepared by Dr. Williams, of Haywards Heath:—
List op Pensions granted to Medical Superintendents op County Asylums
in England and Wales.
Superintendent’s Name
and Date of Retirement.
Name of
Asylum.
Amount
of
Pension.
Proportion to
Salary and
Allowances.
Length of
Service.
1887. Dr. Jepson
City of London
£800
Two-Thirds.
23 years.
1887. „ Pater
Stafford
£300
One-Third.
13 „
1886. „ Symes
Dorset
£450
One-Half.
32 „
1886. „ Hills
Norfolk
£600
Two-Thirds.
25 t,
1886. „ Gil land
Berks
£400
One-Half.
16 „
1885. „ Manley
Hants
£800
Two-Thirds.
29 »t
1883. „ McCullough
Monmonth, &c.
£730
Two-Thirds.
25
1882. „ Toller
Gloucester ...
£550
One-Half.
l9 if
1882. „ Brushfield ...
Surrey
£700
Two-Thirds.
16 „
1881. „ Sheppard ...
Colney Hatch
£450
One-Half.
20 ji
1880. „ Davies
Stafford
£250
One-Third.
22 ..
1878. „ Holland
Lancashire ...
£750
Two-Thirds.
28 ,,
1876. „ Kirkman ...
Kent
£400
One-Half.
12 „
1876. „ Broadhurst...
Lancashire ...
1 £300
One-Half.
33 ,,
1876. „ Kirkman ...
Suffolk
1 £600
Two-Thirds.
45 „
1874. „ Denne
Three Counties
£500
Two-Thirds.
20* ,,
1872. „ Begley
Han well
£466
Two-Thirds.
34 „
1871. „ Hitchman ...
Derby
£400
One-Half.
21 ,»
1870. „ Boyd
Somerset
£450
One-Half.
21 „
1868. „ Hill
North Riding
£533
One-Half.
20 „
1868. „ Ley
Oxford
£250
One-Third.
23 „
1867. „ Lawrence ...
Cambridge ...
£50
7 „
1864. „ Huxley
Kent
£350
TwovThirds.
17 „
1862. „ Williams ...
Gloucester ...
£300
One-Third.
17 „
1851. „ Prosser
Kent
£150
13 „
Average length of Service—22 years. Average Pension—nearly £500.
Digitized by L^ooQLe
1888.]
Notes and News,
653
EXAMINATION IN PSYCHOLOGICAL MEDICINE.
The next examination in Ireland for the Certificate of Efficiency in Psycho¬
logical Medicine will be held at the Richmond Asylum, Dublin, Thursday,
February 16,1888.
Correspondence .
MEDICAL AND CHEMICAL ASSESSORS.
To the Editors of “The Journal op Mental Science.”
Sirs, — I respectfully submit the annexed measure to the consideration of
yoor readers. I shall not trespass upon your valuable space by sketching, or
commenting upon, the history of the decline and fall of medical expertism in
England. The fact remains. The instant reverence with which medieval
tribunals bowed to its verdict; the tolerance shown, for example, by our own
House of Lords to the usurpation of their judicial functions by the seven noble
kinswomen to the Countess of Essex, who were all “ sticklers for the nullity,”
has ceased, and very few and very feeble have been the voices raised to con¬
demn the dictum of Bonnies —Vexpertise riest qu’un verre qui grossit let ohjets.
The discreditable feud between legal and medical expertism is not to be termi¬
nated by concealing it under a thin veneer of superficial courtesy or a false
analogy to the duties of counsel. It is the logical issue of the historical
accident which, as civil procedure in England gradually became inquisitorial,
substituted the medical advocate for the scientific assessor.
In drafting this measure, which is borrowed partly from the resolutions of an
American medico-legal society, and partly from the Admiralty Jurisdiction
Acts, I have had the benefit of the invaluable advice of Dr. Maudsley, and of
my friend Dr. Henry D. Littlejohn, of Edinburgh.
I am, Ac.,
A. Wood Renton.
8, Middle Temple Lane,
17th October, 1887.
Medical and Chemical Assessors Act, 1888 .
Be it enacted, etc., as follows :
1. This Act may be cited as the Medical and Chemical Assessors Act, 1888 .
2. In the interpretation, and for the purposes of this Act, the following terms shall have
the respective meanings hereinafter assigned to them, that is to say :
“ Medico-legal ” issue shall mean any issue arising upon the trial of any civil cause
or criminal prosecution for the determination of which the opinion of medical or
chemical experts may be deemed necessary.
“Judge” shall mean any person or persons invested by law with judicial authority,
before whom, in the lawful exercise of such authority, any medico-legal issue may
arise.
“ Registrar ” shall include any person who acts in the capacity of a registrar to any
judge, as hereinbefore defined.
3. The provisions of this Act shall apply to the United Kingdom of Great Britain and
Ireland.
4. Upon the commencement of this Act duly qualified persons shall forthwith be appointed
as follows to act in the manner hereinafter provided as medical and chemical assessors in
England, Scotland, and Ireland respectively : The Lord Chancellor of England shall appoint
twenty-four medical and twenty-four chemical assessors; the Lord President of Scotland
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Notes and News .
654
[Jan.,
and the Lord Chancellor of Ireland shall each appoint twelve medical and twelve chemical
assessors, to act within their respective jurisdictions.
5. Every assessor shall receive notice in writing of his appointment, and every such
appointment shall be for the period of three years from and after the date of such notice.
6. (i.) At any time before or during the trial of any civil cause or criminal prosecution,
any judge may require the registrar to summon to his assistance not less than three medical
or chemical assessors.
(ii.) Every assessor so summoned shall be bound to attend at the trial and assist the judge
in the mariner hereinafter provided, and for every wilful disobedience to such summons
shall be liable at the discretion of the judge to a penalty not exceeding five pounds, and
shall receive for his services a fee, fixed by the judge after the trial, of not less than five
guineas a day or for any part of a day, together with such an allowance for travelling and
incidental expenses as the judge may direct.
(iii.) The said fee and allowance shall be payable out of the county rates.
7. It shall be the duty of every assessor summoned to and attending any trial as afore¬
said to assist the judge by answering any questions, and by expressing in open court his
opinion with reference to any medico-legal issue that may arise or may have arisen
therein. But the judge, or in cases tried with a jury, tlie jury, shall not be bound to follow
the opinion of any, or of a majority, of the assessors, unless he or they concurs or concur
in it.
8. Nothing in this Act contained shall affect, or in any way prejudice, the right of any
party to any civil cause or criminal prosecution to support his case, as hitherto, by the evi¬
dence of medical or chemical experts.
9. This Act shall commence and take effect from and after the first day of Jan nary,
1889.
10. Section fifty-six of the Judicature Act, 1873, from and including the words 4 * other
than ” down to and including the word “ crown ” is hereby repeated.
Obituary.
DR. J. N. RAMAER.
Psychological Medicine in Holland received a severe blow on the 2nd of
November, 1887, by the decease of Dr. J. M. Ramaer.
He was born on the 20th of April, 1817, at Bois le Dno, and attended the
grammar school at that place. His schoolfellows say that he was one of the
best scholars, and that he displayed a great aptness in mastering difficulties.
He afterwards studied medicine at Utrecht, where he was a pupil of Professor
Schroeder vau der Kolk. His medical degree was taken at Groningeu, to which
place his parents moved after a few years. The degree of M.D. was conferred
upon him after his writing and defending a dissertation: “ De ^Ethiopica
generis hnmani varietate.”
After leaving the University of Groningen he Bet out on a tour to the schools
of Vienna, Munich, and Paris, previously to his settling as a physician at
Rotterdam in 1840.
The lessons of Professor van der Kolk caused him to make nervous and
mental diseases his favourite study, and it was at the recommendation of this
great anatomist and neurologist that Ramaer was appointed medical superin¬
tendent to tho lunatic asylum at Zutphen. He was appointed in 1841 and
entered upon his duties on 18th January, 1842.
It was in 1841 that the first law was passed in the Netherlands which greatly
improved the lot of the insane, and it shows the great trust which Van der Kolk,
the auctor intellectualis of the law, put in Ramaer, then only 24 years old. His
subsequent career showed that the trust was well deserved. He devoted his
energy and powers to the Zutphen Asylum till 1863, when he was appointed
medical superintendent of the asylum at Delft. He stayed at Delft six years,
and on the 1st of July, 1869, he moved to the Hague, where he settled as
Digitized by L^ooQle
1888.]
Notes and News.
65o
physician for nervous and mental diseases. The Board of Governors of the
Delft Asylum, wishing to profit by his experience and learning, appointed him
consulting physician to their asylum. This honourable post he resigned in 1872,
having obtained a call from the Home Office to be inspector of lunatic asylums.
It is only natural that a law, however excellent, should have many deficien¬
cies which are only discovered after such a law has been in existence for some
time. And so it was with the law passed in 1841. When Bamaer came into
authority he kept urging the necessity that the old law should be recalled, and
another and better one be substituted. His endeavours were successful, and
on the 1st of October, 1884, he had the satisfaction of seeing the present law
of lunacy issued.
It was during his stay at Zutphen that he started the plan of uniting the differ¬
ent medical associations of different places into one general medical society,
and it is in a great part owing to his increasing endeavours and unfailing
energy that he saw his favourite plan improve, and when the general medical
association celebrated its twenty-fifth anniversary, Bamaer had the great satis¬
faction of delivering the presidential address.
Another medical society gratefully recognizes him as its founder, viz., the
Psychological Society, of which he resigned the chair when appointed to be
Inspector of Lunacy.
The King decorated him with the Order of the Lion, and its device, “ Virtus
nobilitat,” was well placed on his noble breast.
He was an honorary member of several learned societies, one of which was
the Medico-Fsychological Association of England. He was the author of several
papers relating to our branch of medicine.
If it may be said that be tasted the sweets of life, still he suffered from
bereavements. He lost an only daughter, a eon (a promising young barrister),
and a well beloved wife. An indefatigable worker in his asylum and his study,
he w as a kind father and cheerful friend, and those who enjoyed his friendship
and hospitality all agree in their praises of his conversational powers and the
.vast amount of his general information.
He encouraged work, and stimulated young physicians to search the vast
field before them.
His death was occasioned by a comparatively trifling cause. While cutting a
com his knife slipped, and he received a small wound, which caused him little,
if any pain. Unfortunately he neglected this small scratch, and continued
walking. Very soon after an abscess formed, and, notwithstanding the best
nursing and the most stringent antiseptic treatment, sloughing set in, and in a
few weeks caused his death.
A good and a noble man has departed this life; well may his family w r eep
for him, but let those he left behind, find consolation in the consciousness
that the deceased bore a name which was honoured and respected throughout
the land.
F. M. Cowan, M.D.
Dordrecht.
[We add our lively regrets to those of Dr. Cowan at the loss of this able and
genial physician, who became an Honorary Member of the Association a year
ago. He took an active part in the Congress of Mental Medicine held at Ant¬
werp in 1885, and at the recent inauguration of Guislain’s statue at Ghent. He
was present as the representative of Dutch Psychology, and he delivered an
able and feeling speech at the banquet. We trust that as impartial and ex¬
perienced an Inspector of asylums will be appointed his successor. He cer¬
tainly will not be more so.]
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656
Notes and News .
DR. FOVTLLE.
As the last sheet goes to press the melancholy intelligence reaches us that
this eminent alienist is dead. The distinguished son of a distinguished father, he
has occupied for many years an honourable position in psychological medicine
as the Medical Superintendent of large Asylums, and &s an Inspector of Insti¬
tutions for the Insane. Till quite recently his friends looked forward to hia
continuing to fulfil his responsible duties for many years. We are informed
that the first symptoms of his disorder made their appearance last July, and
demanded absolute repose for some time. He had regained his health, when
in October he had to resume his official inspection of asylums. During his
visit for this purpose to the south of France he got a chill one evening, and the
symptoms reappeared with such severity that he was obliged to return home to
Paris, when he took to the bed which he never left. For the last three weeks
it was but too clear how the disease would terminate, and he died of Bright's
disease December 15th, 1887. As his friend M. Motet truly says in communi¬
cating to us the sad news: “ Mental Medicine has sustained a severe loss, and
the Department of Asylum Inspection will not easily find another man so pro¬
foundly honest, whose just and impartial mind solved in the best manner the
most delicate questions as they arose/* With his bereaved family and his
colleagues, who so greatly deplore his loss, we express our most cordial sympathy
and heartfelt regrets. We do not forget his generous appreciation of the work
done by Englishmen in reforming the condition of the insane, and the justice he
rendered to our asylums in the well-known work written a few years since,
which showed how thoroughly conversant he was with our lunaoy legislation
as well as our institutions.
Our space will not allow of more than this brief tribute to the memory of
our lamented confrere. In our next number we shall give a sketch of his life
and writings.
Appointments.
Bubd, E. Lycett, B.A., M.B., B.C.Cantab., appointed Second Medical
Visitor to the Private Asylums of Salop and Montgomery.
Hyslop, Theo. B., M.B., C.M.Edin., appointed Assistant Medical Officer to
the Royal Albert Asylum for Idiots and Imbeciles, Lancaster.
Williams, Dr. S. D., Medical Superintendent of the Haywards Heath
Asylum, has resigned, after holding the appointment 20 years.
We regret that we have been obliged to postpone Reviews of numerous
works, as also an excellent Address by Professor Mierzejewski, at the Univer¬
sity of St. Petersburg.
Digitized by L^ooQle
INDEX TO VOL. XXXIII.
Aconite, employment of, in epilepsy, 311.
Acute mania, post-mortem appearances in, 20.
Admission to asylums of doubtful cases, 604.
A dmissi ons to asylums less during depression of trade, 454.
Adolescence, insanity of, 648.
JStiology of puerperal insanity, 169, 372, 487.
Agoraphobia, 213.
American asylums, experience of, 638.
„ problems in psychiatry, 190.
„ retrospect, 148.
Anatomy of the brain and spinal cord. (Rev.), 426.
„ „ movement, lectures on. (Rev.), 430.
„ pathological and pathogenesis. (Rev.), 427.
Animal magnetism, 627.
Aphasia from cerebral disease, by Dr. Ross. (Rev.), 293.
„ and its relation to apprehension, 447.
„ distinction between word-deafness and word-blindness, 628.
Appointments, 168, 340, 482, 656.
Art, les demoniaques dans 1*. (Rev.), 583.
„ the philosophy of. (Rev.), 130.
Artificial somnambulism, 142, 438, 627.
Asclepiad. (Rev.), 597.
Assessors, medical and chemical, 653.
Assistant medical officer and superintendent, difference between, 99.
Asylum, Beverley, plans of hospital for, 48.
„ Irish, our laws and our staff, 379.
„ attendants, address to, 599.
„ „ training of, 452.
„ „ fewer hours for, 612,616.
„ medical officers’ superannuation pensions, 96, 324, 328,649-651.
„ in Paris, a visit to, 333.
„ reports, 1886, 310, 448, 603.
„ service provident scheme, 167.
Ataxo-spasmodic tabes, 82.
Athetosis connected with insanity, 632.
Baker, Dr., on an American crib bedstead, 152.
Ball, Prof. B., on contagiousness of insanity, 140. .
Beach, Dr. Fletcher, case of imbecility with choreic movements, 254.
Before trial, what should be done, etc., 424.
Beaunis, Dr., on artificial somnambulism, 142.
*
658
INDEX.
Begley, Dr. W. C., death of, 337.
Bill, Lunacy Acts Amendment, 276,321, 346, 406, 467.
Blyth, Mr. A. W., lead in the brains of factory operatives dying suddenly, 483.
Boarding out, 320,610. * J
Botany, handbook of. (Rev.), 300.
Boyd, Stanley, Mr., his edition of “ Droit” (Rev.), 133.
Brain and spinal cord, anatomy of. (Rev.), 426,694.
i# ». tt t t diagnosis of diseases of. (Rev.), 600.
„ haemorrhages and false membranes in, 609.
„ intracranial motions of, 141.
„ thermometry, 142.
British Medical Association—Dublin Meeting, 1887—473.
Brown, Dr. Sanger, suggestions on the construction and organization of
hospitals for the insane, 64.
Brunton, Dr. Lauder, pharmacology and therapeutics. (Rev.), 590.
Bullen, Mr. St. John, cases of multiple sarcomata of cerebrum, 533.
Buzzard, Dr. T., on some forms of paralysis from peripheral neuritis, 131.
Calabar-bean in early stage of general paralysis, 311.
Campbell, Dr. C. M., a case of moral insanity, 74.
Carter, Mr. R. B., memorandum on Chauffat, 273.
Catalepsy, case of, with observations, 163.
„ cases of, with treatment, 259.
Cephalic thermometry, 142.
Certificate of efficiency in psychological medicine, 108,168, 408, 480.
Chauffat, case of prolonged sleep, 267, 273.
Charcot, Dr. J. M., Lemons sur les maladies du systeme nerveux. (Rev.), 576.
*» »» tt Les D&noniaques dans Tart. (Rev.), 583.
Chicago, study of insanity statistics of, 190.
Childhood and youth, mental affections of. (Rev.), 591.
Chronic lunatics, best location for, 135.
Choreoid movements, case of imbecility with, 254.
^ r * ®^ olo «y* pathology and treatment of puerperal insanity,
169, 372, 487.
Clark, Mr. F. W., hysteria in men, 543.
Cocaine in the treatment of mental disorders, 230.
Commissioners in Lunacy 41st report, March, 1887,553.
Concomitance, doctrine of, 37.
Contagiousness of insanity, 140.
Convalescent cases, early discharge of, 451.
Copenhagen Congress, 134.
Correspondence-
Asylum service provident scheme, Dr. Clark, 167.
A visit to asylums in Paris, Dr. R. Jones, 333.
Eames memorial fund, 333.
Medical and chemical assessors, Mr. Renton, 653.
Superintendents dealing harshly with attendants, Dr. Urquhart. 337
Crib-bedstead, American, 152.
Criminal cases, defence of insanity in, 426.
Curability of insanity, 118, 429.
Davies, Rev. W. G., the true theory of induction, 219.
Degeneration and insanity, 147.
Dementia, primary, doubtful cases, 50.
_ » . »» with ataxo-spasmodic tabes, 82
Demomaque8 dans Tart. (Rev.), 300, 583.
Digitized by L^ooQle
INDEX.
659
Diathesis of the degenerate, or the neuropathic diathesis, 497.
Dictionary of terms used in medicine, etc. (Rev.), 601.
Diseases of the nervous system. (Rev.), 289.
Dix, Dorothea L., obituary and photograph, 477.
Dodds, Dr. W. J., a case of epilepsy, 164, 401.
Doute, folie du, by Prof. Kovalewsky, 209, 624.
Dowden, Dr. E., life of Shelley. (Rev.), 113, 303, 409.
Down, Dr. L., mental affections of childhood and youth. (Rev.), 691.
Drainage, defective, and typhoid, 610.
Droit's surgeon’s vade mecum. (Rev.), 133.
Drunk, or Insane ? Medico legal case, 536.
Dundee Royal Asylum, treatment of insane in, sixty years ago, 1.
Karnes memorial fund, 333.
Earle, Dr. Pliny, the curability of insanity, 148.
Employment of patients, value of, 364,466, 611, 616.
Encephale, structure et description iconographique du cerveau, du cervelet et
du bulbe. (Rev.), 302.
English retrospect, asylum reports, 310, 448, 603.
Epileptic fit, universal symptomatology of an, 26.
Epileptics at the Bicetre Asylum, 626.
Epileptic suffocated in a Scotch asylum, 317.
„ murder by an, 446.
Epilepsy, a case of, 164, 401.
„ reflex, 446.
Erysipelas, fatal case in an asylum, 317.
Escapes of patients, friends conniving at, 327.
Evolution and dissolution of the nervous system, 26.
Examination in honours, London University, 110.
„ >i psychological medicine, 108,168, 408, 480.
False membranes within the cerebral subdural space, 609.
Fire in Aberdeen Asylum, 448.
„ „ E. Riding Asylum, Yorks, 616.
Folie morale , 139.
„ d deux , 140,473.
„ du doute, 209, 524.
„ raisormante , 140.
Forging certificates of character, 661.
Fondle, Dr., death of, 666.
Fox, Dr. Long, influence of the sympathetic on disease, 293.
Francis, Dr., out-door work as a remedial agent in insanity, 364.
French retrospect, 134,139, 438, 626.
Functions of the brain as held by Goltz, 140.
Fungi, British, textbook of. (Rev.), 300.
„ death of a patient from eating, 615.
Galvanism in the treatment of insanity, 269, 386.
Gaskell prize, 108.
Gedenktage der Psychiatric und ihrer Hiilfsdisciplinen in alien L&ndern. Von
Dr. H. Laehr. (Rev.), 297.
Gehim (anatomisch), by Prof. Mendel. (Rev.), 594.
General paralysis, microscopical appearance of brain, 22,23.
„ „ heredity in, 137.
„ „ rdle of syphilis in, 138.
w „ change in duration of, 313.
„ „ decrease in number of cases of, 614.
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660
INDEX.
Geoghegan, Dr* supplementary note on a case of mental stupor, 73.
German retrospect, 443. M _ . _ _ _ a .
Geschicte der Psychiatrie in der 2 ten Halfte des Vongen Jahrhunderts. (Rev.)*
696 **
Gesundheitspflege in der Mittelschule, Hygiene des Korpers nebst beilauflgen
Bemerkungen. (Rev.), 696.
Gilland, Dr. R. P., obituary notice, 167.
Gowers, Dr., diseases of the nervous system. (Rev.), 289.
Granger, Dr., how to care for the insane. (Rev.), 592.
Guislain, inauguration of statue of, 476.
Gymnastics, Swedish, educational and medical, 432, 617.
Haemorrhages and false membranes within the cerebral subdural space in the
insane, 609.
Hay fever, a true neurosis, 636.
Hawkins, Rev. H., address to asylum attendants. (Rev.), 599.
Healing art, or chapters on medicine, diseases, remedies and physicians, etc.
HeSth of^nations, a review of the works of Edwin Chadwick. (Rev.), 423.
Heimann, Dr., cocaine in the treatment of mental disorders, 230.
Hemiplegia, a new symptom in, 443.
Heredity in general paralysis, 137.
„ „ nervous diseases, 497. .
Honours examination in psychological medicine, 108.
Hospital for infectious cases at Beverley, 48. .
„ „ insane, suggestions on construction and organization of, 54.
Houghton tragedy, the, 281.
Hume. (Rev.), 128.
Hygiene in schools, 595.
Hyoscine, hydrobromate of, in insanity, 311.
Hypnotism, artificial somnambulism, 142, 438, 627.
Hypnotisms et magnetisms; exposd des phenomdnes observes pendant le
gommeil nerveux provoqud. (Rev.), 422.
Hypnotism, by M. Beaunis, 438.
„ „ M. Binet, etc., 627.
Hypnotismus, der. (Rev.), 697.
Hysteria, certain phases of, 579.
„ in men, 543.
Idiots Act, 1886,103. .
,, and imbeciles, provision for indigent, 560.
Illustrations of normal and diseased nerve cells, etc., 20.
Imbecility with choreic movements, case of, 264.
Induction, the true theory of, 219.
Infectious disease, hospital for, 48.
Influence of the sympathetic on disease. (Rev.), 293.
Insane, treatment of, sixty years ago, 1.
„ hospitals for, construction, etc., of, 54.
„ how to care for the. (Rev.), 592.
„ nursing and care of the. (Rev.), 693.
„ reforms in the treatment of. (Rev.), 596.
Insanity, curable. (Rev.), 126.
„ contagious? 140.
„ and degeneration, 147.
„ increase of, in Massachusetts, .149.
„ puerperal, aetiology, pathology, and treatment of, 169, 372, 487.
„ statistics of, in Chicago, 190.
Digitized by
INDEX.
661
Insanity, masturbatic, 67, 238, 396.
„ use of galvanism in treatment of, 386.
„ treatment of, by gymnastics, 622.
„ treatise on the defence of. (Rev.), 424, 426.
„ curability of. (Rev.), 429.
„ and intemperance, 607.
International medical congress, 633.
Irish asylum laws and staff, 379.
„ lunacy laws, 407.
„ reports of lunacy inspectors, 667.
„ meeting of Psychological Association, 649,
Irresistible criminal impulse theory, 298.
Jackson, Dr. Hughlings, remarks on evolution and dissolution of the nervous
system, 26.
Jewell, Dr., of Chicago, death of, 339.
Keser, Dr., a case of prolonged sleep, 267. _ . . , ,
Kiernan, Dr., Amencan problems in psychiatry, illustrated by a study or
Cook County statistics, 190.
Kirkman, Dr., death of, 339.
Kinkead, Dr., a medico-legal study, 636.
Kovalewsky, Prof., folie du doute, 209,624.
Laehr, Dr., gedenktage der psychiatric und ihrer hiilfsdisciplinen in alien
Landero. (Rev.), 297.
Law, lunacy, “ not more than seven clear days, 547.
Lead in brains of two lead factory operatives, 483.
Le 9 ons sur les maladies du systeme nerveux faites a la Saltpetnere. (Rev.), 67o.
Lectures to nurses, attendants, etc., 604.
lie grain on degeneration and insanity, 147.
Life of Shelley, by Dr. E. Dowden. (Rev.), 113, 303, 409.
Local Govemment;Bill, 364. ^ oo .
Lowe. Mr ., appeal to House of Lords, 331.
Lunacy Acts Amendment Bill, 111, 164,276, 321, 342,345, 406,467.
in many lands, by Mr. Tucker. (Rev.), 688.
„ law, Irish, 407.
legislation in Scotland, 644.
„ reports, 167, 663.
asylums, 310, 448, 603. .
Lunatics sent to asylums under order of two magistrates—abuse of order, 614.
Madeod, Dr., plans and description of a detached hospital for cases of in-
Magnetimie^^ypnotismej expose dea phenomdnes observes pendant le
sommeil nerveux provoqud. (Rev.), 422.
Mania, recurrent, 21.
Mattie raUonnante ou folie morale, loo,
Manuel pratique de medicine merit ale, 628.
Massachusetts, increase of insanity in, 149.
Masturbatic insanity, 57, 238,395.
McCann, murder of, by a lunatic, 281.
Medical gymnastics or movement cure, 617.
„ treatment of lunatics 60 years ago, 10.
Medico-legal study—case of M. R., 636.
Digitized by L^ooQle
662
INDEX.
Medico-Psychological Association-
Meeting in London, 23rd Feb., 1887,162.
„ Glasgow, 10th March, 1887, 161.
„ London, 17th May, 1887, 321.
„ Edinboro’, 1st April, 1887,329.
Annual Meeting in London, 27th July, 1887, 456, 467.
Meeting in London, 11th Nov., 1887, 630.
„ Edinboro’, 10th Nov., 1887, 644.
„ Dublin, 1st Dec., 1887, 649.
Presidential address, 343.
Honours examination (Gaskell prize), July, 1887, 341.
Examinations and prizes, 108, 168, 408, 480.
Memory in artificial sleep, 146.
Mendel, Prof., Gehirn. (Rev.), 694.
Mental affections in childhood and youth. (Rev.), 691.
Mental disturbance having well-defined characters both clinically and patho-
genically, 60.
Mental stupor, supplementary note on case of, 73.
Meschede, Dr., concerning a new form of mental disturbance, etc., 50.
Microscopical illustrations of brain degeneration, 20.
Mills, Dr. 0., nursing and care of the nervous and insane. (Rev.l. 693.
Mitchell, Sir Arthur, K.C.B.,482.
Monomaniac, suicide of a theistic, 278.
Monomanie sans dSlire. (Rev.), 298.
Movement cure, 432, 617.
Moral insanity, case of, 74,162.
„ perversion or insanity, 162.
Moseley, Mr., insanity curable. (Rev.), 126.
Murder of McCann, 281.
„ M. D., 636.
Muscular atrophy, 677.
Nervous diseases and their diagnosis. (Rev.), 431.
„ system, evolution and dissolution of the, 26.
„ „ diseases of the, Dr. Gowers. (Rev.), 289.
„ >» >* >» „ Prof. Charcot, 676.
Neurasthenia, 210,602.
Neuritis, peripheral, paralysis from, 131.
Neuropathic diathesis, 497.
“ Not more than seven clear days,” 647.
Nursing and care of the nervous and insane, 693.
Obituary notices—
Begley, Dr. W. C., 337.
Gilland, Dr. R. B., 167, 345.
Kirkman, Dr., 339, 345.
Nairne, Dr., 344.
Foville, Dr., 656.
Jewell, Dr., 339.
Lalor, Dr., 344.
Dix, Miss, 477.
Ramaer, Dr., 664.
Observations on the spinal cord in the insane, 292.
“Observation ward” for suicidal cases, 643.
Occupation, value of. See Employment.
“ Open door M system, 455,
Original articles—
Beach, Dr. F., a case of imbecility with choreic movements, 264.
Blyth, Dr. A. W., the distribution of lead in the brains of two lead factor?
operatives dying suddenly, 483. *
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INDEX.
663
Brown, Dr. S., suggestions on the construction and organization of hos¬
pitals for the insane, 64.
Biilen, Mr. F. St. John, case of multiple sarcomata of the cerebrum, 533.
Campbell, Dr. C. M., a case of moral insanity, 74.
Clark, Dr. A. C., setiology, pathology, and treatment of puerperal insanity,
169,372,487.
Clark, Mr. F. W., hysteria in men, 543.
Davies, Kev. W. G., the true theory of induction, 219.
Dodds, Dr. W. J., a case of epilepsy, 401.
Francis, Dr. L., out-door work as a remedial agent in insanity, 364.
Geoghegan, Dr., supplementary note on a case of mental stupor, 73.
Heimann, cocaine in the treatment of mental disorders!, 230.
Jackson, Dr. J. H., remarks on evolution and dissolution of the nervous
system, 25.
Keser, Dr. J., a case of prolonged sleep, 267.
Kieman, Dr. J. G., American problems in psychiatry, 190.
Kinkead, Dr. R. J., case of M. R., a medico-legal study, 536.
Kovalewsky, Prof. P. J., folie du doute, 209, 524.
Macleod, Dr., M.D., plans and description of a detached hospital for cases
of infectious disease, 48.
Massachusetts, increase of insanity in, 149.
Meschede, Dr., concerning a new form of mental disturbance, having
well-defined characters both clinically and pathogenetically, 60.
Needham, Dr. F., presidential address, 1887,343.
Palmer, Dr. E., illustrations of normal and defective development of the
multipolar cells of the cerebral cortex, etc., 20.
Revington, Dr. G. T., the neuropathic diathesis, or the diathesis of the
degenerate, 497.
Rorie, Dr. J., on the treatment of the insane sixty years ago, as illustrated
by the earlier records of the Dundee Royal Asylum, 1.
Robertson, Dr. A., on catalepsy with cases. Treatment by high tem¬
perature and galvanism to head, 259.
Smith, Dr. R. P., cases of typhoid fever in the insane, 90.
Spitzka, Dr. E.C., cases of masturbation (masturbatic insanity), 57,238,395.
Stewart, Dr. R. S., ataxo-spasmodic tabes (ataxic paraplegia) occurring
in a case of primary dementia, 82.
Wiglesworth, Dr. J., on the use of galvanism in the treatment of certain
forms of insanity, 385.
-on haemorrhages and; false membranes, within the cerebral subdural
space occurring in the insane, 509.
Woods, Dr. O., our laws and our staff (Irish), 379.
Out-door exercise, 608-609.
Out-door work as a remedial agent, 364.
Pachymeningitis, 509, 581, 630.
Palmer, Dr. E., illustrations of normal and defective development of the
multipolar cells of the cerebral cortex, etc., 20.
Paralysis from peripheral neuritis, 131.
Paraplegia, ataxic, 82.
Paranoia, 192.
Paris, a visit to asylums in, 333.
Parliamentary committee of the Association on the Lunacy Acts Amendment
BiU, 321.
Pathological anatomy and pathogenesis, text-book of, 294.
Pathology of the brain, 20.
„ ,, puerperal insanity, 169, 372, 487,
Pauper lunacy, amount of in Fife and Kinross, 316,
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IXDEX.
Pellagra, 660.
Pensions, suggestions for asylum, 328.
„ to officers and servants of asylums, 329.
„ of medical superintendents, 651.
Pharmacology and therapeutics. (Rev.), 590.
Pharmaceutic and therapeutic memoranda, 332.
Philosophy of art. (Rev.), 130.
Physiological psychology, elements of. (Rev.), 430.
Physionomie, chez Thomme et chez les animaux, dans ses rapports. (Rev.), 586.
Plumbism, with lead in the brain, 483.
Pneumonia, outbreak of, in asylum, 606.
Porencephaly, 444, 446.
Presidential address, 343, 467.
Prolonged sleep, case of, 267.
Provision for indigent idiots and imbeciles, 560.
Psychiatric, ein kurzes Lehrbuch fiir Studiende und Arzte. (Rev.), 601 , 602 .
Psychiatry, American problems of, 650.
Psychosen, der Verlauf der, 602.
Puerperal insanity, 169, 372, 487.
Pump, the Allen surgical, 644.
Ramaer, Dr. J. N., obituary notice, 654.
Reception houses for discharged patients, 471.
Renton, Mr. A. W., monomania sans delire; an examination of the irresistible
criminal impulse theory, 298.
Renton, Mr. A. W., medical and chemical assessors, 653.
R6gis, M., manuel pratique de medicine mentale, 628.
Reports of the Commission in Lunacy for England, 1887, 553.
„ „ „ for Scotland, 559.
„ inspectors of Irish lunatic asylums, 567.
Revington, Dr. G. T., the neuropathic diathesis, or the diathesis of the de¬
generate, 497. N
Rheumatism, chronic articular, 578.
Riel, study of the mental condition of, 139.
Robertson, Dr. A*, on catalepsy, with cases. Treatment of high temperature
and galvanism to head, 163, 259.
Rorie, Dr. J., on the treatment of the insane sixty years ago, etc., 1.
Ross, Dr. J., on aphasia. (Rev.), 293.
Rutherford, Dr., and his assistant medical officer, 99.
“ Samaritan fund ” for discharged patients, 449.
Sanborn, F. B., Mr., on insanity in Massachusetts, 149.
Sanitary improvements in asylums, 318.
Sarcomata of the cerebrum, 533.
Savage, Dr., notes on the International Congress in Washington, 633.
„ „ on “ whether there is ever sufficient reason for the use of strong
.clothing and side-arm dresses,” 153.
Scandinavian retrospect, 134, 432, 617.
Schack, Major S., la physionomie, chez Fhomme et chez les animaux, dans lea
rapports. (Rev.), 586.
Sciatica, 581.
Sciatic nerve, symptoms following injury of, 581.
Scotland, twenty-ninth annual report of Commissioners in Lunacy for, 559.
Scottish meeting of Association, March, 1887,161.
,1 „ „ Nov., 1887,644.
Shaftesbury, Earl of, life and work of. (Rev.), 282, 417.
Shelley, life of. (Rev.), 113,303, 409.
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Sleep! a case of prolonged, 267.
Smith, Dr. E. P., cases of typhoid fever in the insane, 90, 160.
Somnambulisms provoque; etude, physiologique et psvchologique, 142.
Spinal cord in the insane, observations on. (Rev.), 292.
Spitzka, Dr., cases of masturbation (masturbatic insanity), 57, 238, 395.
St. John Bullen. See Bullen.
Stewart, Dr. E. S., ataxo-spasmodic tabes (ataxic paraplegia) occurring in a
case of primary dementia, 82.
Stewart, Mr. A., our temperaments: their study and their teaching. (Ret.), 295.
Strong clothing and side-arm dresses, 153.
Stupor, mental, 50, 73.
Suckling, Dr. C. W., diagnosis of diseases of the brain, spinal cord, and nerves,
OEtev.), 600.
Suicide of a theistic monomaniac, 278.
„ of a patient, 448.
Superannuation—pensions of medical officers, 96, 324, 649, 651.
Sydney University, 333.
Sympathetic on disease, influence of, 293.
Syphilis, r61e of, in general paralysis, 138.
8yst5me.nerveux, lemons sur, par M. Charcot. (Eev.), 300.
Swedish gymnastics: educational and medical, 432.
Tabes, ataxo-spasmodic, 82.
Temperaments: their study and their teaching, 295.
Theistic monomaniac’s suicide, 278.
Training institution for idiots and imbeciles, 103.
Treatment of catalepsy by high temperature and galvanism, 259.
„ mental disorders by cocaine, 230.
„ symptoms of insanity, 361.
„ insanity by out-door work, 364.
„ „ galvanism, 385.
„ „ direct medication, 605.
„ „ sixty years ago, 1.
„ puerperal insanity, 169, 372, 487.
Tremors and choreiform movements, 582.
True theory of induction, 219.
Tucker, Mr. G. A., lunacy in many lands, 588.
Tuke, Dr. Hack, Scandinavian and French retrospect, 134.
„ „ American retrospect, 148.
„ „ French retrospect, 438, 626.
„ „ Obituary Notices of Miss D. L. Dix, Eamaer, and Foville,
477, 654, 656.
Typhoid fever in the insane, 90,160,610.
University of London M.D. examination, 110.
Visiting of patients by friends, 313.
Visual power in nervous diseases, 443.
Washington, notes on the International Congress in, 633.
Wet and dirty cases but not lunatics, sent to asylums, 318.
Whirling chairs, 7.
White, Miss E., Swedish gymnastics: educational and mental, 432,617.
Wiglesworth, Dr. J., on the use of galvanism in the treatment of certain
forms of insanity, 385.
- on haemorrhages and false membranes within the cerebral subdural
space occurring in the insane, 509.
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INDEX*
Woods, Dr. Oscar, our laws and our staff, 379.
Word-blindness, 681.
Ziegler, Prof. E., a textbook of pathological anatomy and pathogenesis.
(Key.), 294, 427.
Illustrations.
Lithograph of the multipolar cells of the cerebral cortex, illustrating Dr.
Palmers paper, 20, 22, 23, 24.
Photo-lithograph of plans of a detached hospital for infectious cases, illus¬
trating Dr. Macleod*8 paper, 48.
Photo-lithograph of plan of hospital for the insane, illustrating Dr. S. Brown’s
paper, 66.
Table of analysis of cases of masturbation, by Dr. Spitzka, 62.
Two coloured lithographs of brain structure, illustrating Dr. F. Beach’s paper,
256.
Photograph of Miss Dorothea L. Dix (“ The American Invader ”), 477.
Coloured lithograph of brain disease, illustrating Dr. Wiglesworth’s paper,
609.
Table showing condition of subdural spaces, etc., illustrating Dr. Wiglee-
worth’s paper, 623.
Lithograph of sarcomata of brain, illustrating Dr. Bullen's paper, 533.
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