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THE JOURNAL
OP
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.
“ Nos vero intellectnm longius a rebus non abttr&himus quam ut rerum imagines et
radii (ut in senau fit) coire possint.”
Francis Bacon, Prolig . Itutaurat. Mag.
VOL. XXXIX.
LONDON:
J. and A. CHURCHILL,
NEW BURLINGTON STREET.
MDCCCXCIII.
Digitized by
y Google
“ 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 ot
Plato to the present, with so much labour and so little result. But while we ad¬
mit that metaphysics may be called one department of mental science, we main¬
tain that mental physiology and mental pathology are also mental science under
a different aspect. While metaphysics may be called speculative mental science,
mental-physiology and pathology, with their vast range of inquiry into insanity,
education, crime, and all things which tend to preserve mental health, or to pro¬
duce mental disease, are not less questions of mental science in its practical, that
is, in itr sociological point of view. If it were not unjust to high mathematics
to compare it in any way with abstruse metaphysics, it would illustrate our
meaning to say that our practical mental science would fairly bear the same rela¬
tion to the mental science of the metaphysicians as applied mathematics bears to
the pure science. In both instances the aim of the pure science is the attainment
of abstract truth ; its utility, however, frequently going no further than to serve
as a gymnasium for the intellect. In both instances the mixed science aims at,
and, to a certain extent, attains immediate practical results of the greatest utility
to the welfare of mankind; we therefore maintain that our Journal is not in¬
aptly called the Journal of Mental Science , although the science may only at¬
tempt to deal with sociological and medical inquiries, relating either to the pre¬
servation of the health of the mind or to the amelioration or cure of its diseases ;
and although not soaring to the height of abstruse metaphysics, we only aim at
such metaphysical knowledge as may be available to our purposes, as the mecha¬
nician uses the formularies of mathematics. This is our view of the kind of
mental science which physicians engaged in the grave responsibility of caring
for the mental health of their fellow men, may, in all modesty, pretend to culti¬
vate ; and while we cannot doubt that all additions to our certain knowledge in
the speculative department of the science will be great gain, the necessities of
duty and of danger must ever compel us to pursue that knowledge which is to
be obtained in the practical departments of science, with the earnestness of real
workmen. The captain of a ship would be none the worse for being well ac¬
quainted with the higher branches of astronomical science, but it is the practical
part of that science as it is applicable to navigation which he is compelled to
study.”— J. C. Buchiill, M.D., F.R.S.
y £
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THE
MEDICO - PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.
THE COUNCIL, 1898-94.
president.— JAMES MURRAY LINDSAY, M.D.
president-elect.— CONOLLY NORMAN, FJLC.P.I.
ex-president.— ROBERT BAKER, M.D.
treasurer.— JOHN H. PAUL, M.D.
EDITORS OP JOURNAL
D. HACK TUKE, M.D.
GEO. H. SAVAGE, M.D.
irawftll f PERCY SMITH, M.D.
auditors { g HAYES NEWINGTON, M.B.C.P.Ed.
HON. SECRETARY POR IRELAND.— CONOLLY NORMAN, F.R.C.P.I.
HON. SECRETARY POR SCOTLAND. —A. R. URQUHART, M.D.
general secretary.— FLETCHER BEACH, M.B.
REGISTRAR.— J. B. SPENCE, M.D.
MEMBERS OP COUNCIL.
JAMES RUTHERFORD, M.D.
J. G. McDOWALL, M.B.
H. GARDINER HILL, M.R.C.S,
B. B. FOX, M.D.
J. E. M. FINCH, M.D.
C. HETHERINGTON, M.B.
T. OUTTERSON WOOD, M.D.
F. 0. GAYTON, M.D.
F. A. ELKINS, M.B.
H. T. PRINGLE, M.D.
J. MACPHERSON, M.D.
A. R. TURNBULL, M.B.
C. A. MERCIER. M.B.
E. W. WHITE, M.B.
H. STILWELL, M.D.
A. D. O’C. FIN EGAN, L.K.Q.C.P.I.
0. S. MORRISON, L.K.C.P.
W. I. DONALDSON, M.B.
PARLIAMENTARY COMMITTEE.
Db. BLANDFORD.
Dr. H. HAYES NEWINGTON.
Db. WILLIAM WOOD.
Dr. CLOUSTON.
Dr. SAVAGE.
Db. PAUL.
Dr. STOCKER.
Mb. LEY.
Dr. HACK TUKE.
Dr. MICKLE.
Dr. WIGLESWORTH.
Mr. WHITCOMBE.
Dr. MURRAY LINDSAY.
Dr. WHITE.
Dr. REES PHILIPPS.
Mr. CONOLLY NORMAN,
Dr. URQUHART.
With power to add to their number.
Alphabetical List of Members of the Association , with the year in which they
joined . The Asterisk means Members who joined between 1841 and 1855.
1891. Adair, Thomas Stewart, M.B., G.M. Edin., Assistant Med : cal Officer and
Pathologist, Wadsley Asylum, near Sheffield.
1874. Adam, James, M.D. St. And., Private Asylum, West Mailing, Kent.
1868. Adams, Josiah 0., M.D. Durh., F.R.C.S. Eng., Brooke House, Upper
Clapton, London.
■ 3
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ii. Members of the Association .
1857. Adams, Richard, L.R.G.P. Edin., M.R.C.S. Eng., Medical Superintendent,
Comity Asylum, Bodmin, Cornwall.
1892. Adkins, Percy Rutherford, M.B., B.S., Junior Assistant Medical Officer,
Burntwood Asylum, Burntwood, near Lichfield.
1880. Agar, S. H..L.K.Q.C.P., Glendossil, Henley-in-Arden.
1886. Agar, S. Hollingsworth, jun., B.A. Cantab*, M.R.C.S., Glendossil,
Henley-in-Arden.
1890. Alexander, Robert Reid, M.D. Aber., Medical Superin fendenb, Male Depart¬
ment Hanwell Lunatic Asylum.
1869. Aldridge, Chas, M.D.Aberd., L.R.C.P., Plympton House, Plympton,
Devon.
1882. Alliott, A. J., M.D., Rosendal, Sevenoaks.
1885. Amsden, G., M.B., Medical Supt., County Asylum, Brentwood, Essex.
1890. Anderson, Douglas Hamilton, M.B., C.M. Edin., Ferncliffe, Grange over
Sands.
1888. Anderson, W. A., M.B., Bucks County Asylum, Stone, Aylesbury.
1887. Aplin, A., M.R.C.S.E. and L.R.C.r. Lond., Med. Supt. Co. Asylum,
Snenton, Nottingham.
1892. Atherstone, Walter H., M.D., Surgeon Superintendent, Port Alfred
Asylum, South Africa.
1875. Atkins, Ringrose, M.A., M.D. Queen’s Univ. Ire., Med. Superintendent,
District Asylum, Waterford.
1891. Aveline, Henry T. S., M.R.C.S., L.R.C.P., M.P.C., Assistant Medical
Officer, Bristol City and County Asylum.
1878. Baker, H. Morton, M B. Edin., Assistant Medical Officer, Leicester Borough
Asylum, Leicester.
1888. Baker, John, M.B., H.M. Convict Prison, Portsmouth.
1876. Baker, Robert, M.D. Edin., Visiting Physician, The Retreat, York
(President, 1892.), 41, The Mount, York.
1890. Barker, Walter H., M.R.C.S.Eng., L.R.C.P.Edin., B.A.Cantab., M.A.Mel-
bourae, Deputy Medical Superintendent, Hospital for the Insane,
Kew, Melbourne.
1878. Barton, Jas. Edwd., L.R.C.P. Edin., L.M., M.R.C.S., Medical Superin¬
tendent Surrey County Lunatio Asylum, Brookwood, Woking.
1889. Barton, James Robert, L.R.C.S.I., L.K.Q.C.r.I., and L.M., Senior Assis¬
tant Medical officer, South Yorkshire Asylum, Wadsley, Sheffield.
1864. Bayley, J., M.R.C.S., Med. Supt., Lunatic Hospital, Northampton.
1874. Beach, Fletcher, M.B., F.R.C.P. Lond., formerly Medical Superintendent,
Darenth Asylum, Dartford ; Two Elms, Chislehurst Road, Sidcup,
Kent, and 64, Welbeck Street, W. (Gen. Secretary.)
1892. Beadles, Cecil F., M.R.C.S., L.R.C.P., Assistant Medical Officer, Colney
Hatch Asylum.
1881. Benedikt, Prof. M., Franciskaner Platz 5, Vienna. (Hon. Member.)
1872. Benham, H. A., M.D..Medical Superintendent, City and County Asylum,
Stapleton, near Bristol.
1865. Biffi, M., M.D., Editor of the Italian " Journal of Mental Science,” 16,
Borgo di San Celso, Milan. (Hon. Member.)
1864. Bigland, Thomas, M.R.C.S. Eng., L.S.A. Lond.,Bigland Hall,Backbarrow,
near Ulverston, Lancashire.
1883. Blair, Robert, M.D., Medical Superintendent, Woodilee Asylum, Lenzie,
near Glasgow.
1893. Blake, Henry, M.B. Lond., Stone House, Great Yarmouth.
1879. Blanchard, E. S., M.D., Medical Superintendent, Hospital for Insane,
Charlotte Town, Prince Edward’s Island.
1857. Blandford, George Melding, M.D. Oxon., F.R.Q.P. Lond., 48, Wimpole
Street W. (President, 1877.)
1888. Blaxland, Herbert, M.R.C.S., Med. Supt., Callan Park Asylum, New Sonth
Wales.
1890. Blumer, G. Alder, M.D., Medical Superintendent of the State Hospital for
the Insane, Utica, N.Y., U.S.A.
1892. Bond, Charles Hubert, M.B., C.M. Edin,, London County Asylum,
Banstead, Sutton, Surrey.
1877. Bower, David, M.B. Aberd., Springfield House, Bedford.
1877. Bowes, John Ireland, M.R.C.S. Eng., L.S.A., Medical Superintendent,
County Asylum, Devizes, Wilts.
Digitized by ^ooQle
Members of the Association ,
iii,
1893. Bowes. William Henry, M.D. Lond., Assistant Medical Officer, Plymouth
Borough Asylum, Ivy bridge, Devon.
1883. Boys, A. H., L.R.C.P. Edin., Chequer Lawn, St. AJbans.
1891. Braine-Hartnell, George, L.R.C.P.Lond., M.R.C.S.Eng., Sen. Assist. Med.
Officer, County and City Asylum, Powick, Worcester.
1893. Bramwell, John Milne, M.B., C.M. Edin., 2, Henrietta Street, Cavendish
Square, London, W.
1881. Brayn, K., L.R.C.P. Lond., Invalid Convict Prison, Knapp Hill, Woking.
1892. Bristowe, Hubert Carpenter, M.D. Lond., Second Assistant Medical Officer,
Somerset and Bath Asylum, Wells, Somerset.
1864. Brodie, David, M.D. St. And., L.R.C.S. Edin., 12, Patten Road, Wands¬
worth Common, S.W.
1881. Broeius, Dr., Bendorf-Sayn, near Coblenz, Germany. (Hon, Member,)
1876. Browne, Sir J. Crichton, M.D. Edin., F.R.S.E., Lord Chancellor’s Visitor,
New Law Courts, Strand, W.C. (Hon. Member.) (President, 1878.)
1881. Brown-S6quard, C., M.D., 19, Rue Francis l er , Paris. (Hon. Member.)
1891. Bruce, John, M.B., C.M.Ed., M.P.C., 78, Cartergate, Grimsby.
1893. Brunton, Walter Reyner, M.B. Durh., Assistant Medical Officer, Borough
Asylum, Milton, Portsmouth.
# Brushfield, Dr., Budleigh Salterton, Devon.
# Bucknill, John Charles, M.D. Lond., F.R.C.P. Lond., F.R.S., J.P., late Lord
Chancellor’s Visitor; Bournemouth. ( Editor of Journal, 1862-62.)
(President 1860 )
1892. Bullen, Frederick St. John, M.R.C.S. Eng., Assistant Medical Officer, West
Riding Asylum, Wakefield.
1890. Burke, John R., M.D., Deputy Inspector General of Hospitals and Fleets
(retired); late Assistant Meaical Officer, Central Criminal Asylum,
Dundrum, Co. Dublin. Ireland.
1869. Burman, Wilkie J., M.D. Edin., Karasbury, Hungerford, Berks.
1867. Byas, Edward, M.R.C.S. Eng., Grove Hall Asylum, Bow, London, E.
1871. Cadell, Francis, M.D.Edin., 22, Anislie Place, Edinburgh.
1891. Caldecott, Charles, M.B., B.S.Lond., M.R.C.S., The Grove, Jersey.
1889. Callcott, J. T., M.D., Medical Superintendent, Borough Asylum, Newcastle-
on-Tyne.
1879. Campbell, Colin M., M.B., C.M., 38, Warrender Park Terrace, Edinburgh.
1867. Campbell, John A., M.D. Glas., Medical Superintendent, Cumberland and
Westmorland Asylum, Garlands, Carlisle.
1880. 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. (Hon. Member.)
1890. Cameron, James, M.B., C.M.Edin., Stonefield Terrace, Dewsbury, Yorks.
1874. Cameron, John, M.D. Edin., Medical Supt., Argyll and Bute Asylum,
Lochgilphead.
1891. Carswell, John, L.R.C.P.Edin., L.F.P.S.Glas., Certifying Medical Officer,
Barony Parish, 2, Lansdowne Crescent, Glasgow.
1881. Case, H., M.R.C.S., Med. Supt., Leavesden, Herts.
1874. Cassidy, D. M., M.D., C.M.McGill Coll., Montreal, D.Sc. (Pub. Health),
Edin., F.R.C.S.Edin., Med. Superintendent, County Asylum, Lancaster.
1888. Chambers, James, M.D., M.P.C., 'ihe Priory, Roehampton.
1887. Chapin, John B., M.D., Pennsylvania Hospital for the Insane, Philadelphia,
U.S.A. (Hon. Member.)
1865. Chapman, Thomas Algernon, M.D.Glas., L.R.C.S.Edin., Hereford Co.
and City Asylum, Hereford.
1880. Christie, J. W. Stirling, M.D., Med. Supt., County Asylum, Stafford.
1878. Ciapham, Wm. Crochley S., M.D., M.R.C.P., The Grange, Rotherham.
1863. Clapton, Edward, M.D. Lond., F.R.C.P. Lond., late Physician, St.
Thomas’s Hospital, late Visitor of Lunatics for Surrey; 22, St.
Thomas’s Street, Borough, S.E.
1879. Clark, Archibald C., M.D. Edin., Medical Superintendent, Glasgow District
Asylum, Both well.
1879. Clarke, Henry, L.R.C.P. Lond., H.M. Prison, Wakefield.
* ) Cleaton, John D., M.R.C.S. Eng., Commissioner in Lunacy, 19, Whitehall
1867. j Place, S.W. (Hon. Member.)
Digitized by L^ooQle
iy. Members of the Association .
1862. Clouston, T. S., M.D. Edin., F.B.C.P. Edin., F.B.S.E., Physician Superin¬
tendent, Royal Asylum, M orningside, Edinburgh. (Editor of Journal,
1873-1881.) (President 1888.)
1879. Cobbold, C. S. W., M.D., Bailbrook House, Bath.
1892. Cole, Robert Henry, M.B. Lond., L.R.C.P. Lond., M B.C.S. Eng., Mcor-
croft, Hillingdon, Uxbridge.
1888. Cones, John A., M.R.C.S., Burgess Hill, Sussex.
1882. Compton, T. J., M.B., C.M. Aberd., Heigham Hall, Norwich.
1878. Cooke. Edwd. Marriott, M.B., M.R.C.S. Eng., Med. Supt., County Asylum,
Worcester.
1887. Cope, George P., L.K.Q.C.P.I., M.P.C.,43, Harrington Street, Dublin.
1891. Comer, Harry, M.B.Lond., M.R.C.S., L.R.C.P., M.P.C., Assistant Medical
Officer, Bethlem Royal Hospital, S.E.
1872. Courtenay, E. Maziere, A.B., M.B., C.M.T.C.D., M.D., Inspector of
Lunatics in Ireland, Lunacy Office, Dublin Castle. (Hon, Member
1891.)
1891. Cowan, John J., M.B., C.M. Edin., Assistant Medical Officer, Roxburgh
District Asylum, Melrose.
1893. Cowen, Thomas Phillips, M.B., B.S. Lond., Assistant Medical Officer,
County Asylum, Prestwich, Manchester.
1884. Cox, L. F., M.R.C.S., Med. Supt., County Asylum, Denbigh.
1878. Craddock F. H., B.A. Oxon, M.R.C.S. Eng., L.S.A., Med. Supt., County
Asylum, Gloucester,
1892. Craddock, Samuel, M.R.C.S. Eng., South Hill House, Bath.
1893. Craig, Maurice, M.A., M.B., B.C. Cantab., Clinical Assistant Bethlem
Royal Hospital, London, S.W.
1884. Curwen, J., M.D., Warren, Pennsylvania State Hospital for the Insane,
U.S.A. (Hon. Member.)
1869. Daniel, W. C., M.D. Heidelb., M.R.C.S. Eng., Epsom, Surrey.
1868. Davidson, John H., M.D.Edin., Med. Supt., County Asylum, Chester.
1874. Davies, Francis P., M.D. Edin., M.R.C.S. Eng., Kent County Asylum,
Banning Heath, near Maidstone.
1891. Davis, Arthur N., L.R.C.P., L.R.C.S. Edin., Medical Superintendent,
Borough Asylum, Ivy bridge, Devon.
1869. Deas, Peter Maury, M.B. and M.S. Lond., Medical Superintendent, Wonford
House, Exeter.
1876. Denholm, James, M.D., Flodden Lodge, Corahill-on-Tweed.
1876. Dickson, F. K., F.B.C.P. Edin., Wye House Lunatic Asylum, Buxton,
Derbyshire.
1879. Dodds, Wm. J., M.D., D.Sc. Edin., Colonial Secretary’s Office, Cape
Town, Cape of Good Hope, South Africa.
1886. Donaldson, R. Lockhart, A.B., M.B., B.Ch. Univ. Dub., M.B., M.P.C.,
Assistant Medical Officer, District Asylum, Monaghan.
1889. Donaldson, William Ireland, B.A., M.B., B.Ch., Univ. Dublin, Assistant
Medical Officer, London County Asylum, Canehill, Purley, Surrey.
1892. Donelan, Dr., Richmond District Asylum, Dublin.
1892. Dillei, Dr. Thro., 434, Penn Ave, Pittsburgh, Pa., U.S.A.
1891. Douglas, Archibald Robertson, L.R.C.S., L.R.C.P.Edin., Assistant Medical
Officer, East Riding Asylum, Beverley.
1890. Douglas, William, M.D. Queen’s University, Irel., M.R.C.S.Eng., Medical
Officer, Provident Dispensary, Leamington Spa, Dalkeith House, 7,
Clarendon Place, Leamington Spa.
# Down, J. Langdon Haydon, M.D. Lond., F.R.C.P. Lond., late Resident
Physician, Earlswood Asylum; 81, Harley St., Cavendish Sq., W.,
ana Normans field, Hampton Wick.
1884. Drapes, Thomas, M.B., Med. Supt., District Asylum, Enniscorthy, Ireland.
1880. Dunlop, James, M.B., C.M., 298, Bath Street, Glasgow.
1874. Eager, Reginald, M.D. Lond., M.R.C.S. Eng., Northwoods, near Bristol.
1873. Eager, Wilson, L.R.C.P. Lond., M.R.C.S. Eng., Med. Superintendent,
County Asylum, Melton, Suffolk.
1893. Eardley-Wilmot, Chester, M.D. Durh., Assistant Medical Officer, Middlesex
County Asylum, Tooting, London, S.W.
1888. Earle, Leslie, M.D. Edin., 21, Gloucester Place, Hyde Park, W.
1891. Earls, James Henry, MJX^M.Ch., etc., Ticehurst, Sussex.
Digitized by ^ooQle
Members of the Association ,
V,
1886. East, Edward, M.R.C.S. and L.S.A., 16, Upper Berkeley Street, W.
1862. Eastwood, J. William, M.D. Edin., M.R.C.P. Lond., Dinsdale Pttk,
Darlington.
1879. Echeverria, M. G., M.D., care of Dr. Hack Take, Lyndon Lodge, HanwelL
{Hon Member.)
1889. Elkins, Frank A., M.B., C.M. Edin., M.F.G., Momingtide Asylum, Edin-
burgh.
1873. Elliot, G. Stanley, M.R.C.P. Ed., L.R.C.S. Ed., Medical Superintendent,
CatArluim, Surrey.
1890. Ellis, William Gilmore, M.D. Brux., Superintendent, Government Asylum,
Singapore.
1892. Eustace, J. N., M.D., Hampstead, Glasnevin, co. Dublin.
1861. Eustace, J., M.D. Trin. Coll. Dub., L.R.O.S.I.; HigMeld, Drumoondra,
Dublin.
1891. Ewan, John Alfred, M.A., M.B., C.M.Edin., M.P.G., Assistant Medieal
Officer, Dorset County Asylum, Dorobester.
1884. Ewart, C. Theodore, M.B. Aberd., C.M., Assistant Medical Officer, Cdney
Hatch Asylum, Middlesex.
1888. Esard, E. H., M.D., D.Sc. Edin., M.P.C., 220, Lewisham High Road, St.
John’s, S.E.
1865. Falret, Jules, M.D., 114, Rue du Bac, Paris. (Hon. Member.)
1892. Farquharson, Alexander Charles M.D., M.C-, D.P.H. Camb., Senior As¬
sistant Med. Officer. Burntwood Asylnm, Barntwood, near Lichfield.
1893. Fennings, Arthur Allen, M.B., B.S. Durh., Senior Assistant Medical Officer,
Camberwell House, Camberwell, London. S.E.
1892. FM, Dr. Charles, 87, Boulevard St. Michel, Paris. (Hon. Member.)
1867. Finch, W. Corbin, M.R.C.S. Eng., Fisherton House, Salisbury.
1873. Finch, John E. M., M.D., Medical Superintendent, Borough Asylum,
Lei ces te r.
1889. Finch, Richard T., B.A., M.B. Cantab., Resident Medical Officer, Fisherton
House Asylum, Salisbury.
1890. Findlay, George, M.B, C.M. Aber., Brailes, Shipstone-on-Stour.
1882. Finegan, A. D. O’Connell, L.K. and Q.C.P.I., Med. Supt., District Asylum,
Mullingar.
1889. Unlay, Dr., County Asylum, Bridgend. Glamorgan.
1882. Finlayson, James, M.B., 2, Woodside Place, Glasgow.
1891. Finny, W. E. >t. Lawrence, M B. Un v. Ireland, Kenlis, Queen’s Road,
Kingston Hill, Surrey.
1888. Fitsgerald, G. C., M.B,., BC. Cantab., M.P.C., Medical Superintendent,
Kent County Asylum, Chartham, near Canterbury.
1872. Fletcher, Robert Vicars, Esq., F.R.C.S.I., L.K.Q.C.P.I. and L.R.C.P. Ed*,
Medical Superintendent, District Asylum, Ballinasloe, Ireland.
1892. Forrest, J. G. Stracey, 151, London Road, St. Leonards.
1880. Fox, Bonville Bradley, M.A. Oxon., M.D., M.R.C.S., Brislington House,
Bristol.
1861. Fox, Charles H. t M.D. St. And., M.R.C.S. Eng., Brislington House. Bristol*
1885. Francis, Lloyd, M.A., M.D. Oxon., Medical Superintendent, Earlswood
Asylum, Redhill, Surrey.
1881. Fraser, Donald, M.D., 44, High Street, Paisley.
1872. Fraser, John., M.B., C.M., Deputy Commissioner in Lunacy, 19, Stratheam
Road, Edinburgh.
1868 .1 Gairdner, W. T., M.D. Edin., F.R.S., Professor of Practice of Physic, 225,
1888. J St. Vincent St., Glasgow. (President, 1882.) (Hon. Member.)
1873. Gamer, W. H., Esq., F.R.C.S.I., A.B.T.C.D., M.edical Superintendent,
Clonmel District Asylum.
1893. Garth, H. C., M.B.. C M. Edin., care of Dr. Symes Saunders, Exminster
Asylum, near Exeter.
1867. Gasquet, J. R., M.B. Lond., St. George’s Retreat, Burgess Hill, and 127,
Eastern Road, Brighton.
1890. Gaudin. Francis Neel, M.R.C.S., L.S.A., M.P.C., Medical Superintendent,
The Grove, Jersey.
1885. Gayton, F. C., M.D., Brookwood Asylum. Surrey.
1871. Gelston, R. P., L.K. and Q.C.P.I., L.R.C.S.2, Medioal Supt,, District
Asylum, Ennis, Ireland,
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VI.
Member8 of the Association ,
1892. Gemmel, James Francis, M.B, Glas., Assistant Medical Officer, County
Asylum, Lancaster.
1889. Gibbon, William, L.K.Q.C.P., L.F.P.S. Glas., Senior Assistant Medical
Officer, Joint Counties Asylum, Carmarthen.
1889. Gill, Dr. Stanley, B.A., M.D., M.R.C.P. Lond., Shaftesbury House,
Formby, Lancashire.
1878. Glendinning, James, M.D. Glas., L.R.C.S. Edin., L.M., Med. Snpt., Joint
Counties Asylum, Abergavenny.
1886. Godding, Dr., Medical Superintendent, Government Hospital for Insane,
Washington, U.S. (Hon. Member.)
1892. Goldie. E. Milliken, M.B., C.M.Edin., Poplar and Stepney Sick Asylum,
Devons Road, Bromley, London, E.
1889. Goodall, Edwin, M.D., M.S.Lond., M.P.C., West Biding Asylum, Wakefield.
Gordon, W. S , M.B., District Asylum, Mullingar.
1888. Graham, T., M.D. Glasg., 3, Garthland Place, Paisley.
1887. Graham, W« M.B., Med. Supt, District Asylum, Armagh.
1890. Gramshaw, Farbrace Sidney, M.D., L.K.Q.C.P.Irel., L.R.C.S.Edin., L.M.,
L. A.H.Dub., The Villa, Stillington, Yorkshire.
1891. Greatbatch, Herbert W., M.B., C.M.Edin., 5, Hill Place, Stoke-on-Trent,
Staffordshire.
1886. Greenlees, T. Duncan, M.B., Medical Superintendent to the GrahamBtown
Asylum, Cape of Good Hope.
1892. Griffin, Dr., District Asylum, Killamey, Ireland.
1886. Grubb, J. Strangman, L.R.C P. Ed., North Common, Ealing, W.
1879. Gwynn, S. T., M.D., St. Mary’s House, Whitechurch, Salop.
1888. Habgood, W., M.D., L.R.O.P., Jun. Constitutional Club, Regent Street, S.W.
1866. Hall, Edward Thomas, M.R.C.S. Eng., Newlands House, Tooting Beck
Road, Tooting Common, Chelsea, S.W.
1875. Harbinson, Alexander, M.D. Irel., M.R.C.S. Eng., Assist. Med. Officer,
County Asylum, Lancaster.
1887. Harding, William, M.B., C.M. Ed., Assist. Med. Officer, County Asylum,
Berrywood, Northampton.
1884. Harmer, Wm. Milsted, F.R.C.P. Ed., Physician Supt., Redlands, near
Tonbridge, Kent.
1886. Harvey, Croshie Bagenal, L.A.H., Asst. Med. Officer, District Asylum,
Clonmel.
1892. Haslett, William John, M.R.C.S., L.R.C.P., Resident Med. Superintendent,
Halliford House, Sunbury-on-Thames.
1892. Hatchell, Dr. J., District Asylum, Maryborough, Ireland.
1892. Hatchell, Dr. George, District Asylum, Castlebar, Ireland.
1875. Haughton, Rev. Professor S., School of Physic, Trinity Coll., Dublin,
M. D.T.C.D., D.C.L. Oxon, F.R.S. (Hon. Member.)
1891. Havelock, John G., M.B., C.M.Edin., Sen. Assist. Medical Officer, Montrose
Royal Asylum.
1890. Hay, Frank, M.B., C.M., Assistant Medical Officer, James Murray’s Royal
Asylum, Perth.
1868. Hoarder, George J., M.D. St. And., L.RC.S. Edin., Medical Superinten¬
dent, Joint Counties Asylum, Carmarthen.
1885. Henley, E. W., L.R.C.P., County Asylum, Gloucester.
1877. Hetherington, Charles, M.B., Med. Supt., District Asylum, Londonderry,
Ireland.
1877. Hewson, R. W., L.R.C.P. Ed., Med. Supt., Coton Hill, Stafford.
1891. Heygate, William Harris, M.R.C.S.Eng., L.S.A., Cranmere,Cosham, Hants.
1879. Hicks, Henry, M.D. St. And., M.R.C.S. Eng., F.R.S., F.G.S., Hendon
Grove House, Hendon, Middlesex.
1879. Higgins, Wm. H., M.B., C.M., Med. Supt., County Asylum, Leicester.
1882. Hill, Dr. H. Gardiner, Medical Superintendent, Middlesex County Asylum,
Tooting.
1857. Hills, William Charles, M.D. Aber., M.R.C.S. Eng., Thorpe-St. Andrew,
near Norwich.
1889. Hind, Hy. Joseph, M.R.C.S. and L.S.A., Assistant Medical Officer, 3,
Cambridge Park, Twickenham.
1871. Hingston, J. Tregelles, M.R.C.S. Eng., Medical Superintendent, North
Biding Asylum, Clifton, York.
Digitized by Google
Members of the Association.
vu.
1881. Hitchcock, Charles Knight, M.D., Bootham Asylum, York.
1892. Holmes, James, M.D. Edin., Overdale Asylum, Whitefield, Lancashire.
1863. Howden, James C., M.D. Edin., Medical Superintendent, Montrose Royal
Lunatio Asylum, Sunny side, Montrose.
1881. Hughes, C. H., M.D., St. Louis, Missouri, United States. (Hon. Member.)
1857. Humphry, J., M.R.C.S.Eng.,Med. Sup., County Asylum, Aylesbury, Bucks.
1888. Hyslop, Theo. B., M.B., C.M. Edin., M.P.C., Asst. Med. Officer, Betblem
Koval Hospital, S.E.
1882. Hyslop. James, M.D., Pietermaritzburg Asylum, Natal, S. Africa.
1865. lies, Daniel, M.R.C.S. Eng., Resident Medical Officer, Fairford House
Retreat, Gloucestershire.
1871. Ireland, W. W., M.D. Edin., Mavisbush, Polton, Midlothian.
1877. Isaac, J. B., M.D. Queen’s Univ,, Irel., Assist. Med. Officer, Broadmoor,
near Wokingham.
1866. 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.
1858. Jamieson, Robert, M.D. Edin., L.R.C.S. Edin., Royal Asylum, Aberdeen.
1860. Jepson, Octavius, M.D. St. And., M.R.C.S. Eng., Elmfield, Newlands
Park, Sydenham, S.E.
1882. Jeram, J. W., L.R.C.P., Hambledon, Cosham, Hants.
1893. Johnston, Gerald Herbert, L.R.C.S. and P. Edin., Assistant Medical
Officer, North Riding Asylum, Clifton, Yorks.
1890. Johnston, John MoCubbin, M.B., C.M., M.P.C., Town’s Hospital, Parlia¬
mentary Road, Glasgow.
1878. Johnstone, J. Carlyle, M.D., O.M., Medical Superintendent, Roxburgh
District Asylum, Melrose.
1866. Jones, Evan, M.R.C.S. Eng., Ty-mawr, Aberdare, Glamorganshire.
1880. Jones, D. Johnson, M.D. Edin., Senior Assistant Medical Officer, Banstead
Asylum, Snrrey.
1893. Jones, R., M.D. Lond., B.S., F.R.C.S., Medical Superintendent, London
County Asylum, Clay bury.
1879. Kay, Walter S., M.D , Medical Superintendent, South Yorkshire Asylum,
Wadsley, near Sheffield.
1886. Keay, John, M.B., Med. Supt., Mavisbank, Polton, Midlothian.
1893. Kershaw, Herbert Warren, M.R.C.S. Eng., L.R C.P. Lond., Senior As¬
sistant Medical Officer, North Riding Asylum, Clifton, Yorks.
1880. Komfeld, Dr. Herman, Grottkau, Silesia, Germany. (Corresponding
Member.)
1889. Kowalewsky, Professor Paul, Kharkoff, Russia. (Corresponding Member.)
1881. Krafft-Ebing, R. v., M.D., Vienna. (Hon. Member.)
1866. Laehr, H.. M.D., Schweizer Hof, bei Berlin, Editor of the “Zeitsohrift fur
Psychiatric. 51 (Hon. Member.)
1892. Lawless, Dr. Geo. Robert, A.M.O., Distiict Asylum, Sligo.
1870. Lawrence, A., M.D., County Asylum, Chester.
1890. Lawson, Robert, M.D., Deputy Commissioner in Lunacy, Edinburgh.
1883. Layton, Henry A., L.R.C.P. Edin., Cornwall County Asylum, Bodmin.
1883. Legge, R. J., M.D.. Assist. Med. Officer, County Asylum, Derby.
1887. Lentz, Dr., Asile d’Ali6n6s, Tournai, Belgique. (Hon. Member.)
1858. Lewis, Henry, M.D. Brux., M.R.C.S. Eng., L.S.A., late Assistant Medical
Officer, County Asylum, Chester; West Terrace, Folkestone, Kent.
1879. Lewis, W.Bevan, L.R.C.P. Lond., Med. Supt., West Riding Asylum, Wake*
field.
1863. Ley, H. Rooke, M.R.C.S. Eng., Medical Superintendent, County Asylum,
Prestwich, near Manchester.
1859. Lindsay, James Murray, M.D. St. And., F.R.C.S.and F.R.O.P. Edin.,Med.
Supt., County Asylum, Mickleover, Derby. (President, 1893.)
1883. Lisle, S. Ernest de, L.K.Q.C.P., Three Counties Asylums, Stotfold,
Baldock.
1890. Little, Arthur Nicholas, M.B.Lond., M.R.C.S., L.S.A., Assistant Medical
Officer, Holloway Sanatorium, Virginia Water.
1888. Little. W. Maxwell, M.D. Edin., Assist. Med. Off., County Asylum, Thorpe,
Norwich.
1888. Lofthouse, Arthur, M.R.C.S., etc., Assist, Med, Off., County Asylum.
Nottingham.
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VUl,
Members of the Association ,
1872. Lyle, Thos., M.D.Glas., 34. Jesmond Hoad, Newcastle-on-Tyne.
1890. Lyons, Algernon Wilson, M.B.Lond., M.RC.S., L.R.C.P., 80, St. George’s
Road, Eccleston Square, London, S.W.
1880. MacBryan, Henry C., Kingsdown House, Box.
1884. Macdonald, P. W., M.D., C.M., Med. Supt., CJoonty Asylum, near Dor¬
chester, Dorset.
1893. Macevoy, Henry John, M.D. Lond., 41, Buckley Road, Brondesbury,
London, N.W.
1883. Macfarlane, W. H., New Norfolk Asylum, Tasmania.
1891. Mackenzie, Henry J., M.B., C.M.Edin., M.P.C., Assistant Medical Officer,
The Retreat, York.
1886. Mackenzie, J. Cumming, M.B., C M., M.P.C., Medical Superintendent,
District Asylum Inverness.
* Mackintosh, Donald, M.D. Durham and Glas., L.F.P.S.Glas., 10, Lancaster
Road, Belsize Park, N.W.
1886. Maclean, Allan, L.R.C.S. Ed., Harpenden Hall, Herts.
1873. Macleod, M. D., M.B., Med. Superintendent, East Riding Asylum, Beverley,
Yorks.
1882. Macphail, Dr. S. Rutherford, Derby Borough Asylum, Rowditch, Derby.
1872. Major, Herbert C., M.D., 114, Manningham Lane, Bradford, Yorks.
* Manley, John, M.D. Edin., M.R.C.S. Eng., Highfield, Tulse Hill, S.W.
1871.) Manning, Frederick Norton, M.D. St. And., M.R.C.S. Eng., Inspector of
1884. J Asylums for New South Wales, Sydney. (Hon. Member.)
1865. Manning, Harry, B.A. London, M.R.C.S., Laverstock House, Salisbury.
1871. Marsh, J. Wilford, M.R.C.S. Eng., L.S.A., Medical Superintendent,
County Asylum, Lincoln.
* Marshall, William G., F.R.C.S., 72, Bromfelde Road, Clapham, S.W.
1888. McAlister, William, M.B., C.M., Strnan Villas, Kilmarnock.
1886. MoCreery, James Vernon, L.R.C.S.I., Medical Superintendent, New
Lunatic Asylum, Melbourne, Australia.
1870. McDowall, T. W., M.D. Edin., L.R.C.8.E., Medical Superintendent,
Northumberland County Asylum, Morpetn.
1876. McDowall, John Greig, M.B. Edin., Medical Superintendent, West Riding
Asylum, Menston, near Leeds.
1882. McNaughtan, John, M.D., Med. Supt., Criminal Lunatic Asylum, Perth.
1886. Macpherson, John, M.B., M.P.C., Medical Superintendent, Stirling Asylum,
Larbert.
1890. Menzies, W. F., M.D., B.Sc.Edin., Senior Assistant Medical Officer,
County Asylum, Rainhill.
1891. Mercier ? Charles A., M.B.Lond., F.R C.S.Eng., Lecturer on Insanity, West¬
minster Hospital; Flower House, Southend, Catford, S.E.
1877. Merson, John, M.D. Aberd., Medical Superintendent, Borough Asylum,
Hull.
1871. Merrick, A. S., M.D. Qu. Uni. Irel., L.R.C.S. Edin., Medical Superin¬
tendent. District Asylum, Belfast, Ireland.
1867. Meyer, Ludwig, M.D,, University of Gottingen. (Hon. Member.)
1871. Mickle, Wm Julius, M.D., F.R.C.P. Lond., Med. Superintendent, Grove
Hall Asylum, Bow, London.
1867. Mickley, George, M.A., M.B. Cantab., Medical Superintendent, St. Luke’s
Hospital, Old Street, London, E.C.
1893. Middlemass, James, M.B., C.M., B.Sc. Edin.,, Junior Assistant Physician,
Royal Edinburgh Asylum.
1892. Middleton, Dr., District Asylum, Mullingar, Ireland
1881. Mierzejewski, Prof. J., Medico-ChirurgicalAcademy, St. Petersburg. (Hon.
Member.)
1883. Miles, Geo. E., M.R.C.S., Callan Asylum, Sydney, N.S.W.
1893. Mills, John.JM.B., B.Co ., and Diploma in Mental Diseases, Royal University
of Ireland, Assistant Medical Officer, District Asylum, Ballinasloe.
1887. Miller, Alfred, M.B. and B.C.Dub., Medical Superintendent, Hatton
Asylum, Warwick.
1866.7 Mitchell, Sir Arthur, M.D. Aberd., LL.D., K.C.B., Commissioner in Lunacy
1871 .) for Scotland; 34, Drummond Place, Edinburgh. (Hon. Member.)
1881. Mitchell, R. B., M.D., Med. Supt., Midlothian District Asylum.
1885. Molony, John, F.K.Q.C.P., Med, Supt., St. Patrick’s Hospital, Dublin.
Digitized by Google
Members of the Association . ix.
1878. Moody. James M., M.B.C.S. Eng., L.B.C.P. and L.M. Edin., Med. Supt.,
County Asylum, Cane Hill, Surrey.
1885. Moore, E. E., M.B. Dub., M.P.C., Medical Superintendent, District Asylum,
Letterkenny, Ireland.
1891. Moore, George, J.P. M.D., M.B.C.S., Medical Superintendent, Jersey
Lunatic Asylum.
1886. Morel, M. Jules, M ,D., Hospice Guislain, Ghent. ( Corresponding Member.)
1892. Morrison, Cuthbert S., L.&.C.P. and S.Edin« Assistant Medioal Officer,
County and City Asylum, Burghill, Hereford.
1880. Motet, M., 161, Bue ae Charonne, Paris. (Eon. Member.)
1862. Mould, George W., M.B.C.S. Eng., Medical Superintendent, Royal Lunatio
Hospital, Cheadle, Manchester. (Pkesident, 1880.)
1878. Muirhead. Claud. M.D., F.R.C.P. Edin., 30, Charlotte Square, Edinburgh.
1867. Mundy, Baron Jaromir, M.D. Wurzburg, Professor of Military Hygiene,
Universit&t, Vienna. (Eon. Member.)
1893. Murchison, Finlay, M.A., M.B., C.M. Edin., Besident Proprietor, Wyke
House, Isleworth, Middlesex.
1893. Murdoch, James, William Aitken, M.B., C.M. Glas., Medical Superinten¬
dent, Berks County Asylum, Wallingford.
1878. Murray, Henry G., L.K.Q.C.P. Irel , L.M., L.B.C.S.I., Assist. Med. Off.,
Prestwich Asylum, Manchester.
1891. Musgroye, C. D. Dr., Cliff Terrace, Kendal, Westmoreland.
1886. Myles, William Zachary. L.F.P.S., Med. Supt.. District Asylum, Kilkenny.
1890. Rash, Vincent, L.K.Q.C.P., Assistant Medical Officer, Richmond District
Asylum, Dublin.
1859. Needham, Frederick, M.D. St. And., M.R.C.P. Edin., M.R.C-S. Eng.,
Commissioner in Lunacy, 19, Whitehall Place, S.W. (President,
1887.) (Hon. Member.)
1880. Neil, James, M.D., M.P.C., Asst. Med. Officer, Wameford Asylum. Oxford.
1875. Newington, Alexander, M.B. Camb., M.B.C.S. Eng., Woodlands, Ticeburst.
1873. Newington, H. Hayes, M.R.C.P. Edin., M.B.C.S. Eng., Ticehurst, Sussex.
(President, 1889.)
1893. Newington, John, L.8.A., Tattlebury House, Goudhurst, Kent.
1881. Newth, A. H., M.D., Haywards Heath, Sussex.
1869. Nicolson, David, M.D. and C.M. Aber., late Med. Off., H.M. Convict Prison,
Portsmouth. Med. Supt., State Asylum, Broadmoor, Wokingham,
Berks.
1893. Nobbs, Athelstane, M.B., C.M. Edin., Assistant Medical Officer, Northum¬
berland County Asylum, Morpeth.
1888. Nolan, Michael J., L.K.Q.C.P.I., M.P.G., Assist. Med. Officer, Biohmond
Asylum, Dublin.
1892. Noott, Reginald Harry, M.B., C.M.Edin., Senior Assistant Med. Officer,
Broadmoor Criminal Lunatic Asylum, Crowthorne, Wokingham.
1869. North, S. W., M.B.C.S. Eng., F.G.S., 84, Micklegate, York, Visiting
Medicbl Officer. The Retreat, York.
1880. Norman, Conolly, F.R.C.P.I., Med. Supt., Richmond District Asylum.
Dublin, Ireland. (Hon. Secret ary for Ireland.) (President-Elect.)
Nugent, Sir John, M.B. Trin. Col., Dub., L.R.C.S. Ireland. (Eon.
Member.)
1885. Oakshott, J. A., M.D., Assist. Med. Officer, District Asylum, Cork.
1891. O’Farrell, G.P., M.D., M.Ch.Univ. Dublin. Inspector of Lunatics in Ireland,
19, Fitzwilliam Square, Dublin. {Eon. Member.)
1892. O’Flaherty, Dr., District Asylum , Dowiipatriek, Ireland.
1892. O’Mara, Dr., District Asylum, Limerick, Ireland.
1881. O’Meara, T. P., M.B., Med. Supt., District Asylum, Carlow, Ireland.
1886. O’Neill, E. D., L.K.Q.C.P., Med. Supt., The Asylum, Limerick.
1868. Orange, William, M.D. Heidelberg, F.B.C.P. Lond., C.B., 12, Lexham
Gardens, London. (President, 1883.)
1893. Osburne, Cecil A P., F.R.C.S. Edin., L.R.C.P. Edin., Surgeon to the
Admiralty, Hythe, The Oaks, Hythe, Kent.
1890. Oswald, Landel R., M.B., M.P.C., Senior Assistant Medical Offioer, Glas¬
gow Boyal Asylum, Gartnavel.
* Palmer, Edward, M.D. St. And., M.R.C.P. Lond., M.B.C.S., 87, Har-
oourt Terrace;, London, S.W.
Digitized by ^ooQle
X.
Members of the Association •
1886. Parant, M. Victor, M.D., Toulouse. (Corresponding Member.)
1892. Patterson, Arthur Edward, M.B., C.M.Aber., Assistant Medical Offioer,
City of London Asylum, Dartford.
1872. Patton, Alex., M.B., Besident Medical Superintendent, Farnham House,
Finglas, Co. Dublin.
* Paul, John Hayball, M.D. St. And., M.R.C.P. Lond., F.B.C.P. Edin.;
Camberwell Terrace, London, S.E. (Treasurer.) .
1889. Peacock, Dr., L.B.C.P. and L.M. Edin., M.R.C.S. and L.S.A.. Lond., Besi-
dent Medical Officer and Proprietor, Ashwood House, Kingswinford,
Dudley, Staffordshire.
1881. Peeters, M., M.D., Gheel, Belgium. (Hon. Member.)
1870. Peddie, Alexander, M.D. Edin., F.R.C.P. Edin., F.R.S. Edin., 15, Rutland
Street, Edinburgh.
1873. Pedler, George H., L.R.C.P. Lond., M.R.C.S. Eng., 6, Trevor Terrace,
Knightsbridge, S.W. _
1893, Perceval, Shrank, M.R.C.S. Eng., L.R.C.P. Lond., Assistant Medical Officer,
County Asylum, Prestwich, Manchester.
1874. Petit, Joseph, L.R.C.S.L, Med. Supt., District Asylum, Sligo.
1878. Philipps, Sutherland Rees, M.D., C.M. Qo. Univ. Irel., F.R.G.S., St. Anne's
Heath, Chertsey.
1875. Philipson, George Hare, M.D. and M.A.Cantab., F.R.C.P. Lond., 7j Eldon
Square, Newcastle-on-Tyne.
1891. Pierce, Bedford, M.D.Lond, M.R.C.P., Medical Superintendent, The
Retreat, York.
1888. Pietersen, J. F. G., M.R.C.S., Ashwood Hoose, Kingswinford, near Dudley,
Stafford.
1886. Pilkington, F. W., L.R.C.P. Lond., Adlington, Lancashire.
1871. Pim, F., Esq., M.R.C.S. Eng., L.K. and Q.C.P. Ireland, Med. Supt.,
Palmerston, Chapelizod, Co. Dublin, Ireland.
1890. Pitcairn, John James, L.R.C.P., M.R.C.S., M.P.C., Assistant Surgeon,
H.M. Prison, Holloway.
1873. Pitman, Sir Henry A., M.D. Cantab., F.R.C.P. Lond., Registrar of the
Royal College of Physicians, Enfield, Middlesex. (Hon. Member.)
1878. Platt, Dr., St. James' Lodge, West End Lane, West Hampstead, N.W.
1877. Plaxton, Joseph Wm., M.R.C.S., L.S.A. Eng., Lunatic Asylum, Kingston,
Jamaica.
1889. Pope, George Stevens, L.R C.P. & S. Edin., L.F.P. k S. Glas., Assistant
Medical Officer, Cane Hill Asylum, Purley, Surrey.
1876. Powell, Evan, M.R.C.S. Eng., L.S.A., Medical Superintendent, Borough
Lunatic Asylum, Nottingham.
1891. Price, Arthur, M.R.C.S., L.S.A., M.P.C., Medical Officer H.M. Prison,
Birmingham, 2, Handswoith New Road, Birmingham.
1875. Pringle, H. T., M.D. Glasg., Medical Superintendent, County Asylum,
Bridgend, Glamorgan.
1892. Rainsford, Frederick Edward, M.B.Dublin, Second Assistant Medical
Officer, City and County Lunatic Asylum, Fishponds, near Bristol.
1870. Rayner, Henry, M.D. Aberd., M.R.C.S. Eng., 2, Harley Street, London, W.,
and Upper Terrace House, Hampstead, London, N.W. (President,
1884.) (Late General Secretary.)
1889. Raw, Nathan., M.D., M.P.C., Infirmary and Dispensary, Bolton.
1893. Rawes, William, M.B. Durh., F.R.C.S. Eng., Assistant Medical Officer,
St. Luke’s Hospital, London.
1890. R6gis, Dr. E., 54, Rue Huguerie,Bordeaux. (Corresponding Member.)
1887. Reid, William, M.D., Physician Superintendent, Royal Asylum, Aberdeen.
1891. Renton, Robert, M.B, C.M.Edin., M.P.C., Montague Lawn, London Road,
Cheltenham.
1886. Revington, Geo., M.D. and Stewart Scholar Univ. Dublin, M.P.C.,
Med. Superintendent, Central Criminal Asylum, Dundrum, Ireland.
1889. Richards, Joseph Peeke, M.R.C.S., L.S.A.,6, Freeland Road, Ealing, W.
1869. Richardson, Sir B. W., M.D. St. And., F.R.S., 25, Manchester Square, W.
(Hon, Member.)
1891. Ridley, John Brooke, M.B., C.M.Edin., Assistant Medical Officer, Darenth
Asylum, Dartford.
1890. Ritti, Dr. J. M., Maison National© de Charenton, St. Maurice, Seine,
France. (Corresponding Member.)
Digitized by Google
Members of the Association . xi.
1893. Rivers, William E. Rivers, M.D. Loud., Clinical Assistant, Bethlem Royal
Hospital, London, S.E.
1871. 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, Gunsgreen, The Drive, Wimbledon.
{General Secretary , 1856-62.) {Editor of Journal, 1862-70.) (Presi¬
dent, 1867.) (Hon. Member.)
1887. Robertson, G. M., M.B., C.M., M.P.C., Medical Superintendent, Perth
District Asylum, Murthley.
1876. Rogers, Edward Coulton, M.R.C S. Eng., L.S.A., Co. Asylum, Fulbonrn,
Cambridge.
1859. Rogers, Thomas Lawes, M.D. St. And., M.R.C.P. Lond., M.R.C.S. Eng.,
Eastbank, Court Road, Eltham, Kent. (President, 1874.)
1879. Ronaldson, J. £., L.R.C.P. Edin., Medical Officer, District Asylum,
Haddington.
1879. Roots, William H., M.R.C.S., Canbury House. Kingston-on-Thames.
1860. Rorie, James, M.D. Edin., L.R.C.S. Edin., Medical Superintendent, Royal
Asylum, Dundee. {Late Hon. Secretary for Scotland.)
1890. Rosenblum, Edward Emerson, M.B., B.S. Melbourne, Senior Assistant
Medical Officer, Lunatic Asylum, Yarra Bend. Melbourne.
1888. Ross, Chisholm, M.B. Ed., M.D. Sydney, Gladesville Asylum, New South
Wales.
1886. Roussel.M. Th6ophile, M.D., SSnateur, Paris. {Hon. Member.)
1884. Rowe. E. L., L.R.C.P. Ed., Medical Superintendent, Borough Asylum,
Ipswich.
1883. Rowland, E.D. ? M.D., C.M. Edin., the Public Lunatic Asylum, Berbice,
British Guiana.
1877. Russell, A. P., M.B. Edin., The Lawn, Lincoln.
1883. Russell, F. J. R.. L.K Q.C.P. Irel., Tramore, St. Leonards-on-Sea.
1892. Ruttledge, Dr., District Asylum, Londonderry, Ireland.
1866. 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 f 1876-86.)
1887. Rutherford, W., M.D., Consulting Physician, Ballinasloe District Asylum,
Ireland.
1889. Ruxton, William Ledington, M.D. and C.M., Assistant Medical Officer,
South Yorkshire Asylum, Wadsley, Sheffield.
1879. Sankey, H. R., M.B., Boreatton Park, Shrewsbury.
* Sankey, R. Heurtley H., M.R.C.S. Eng., Medical Superintendent, Oxford
County Asylum, Littlemore, Oxford.
1891. Saunders, Charles Edwards, M.D.Aber., M.R.C.P.Lond., Medical Superin*
tendent^ Haywards Heath Asylum, Sussex.
1873. Savage. G. H.. M.D. Lond., 3, Henrietta Street, Cavendish Square, W.
(Editor of Journal.) (President, 1886.)
1862. Schofield, Frank, M.D. St. And., M.R.C.S., Medical Supt., Camberwell
House, Camberwell.
1887. Schiile, Heinrich, M.D., Illetiau, Baden, Germany. {Hon. Member.)
1884. Scott, J. Walter, M.R.C.S., M.P.C., Hightield, Tulse Hill, S.W.
1889. Scowcroft, Walter, M.R.C.S.. Senior Assistant Medical Officer, Royal
Lunatic Hospital, Cheadle.
1880. Seccombe, Geo., L.R.O.P.L., The Colonial Lunatic Asylum, Port of Spain,
Trinidad, West Indies.
1879. Seed, Win., M.B. C.M. Edin., The Poplars, 110, Waterloo RoAd,
Asliton-on-Ribble, Preston.
1889. Sells, Charles John, L.R.C.P., M.R.C.S., L.S.A., Honorary Medical Officer,
Royal Surrey County Hospital ; White Hall, Guildford.
1885. Sells, H. T., 2, London Road, Northfleet, Kent.
1881. Semal, M., M.D., Mons, Belgium. {Hon. Member.)
1893. Semelaigne, R£n6, Dr., Secretaire des Stances de la Soci6t4 M6dico-
Psychologique de Paris, Avenue de Madrid, Neuille, Seine, Paris.
(Corresponding Member.)
1882. Seward, W. J., M.D., Med. Superintendent, Colney Hatch, Middlesex.
1891. Shaw, John Custance, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Hull Borough Asylum.
Digitized by ^ooQle
XU.
Members of the Association ,
1867. Shaw, Thomas 0., M.D. Lond., F.R.C.P. Lond., Medical Superintendent,
Middlesex County Asylum, Banstead, Surrey.
1880. Shaw, James, M.D., Donard House, Kensington, Liverpool.
1891. Shaw, Harold B., B.A., M.B., B.S., D.P.H.Camb., Senior Assistant Medical
Officer, County Asylum, Fareham. Hants.
1882. Sheldon, T. S., M.B., Med. Supt., Cheshire County Asylum, Parkside,
Macclesfield.
1886. Sherrard, C. D„ M.R.C.S., Avalon, Eastbourne.
1877. Shuttleworth, G. E., M.D. Heidelberg, M.R.C.S. and L.S.A. Eng., B.A.
Lond., late Medical Superintendent, Royal Albert Asylum, Lan¬
caster ; Ancaster House, Richmond.
1880. 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.) {Hon. Member.)
1889. Simpson, Samuel, M.B. and M.C.H. Dublin, M.P.C., Northumberland
House. Green Lanes, Finsbury Park, N.
1888. Sinclair, Enc, M.D., Med. Supt., Gladesville Asylum, New South Wales.
1870. Skae, C. H., M.D. St. And., Medical Superintendent, Ayrshire District
Asylum, Glengall, Ayr.
1891. Skeen, James Humphrey, M.B., C.M.Aber., Assistant Physician, Stirling
District Asylum, Larbert.
1858. Smith, Robert, M.D. Aberd., L.R.C.S. Edin., Medical Superintendent,
County Asylum, Sedgefield, Durham.
1886. Smith, K. Gillies, M.A., B.Sc., M.R.C.S., City Asylum, Gosforth, New-
castle-on-Tyne.
1885. Smith, R. Percy, M.D., B.S., F.R.C.P., M.P.C., Bethlem Hospital, St.
George’s Road, S.E.
1890. Smith, Telford, M.D. Dub., Medical Superintendent, Royal Albert Asylum,
Lancaster.
1884. Smith, W. Beattie, F.R.C.S. Ed., L.R.C.P. Lond., Medical Supt., Hospital
for the Insane, Ararat, Victoria.
1892. Smyth, W. Johnson, M.B. Edin., Chelsea Barracks. London.
1881. Snell, Geo. ? M.D.Aber., M.R.C.S.Eng., Medical Superintendent, Publio
Lunatic Asylum, Berbice, British Guiana.
1885. Soutar, J. G., Barn wood House, Gloucester.
1875. Spence, J. Beveridge, M.D., M.C. Queen’s University, Medical Superinten¬
dent, Burntwood Asylum, near Lichfield. {Registrar.)
1883. Spence, J. B., M.D., M.C., Asylum for the Insane, Ceylon.
1879. Squire, R. H., B.A. Cantab., Assist. Medical Officer, Whittingham Asylum,
Lancashire.
1891. Stansfield, T. E. K., M.B., C.M.Edin., Senior Assistant Medical Officer,
London County Asylum, Cl ay bury.
1888. Stearns, H.P., M.D., The Retreat, Hartford, Conn., U.S.A. (Hon. Member.)
1868. Stewart, James, B.A. Queen’s Univ., M.R.C.P. Edin., L.R.C.S. Ireland,
late Assistant Medical Officer, Kent County Asylum, Maidstone,
Dunmurry, Sneyd Park, Clifton, Gloucestershire.
1884. Stewart, Robert S., M.D.,C-M., Assistant Medical Officer, County Asylum,
Glamorgan.
1887. Stewart, Rothsay C., M.R.C.S., Assist. Med. Officer, County Asylum,
Leicester
1862. Stilwell, Henry, M.D. Edin., M.R.C.S.Eng., Moorcroft House, Hillingdon,
Middlesex.
1864. Stocker, Alonzo Henry, M.D. St. And., M.R.C.P. Lond., M.R.C.S. Eng.,
Medical Superintendent, Peckham House Asylum, Peckham.
1887 Stoker, Wm. Thornley, M.D., Surgeon, St. Patrick’s Hospital, 16, Harcourt
Street, Dublin.
1881. Strahan, S. A. K., M.D., Assist. Med. Officer, County Asylum, Berrywood,
near Northampton.
1868. Strange, Arthur, M.D. Edin., Medical Superintendent, Salop and Mont¬
gomery Asylum, Bicton, near Shrewsbury.
1885. Street, C. T., M.R.C.S., L.R.C.P., Haydock Lodge, Ashton, Newton-le-
Willows, Lancashire.
1891. Suckling, Cornelius, M.D.Lond., M.R.C.P.Lond. Physician, Queen’s
Hospital Birmingham, 103, Newhall Street, Birmingham.
Digitized by Google
Members of the Association «
• • *
XUl.
1886. Suffern, A. 0., M.D., Medical Superintendent, Buberj Hill Asylum, near
Bromsgrove, Worcestershire.
1870. Sutherland, Henry, M.D. Ozon, M.R.C.P. London, 6, Richmond Terrace,
Whitehall, S W.; Newlands House, Tooting Bee Road, Tooting
Common, S.W.; and Otto House, 47, NorthendRoad, West Kensing¬
ton, W.
1868. Swain, Edward, M.R.C.S., Medical Superintendent, Three Counties*
Asylum, Stotfold, Baldock, Herts.
1877. Swanson, George J., M.D. Edin., Lawrence House, York.
1893. Symmers, William St. Clare, M.B., C.M. Aber., Pathologist, County
Asylum, Prestwich, Manchester.
1881. Taraburini. A., M.D., Reggio-Emilia, Italy. (Eon. Member.)
1857. Tate, William Barney, M.D. Aberd., M.R.C.P. Lond., M.R.C.S. Eng.,
Med. Supt. of the Lunatic Hospital, The Coppice, Nottingham.
1892. Temple, Lewis Dunbar, M.B., C.M.Edin., late Clinical Assistant, Darenth
Asylum, Ballantrae, Ayrshire.
1888. Thomas, E. G., M.B. Edin., Ass. Med. Off., Caterham Asylum, Surrey.
1880. Thomson, D. G., M.D., C.M , Med. Supt., County Asylum,Thorpe, Norfolk.
1890. Tuckey, Charles Lloyd, M.D., C.M.Aber., 14, Green Street, Grosvenor
Square, London.
1866. Tuke, John Batty, M.D. Edin., 20, Charlotte Square, Edinburgh.
(Eon. Secretary for Scotland , 1869-72.)
1888. Tuke, John Batty, Junior, M.B., C.M., M.R.C.P.E., Resident Physician,
Saughton Hall, Edinburgh.
* Tuke, D. Hack, M.D. Heidel., F.R.C.P. Lond., M.R.C.S. Eng., LL.D., for¬
merly Visiting Physician, The Retreat, York; Lyndon Lodge, Han-
well, W., and 63, Welbeck Street, W. ( Editor of Journal .) (PRESI¬
DENT, 1881.)
1881. Tuke, Chas. Moles worth, M.R.C.S., Manor House, Chiswick.
1885. Tuke, T. Seymour, M.R.C.S., M.B.Oxford, Manor House, Chiswick.
1877. Turnbull, Adam Robert, M.B., C.M. Edin., Medical Superintendent, Fife
ana Kinross District Asylum, Cupar.
1889. Turner, Alfred, M.D. and C.M., Assistant Medical Officer, West Riding
Asylum, Menston, Yorkshire.
1890. Turner, John, M.B., C.M. Aber., Senior Assistant Medical Officer, Essex
County Asylum.
1878. Urquhart. Alexr. Beid, M.D., Physician Supt., James Murray’s Royal
Asylum, Perth. (Hon. Secretary for Scotland.)
1881. Virchow, Prof. R., University, Berlin. (Hon. Member.)
1881. Voisin, A., M.D., 16, Rue Seguin, Paris. (Hon. Member.)
1876. Wade, Arthur Law, B.A., M.D. Dub., Med. Supt., County Asylum, Wells,
Somerset.
1884. Walker, E. B. C., M.B., C.M. Edin., Assist. Med. Officer, County Asylum,
Haywards Heath.
1877. Wallace, James, M.D., Visiting Medical Officer, Parochial Asylum,
Greenock.
1876. Wallis, John A., M.D. Aberd., L.R.C.P. Edin., Medical Superintendent,
County Asylum, Whittingham, Lancashire.
1883. Walmsley, F. H., M.D., Medical Supt., Darenth Asylum, Dartford, Kent.
1892. Ward, Dr. District Asylum, Ballinasloe, Ireland.
1873. Ward, FredericH., M.R.C.S. Eng., L.S.A., Assistant MedioalOfficer, County
Asylum, Tooting, Surrey.
1871. Ward, J. Bywater, B.A., M.D. Cantab., M.R.C.S. Eng., Medical Superin¬
tendent, Wameford Asylum, Oxford.
1889. Warnock, John, M.D., C.M., B.Sc., M.R.C.S., Peckham House, Peckham,
S.E.
1891. Watson, George A., M.B., C.M.Edin., M.P.C., Senior Assistant Medical
Officer, City Asylum, Birmingham.
1885. Watson, William Riddell, L.R.C.S. & P. Edin., Go van Parochial Asylum,
Glasgow.
1880. Weatherly, Lionel A., M.D., Bailbrook House, Bath.
1880. West, Geo. Francis, L.R.C.P. Edin., Assist. Med. Officer, District Asylum,
Omagh, Ireland.
1872. Whitcombe, Edmund Banks, M.R.C.S., Medical Supt., Winson Green
Asylum, Birmingham. (President, 1891.)
Digitized by ^ooQle
Members of the Association,
xiv.
1884. White, Ernest, M.B. LoncL, M.B.C.F., City of London Asylum, Stone,
Dartford, Kent.
1889. Whitwell, James Bichard, M.D. and C.M., Assistant Medical Officer, West
Biding Ajylum, Menston, near Leeds.
1870. Wickham, R. H. B., M.D., F.R.C.S. Edin., West Mead, Dawlish, South
Devon.
1883. Wigles worth, J M M.D. Lond., Bainhill Asylum, Lancashire.
1857. Wilkes, James, F.B.C.S. Eng., late Commissioner in Lunacy; 18, Queen’s
Gardens, Hyde Park. (Hon. Member.)
1887. Will, Jno. Kennedy, M.B., C.M., M.P.C., Bethnal House, Cambridge
Road, E.
1862. Williams, S. W. Duckworth, M.D. St. And., L.B.C.P.Lond., Chislehurst,
Marlboro* Road, Bournemouth.
1863. ) Williams, W. Rhys, M.D. St. And., M.R.C.P. Ed., F.K. andQ.C.P., Irel.,
1878. J late Commissioner in Lunacy, Linden House, Bertie Road, Learning-
ton. (Hon. Member ).
1893. Wills, Ernest, M.D. Lond., M.B.C.P. Lond., Second Assistant Medioal
Officer, London County Asylum, Claybury.
1890. Wilson, George R., M.B., C.M., M.P.C., Assistant Medical Officer, Royal
Edinburgh Asylum.
1891. Wilson,^ John Thomson, M.B., C.M.Aberdeen, M.P.C., 55, Hill Street,
Springburn, Glasgow.
1885. Wilson, G. Y., M.D., Assist. Med. Officer, District Asylum, Cork.
1875. Winslow, Henry Forbes, M.D. Lond., M.R.C.P. Lond., 14, York Plaoe,
Portman Square, London, and Hayes Park, Hayes, near Uxbridge,
Middlesex.
1869. Wood, T. Outterson, M.D., M.R.C.P. Lond., F.R.C.P., F.R.C.S. Edin., 40,
Margaret Street, Cavendish Square, W.
1879. Wood, Wm. E. R., M.A., M.B., F.R.C.S. Edin., The Priory, Roebampton.
1869. Wood. B.T., Esa., M.P., Chairman of the North Riding Asylum, Conyng*
ham Hall, Knaresboro. (Hon. Member.)
1873. Woods, Oscar T., M.B., M.D. (Dub.), L.R.C.S.I., Medical Superintendent,
District Asylum, Cork.
1885. Woods, J. F., M.R.C.S., Med. Supt., Hoxton House, N.
1884. Workman, J., M.D., Toronto, Canada. (Hon. Member.)
1877. Worthington, Thos. Blair, M.A., M.B., and M.C. Trin. Coll., Dublin, Med.
Supt., County Asylum, Knowle, Fareham, Hants.
1865. Wyatt, Sir William H., J.P., Chairman of Committee, County Asylum,
Colney Hatch, 88, Regent’s Park Road. (Hon. Member.)
1862. Yellowlees, David, M.D. Edin., F.F.P.S. Glasg., LL.D., Physician-Superin¬
tendent, Royal Asylum, Gartnavel, Glasgow. (President, 1890).
1882. Young, W. M., M.D., Assist. Med. Officer, County Asylum, Melton, Suffolk
Ordinary Members .
Honorary Members .
Corresponding Members
Total ...
... 424
... 46
7
... 477
Members are particularly requested to send changes of address, etc., to Dr.
Fletcher Beach, the Honorary Secretary, 11, Chandos Street, Caven¬
dish Square, London , W., and in duplicate to the Printers of the
Journal, South Counties Press Limited, Lewes, Sussex.
Digitized by ^ooQle
XV,
List of those who have passed the Examination for the Certificate of Efficiency
in Psychological Medicine, entitling them to append M.P.O. (Med. Psyoh.
Certif.) to their names.
Adamson, Robert 0.
Adkins, Percy.
Ainley, Fred Shaw.
Alexander, Edward H.
Anderson, John.
Anderson, A. W.
Andrieson, W.
Armour, E. F.
Attegalle, T. W. S.
Aveline, H. T. S.
Barbour, William
Barker, Alfred James Glanville.
Belben, F.
Bird, James Brown.
Black, Robert S.
Black, Victor.
Bond, C. Hubert.
Bond, R. S. S.
Bowlan, Marcus M.
Boyd, James Paton.
Bristowe, Hubert Carpenter.
Brodie, Bobert C.
Bruce, John.
Brush, S. C.
Bullock, William.
Cameron, James.
Campbell, Alfred W.
Campbell, Peter.
Calvert, William Dobree.
Carmichael, W. J.
Carruthers, Samuel W.
Carter, Arthur W.
Chambers, James.
Chapman, H. C.
Collie, Frank Lang.
Collier, Joseph Henry.
Connolly, Richard M.
Cope, George Patrick.
Conry, John.
Corner, Harry.
Couper, Sinclair.
Cowan, John J.
Cowie, C. G.
Cowper, John.
Craig, M.
Cram, John.
Cruickshank, George.
Cullen, George M.
Dalgetty, Arthur B.
Davidson, William.
Davidson, Andrew.
De Silva, W. H.
Distin, Howard.
Drummond, Russell J.
Donaldsou, R. L. S.
Douglas, A. R.
Fames, Henry Martyn.
Earls, James H.
Eden, Richard A. S.
Edgerley, 8.
Elkins, Frank A.
English, Edgar.
Eustace, J. N.
Evans, P. C.
Ewan, John A.
Ezard, Ed. W.
Fennings, A. A.
Ferguson, Robert.
Fitzgerald, Gerald.
Fraser, Thomas.
Fraser, Donald Allan.
Fox, F. G. T.
Gaudin, Francis Neel.
Gemmell, William.
Geoney, Fred. S.
Giles, A. B.
Gill, J. Macdonald.
Goldie, E. M.
Goodall, Edwin.
Graham, F. B.
Grant, J. Wemyss.
Grant, Lacklan.
Gray, Alex. C. E.
Griffiths, Edward M.
Halsted, H. C.
Haslam, W. A.
Hassell, Gray.
Hector, William.
Henderson, Jane B.*
Henderson, P. J.
Hennan, George.
Hewat, Matthew L.
Hicks, John A., jun.
Hitchings, Robert.
Hotchkis, R. D.
Howden, Robert.
Hutchinson, R. J.
t Hyslop, Theo. B.
Ingram, Peter R.
Jagannadham, Annie W.
Johnston, John M.
Kelly, Francis.
Kelso, Alexander.
Kelson, W. H.
Ker, Claude B.
Kerr, Alexander L.
Keyt, Fred.
LaingjJ. H. W.
Law, Thomas Bryden.
Leeper, Richard R.
Leslie, R. Murray.
Livingstone, John.
Lloyd, R. H.
Low, Alexander.
Macdonald, David.
Macdonald, G. B. Douglas.
Digitized by Google
uai.
xvi.
Macdonald, John.
McAllnm, Stewart.
Macevoy, Henry John.
Mackenzie, Henry J.
Mackenzie, William L.
Mackenzie, John Camming.
Mackie. George
Macmillan, John.
Macneece, J. G.
Macpherson, John.
Marsh, Ernest L.
Meikle, T. Gordon.
Melville, Henry B.
Mitchell, Alexander.
Mitchell, Charles.
Monteith, James.
Moore, Edward Erskine.
* Mortimer, John Desmond Ernest,
Myers, J. W.
Hair, Charles R.
' Naim, Robert.
Neil, James.
Nolan, Michael James.
Oswald, Landel R.
Parker, William A.
Parry, Charles P.
Patterson, Arthur Edward.
Pieri8, William C.
Pilkington, Frederick W.
Pitcairn, John James.
Porter, Charles.
Price, Arthur.
Rainy, Harry, M.A.
Rannie, James.
§ Raw. Nathan.
Reid, Matthew A.
Renton, Robert.
Rice, P. J.
Rigden, Alan.
Ritchie, Thomas Morton.
Rivers, W. H. R.
X Robertson, G. M.
Rose, Andrew.
Row and, Andrew.
Rust, James.
Scott, J. Walter.
Soott, William T.
Simpson, John.
Simpson, Samuel.
Skeen, James H.
Smyth, William Johnson
Sproat, J. H.
Stanley, John Douglas.
Stavelev, William Henry Charles.
Steel, John.
Stewart, William Day.
Strong, D. R. T.
Slater, William Aroison.
Smith, Percy.
Thompson, George Matthew*
Thorpe, Arnold JB.
Trotter, Robert Samuel.
Tomer, M. A.
Umney, W. F.
Walker, James.
Waterston, Jane Elizabeth.
Watson, George A.
Welsh, David A.
West, J. T.
Wickham, Gilbert Henry.
Whitwell, Robert R. H.
Will, John Kennedy.
Williams, D. J.
Williamson, A. Maxwell.
Wilson, John T.
§ Wilson, G. R.
Wilson, James.
Wilson, Robert.
Wood, David James.
Yeoman, John B.
Young. D. P.
Younger, Henry J.
Zimmer, Carlo Raymond.
• To whom the Gaskell Prize (1887) was awarded,
f To whom the Gaskell Prize (1889) was awarded.
X To whom the Gaskell Prize (1890) was awarded.
§ To whom the Gaskell Prize (1892) was awarded.
Digitized by ^ooQle
THE JOURNAL OF MENTAL SCIENCE.
[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland .] „
No. 164. NE Vm IES ’ JANUARY, 1893. Vol. XXXIX.
PART 1.—ORIGINAL ARTICLES.
The Use of Hypnotism among the Insane . By George M.
Robertson, M.B., M.R.C.P.Edin., Senior Assistant
Physician, Royal Edinburgh Asylum, Morningside.
Last year I paid a visit to the different schools of hypnotism
in France, and I saw hypnotism used as a therapeutic
agent in the wards of Professor Bernheim of Nancy, of Dr.
Luys at the Charity in Paris, and of Dr. Auguste Voisin at
the Salp£tri&re. I became convinced of the reality of the
phenomena, and of its great value as a therapeutic agent in
certain cases, and therefore since my return I have made such
use of it as time and opportunity permitted among the female
pauper patients at Morningside Asylum. I here give an
account of some of the cases I hypnotized and of the various
reasons, both therapeutic and otherwise, for which I made use
of this agent, and I shall conclude with a brief summary of its
uses. I exclude from here, however, all examples of its use for
physical ailments.
The method of hypnotizing I adopted, resembles that used
by Professor Bernheim. I inform the patient that I have the
power of inducing sleep, and obtain the consent and gain the
confidence of the subject. I then quietly suggest the feelings of
sleep, and gradually close the eyes by passing my hand over
the eyelids, and almost always those of my patients whom
I could influence fell into the hypnotic sleep in five or eight
minutes.
I selected cases who I thought would hypnotize readily,
and who did not resist the attempt being made, and if I did
not succeed within ten minutes or a quarter of an hour I gave
up further trial.
One of the very first cases in which I made an attempt was
of a most encouraging nature. This was the case of a woman
XXXIX. 1
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2
The Use of Hypnotism among the Insane, [Jan.,
who is subject to attacks of recurrent mania, which are
ushered in by a long prodromal stage of irritability, excitement,
and severe cephalalgia, accompanied by intractable insomnia.
My object in hypnotizing her was to relieve this troublesome
sleeplessness, and when I decided to do so she had been with¬
out sleep for fully a fortnight, excepting on one occasion, when
she slept for four hours, after having had 40 grs. of chloral
and 60 grs. of bromide of potassium. Lesser doses of these
drugs had been tried and had failed to produce sleep, and as
the patient refused to take any other hypnotic I decided to
give hypnotism a trial.
She occupied a single room without a bedstead, as she was
inclined to be excited, and one evening I entered her room
and told her I had come to send her to sleep. As she half sat
up in bed I told her she would soon feel something from my
hand thrilling through her, and that she would drop asleep.
In less than two minutes her head fell on her breast, her hands
became flaccid, and she was breathing calmly as if asleep. I
told her that she was now sound asleep, that she would remain
so all night, without hearing disturbing noises, and that next
day she would feel much better. She remained in bed as I
had left her for six hours, apparently without moving, and
next day she felt better, and the headache had improved.
Next night I went to her room at the same hour, and told
her I had again come to send her asleep. She was sitting on
the floor with all her bedding lying tossed about, and while
the nurse was making up the bed I stood waiting, with my
hand resting on the patient’s head. In a few seconds, much
less than a minute, 1 was astonished to feel the patient’s head
suddenly drop forward, and on looking I found she had fallen
asleep. The fact of her having become hypnotized came as an
unexpected shock to me, as 1 had then no thoughts of hypno¬
tizing her. On the second night she slept for fully four hours.
After this Dr. Middlemass, one of my colleagues, and I
frequently hypnotized her, and as a rule she slept about four
hours. Soon after this, however, the patient developed more
acute symptoms, and the hypnotic sleep lasted an uncertain
and much shorter time, so we gave it up.
Although sleep was produced in this case when the brain
was needing it badly it did not stop the attack of mania from
coming to a head, for it ran its usual course from first to last.
It is possible the hypnotism was tried at too late a stage.
* Yoisin remarked to me that some cases of slight mania
hypnotize most readily, and it would appear that this case of
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1893.]
3
by Geobge M. Robebtson, M.B.
mine confirms this opinion, for one cannot conceive a case
hypnotizing more readily than this woman did on the second
occasion, when she was hypnotized by me unconsciously. It
would seem that at a certain stage of simple mania attention is
easily aroused, and the imagination is brilliant, so that the
suggested sensations of sleep are vividly felt, and the hypnotic
state is thus readily produced.
I may add that when this patient recovered from this
attack of mania she was conscious of what I had done, but she
said I no longer had this mysterious power over her. I have
since tried three times to hypnotize her, and I have failed to
obtain satisfactory hypnosis.
Another case, which hypnotized with very great readiness,
was that of a woman at the climacteric, who suffered from
hypochondriacal melancholia. She was a very excellent
example of this type of mental disease, and imagined she
suffered from all the ills that she was acquainted with. She
had slight dyspepsia, but she asserted she had cancer or some
other deadly disease; she also had slight cardiac trouble, but
she continually believed she was on the point of dropping
down dead. She was in a run-down condition, and com¬
plained of pains and aches in all the regions of her body. She
was reasonable on most topics not connected with her health,
but her mind was so controlled by the idea that she was an
exhausted, dying woman that she refused to attend to herself
or to the duties of her household. Her mother had also
suffered from the same symptoms when she reached the
climacteric.
As this woman’s delusions were numerous and fleeting I
thought that if she became hypnotized I might remove them
by suggestion, as I believe such cases offer more hope of cure
by this means than delusions of a more fixed nature. The
patient, I found, hypnotized readily, and when asleep I assured
her positively that each of her ailments had disappeared. She
awoke from sleep feeling much happier and stronger, and
thanked me for the good I had done her. This treatment
went on almost daily for about six weeks, and there was an
uninterrupted, steady progress towards complete recovery. It
must, of course, be conceded that in some measure this happy
result was due to tonics, good feeding, occupation, exercise,
and amusements, with the absence of all domestic worries,
but the marked improvement after each hypnotization could
not possibly have been without a very considerable effect also.
Even if it did not directly tend to recuperate the body and
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4 The Use of Hypnotism among the Insane , [Jan.,
brain, which from recent experiments I believe possible, there
can be no doubt that by increasing her temporary well-being
it enabled her to occupy and amuse herself better, and thus
indirectly it must have aided in her recovery.
It was noticed in her case that in the waking condition if
I tried to persuade her that her fancies were unfounded she
would argue, and held to her beliefs more strongly, but when
she was hypnotized she was most deferential and never con¬
tradicted me, but hurriedly accepted my opinions unreservedly
and instantly. This, of course, greatly assisted me in giving
suggestions, and she also gradually became easier to hypnotize,
though she always regarded the process as a disagreeable
necessity. She made a perfect recovery, and has since remained
well.
A class that I have found to be very susceptible to hypnotism
has been that of the comparatively sane epileptics, who, when
they are having a bout of fits, may be violent and excited, but
who in the intervals between these bouts are quiet and sensible.
These patients often complain of headaches and confusion, and
I have frequently dispelled these. For example, a case 1 had.
previously hypnotized very many times, had during twenty-
four hours suffered from several fits. She was confined to
bed, and when I saw her she was very dull, complaining
mournfully of the fits, and. of the exhaustion, headaches,
and great confusion of mind they produced. I told her I
would remove all these, and hypnotized her. I told her that
all her troubles had now gone and that she would waken
bright and well; that she must get up after I left, and be
particularly active and busy. I left the patient, and when she
awoke about a quarter of an hour afterwards the first request
she made was to be given her clothes, and when the charge-
nurse dissuaded her from getting up she insisted on it, and
demanded her clothes. She was now as cheerful as she could
possibly be, and spent the day in a busy and useful manner.
No one could help being impressed with the complete change
in this patient’s emotional and intellectual condition, and I
saw a similar change in one of Dr. Yoisin’s cases.
My patient was evidently labouring under a slight functional
depression of a temporary nature, such as any strong natural
stimulus, as of sudden joy or of anger, might also have dis¬
pelled, yet it is of some value that we should possess the power
of effecting this with such facility by hypnotism.
I have also many times hypnotized excited patients, and put
them to sleep for the sake of peace and quietness. For
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1893.]
5
by George M. Robertson, M.B.
example, we have a patient who has suffered from simple
mania for over a year, who has many delusions, and who is
subject to attacks of considerable excitement and violence.
Owing to a marked inequality of her pupils and a paretic
expression of the face she is now regarded as probably being
a case of general paralysis. I have several times hypnotized
this woman when she has been suffering from one of Jier
outbursts of violence, destructiveness and noise, and sent her to
sleep for periods varying from a quarter-of-an-hour to two
hours. At the termination of her sleep she would, as a rule,
awaken in a quiter frame of mind, with the impulsive outburst
blown over. This woman has a personal regard for me, as
the result of some delusion, which enables me to hypnotize her
with great facility, even when very excited, but no permanent
good has resulted from my suggestions to her.
We have another case of recurrent mania, with a periodic
relapse at every month, when for several days she is restless,
tricky, talkative, and very annoying to her neighbours. I
have hypnotized her on these occasions, and let her sleep
for a short time. No lasting benefit was obtained in this case,
and we have since used sulphonal, with excellent results,
completely suppressing these recurrent attacks.
In a third case, one of puerperal mania in an adolescent who
had quieted down, but who was subject to hysterical emotional
attacks, I have also used hypnotism. She would sob, scream,
and throw her limbs about, and on these occasions I would send
her to sleep for several hours. By this means the attacks would
be cut short, and she herself and her neighbours would have
peace and quietness, whereas otherwise the attack would last for
hours. These hysterical attacks occurred at monthly intervals,
and on several occasions they passed into sharp attacks of simple
mania of a short duration, and I have grounds for believing
that suppression of these emotional crises by hypnotism, on
some occasions, may have enabled the patient to pass a critical
period without lapsing into mania.
I also make use of hypnotism for the same purpose in the
case of an excited epileptic. This woman is one of those
evil characters who are more bad than mad, and who had
lived a vicious, uncontrolled life outside, till her bad temper,
aggravated by drink and the epileptic diathesis, brought her
to the asylum. She would remain comparatively quiet for
several months, and then the evil and the suppressed excite¬
ment within her would come to a height, and, exploding,
would vent itself in destruction of property and injury to
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6
The Use of Hypnotism among the Insane , [.Jan.,
individuals, or else it would disappear after an epileptic fit. I
hypnotized this woman several times during quiescence in
order to make her an easy subject, as I felt that she was a
suitable and desirable case to control by this means when the
emergency should arise. Whenever she is in one of her violent
and excited moods now I hypnotize her, and suggest to her
that she is not to feel nervous and irritable, that she is to
control herself and be quiet, and, as a rule, I let her sleep for
an hour or two. I have several times done this with marked
advantage, and she has awakened in a much sweeter frame of
mind. The last time I hypnotized her she was labouring
under intense excitement, and had, out of sheer desire to do
violence, wrenched off the door of a cupboard and the iron
fastening of a shutter when no one was near; she had also
come to blows with several people, and was scolding at the
top of her voice. I said I would hypnotize her, and to this
she always objects; but I insisted on it, and although she
protested, she went deeply over. I told her to be quiet
and to sleep till tea-time, which would be about five hours
later. Unfortunately at the end of two hours she was wakened
by a patient who had entered her room, but she awoke calm,
and remained quiet all the afternoon. In the evening, how¬
ever, something again set her up, and she became extremely
violent and abusive, but now, strange to say, she refused
positively to go to sleep, and so, after five minutes’ trial, I gave
it up. This is the only occasion on which I have failed with
her, and I think it was because the excitement had reached too
high a pitch, for during the night she became acutely maniacal,
and required seclusion next day. It remains a question for
speculation whether the attack, like others, might not have been
prevented from developing had she been allowed to sleep all
the afternoon.
This case is also interesting, as showing on another occasion
what may happen from carelessness on the part of the
hypnotizer. She had complained to me of rheumatic pains in
her legs and lameness, and after I had removed the pains by
suggestion, I told her that when she awoke she had to run up
and down the ward, meaning by this only once. I gave her
this suggestion to demonstrate that all the lameness had dis¬
appeared. I left, and in a few minutes she awoke in a slightly
sleepy condition, and then made a rush down the ward. In
a few minutes she made a rush back again, and then she carried
out this suggestion all the afternoon, being in a somewhat
peculiar mental state, as if she wondered why she wafc doing
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1893.]
by George M. Robertson, M.B.
7
this. Had I been informed of this at the time I should have
re-hypnotized her and put a stop to it, but I was not told till
next visit. I think, however, this demonstrates that sugges¬
tion to hypnotized patients should be very clear and simple,
especially in dealing with the insane, that it is preferable to
see your patient thoroughly awake before you leave, and that
suggestions in the hypnotic state make a deep impression.
As demonstrating the power of hypnotism, if not its thera¬
peutic value, I shall describe the use I have made of it in pro¬
bably the most unmanageable female case that has been in
Morningside for ten years. A good criterion of the great
difficulties connected with this case is the fact that she is the
only person that I have seen, during five years 1 residence here,
mechanically restrained, except for surgical reasons. She is a
well-developed woman of 25, with an insane heredity, who has
led an exciting and fast life. She was married, and a mother
when she was fifteen. She has been on the stage, and has
probably indulged to excess. She is now subject to the most
frightful outbursts of suicidal and homicidal violence, accom¬
panying a state of acute mania. These outbreaks occur very
suddenly, with only a few hours’ warning, usually at monthly
intervals, and the attack lasts about three weeks, gradually
passing away. In the intervals between the attacks she is
quiet and resonable, though her power of self-control is very
poor. As in a former case, I practised hypnotizing this woman
when she was quiet, and found that she went over with ease
and fairly deeply, as she had no recollection of what happened
in the hypnotic state.
I first made use of hypnotism in her case for the sleeplessness
which troubles her in a certain period of the mental cycle, and
she would thus sleep all night. At this stage she was usually
fairly sensible, and when hypnotized I had considerable com¬
mand over her. For example, I have closed her eyes and told
her it was impossible to open them, and she has been unable to
do so, though on one occasion I believe she rubbed them with
saliva for two hours to remove the “ gum that was fixing them.”
I have next hypnotized her very often in order to get her to
take sulphonal. On account of her violence and homicidal
tendencies it is often necessary to keep her well under the
influence of sulphonal, but as she knows from long experience
the exact effects of this drug she will not voluntarily take it.
It would be possible, at the cost of much ill-feeling, with the
assistance of several nurses, to give her this with the nasal tube,
but I find it so much simpler and pleasanter for me afterwards
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8
The Use of Hypnotism among the Insane , [Jan.,
to hypnotize her, and then order her to take it. She in¬
variably does this, believing sometimes that it is brandy, some¬
times sugar, and sometimes medicine. When she awakes two
minutes after she has absolutely no recollection of what has
happened, and indignantly refuses to touch sulphonal, which
she asserts she has not taken for months. I suppose, how¬
ever, I have gone through this performance at least three
dozen times, and some of my colleagues have also done it.
The most dramatic and convincing exhibitions of the power
of hypnotism have, however, occurred on the three or four
occasions in which I have hypnotized her against her will, in
the acme of her excitement, when she required to be held by
four nurses. On these occasions her homicidal and suicidal
violence and excitement are so great that it is absolutely
necessary to restrain her either by physical means or by
powerful drugs, and it is impossible for the nurses to hold her
for any length of time. Before I tried hypnotism I used to
give her ^th grain of hyoscine hypodermically, and then three
or four hours afterwards 30 to 60 grains of sulphonal through
the nasal tube, the first to quiet the excitement immediately,
and the second to keep her quiet when once she is so. I
still adopt this plan occasionally, but I have instead several
times hypnotized her and ordered her to take a very large
dose of sulphonal, varying from 45 to 75 grains—usually
60 grains—which from long observation in her case we know
she can stand perfectly. As a result of this in an hour or two
she gets drowsy, and by evening she is lethargic and sleepy.
On these occasions as she is so violent she has, of course, to be
held by several nurses while I send her asleep. She shouts that
she won’t let me do it, and repeats to herself “ I won’t go to
sleep ” over and over again. I close her eyes—often with
great difficulty on account of her struggles—and order her
to sleep. I then protend to observe the symptoms of drowsi¬
ness, and say to the nurses in an aside remark that is intended
for her that she will soon be asleep, and after about three to
five minutes—which is longer than usual with her—she
becomes hypnotized, remains perfectly quiet, and will do
whatever I tell her. Should any medical sceptic see such a
demonstration of the power of hypnotism he could not
possibly desire further proof, but, of course, it is impossible
to arrange these exhibitions, for they only occur on an
emergency. On one occasion in my ward visit with Dr.
Clouston I hypnotized her in this excited state. As I have
already mentioned, it has been necessary on a few occasions to
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9
1893.] by George M. Kobertson, M.B.
put this woman into mechanical restraint. To effect this was
always a work of supreme difficulty, but when she is hypnotized
I tell her I want her to try on a new dress, and she does so
immediately with great willingness, often passing uncompli¬
mentary remarks about its shape. Excepting in the treat¬
ment of the insomnia hypnotism has been of no direct thera¬
peutic value in this case, though it has lessened the difficulties
connected with the management very considerably. Any
suggestions towards improvement of her conduct which I
have addressed to her in the hypnotic state have not appeared
to influence her in the slightest.
There are several facts of interest from a psychological point
of view connected with this case which I may mention.
In the first place, when she is hypnotized her mind does not
come to rest and fall asleep, but like a few other cases she
suffers from an active delirium, and a curious thing about
this delirium is that whatever her state of mind previous to
being hypnotized—whether sane, somewhat excited, or acutely
maniacal—the delirium is always exactly the same. Another
interesting feature is that this delirium, which I can thus arti¬
ficially produce, corresponds to her mental state on admission.
She talks to herself about being sent to the salt mines in
Siberia, about having murdered someone, and about her head
being cut off, and these very statements occur in her medical
certificates on admission. It would appear that there is a
diseased activity in her brain which hypnotism does not affect,
and that when the inhibitory forces are taken off it asserts
itself, and that when seemingly well hypnotism can thus
demonstrate the existence of this latent disease.
In the second place, I find as a rule that the more excited
she is when I hypnotize her, the shorter the sleep is, and
the less control I have over her. I have already stated that
when she is comparatively sane, and I tell her she cannot open
her eyes, the suggestion may persist for two hours, but when
she is excited it may often not last half a minute. For example,
if I ask her to hold her hands together, and keep them down,
unless I repeat this continuously, in the morbidly excited state
of her brain, she appears to forget the suggestion, and soon
raises her hands. I can illustrate this in another way. In her
excited state it was very difficult to get out of her room with¬
out her getting out also, and for this purpose I would hypnotize
her, but very often the moment I took my hands off her fore¬
head she would awaken, and run after me. I found, however,
that by oalling out “ Sleep, sleep/’ I could leave her at leisure,
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10
The Use of Hypnotism among the Insane , [Jan.,
but whenever I stopped repeating the word u sleep” she would
waken. I suppose the explanation of this is that the morbid
excitement in her brain is too strong, and overcomes the
hypnotic influence, unless this is constantly exercised.
A third fact I observed in her case was th^t, whereas a very
little sulphonal aided hypnotism, when she was thoroughly*
under the influence of the drug and had become inattentive,
confused, and stupid, I was unable to hypnotize her satisfac¬
torily. A similar difficulty occurs in dementia.
In many other cases which I have hypnotized I have obtained
results which were not of a conclusive nature, but of which I
am hopeful. For example, the general conduct, the applica¬
tion to work, and the taking of food in several melancholiacs
have greatly improved after hypnotization and suggestion;
but, of course, we all know that a “ good talking to ” will
often do the same thing, and that, therefore, in these cases
there may have been no special virtue in the use of hypnotism.
I have no doubt, however, that cases of this nature will occa¬
sionally occur in which hypnotism will prove to be of striking
service.
I shall now mention some of the peculiarities I have observed
connected with the use of hypnotism among the insane. In
the first place all acknowledge that the insane are difficult to
hypnotize, and as it is out of the question, except for an enthu¬
siast, to go wasting time over failures, for practical purposes
one must select only suitable cases. These are, in my opinion,
the most sensible and reasonable of the patients, and of those
who are excited only those who are still coherent. If such
cases are selected I believe that between a third and a half
may be hypnotized without spending on an average more than
a quarter of an hour over each. I have a decided objection to
melancholiacs, except of the simple variety, as their subject
consciousness is so strong, and they are so wrapped up in their
morbid ideas that, instead of listening to suggestions and
becoming hypnotized, they think all the more of their sub¬
jective ideas. Even with cases who can be hypnotized one’s
success varies greatly, and occasionally in an unexpected
manner they refuse to become hypnotized. Although most of
my patients have gone under fairly deeply, and had no recol¬
lection of what happened, still one’s control over them is not
so strong as over a sane person. The insane patient’s intelli¬
gence is not so good as that of a sane person, and hence, as
must be expected, they do not as a rule take up suggestions so
well, nor do these make so great and lasting an impression on
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11
1893.] by George M. Kobertson, M.B.
them. The hypnotic sleep, I believe, is also much shorter, on
account of the morbid excitement from within the brain
rousing the patient, just as in the state of health we may also
be wakened out of a normal sleep by a vivid dream.
Having now described the limited use I have made of hyp¬
notism (for I have by no means employed it to its full extent),
I shall summarize its uses among the insane.
It may be used firstly as a direct therapeutic agent.
1. In Insomnia .—It may succeed in intractable cases where
drugs have not succeeded well. Hypnotic sleep, being more
closely allied to healthy sleep than is drugged sleep, must be
of great service where the brain nutrition is already bad, and
the additional effect of depressing drugs is undesirable.
2. As a Sedative in Excitement. —It may here be of direct
therapeutic value in preventing an outburst of excitement from
passing into mania in a brain in a highly unstable condition.
3. To Dispel Fleeting Delusional States and the Minor Psy¬
choses. —By means of verbal suggestion in the hypnotic state
these lesser degrees of mental derangement have been removed.
In addition to its direct therapeutic uses hypnotism may be
used for purposes of management.
1. To Overcome the Morbid Resistance of Patients for their
Own Benefit. —Patients often refuse to do what is necessary for
their welfare, and by hypnotizing them they can be made to
do what is desired. I have instanced the giving of medicine,
but many other purposes can be thought of. I have lately
induced a patient to take food in the hypnotic state when she
had required to be artificially fed for a week.
2. As a Substitute for Restraint. —Incases of excitement and
violence, instead of mechanical, physical, or chemical restraint,
we may use hypnotism, which may be described as a form of
mental restraint, either alone or in combination with the last.
It is, however, uncertain, and not always possible.
Many people from reading highly sensational newspaper
accounts of hypnotism, and from the dramatic exhibitions of
public performers, expect miracles to result from the employ¬
ment of hypnotism as a therapeutic agent in insanity, and, of
course, such people are disappointed. I do not believe that
hypnotism can cure pronounced or advanced forms of
mental disease, and I am not hopeful of it even doing good in
cases of fixed delusion. I believe, however, that it may be
used with advantage for the purposes I have indicated, and
that it will eventually have a recognized position as a minor
therapeutic agent.
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12
The Use of Hypnotism among the Insane . [Jan.,
It remains to be said, in conclusion, that although no person
could reasonably deny the great good that it may do in
individual cases, or the fact that in medical hands legitimately
employed with caution it appears to produce no direct harm,
yet there may result indirect harm to a community from its
adoption, from the frame of mind that it engenders among
ignorant and superstitious people. In an asylum, if exten¬
sively used, it may increase and strengthen the delusions
about hypnotism, and about unseen agencies in general, and
we have had one case here who, when she learnt that I made
use of hypnotism, although not with her, imagined that all her
delusions were confirmed, and became very difficult to manage,
if not positively dangerous. This objection, however, may
just as legitimately be urged against the use of the battery for
electro-therapeutics, or against the introduction of the electric
light and telephones in our modern institutions.
The Psychological Examination of Prisoners . By Dr. Jules
Morel, Hospice-Guislain, Ghent.*
I think it is a general rule in all well-organized prisons,
that, periodically, the staff holds meetings to take decisions
upon the measures to be taken concerning the prisoners
whose conduct is not, or has not been, following the regula¬
tion of the house.
After each meeting, minutes of transactions are made and
sent to the higher authorities, and usually to the Minister
of Justice. M. Lejeune, Minister of Justice in Belgium,
was struck by the examination of these minutes in our
country, and stated that they were almost always the same
prisoners of whom complaints are made and against whom
disciplinary cautions were taken.
A doubt came to the Belgian Minister, and his Excellency
asked himself if these rebellions against discipline were not,
in reality, signs of mental instability. M. Lejeune decided to
establish a medico-psychological inquiry in one of the Belgian
prisons, with the recommendation to pay special attention
to these so-called undisciplined. Amongst these, there were
fourteen prisoners absolutely unable to submit themselves to
the regulations of the house. The examination of their
* Paper read at the Psychology Section of the British Medical Associa¬
tion, held at Nottingham, July, 1892.
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13
1893.] The Psychological Examination of Prisoners .
mental state proved that, among these fourteen prisoners,
there were eight who showed symptoms of such a madness
that one was obliged to proceed immediately to place them
in a lunatic asylum.
The medico-psychological inquiry was suspended after the
examination of 291 prisoners. The Minister of Justice
was then convinced that, henceforth, the medico-psycho-
logical examination of the prisoners was to be made by
special physicians, and created a service of mental medicine.
Three alienists were appointed, and each of them has now
the charge of the psychiatric service in nearly twelve prisons.
The results obtained since the inauguration of this service
in the Belgian prisons are already sufficient to allow us to
judge about the importance of the new ministerial decision.
I have thought it of very great interest to make the
results known, and, consequently, to conclude that the
inconveniences stated in the Belgian prisons very probably
exist in all the other prisons of the world.
My aim is to call the attention of the foreign-authorities,
in order to help and convince them that prisons always
contain a certain proportion of insane people, and that it is
very important a similar medico-psychological service should
be adopted everywhere. I even think that it is no more
possible to doubt that this service recently instituted in
Belgium, and only applied to the prisoners whose mental
state of health seems suspicious to the officers of the prisons,
will be enlarged and spread in a short time over all the
recidivists for the different kinds of crimes and offences of a
certain degree. The aim of the mission of the alienists of
the Belgian prisons is to remove and to certify all the
prisoners whose physical state is incompatible with the
habitual regime of the prisons, to submit immediately to
treatment all recent cases of mental diseases susceptible to
the necessary care at the prison itself, and giving some hope
of a relatively prompt recovery; finally, to call the special
attention of the officers of the prisons to all doubtful cases.
If the medico-psychological service could, at a future
time, be applied to all the recidivists and all the great
criminals, it would offer many and great advantages; it
would allow us to make up very complete reports of the
mental state of the convicts, and these notes should become
of the highest importance.
1st. It would record the psychical deficiencies of the
convicts; it would allow us to class these delinquents, and
Digitized by ^ooQie
14 The Psychological Examination of Prisoners, [Jan.,
subsequently to begin an individual treatment, so far as
their cerebral power allows it.
2nd. It would allow us, by these means, to make known
the undisciplined and those who would simulate mental
disease; it would allow us to take the necessary measures to
repress their conduct.
3rd. To the guardians, officers, and even to the higher
authorities, who wish to have a serious and scientific
opinion concerning the convicts under their care and to
employ all possible indulgence, it would be very useful,
especially when they have to apply either conditional or
final liberation, or special measures of protection in their
favour when they leave the prison.
4th. The magistrate, instructor, and the judges would be
enabled to consult these notes with profit in all cases when
recidivists should be brought again before them. As a
matter of fact, in most cases these magistrates were unable
to form an exact opinion of the psychological state of the old
convicts. The examination of the new documents would
make it easy to form a more rational opinion of the degree
of indulgence or severity with which they should act accord¬
ing to the reformation the old criminals have shown during
and after the time of their detention.
We are aware that the natural conclusions of such a psy¬
chological examination would be the necessity of a grand
reform in the penitentiary system, and perhaps also the
revision of certain parts of the penal law.
My experience of the study of the convicts submitted to
my examination since the 1st of June, 1891, till the 30th of
May, 1892, completely demonstrates the necessity of the re¬
organization of the treatment of the inmates of prisons. It
proves:—
1st. That every prison with a population of, for instance,
one thousand or more convicts should have a special ward in
which one could take proper care of all the criminals who
have become insane during their detention and are suscep¬
tible of recovery.
The treatment of the criminal and curable lunatics in a
separate building of a prison seems to me to have great
advantages. On their discharge these unhappy men should
not have the stigma of having been in a lunatic asylum, and
consequently it should be easier to them to reconquer an
honourable place in society. The special lunatic asylums for
the criminals ought only to be opened for those whose mental
Digitized by ^ooQie
1893.]
by Dr. Jules Morel.
15
condition should not allow of a rational treatment in the
division of the prison called the lunatic ward; they should
also receive the insane criminals whose incurability is more
or less established.
2nd. That each prison, and a portion in each ward destined
for criminals having become lunatic, ought to have a special
staff of attendants with the necessary qualities, instruction,
and education required to treat rationally the convicts who
become insane.
3rd. That all convicts belonging to the class called imbe¬
ciles ought to receive special physical and mental care.
They ought not to be discharged before the end of the dura¬
tion of their imprisonment, because it is this class of de¬
generates that furnishes the great contingent of recidivists.
One ought also to group in this class those criminals who,
bv their former way of living, have weakened their body and
mind.
4th. That society does not take sufficient care to preserve
malefactors from relapse. In the present state of things,
and almost generally, the old criminals feel themselves
abandoned by those who ought to protect them in a social
point of view ; very often they are obliged to ask for hospi¬
tality in lodgings, nearly always inhabited by the lowest
class of society. It is not easy for them to find work again,
and consequently they feel obliged to spend the best part of
their time in these houses of ill fame. With the little money
they have they begin to drink. They make the acquaintance
of bad people, and by-and-bye they begin to provoke, or are
provoked, to commit new crimes.
The medico-psychological examination has often proved
that these individuals on leaving the prison cured, as much
as possible, physically and morally, if they are obliged to
follow the course we have described, soon decline again
mentally, and, above all, lose their will and their self-
respect.
Lombroso’s school does not sufficiently understand the im¬
portance of the moralization of the criminals and of the
protection of those to whom the doors of the prison are
opened. We have the proof of it in what we daily see in
lunatic asylums, which have in their population numerous
individuals of whom criminals can be manufactured at leisure.
I may mention the degenerated cases of moral insanity and
those of mental weakness. Amongst them there are many
that are able to receive a sufficient education and moraliza-
Digitized by A^OOQie
16
The Psychological Examination of Prisoners. [Jan.,
tion to give them, on parole, a very high degree of liberty. I
dare to say so in a country where there are so many adherents
of non-restraint.
If many convicts were submitted to treatment similar to
that practised in our lunatic asylums, would relapses be so
frequent? I have the firm conviction that the future will
solve this question, and the more promptly because govern¬
ments would understand the great necessity of introducing
in a short time a medico-psychological service in all their
prisons.
Neural Action Corresponding to the Mental Functions of the
Brain. By Francis Warner, M.D., F.R.C.P., Physician
and Lecturer on Therapeutics and Materia Medica at the
London Hospital.*
While working purely on the lines of physical science it will
be admitted that all observations recorded should be described
in terms connoting physical phenomena, so given as to be
capable of repetition, and, if possible, of measurement. No
forces and no causes can be admitted as potent except those
known to physiology and other branches of physical investiga¬
tion. It follows that in dealing with the mental functions of
.the brain—here termed psychosis—we have nothing to do with
“ mind as an abstract entityor with processes of feeling and
consciousness, and must confine our attention to neural acts
without either admitting or denying the existence of other
potencies with which, while working on the lines of physical
science, we are not concerned.
I will confine my remarks to action in the brain of man, as it
may be inferred from facts observed. It is convenient to com¬
mence with observations in the infant when the neural arrange¬
ments are congenital, and trace by observation the development
of indications of psychosis under impressions received from the
environment.
In the healthy and well-developed new-born infant universal,
slow, spontaneous movements, particularly in the digits and
other small parts, are seen; this I have described as micro¬
kinesis. f It is not at first co-ordinated by impressions from the
environment. In neural action it is inferred to correspond
* Paper read at the Psychology Section of the B. M. Association, held at
Nottingham, July, 1892.
f See Take’s “ Dictionary of Psychological Medicine.”
Digitized by ^ooQle
1893.]
Mental Functions of the Brain .
17
with slow spontaneous action of many separate nerve-centres.
At the age of three months some temporary co-ordination of
the microkinesis is seen, the hands, head, and eyes moving
towards an object, but this effect immediately follows the
stimulus. There is some potentiality for psychosis.
At the age of four or five months the sight of an object may
temporarily inhibit the microkinesis—attention is attracted.
Head, eyes, and hands turn towards the object seen, then all
movement is arrested for a moment; subsequently the child
performs a new action, and seizes the object. Here, I think,
we see the earliest indication of something that may be called
“ mental action. 55 It seems to me from observation of this
“ period of inhibition of microkinesis or latent period of the im¬
pression 55 that neural action of a new kind is observed, for this
latent period is followed by a new action, and it must be
inferred that during the latent period the neural arrangements
were prepared for the new action. What can these neural
arrangements be ? Let us reconsider the facts, and see what
they may teach us. Microkinesis indicates spontaneous action
of many separate nerve-centres; the period of inhibition of
movement indicates temporary arrest of their efferent function
in producing movement, and this is an active result of a sight
impression; it cannot be a period of negative-action, for it is
followed by visible new action clearly sequential to the impres¬
sion. I infer that an active neural arrangement (diatactic
action) was formed among the centres by the impress of sight
during the period of arrest of motor function. Let a, b , c, d, e
represent separate, visible parts acting spontaneously; we infer
separate spontaneous action (motor) in nerve-centres A, B, C,
D, E. During the period of arrest of microkinesis A, B, C,
D, E are not exercising motor function, but it is inferred that
they are still active, for later we observe new movements,
ab , ad, ce indicating the co-ordinated action of AB, AD, CE.
It is this neural arrangement (diatactic action) for the action of
nerve-centres in certain groups during the temporary arrest of
their motor action that I infer to correspond to a simple
mental act.
How is the intellectual power evolved? Following the
hypothesis just given we must inquire how the neural arrange¬
ments for the action of cells in certain groups are established.
There appears to be a law of widespread import concerning
cellular growth and action. “ Like cells co-nourished, and per¬
forming their function synchronously under control of some
stimulus, tend afterwards to act together in similar groups, and
xxxix. 2
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18
Mental Functions of the Brain . [Jan.,
this tendency is strengthened by repetition.” Thus co-ordina¬
tion of nerve-centres is built up. In the case of the infant,
suppose the sight of the red ball forms groups AB, AD, CE,
indicated by movements ab, ad, ce, on repetition of the experi¬
ment the action becomes more exact and more similar on
successive occasions. In adult life neural arrangements cor¬
responding to ideas (percepts) are formed by sight of objects,
and the printed page, repetition of the sight thereof, deepens
the impression and fixes it, and the neural impress is retained ;
trains of thought may thus be established, leading in the end
to expression or action. In the adult, as in the child, inhibi¬
tion of movement is favourable to thought, the motor action is
suspended and replaced by the formation of a series of neural
groups, which finally produce an expression by movement. A
train of thought must, according to the hypothesis, correspond
to the preparation of groups of centres for action in a series
under some stimulus whose repetition is followed by increasing
rapidity and accuracy, e.g., repetition of a poem frequently
read or a series of motor exercises imitated by sight from the
teacher. The laws of logic may be shown to be in harmony
with the physiological law. Good intellectual action does
not produce more physical wear than defective action, because
there is no greater amount of nerve energy in one group of
cells than in another corresponding; the value of the intellectual
act depends upon its complete control by the stimulus. Sound
intellectual function is in harmony with the environment, be¬
cause it has been built up by it.
I have but briefly sketched my own ideas on a difficult
subject, hoping to learn from others the results of their
observations and study.
Sensations of Cephalic Pressure and Heaviness . Carebaria ,
Pesanteur de tele. Kopfdruck . By Harry Campbell,
M.D.
Among the many abnormal cephalic sensations the following
constitute an important group :—
a. Sensations of pressure upon the head.
b. Sensations in which the head seems heavy.
c. Sensations of a vaguer character, though probably
related to the other two, the patient often complain¬
ing of a heaviness in the head.
To this group the terms “ carebaria,” “ pesanteur de tete,”
Digitized by ^ooQle
1893.] Sensations of Cephalic Pressure and Heaviness. 19
u Kopfdruck,” are applied indifferently. I shall for con¬
venience use only the “ Kopfdruck ” of the Germans.
a. Cases of pressure upon the head. The most common
site of this sensation is the crown. The following are from my
note book :—■*
Feels a pressure upon the crown (several cases).
Feels as if someone were pressing the brain down.
“ Feels as if the ceiling were coming down, and were close to
her, instead of being a long way ofE. ,,
Sometimes this sensation is so marked that the patient
fancies some heavy substance is resting upon the head :—
Feels as if something were actually resting on the head—“ keeps
feeling for it.”
Feels as if a ton weight were on the crown.
Feels as if “ somebody were sitting upon the top of the head.”
Feels as if a hot plate were resting on the crown.
Feels as if something heavy were pressing on the crown.
Next to the vertex, the most common seat of pressure-
sensation is the forehead, and when this is the case the eyes
are often involved in it. One patient felt a weight over the
bridge of the nose; another complained of a sensation as of a
band held tight across the brow; another felt as if the fore¬
head were bandaged lightly up; while in one case there was a
feeling of something pressing against the right temple. The
sensation is less often experienced at the occiput; to one
patient it seemed as if a ton weight were pressing upon the
occiput and nucha.
The pressure may be felt on any two of the above regions at
once, e.g. 9 the forehead and crown, the occiput and crown, the
forehead and occiput. Sometimes it is felt on both sides of the
head:—
'Feels as if something were pressing on either side of the head.
Has feeling as of a weight on the crown, and sometimes the
head appears to be pressed on both sides.
Or the sensation may extend round the entire head:—f
Feels as if a cord were tied tightly round the head, especially in
the frontal region.
* Langius, referring to the vertex, observes :—“ Ubi mulieres glaciei frigns
et pondus se sentire fatentur.” Quoted by Stuokens, “ De dol. cap.,” Brux.,
1787. Bellini, “ De Urinis et Pulsibus,” Leipsig, 1698, and many other of the
older authors refer to the same passage.
f Wepfer writes of one of his oases—“ There is, moreover, a constriction or
tightening of the head as if it were bound round about by a cord or bandage.”
“De Affect. Capitis.” Scaphusii, 1727.
Digitized by ^ooQle
20 Sensations of Cephalic Pressure and Heaviness , [Jan.,
Feels as if a string were tied round the head.
Feels as if something tight were tied round the head.
Feels as if a band of iron surrounded the head.
Feels as if an iron band encircled the head and were being
tightened up.
In all the above instances the abnormal sensation was more
or less limited to certain regions of the head. In the following
it involved a much more extensive area, the whole, or a large
part of the head seeming to be encased in a tight-fitting cap
which exerted an equal pressure in its several parts :—
Feels as if the head and jaws were fixed in an iron vice.
Feels as if something were closely fitting the head, and were
being screwed up tighter.
Feels as if the head were encased.
Feels as if the head were bandaged.
Feels as if the head were covered with a close-fitting skin, which
was being tightened.
Perhaps some of the cases in which tightness is complained
of are related to the last class, as, for example :—
Complains of tightness in the head.
Complains of a dreadful tightness.
Feels as if the skin of the head were too tight—as if the head
were bursting. (This sensation is very common).
It must here be pointed out that the abnormal sensation is
not always limited to the same position in the same individual.
It may be felt sometimes in one part, sometimes in another, as
in one patient who complained that the pressure sometimes
involved the sides of the head and sometimes the crown.
It will be observed that the sensation of pressure was, in one
of the above cases, felt at the back of the neck. I have met
with instances in which it involved other regions—for example,
the shoulders and upper part of the back. Dyspeptics, as is
well known, often complain of “ weight on the chest,” but how
far the sensation is related to that under consideration I
cannot say.
b . In the case of the second class of abnormal cephalic
sensations, viz., heaviness of the head, the sense of pressure
may or may not be present:—*
Head feels too heavy (several cases).
Head feels too heavy on shoulders—as “ heavy as lead.”
* Willis describes the case of a woman suffering from headache who was
also “ vexed with a weight of her whole heady a numbness of her senses, and a
dulness of mind.” (Eng. Trans, of his works.)
Digitized by ^ooQle
1893.] by Harry Campbell, M.D. 21
Head is so heavy, feels she must rest it.
Feels “top-heavy.”
Has to hold head up—it is so heavy.
Whole head feels heavy; feels she cannot lift it from the pillow.
Sensation as of a heavy load at the back of the head.
A ton weight seems to be weighing the back part of the head
downwards.* * * §
c. In the third class the vaguely-defined sensation is not one
of compression, nor of the head being unduly heavy; it is
rather one of heaviness, or some allied sensation, usually
described as felt within the head. It is, I need hardly say, by
no means easy to identify the sensation patients thus try to
describe. It is, perhaps, like that which many feel before a
thunderstorm, or which occurs as a result of mppressio men -
sium , or when one is morbidly sleepy. I presume that it
answers to the jfaprj^apia {x a PV = head ; fiapr) = weight) of
Galen, alluded to several times in his works. Thus, according
to him, one of the evils of the west wind was u carebaria ”+
which might also be induced by too much sleep, or sleep taken
at unwonted times.J Another supposed cause is referred to in
the following words: —•" Alii, nisi assidue coeant, capitis
gravitate molestantur.Ӥ These and many other passages
suggest that his “ carebaria ” describes rather a confused sen¬
sation of heaviness within the head than pressure upon it, or a
feeling of unwonted weight. The following are illustrative
cases from my notes :—
Has unpleasant feeling at back of head as if wanting to go to
sleep.
Heavy feeling in the head (several cases).
Heaviness in the forehead during stooping.
The word u oppressive” was occasionally employed by
patients.
Any of the three varieties of sensation just considered may
occur with or without pain. Sometimes the pain is felt as
distinct from the “ Kopfdruck,” when the patient will com¬
plain, e.jf., of headache and pressure on the crown. Often, how¬
ever, the sensations cannot be mentally differentiated, the
* One of Wepfer’s oases felt “as if a weight of lead were suspended from
the back of the head ” (op. cit., p. 103).
f Kuhn’s edition, Vol. xvi., p. 412.
i Vol. xv., p. 625.
§ Vol. viii., p. 417.
Digitized by ^ooQie
22 Sensations of Cephalic Pressure and Heaviness , [Jan.,
patient complaining of a pressing or heavy pain . The follow¬
ing are instances:—
Has “heavy” pains (several cases).
Has heavy agony.
Has pressing pain.
Has pressing pain, as if she would “ go out of her mind.”
Compares the pain in the head to a pressure on it.
Complains of a heavy, stupid, “ silly ” headache.
The sensations of heaviness, pressure on the head, etc., may
be unattended by any other abnormal sensation, or they may
occur in combination with tenderness, pain, burning, irritation,
a sense of coldness, and other sensations. The accompanying
table exhibits combinations I have observed:—
Pressure,
etc.
Tender¬
ness.
Pain.
Burning.
Irrita¬
tion.
Sensation
of cold.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Pain, tenderness, and pressure, involving generally the crown,
perhaps constitute the most frequent combination. Tenderness
and weight also frequently occur in the same region, and it is
worthy of remark that when the sensation of pressure on the
crown is combined with pain, the patient has more than once
Digitized by Google
23
1893.] by Harry Campbell, M.D.
complained of feeling as if he would go out of his mind.
Pain and pressure are often felt in the forehead.
The various combinations exhibited in the table affected the
same part of the head at the same time, but the areas involved
by the component sensations were not in all cases exactly co¬
extensive. It may happen, however (though such cases are not
taken account of in the table) that while the pressure is felt in
one part of the head, the other sensations—pain, burning, or
what not—involve some other part. Thus there may be
frontal pain with tenderness and pressure on the crown;
occipital pain with a sensation of pressure on the forehead.
These various facts tend to show that the sensation of
pressure does not stand in any necessary relation to the other
sensations enumerated—that, in fact, its nervous mechanism is
separate from, or independent of, that belonging to any of the
others.
The Eyes. —A word as to the sensations of weight and
pressure in connection with the eyes and eyelids. Patients
frequently complain of a weight in the eyes, and it is difficult
to determine whether the sensation is in the eyeball itself or in
the eyelid. The patient generally specifies the lids, often un¬
consciously quoting from Shakespeare *
Heavy frontal ache ; seems to weigh eyelids down.
Frontal pain; eyelids pressed down.
Vertical pain; weight over eyelids with it.
Sometimes, however, he complains—more vaguely—of the
eyes being heavy and compelling him to close the lids:—
Heavy dreary feeling in the eyes ; can scarcely open them.
Frontal headache and weight in the eyes; cannot keep them
properly open.
The weight in the eyes causes them to shut.
It seems certain that the feeling of weight may be actually
located in the eyeball:—
Frontal ache; feels as if the eyes would drop out.
Heavy feeling, as if someone were dragging the eyes down the
face.
When pain comes on, feels as if a weight were pressing the
eyeballs down.
* The following passage from Stahl is interesting in this oonneetion:—“ Es
driicke ihnen in den Stim nicht anders, als ob ein Stein darinnen lage; Kdnnen
kanm die Angen dafur anfttmn, und ins Licht sehep.” — fl. E. Stahl, Med. Dog.
Syst., etc., Seo. II., Halae, 1707, p. 683.
Digitized by t^ooQle
24 Sensations of Cephalic Pressure and Heaviness , [Jan.,
Feeling of weight in the eyes ; feels as if they would drop out
on looking down.
In one patient the weight seemed to be between the back of the
eyes and the top of the head.
Causation .—1. Clinical Aspect.—Kopfdruck is essentially a
manifestation of nervous debility (neurasthenia), and Range’s
long article on the subject* is largely devoted to a description
of what would now be called the neurasthenic state. Gowers,
who regards it as a symptom of hypochondria, maintains—in
accordance with this view—that it is more frequently met with
in men than women, but my experience is the reverse of this :
I find it exceedingly common among women, especially those
who are debilitated from excessive nursing, or from poverty,
those who are suffering from menstrual derangement, and,
above all, those who are passing through the climacteric. It
is, therefore, very common among the poor women met with in
London out-patient rooms. I scarcely think I am exaggerating
when I say that it and scalp-tenderness are more frequently
present than not among them.
Regarding, then, general nervousness as the chief factor in
its causation, two or three minor causes should be noticed.
(a.) Catarrh involving the frontal sinuses is very apt to be
complicated by pain and a sensation of weight in the fore¬
head—a fact noted by more than one writer (Labarraque,
Runge).
(b.) Affections of the eye, e.gr., errors of refraction, may lead
to a similar result (Runge).
(c.) Ear-disease is a frequent cause of Kopfdruck. Thus
McBride writes : “ A symptom very commonly met with in
various forms of ear-disease is a sensation of pressure or weight
in the head.”t Runge also refers to this cause, and Morison
points out that Kopfdruck thus arising is often limited to the
side of the head on which the ear-disease is situated—-a fact
which I can confirm. He writes : “ Among the minor and pain¬
less, but nevertheless very disagreeable symptoms of unilateral
catarrh of the outer or middle ear, is that of a sense of weight
and numbness over the affected half of the head; ” { and he
elsewhere points out that these sensations may be relieved by
packing the opposite and unaffected ear.§
(tf.) Finally, it may be mentioned that some have thought
* “ Arohiv f. Psych.,” Band vi., p. 627.
f “ Diseases of the Throat, etc.,” 1892, p. 395.
t “ Praotitioner,” Vol. xxxvii., p. 173.
§ “ Lancet/’ Yol. i., p. 519, 1883.
Digitized by C^ooQle
1893.]
by Harry Campbell, M.D.
25
Kopfdruck a characteristic of syphilitic headache. J. Rumpf,*
e.g., states that a “ nightly increasing sense of pressure on the
crown, though not always, is sometimes referable to syphilis,”
and he cites a case of syphilis in which such a sensation became
intensified towards evening, reaching its height at 2 a.m., and
then diminishing, but never actually disappearing. He adds :
“ This symptom (wie ich schon friiher gegenfiber Seeligmfiller
ausgeffihrt habe) is certainly not absolutely characteristic ”—
thereby implying that it had been so considered. Ross also f
speaks of syphilitic headache as being attended by Kopf¬
druck.
2. Anatomical Aspect.—Concerning the anatomical changes
which lead to the phenomena of Kopfdruck, nothing can be
said with certainty. Ziem explains vertical headache with a
sensation of pressure by supposing congestion of the superior
longitudinal sinus and its emissary veins ; { while Runge §
attributes the sensation to pressure on the sensory nerves of
the cranium and scalp, owing to disturbance in the circulation
wrought through the vaso-motor nerves. He manifestly
regards it as set up essentially in the periphery.
The feeling of tightness in the head, as if a tight skin were
enveloping the cranium, or a tight cap compressing it closely,
may possibly be sometimes associated with local vascular dis¬
tension, || indeed,.in some of these cases the patient feels “as
if his head were going to burst.” Gowers obviously attaches
little importance to anatomical changes in the envelopes of the
brain as a cause of the phenomena, regarding the mental state
of the patient as the chief agent in the production of Kopf¬
druck and other cephalic sensations. “ There is probably at
the outset some actual sensory impression, often some headache,
and the attention is constantly directed to the part, with the
result that the patient perceives sensations which, under normal
circumstances, would be unperceived. Nerve-impulses, in
health unnoticed, must be continually passing from all parts to
the centres, and they may be readily perceived if attention is
directed to them. ... If the reader will direct his attention
to the vertex, he will probably soon be able to detect a distinct
* “Die Syph. Erkrankungen des Nervensy stems,” Wiesbaden, 1887, p.252;
also p. 273 and p. 275.
+ “ Diseases of the Nerv. System,” Vol. i., p. 692.
$ “ Monatsoh. f. Ohrenheilkun.,” Nos. 8 and 9, 1886.
$ Op. cit. } p. 641.
|| The following passage from Galen—Kuhn’s edit., Latin translation—is
worthy of qnotation in this connexion: “ Alii caput contundi distendique sen-
tiunt.”—Yol. viii., p. 204.
Digitized by ^ooQle
26 Sensations of Cephalic Pressure and Heaviness , [Jan.,
sense of pressure there, especially if he is fatigued or has been
engaged in mental work.” *
That a concentration of attention on the affected part may
be partly responsible for the abnormal sensations thus felt,
especially in men, I fully admit, but I do not think it is an
essential element in causation. In the vast majority of the
cases I have met with, the sensation has arisen spon¬
taneously.
Psychic Nature of the Abnormal Sensations .—Concerning
the psychic nature of the vague sensations of heaviness felt
within the head, I shall say nothing further than that they are
essentially morbid, like giddiness—not related, that is to say,
to any normal sensations, to any sensations met with in perfect
health. Those cases, on the other hand, in which the head
feels abnormally heavy, might possibly be explained by
assuming some modification in the muscular sense belonging
to the muscles which support the head—indeed, one does not
quite see how it could actually feel heavy except through this
sense. Similarly, a feeling of weight in the upper lids is pro¬
bably a modification of the muscular sensibility of the levatores
palpebrarum. I may here remark that I have found posture
exercise a variable influence on the sensation of heaviness of
head, a change of position, as from sitting or standing to lying
down, sometimes diminishing it, at others having no effect; and
in the latter case the origin of the sensation must, one would
think, be essentially central.
As regards the pressure-sensations: when a weight is
placed on the top of the head, not only is the scalp pressed,
but the action of the muscles supporting the head is modified;
therefore, in this case the feeling of weight is a complex of
cutaneous sensation and muscle-sensation (= “ muscular
sense ”), and the like is true when pressure is applied to one
side of the head (if the pressure is equal on both sides or all
round, no muscles are called into action). The question we
have to decide, therefore, is whether the abnormal sensation of
pressure involves a muscular element. The fact that it
generally continues when the head is entirely supported, as in
lying down, suggests a negative answer, since the supporting
muscles of the head are not then called into action. I say
suggests^ for the muscle sense might be involved independently
of muscular action.
* “A Manual of Diseases of the Nervous System,” 1888, Yol. ii., p. 802.
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1893.]
by Habky Campbell, M.D.
27
Historical .—I have already referred to some passages from
Galen, in which he alludes to carebaria, and may now add the
following:—
In Yol. xvii. (Part 1, p. 33), the influence of Auster is
again alluded to. In Yol. xvi. (p. 115) he mentions a re¬
dundancy of humours, and in Yol. xv. (p. 781) stagnation of
blood as causes of carebaria; while in Vol. xvi. (p. 798) he
speaks of this sensation as a sign of haemorrhage. According
to him, the bath removes it (Vol. xv., p. 719), and sneezing
appears to alleviate it (Yol. xviii.. Part 1, p. 159).
Aretaeus, writing on chronic headache, observes that it may
be accompanied by great dulness and weight in the head.* * * §
Stahlf has an interesting passage referring to “ pressing 99
pains.
Jott,i writing on nervous headache in women, says the pain
in his cases was severe, and often combined with a sensation
of weight.
Carebaria is frequently mentioned by authors from the time
of Galen down to the present. See, for instance, Colin § and
Labarraque.|| Runge, in a paper already referred to, devotes
54 pages to the subject, under the title of t( Kopfdruck,”
but he occupies himself chiefly with a description of ner¬
vousness in general, citing a number of cases, and dealing
in detail with treatment. He remarks upon the tendency dis¬
played by patients afflicted with Kopfdruck to rub the head,
and states that pain is present in one-fifth of the cases only.
Among the causes he gives are affections of the eyes, ears,
frontal sinuses, throat, gastric and uterine troubles, and many
of the recognized causes of nervousness.
* “ On the Causes and Signs of Acute and Chronic Diseases,” translated by
T. E. Reynolds, Lond., 1837, p. 59.
t Op. ext., p. 680.
X “ Neue Zeitsch. f. Geburtskunde,” 1842, Band ii., p. 70.
§ “ Diet. Ency. des Scien. M6d. Art. Cfcphalalgie
|| “ Essai sur la C^phalalgie.”
Digitized by L^ooQle
On so-called Paranoia. By E. L. Dunn, B.A., M.B., etc.,
Wakefield Asylum.*
The class of cases described under the term Paranoia have
long been recognized in England, though, perhaps, they
have not been studied to such an extent as on the Continent,
and have, no doubt, been looked at from a different point of
view. The word in Greek literally means “ madness;” we
find it employed by authors synonymously with the terms
Wahnsinn and Verriicktheit, and on account of the confusion
existing between these, Mendel, in 1881, and Werner, in
1889, proposed to substitute “ paranoia ” for them. In this
sense it may be taken to mean " systematized insanity,” a
definition which covers all classes of paranoia.
The first difficulty which one encounters in studying the
literature of paranoia is the question of the acute and
chronic forms of the disorder. The acute form, first des¬
cribed by Westphal in 1878, has been admitted by Meynert,
Amadei, and Tonnini, and others. Under this heading we
find included cases ranging in variety from acute hallucina¬
tory insanity with delusions, to cases of melancholia with
stupor and the katatonia of Kahlbaum. Truly this is a pro¬
tean disorder. On the other hand the existence of an acute
form of paranoia is denied by Krafft-Ebing, Mosselli, Tanzi
and Riva, and other alienists. With the lattef we are dis¬
posed to agree; we are unable to find any sufficient connec¬
tion between the forms described and chronic paranoia to
warrant their being classed under that heading. Many of
the forms described as acute paranoia have few or no
common pathognomic symptoms, and in addition show few
points of differential diagnosis from the received acute
psycho-neuroses. The introduction of the term is to be
deprecated as rendering more complex an already involved
subject.
Chronic paranoia is, by those who admit it, divided into two
forms—Primary or originating de novo, the most important
and typical form, and secondary, the termination of a pre¬
vious psycho-neurotic state.
Of the forms of paranoia generally recognized, that of
paranoia persecutoria is the most important. This corres-
* Paper read at the Psychology Section of the B. M. Association, held at
Nottingham, July, 1892.
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Paranoia .
29
1893.]
ponds roughly to the delire chronique of Magnan and other
French authors. It is described by MM. Magnan and
Serieux * as a primary disorder always identical with itself,
which runs through four definite stages, always succeeding
one another in a fixed order. First, the incubation period,
characterized by restlessness and suspicion. In the second
stage the delusion of persecution appears and the delusional
conceptions become systematized under the influence of aural
and other hallucinations. The third stage is characterized
by the appearance of ideas of grandeur, and the fourth by
dissolution of the delusional states and weak-mindedness.
Magnan states that the disorder often attacks those free
from hereditary taint, and who previous to the attack have
been of fully developed intelligence and have shown no sign
of moral or intellectual anomaly. Before proceeding to dis¬
cuss this form of paranoia further it will be well to give a
short resume of the history and principal views held on the
subject.
Lasdgue, in 1852,+ described systematized ideas of per¬
secution, the first clear description of the subject. He
included in his delire de persecution cases without pro¬
dromal period, cases without hallucinations and some sub¬
acute alcoholics.
Morel, in 1860,+ in his two classes of hereditary insanity
described almost all classes of primary systematized delu¬
sions. He describes the peculiarities of these subjects, and
insists on the great frequency of systematization in these
forms, and the rapidity of appearance of the delusional
ideas in some cases and their slow evolution in others. In
his chapter of hypochondriacal neuroses he describes per¬
secuted patients who became exalted, but insists on their
having been hypochondriacal at first.
Griesinger, in 1861, described systematized.insanity, con¬
sidering it always secondary to mania and melancholia. In
1867 § he retracted this opinion and admitted with Snell ||
the primary origin of mixed states of persecution and
grandeur (Primare Yerriicktheit). He described also the
hypochondriacal and erotic forms.
Sander,! in 1868, described a form of Primare Verriickt-
* “ DSlire Chronique,” Magnan et Serieux, Paris, 1892.
f “ Archiv. Gen de M6d.,” Pev., 1852.
% “ Traits des maladies mentales,” 1860.
§ Griesinger, “ Archiv f. Psych.,” B. 1, S. 148, 1867.
|| Snell, “ Allgem. Zeitschr. f. Psych.,” B. xxii., p. 368, 1865.
! Sander, “ Archiv f. Psych.,” B. 1, S. 387,1868-69.
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sa
Paranoia,
[Jan.,
heit, which he calls “ originare.” These patients manifest
intellectual anomalies due to heredity from infancy. They
form into two classes. Some arrived at the period of
puberty are seized with hallucinations and delusions and fall
rapidly into dementia. Others live for some time in society
conspicuous for their eccentricities ; the morbid subjectivity
of which they are the prey increases, and from this they
ultimately develop ideas of persecution and poisoning.
Foville, * * * § in 1871, described the delusion of grandeur,
megalomanie. In this he includes both persecuted patients
with long incubation periods who have become exalted and
also cases with primary exaltation, and others without
hallucinations.
Westphal,f in 1878, divided systematized insanity into
four classes—the hypochondriacal form of Morel, the chronic,
acute, and originate forms, the latter being the only one in
which he admits a degenerative basis.
Mendel,J in 1883, insists on primary paranoia. He divides
it into simple and hallucinatory, acute and chronic. He
also describes originate paranoia (always hereditary and
degenerative) and the quarrelling insanity. He further
admits secondary paranoia, but insists on its rarity.
Among more recent writers on the subject, the following
views have been published :—
Krafft-Ebing § considers paranoia solely a chronic dis¬
order and never developing except in those with hereditary
taint; in fact, the paranoia is often merely a hypertrophy of
an originally abnormal character. He describes the incuba¬
tion period as lasting months to years and characterized by
suspicion; the actual disorder is marked by sense perversions
and hallucinations.
The main symptom of the disorder is delusion devoid of
affective basis, from the outset systematic and methodical,
and the primary creations of a disordered brain. Other
psychoses may occur in its course, and the disease terminates
in a condition of psychical weakness, which is not true
dementia. He divides the disorder into paranoia “ originate”
and “ tardive.” The originate commences in childhood as
described above. The tardy form is divided clinically,
* Foville, “Etude clinique de la folie aveo predominance de d&ire dee
grandeurs,” 1871.
f Westphal, “ Allgem. Zeitschr. f. Psych.,” B. xxxiv., S. 262,1878.
J Mendel, “ Eulenberg’s Encyclopaedia,” Nov., 1883.
§ “Lehrbuch der Psychiatric,” 1890.
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1893.]
31
by B. L. Dunn, M.B.
according to the contents of the predominating delusion,
into paranoia persecutoria and expansiva, the former being
more frequent. But these can occur after, in conjunction
with or isolated from one another. He makes a further
sub-division of these forms etiologically. He describes the
typical persecution form at length, and the transformation
into exaltation, which he says occurs in one-third of the
cases.
Kraepelin* * * § considers that Verriicktheit develops in a soil
of psychical invalidity with insufficient critical power. This
may be congenital or have supervened in the existence of
the subject. He finally divides systematized insanity into
the expansive and depressive form.
Domenica Janni + expresses similar views as to the etiology
and classification of paranoia, but distinguishes a secondary
form.
Amadei and Tonnini { describe a primary degenerative
form of paranoia and a secondary. They sub-divide these
into simple and hallucinatory forms.
Tanzi and Ifciva§ insist on the degenerative basis of
paranoia. They consider it always to be accompanied by
hallucinations and delusions more or less systematized, but
independent of the emotional condition. In only 14 cases
out of 100 heredity was unknown, but not excluded. They
consider paranoia a constitutional form, the delusion only a
symptom; the anomalies of the degenerative constitution
develop until they reach maturity at about 32 years, the
period when the sound man is at his intellectual height.
They divide paranoia into seven classes according to the con¬
tents of the delusion.
Snell || considers the essential character of paranoia is
delusion based upon hallucinations and having the character
of suspicion and persecution. The pure delusion of exalta¬
tion never occurs in paranoia. The ideas of exaltation may
appear simultaneously with the ideas of persecution, may
appear at the onset, disappear for a time to return later more
marked, or may follow ideas of persecution after a variable
time; the two then persist together. This is the usual rela¬
tion.
* “ Psychiatric, dritte Auflage,” Leipsig, 1889.
f “Manuale delle malattie mentali,” Napoli, 1891.
t La paranoia e le sue forme, “ Archiv Ital. per le malattie nervose,” 1883-84.
§ “La paranoia contribute alia storia della degenerazione psychiohe.”
|| L. Snell, " Zeitschr. f. Psych.,” B. xlvi., Heft, iv., 1889.
Digitized by ^ooQie
32 Paranoia , [Jan.,
We may now turn to the fuller study of paranoia persecu¬
tors, the most important and circumscribed type.
This disorder appears at from 35 to 45 years of age. It is
more frequent in the female sex. Of the various somatic
and other conditions somewhat empirically given as causes,
the climacteric is most important.
The incubation period is long and often passes unnoticed,
the patients at this stage rarely finding their way into
asylums. Its symptoms are indefinite. The patient expe¬
riences a general feeling of malaise and discontent which he
cannot explain. He sleeps badly and loses his appetite.
He becomes nervous and excitable, and shows but little
aptitude for his accustomed work. Gradually he becomes
suspicious, and imagining that people look askance at him
and despise him, remains for some time in the midst of
various doubts which ultimately give way to delusional
interpretations. It is remarkable, according to Lasdgue, that
the circumstances which cause the point de depart of his
delirium are trifles such as would not annoy him in health,
while great misfortunes may happen to the patient without
causing him corresponding mental distress. He remains for
a varying period ill at ease, suspicious of others and con¬
stantly seeking a cause for his abnormal feelings and finding
it in the most insignificant details of life. Constantly on
the watch, any scrap of conversation he may overhear he
attributes to himself as abusive, and suffers from an illu¬
sion of persecution. The idea of persecution constantly
before the patient’s mind at length reacts on the cortical
auditory centre; already prone to illusion, the mere ideation
henceforth suffices to awaken its corresponding auditory
sensation, and the aural hallucination is the consequence.
The patient then enters on the second period of the
disorder. This is characterized by the full development and
complete systematization of the ideas of persecution, and by
hallucinations of all the special senses of a distressing
character, in the following order of association and fre¬
quency :—Hearing; hearing and general sensibility; hear-
ing, general sensibility, taste and smell; and lastly hearing
with taste and smell only. Visual hallucinations are
extremely rare, and if present are usually not related to
the systematized disorder.
The hallucinations of hearing are at first simple, clocks
ticking, buzzing sounds, etc., then come low voices and
whisperings which the patient cannot understand. Soon
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1893.]
by B. L. Dunn, M.B.
33
these develop into isolated words and whole sentences. The
disorder of the cortical centre increases, voices now accom¬
pany the patient everywhere, and he holds imaginary
conversations with his enemies. The function of ideation
finally becomes automatic, and reacting on each occasion on
the disordered auditory centre, calls forth the corresponding
tonal image, and the patients complain that their thoughts
are repeated before they speak them. Hallucinations of
general sensibility may appear at this period or sooner, and
tend to further systematize the ideas of persecution. The
delusional ideas follow a regular course, at first vague, then
soon become more definite. The patient explains his ab¬
normal sensations according to his education and social
status. He accuses in turn electricity or hypnotism as the
cause of his distress, and various secret societies as the
agents therein. Soon he becomes more exact and fixes
upon some definite person. His reaction in •presence of the
delusional idea is at first passive, he merely takes precau¬
tions to avoid his enemies; soon, however, he takes on an
active stage, and resolving to avenge himself becomes most
dangerous. He may remain in this condition for many
years, the delusion stereotyping and co-ordinating itself and
developing a change of personality. In effecting this the
hallucinations of general sense are most important. The
patient, unable to account for the bundle of new sensations
which he experiences, tends to realize a new personality
which may co-exist with the old. Occasionally the pheno¬
menon of loud thoughts assists in this change, the patients
imagining that someone speaks in their head or stomach and
lays hold of their thoughts. At this stage he often takes to
the creation of neologisms, ordinary language being in¬
sufficient to express his unaccustomed sensations. The
delusion of exaltation has now usually been for some time
established; this may be merely a superadded symptom or
occasionally monopolizes the whole disorder.
The transformation to exaltation, for which the patient is
already prepared by his tendency to a change of personality,
and for which the characteristic egoism of the disorder has
rendered the soil ripe, may take place in one of three ways.
(1.) By logical deduction. The patient, at a loss to account
for his constant persecution, imagines that he must have
annoyed some great or powerful person, or that people are
envious of him. From this the transformation to the idea
that he is a great personage himself is easy, and the mental
xxxix. 3
Digitized by ^ooQie
84 Paranoia , [Jan.,
ease consequent on finding the explanation of his woes
tends to further it.
(2.) In some cases the transformation may take place
suddenly under'the influence of a hallucination or illusion.
(8.) Others consider that the exalted idea is merely a
morbid exaggeration of the patient’s original traits. Accord¬
ing to Mairet, these patients have always had a tendency to
megalomania.
In any case the exalted ideas usually supervene, but it must
be remembered that it is occasionally difficult to elicit, as
these patients are often chary of discussing their ambitious
ideas, though such may actually be present in full force.
The ideas of exaltation usually group themselves into
three classes. (1.) Ideas of transformation of personality;
they imagine themselves to be kings, emperors, or gods. (2.)
Ideas of power; they have superhuman or mysterious powers,
they direct the- stars and control the elements. (3.) Ideas
of wealth; they have enormous riches and immense posses¬
sions. Any two or more of these ideas may be present
concurrently. In certain cases, however, these may not be
of so marked a character. Occasionally death may cut off
the patient before the stage of transformation of the
delusion. In any case, however, it is rare for the persecu¬
tory ideas to disappear completely; they usually persist in
some degree in connection with the exaltation * This stage
of exaltation may last a variable time, but ultimately the
patient arrives at the terminal period of weak-mindedness.
On the occurrence of complete dementia as a consequence
of paranoia, authors are divided in opinion. According to
some the termination of paranoia is a condition of psychical
weakness, in which the delusions and hallucinations lose
their power to excite, the patient becomes apathetic and
settles down to some form of employment, while retaining
the power of conversing and reasoning rationally outside the
sphere of his delusion. As, however, paranoia begins in
middle life and requires from twenty to thirty years to run
its full course, in the final stage one must consider the
ordinary mental enfeeblement of old age when estimating
the destruction of mental power due to the psychosis.
Prognosis .—Paranoia is generally admitted to be incur¬
able. Kraffb-Ebing has seen no cure in 700 cases. Metz
and Roller have, however, in a recent number of the “ Zeits. f.
* Cf. Snell, loc. cit.
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1893.]
85
by E. L. Dunn, M.B.
Psychiatrie,” published two cases of cure after influenza. Re¬
missions may, however, occur with complete latency of
symptoms. One must guard against confusing dissimulation
on the part of the patient with these remissions. Exacerba¬
tions or acute psycho-neuroses may occur in the course of the
chronic malady.
Pathological .—With a view to establishing the position of
paranoia as a morbid entity, various hypotheses as to the
seat of lesion in the brain have been suggested. The
primary feature of the disorder consists in the morbid con¬
dition of self-reference without increased emotionalism. To
account for this, Meynert supposes conditions of irritability
in the bulb; these are supposed to cause anomalous hypo¬
chondriacal sensations, which, by keeping alive the egoism
in morbid intensity, produce the characteristic symptom
referred to. Wernicke suggests a focal lesion in those cell
elements which have been regarded as the basis of repro¬
ductive imagination, causing incongruity of reproduced
images with the normal impressions of the outer world. The
conception of a psychical focal lesion was first introduced by
Wernicke in 1874. Sensory aphasia afforded him a pre¬
cedent. Neisser refers the hallucinations and the phenomena
of loud thoughts to a central focal disturbance. Meynert
explains the latter phenomena by supposing an irritation of
the centres of the nervus acusticus; Cramer considers this
symptom as hallucination of the muscular sense in speech
apparatus.* These suggestions are purely theoretical, and
are merely brought forward to show the possibility of re¬
ferring the entire symptoms of the disorder to a definite
localizable disturbance.
Secondary Paranoia .—In this condition a small group of
delusions may remain and become systematized, as the out¬
come of a previous acute psycho-neurosis, almost always
melancholia. In these patients there is profound weakening
of all intellectual processes, judgment and memory. They
are apathetic as to their past and to all that was previously
interesting to them. The delusions are more monotonous
in character and their affective effect is not so marked.
These patients generally terminate in profound dementia,
with loss of social and aesthetic traits.
One other special form of paranoia deserves mention;
paranoia alcoholica—Krafft-Ebing calls this a rare condi-
* C. Neisser, " Centralblatt f. Nervenheilkunde und Psyoh.,” Jan., 1892.
Digitized by ^ooQie
86
Paranoia,
[Jan.,
tion. According to him, the delusions have often a sexual
basis. It is marked by the frequency of visual hallucina¬
tions, the early onset of mental weakness, and the irritability
and brutal behaviour of these patients.
As regards the differential diagnosis of paranoia, we may
just contrast the idea of persecution as appearing in the
melancholic and paranoiac state. Briefly, the melancholiac
has ideas of sin and guilt, he bears his chastisement humbly,
considering it deserved, and if he feels his altruistic feelings
growing cold he regrets it. His delusions are secondary to
the affective state; they revolve around a feeling of depres¬
sion and are rooted in this. The paranoiac , on the other
hand, is chastised for no fault of his own $ he revolts against
his persecutors, his altruistic feelings diminish, but his
intense egoism prevents his regretting them. The affective
state in paranoia is always secondary to the delusive, and is
the logical reaction to it.
The hypochondriac may be confounded with the paranoiac
in the first stage . The former, however, is wrapped up in
his sufferings; he suspects no one and does not look outside
himself for their cause.
In the second stage all delusions of persecution without
hallucinations must be distinguished from paranoia; all cases
in which the delusion constantly varies, and also cases of
delusion arising suddenly without stage of evolution. Accord¬
ing to Magnan, these cases bear the physical or moral
stigmata of degenerescence.
From the third stage , we must especially differentiate
primary delusions of grandeur, in which the prognosis is
often good. The age at which paranoia appears, usually in
middle-life, must be taken into account, but more especially
the evolution of the delusions, their logical connection with
one another, and their dependence on hallucinations.
If we turn again to the classification of continental authors
above quoted, we find grouped together, by various authori¬
ties, cases acute and chronic, hallucinatory and non-
hallucinatory, those with primary exaltation, and those
where the exalted ideas are the result of lengthy evolution.
We find described as different clinical types, under the head
of monomania of exaltation and monomania of persecution,
different stages in the same disorder—a state of affairs
described by Magnan as a “ clinical mosaic,” where one seeks
in vain for a constant cause or fixed prognosis. The same
condition exists in the English Clinical Text-books.
Digitized by ^ooQie
by E. L. Dunn, M.B.
87
1893.]
It cannot be denied, in the face of so many eminent
authorities, that there exists a large group of cases, origin¬
ating primarily from a long period of incubation, following
a constant course evolving through fixed stages, and the
separation of which from others now ranked in the same
class is not difficult. If we are to reclassify the old mono¬
manias and take up a new terminology the classes renamed
should be as distinct as possible. That class termed paranoia
persecutoria by the Germans, delire chronique by the French,
is admittedly the most typical of paranoias, and it would save
much clinical confusion if the term were confined to that
class only, admitting therein all cases whose slow evolution
of delusion and logical systematization in connection with
hallucinations of a painful and distressing kind, points from
the first to a chronic disorder, whether the subject thereof
may happen to bear the marks of a faulty heredity or the
reverse.
Remarks upon the Influence of Intestinal Disinfection in some
Forms of Acute Insanity . By JohnMacphebson, M.B.,
F.R.C.P.E., Stirling District Asylum, Larbert.*
Every asylum physician must regret the necessity that
exists for the employment of narcotic hypnotics in medical
practise among the insane, and there are probably few who
have observed it who do not deplore the far too extensive use
of sedative and depressing drugs, which is unfortunately the
common custom in some asylums.
One is therefore readily led to consider whether some other
means less injurious, more physiological, more permanent in
action might not be substituted for narcotic remedies.
Recently a form of therapeutic fashion has arisen in our
specialty, which in its advocacy of certain new drugs, such
as paraldehyde, urethane, sulphonal, etc., has sought to
classify them as sedatives or hypnotics in contradistinction to
narcotics. Anyone, not a partisan of the use of the drug,
who has observed a patient under the full influence of such
a drug as sulphonal cannot fail to be painfully impressed
by the spectacle, and every doubt as to the alarming narcotic
power of the drug must be dispelled. It is not, however,
* Paper read at the Psychology Section of the B. M. Association, held at
Nottingham, July, 1892.
Digitized by A^OOQie
38 Intestinal Disinfection , [Jan.,
against tbe valuable action of sulphonal in certain cases that
these remarks are indited, but against its misuse and against
the fallacy by which it is sometimes made to appear that the
drug in large doses is not a narcotic poison.
Many physicians, including myself, have been trained to
regard narcotics as injurious (in acute cases), and as tending
to retard the course of recovery. I have invariably found
that after a good night’s sleep, the result of a sedative
narcotic, the excited patient was next day noisier and more
troublesome and the melancholic more distressed in mind.
We have, therefore, to deal with a reaction which can only
be overcome by the continuous administration of the drug,
which in many cases means the emaciation of the patient
and the depression of his physical vitality.
It is claimed for sulphonal that it has the power of ward¬
ing off the periodic attacks of some forms of recurrent
insanity.
It ought to be within the knowledge of asylum doctors, for
it is a well-known fact in the experience of many old asylum
attendants and patients, that there is another and simpler
way by which these attacks are often abortively checked,
namely, by the administration of a smart hydragogue
cathartic purge.
Over and over again have I heard of patients, knowing that
a periodic attack was imminent, asking their attendant for a
dose of salts or a dose of castor oil, a request which was
generally gladly complied with, for both the patient and the
attendant foresaw an anxious time of longer or shorter
trouble before them, which, if once established, no drug had
power to remove.
This fact impressed itself upon my mind, and led me, in
conjunction with the other two or three reasons that follow,
to take up this subject.
Constipation of the bowels undoubtedly tends towards the
exacerbation of the symptoms of acute mental disease, and
an instantaneous though temporary improvement follows the
relief of a loaded intestine.
Again, there is in every acute case of insanity a marked
and apparent disorder of the gastro-intestinal tract.
This affection is probably secondary and sympathetic, but
even then it must exercise through the sympathetic systejn
of nerves an irritating and disturbing influence upon the
general bodily functions, besides being the source of con¬
tinual contamination of the whole system by the formation
Digitized by ^ooQie
1893.] by John Macpherson, M.JB. 39
within it and the absorption from it of the products of putre¬
factive change.
It is possible that the naso-pharyngeal and gastro-in-
testinal affections, which are the concomitants of certainforms
of stupor, are something more than sympathetic, and if not
coincident with the nervous affection are at least symptomatic
of it.
It is a fact that is widely known that the administration of
calomel or other forms of mercury in purgative or laxative doses
is sufficient to induce sleep, and the fact has been pointed out
by Dr. Lauder Brunton that nux vomica in small doses acts in
some cases as a mild hypnotic. Some purgative medicines,
besides calomel, have a soporific influence. But I was chiefly
led to the consideration of this subject by a passage in the
work of Sir Charles Bell upon the nervous system. At page
355 he is describing the treatment of tic douloureux, illus¬
trated by several cases.
After some weeks of attendance, one morning (whilst I was sur¬
rounded by the out-patients) this man, not waiting his turn, burst
through the crowd calling out he was cured! This, no doubt, he
did from his confidence in the interest young and old had taken in
his sufferings. I knew not what I had given him, but looking at
his card I found the following:—01. Tiglii (Croton) gtt. i.; Mas.
Pil. Colocynth Co. 3 i.; misce et ft. pil. xii.—one of the pills to be
taken on going to bed. . . . Impressed with these facts, the moment
that we see the map of the relations of the sympathetic nerve with
the second division of the fifth by a large and direct branch, and
lesser connexions of the same nerve with all the branches of the
fifth, we surely need look no further in explanation of the frequent
and intimate dependence of a painful affection of the face upon the
state of the digestive organs.
This illustrative case is followed by a string of others
hardly less instructive, in which the wonderful effect of this
purgative combination in the relief of trigeminal neuralgia is
set forth. While we are not bound to accept Bell’s explana¬
tion we are still met by the fact that certain drugs in certain
combinations have an action through the intestinal tract
upon the central nervous system. We also know the effect
of disorder of the gastro-intestinal tract upon the nervous
system, and chiefly upon the mental manifestation.
We know that certain forms of gastric and hepatic de¬
rangement are accompanied by mental depression. There is
a form of melancholia which might be described as visceral.
There is great uneasiness over the region of the stomach and
Digitized by ^ooQie
40 Intestinal Disinfection, [Jan.,
bowels, with rapid formation of gases and acid eructations
and physical and mental distress after food. Once it is
established it is relieved, though not cured, by the administra¬
tion of mercurials and gastric tonics. In a certain degree,
however, it may be said that every melancholia is visceral,
or at any rate manifests the constant concomitant of gastro¬
intestinal affection. The mouth is dry, the tongue is furred,
the digestive functions of the stomach impaired, and the
bowels constipated. It is therefore quite conceivable that
the relief of this condition should be followed by the
temporary or permanent relief of the nervous affection, of
which it is a concomitant or secondary effect. But the state
of the gastro-intestinal tract is, 1 believe (and upon this fact
I found my theory of the treatment that follows), in its dis¬
ordered state the source of a further element of complication
and aggravation of acute mental diseases. For it more
readily permits of the formation of poisonous ptomaines,
gases, and other products of putrefactive change which enter
the circulation and deleteriously affect the nervous system.
Recent researches seem to prove that the acid of the gastric
juice is primarily and chiefly an antiseptic agent, and that
its function of aiding peptic digestion is a subsidiary and
secondary one. It is the only example in nature of a mineral
acid being secreted by a living membrane, and the teleo¬
logical view of its origin is strengthened by the fact that in
the mollusca the acid is not hydrochloric, but sulphuric, and
that it contains no digestive ferment.
The total destruction by a healthy stomach of foreign or
pathological germs which might enter with the food and
cause further mischief in the intestines is thus secured.
Where the gastric secretion is perverted, as in acute
mental disease, this antiseptic power is in abeyance. It is
proved that the pancreatic juice, which is alkaline, is very
slightly antiseptic, and according to Bunge so slight is the
antiseptic power of the bile that it will not keep itself fresh
for forty-eight hours.
“With the view of attempting to supplement the weakened
activity of the alimentary tract, and with the object of
checking the formation of ptomaines, due to putrefaction
and imperfect proteid digestion, I resolved to attempt by the
following methods, which though they have only been
followed by partial success, yet appear to suggest a probable
opening up of a new way for the relief and amelioration of
many forms of mental affection.
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1893.]
41
by John Macpherson, M.B.
When a case is admitted that seems a suitable one for this
form of treatment the stomach is carefully washed out, and
the character of the contents is usually such as to justify this
simple procedure “ per se” A dose of calomel varying from
two-and-a-half to four grains, according to the patient, is
administered in the evening, and is followed, if necessary, by
some mild cathartic in the morning.
It is better to continue to wash out the stomach every day
or every second day during the course of the first week, and
to pay special attention to the bowels, which must not be
allowed to become constipated. In order to secure their
action, some form of laxative such as Pulv Rhei. Co. or
cascara and liquorice should be regularly administered.
On the morning of the second day of the patient’s
residence the special treatment is begun, which consists
in the administration of naphthalin in 10 grain doses three
times daily in the interval between meals, which may be
gradually increased until as much as 60 or 80 grains are
given in the course of 24 hours.
After reading the experiments of M. Fere and a paper in
the British Medical Journal by Dr. William Hunter, on
“ The Treatment of Pernicious Anaemia,” I was led to use
beta or iso naphthol, but I afterwards abandoned it entirely
in favour of naphthalin, having had a much more satisfactory
experience in the use of the latter drug.
Naphthalin has the chemical formula C 10 H 8 . It is
excreted in the urine partially unchanged and partially as
beta naphthol C 10 H 7 OH, and partly as phenol C 6 H 6 OH,
so that its power of disinfection seems vastly superior to that
of naphthol.
In my hands, and for the purpose I had in view, naph¬
thalin exercised an incomparably stronger influence than
naphthol.
It is said to be poisonous when absorbed into the system,
and its great insolubility is said to be the safeguard against
its toxic effects. After using it in large doses several
hundred times, I can state that in no instance or at any
time was there the remotest symptom of poisoning apparent.
Further, there was no interference whatever with any of
the functions of the body.
The test of the utility of such a drug as naphthalin in
inhibiting putrefactive change within the body is the
diminution of the aromatic sulphates in the urine.
In order further to prevent the formation of putrefactive
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42
Intestinal Disinfection ,
[Jan.,
products in the intestine, nitrogenous food was, as far as
possible, eliminated from the dietary of the patients under¬
going treatment, and peptonized gruels were, therefore,
administered to those cases requiring food in addition to the
ordinary meals instead of custards.
Nothing in this form of treatment contra-indicates, so far as
I know, the employment of any other drug at the same time.
In none of the cases were single doses of naphtlialin
followed by any marked results. In the great majority of
cases it required continuous administration for several days
to produce the desired effect.
The following cases are given as illustrating the action of
naphthalin, and as typical of the results obtained:—
Case I.—Female, aged 65, suffering from delusional melan¬
cholia, with great excitement, noise, sleeplessness, refusal of food,
and bodily emaciation. She imagined that she was to be burned
alive or scalded to death in a hot bath, and did not cease to scream
and shout with terror and struggle with the attendants. About
one month after admission the usual preliminary treatment was
adopted, and naphthalin in 10 grain doses was administered with
the feeding tube three times a day. Within three days after the
commencement of the exhibition of naphthalin, the patient
became quiet and began to sleep better at night, and by the
end of the first week of treatment she had ceased to manifest any
symptoms except the delusional expressions.
These disappeared gradually, and she finally recovered two
months after the commencement of the special treatment. Weight
during treatment increased from 1121bs. to 1241bs.
Case II.—Female, aged 23, labouring under melancholia, with
impulse, a tendency to stupor and suicide, refusal of food, and
sleeplessness. She was resistive, and refused to answer questions
or to respond in any way when addressed. She was at once put
under treatment, and began to improve forthwith. At the end of
three weeks she was working industriously in the ward and
taking her food well. She replied to questions in monosyllables
or by signing with her head. She continued in this condition
until her removal from the asylum, ten weeks after the com¬
mencement of treatment; Weight at commencement of treatment,
1121 bs.; ten weeks later, 1161bs.
Case III.—Male, 47, melancholia ; had attempted suicide prior
to admission, very depressed and suicidal, refused food, and was
sleepless. No change in his condition having taken place, the
special form of treatment was begun five weeks after admission.
He steadily improved, and was discharged recovered exactly one
month from the date of the commencement of treatment. Weight
before treatment, 1401bs.; weight at time of discharge, 1471bs.
Digitized by ^ooQie
1893.]
by John Macpherson, M.B.
43
Case 4. —Male, 58, presented alternately symptoms of mania
and melancholia, was at times very excited and noisy. He slept
badly and was very tronblesome. He was put upon treatment
about a week after admission, and immediately thereafter calmed
down and became less troublesome. In about three weeks he
became, to outward appearance, quite sane, but retained delusions
regarding his family. Weight before treatment, 1351bs.; after
quiescence, 1411bs.
The following is a brief description of the results of the
treatment of thirty acute cases, chiefly cases of melan¬
cholia :—
Bodily Health .—In no case was there any apparent inter¬
ference with appetite, digestion, assimilation, or with the
regular action of the bowels or the excretory function of the
body.
The action of the drug in the prevention and removal of
anaemia was so marked in the cases treated that I desire to
draw special attention to it.
The bodily weight increased steadily in most of the cases
during the administration of the drug, and it is significant
that in no case was there any loss of weight. When it is
remembered that the dietary was as non-nitrogenous as it
could, physiologically, be made, even to the exclusion of
eggs, it is all the more important to record this fact as
indicating a tendency on the part of the drug to promote
digestion and assimilation. It also proves the power of the
drug directly or indirectly to counteract those conditions of
excitability of the nervous system which are so inimical to
nutrition.
The usual tendency to pigmentation of the skin so com¬
mon in melancholia was checked, as also the dry character
of the skin and its appendages, which was replaced by a
well-nourished, smooth appearance.
The promotion of sleep was perhaps the most unexpected
and gratifying result of the exhibition of naphthalin. In a
few cases single doses of the drug were sufficient to induce
sleep, but in the more severe cases and in the majority of
the cases treated it required the continuous administration
for two or three days before the sleep habit was restored.
When fully under the influence of naphthalin the patients
slept normally and naturally for seven or eight hours, and
awoke apparently refreshed.
In one case, where for three nights in succession 20 to 30
grains of sulphonal did not cause sleep, one dose of naph-
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44 Intestinal Disinfection , [Jan.,
thalin (30 grains) gave the patient a good night’s rest, and
continued to do so upon repetition each night.
In the present negative state of our knowledge with
regard to the mode of action of hypnotics, it is, of course,
impossible to state definitely whether naphthalin is a direct
hypnotic in the sense that paraldehyde or sulphonal is, but I
am inclined to believe that it is not. 1. The sleep was
undoubtedly not narcotic in its nature. 2. It did not
require an increasing dose of the drug to continue its action
each successive night once the sleep habit had been induced.
3. There was no increase of motor restlessness, mental
distress, or excitement on the day following a good sleep.
Therefore it appears more likely that the sleep-inducing
qualities of naphthalin are of an indirect nature, and are
due to the suppression of those causes that prevent normal
sleep.
The Mental Symptoms .—What has just been remarked
regarding the hypnotic effect of naphthalin applies equally
to its action upon the nervous system. It has probably an
indirect, but it may also have some direct, influence upon
the cortex. I have been unable to discover any objective
physical signs indicative of any special action upon the
central nervous system, nor have any of the patients com¬
plained of any subjective sensations or unusual experiences.
The drug undoubtedly cut short some of the attacks,
chiefly milder melancholias. In the majority of cases it
did not shorten the period of mental disturbance, but it
modified the symptoms to a marked extent. The mental
distress and motor restlessness of melancholia rapidly dis¬
appeared, the suicidal cases became quieter, and the
tendency to impulse in all the cases was almost entirely
removed. The aspect of a ward in which five or six recent
acute cases of melancholia lived was so much modified by
this treatment as to be in itself a sufficient justification for
the use of the remedy. These (female) patients represented
most of the ordinary clinical varieties of melancholia, but
gradually the distinctive symptoms of each variety dis¬
appeared, and the patients, though continuing to be
melancholic and delusional, became sedate, industrious,
less dangerous to themselves, and less troublesome to their
nurses.
This power of the remedy to modify the prominent,
troublesome and distressing symptoms of acute melan¬
cholia is all that I now claim for it.
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1893.]
by John Macpberson, M.B.
45
With regard to its use in mania, I am not at present
prepared to make any statement. In one case of acute
mania in an adolescent subject it induced normal sleep, and
by means of single doses administered each evening sleep
continued to be secured to the patient. At the same time
the patient rapidly gained weight.
I feel justified, therefore, in summarizing my knowledge
of naphthalin in the treatment of certain forms of acute
mental disease as follows
1. The drug proved safe and harmless in all the cases.
As much as 170 grains were given to one patient in twelve
hours with no evil effect.
2. It failed in several cases to produce any effect, but
some of the failures I now attribute to the fact that the
drug was not pushed far enough in sufficiently large doses.
3. Its influence upon the bodily condition was to promote
nutrition and to induce normal sleep.
4. Its influence upon the mental state was to modify and
abate the distressing and more violent symptoms, and to
hasten on a condition similar to commencing convalescence.
5. The purely psychical disorder of the brain was in no
way affected by the treatment.
The Payment of Asylum Patients for their Work. By Charles
Mercier, M.B.*
It is unnecessary to expatiate to this Association upon the
extreme desirability of inducing the patients in asylums to
employ themselves usefully, nor is it needful to dwell at
length upon the extreme difficulty that is often experienced
in so inducing them. It may be taken as a fact that many
inmates of asylums who are able to work are unwilling to
do so, and, if we listen to their explanation, the unwilling¬
ness is not altogether unreasonable. “ I was placed here,”
such a patient will say, “ against my will. I did not come
of my own accord. I am under no obligation to facilitate
the plans of those who put me here, nor of those who keep
me here. My refusal to work is a protest against the depri¬
vation of my liberty. If I have to engage in the work of
the asylum I should, in the first place, forego my protest,
and to that extent admit the justice of my incarceration;
* Paper read at the Quarterly Meeting of the Association, November 17th,
1892.
Digitized by ^ooQie
46 The Payment of Asylum Patients for their Work, [Jan.,
and in the second place, by making myself useful to the
authorities, I should give them a positive interest in detain¬
ing me here all the longer. Besides, why should I give the
benefit of my skill and experience free, gratis, and for noth¬
ing to those to whom I am, to say the least, under no obliga¬
tion ? The labourer is worthy of his hire. Before I came
here I worked hard and long. I had no objection then to
work, and whyP I tasted the reward of my labour. I was
paid for what I did, and the more I worked the more pay¬
ment I received. Pay me here for my labour, and I am
willing to work for you.”
Such may not be the very words of the patients who refuse
to work, but such is the sense and the meaning of the answers
that are daily received by the officers of asylums who try to
induce patients to employ themselves, and it is impossible
not to admit the reasonableness of the reply. Such patients
do, it is true, often at length take to work from very weari¬
ness of their idle lives, but this is a motive that cannot be
relied upon, for in some cases the love of idleness grows by
indulgence until all inclination to work disappears, and in
others, even if industrious habits are at length assumed, the
golden moments have been lost; the early weeks or months
of the malady, when the influence of steady occupation in
promoting recovery is most important, have slipped by in
idleness and ennui , and with them has gone the best chance
of the patient's recovery.
To obviate the unwillingness of patients to work, and to
supply them with an inducement to industry, it has been
long recognized that some sort of reward must be held out
to them as a return for their labour; but the reward that
has hitherto been offered, which takes the shape of beer, of
tobacco, or of a trifling addition to the diet, is quite inade¬
quate, both as a reward for the amount and quality of the
work that is done, and as an inducement to idle patients to
become industrious. Some further payment is urgently re¬
quired, but the difficulties in the way of affording a further
payment must be admitted to be great. That payments can¬
not be made in money is almost self-evident. Pecuniary
payments would afford means for the purchase outside the
asylum of articles which it is most undesirable that patients
should possess, and, moreover, would place in the way of
both patients and attendants most undesirable temptations
to theft and swindling of various modes. At the same time
there are very great objections to payments in kind. A pay-
Digitized by ^ooQie
1893.]
by Charles Mercier, M.B.
47
ment in kind does not satisfy. It deprives the payee of the
pleasure of purchasing; it obliges him to accept his payment
in a certain form, which may perhaps be distasteful to him,
and which he will be sure to consider inadequate; and, as at
present practised, it rewards at the same rate the most
highly skilled labour of the most industrious and the occa¬
sional activity of the most unskilled.
It is, however, possible to devise a mode of payment which
offers all the advantages of money payment, and obviates to
a very great extent its disadvantages. This is by creating
a token currency for use in the asylum, in which payments
to the patients could be made, and purchases by them could
be allowed. It would be easy to cut or stamp sheets of brass
or copper into tokens of convenient size, or to issue instead
of them credit notes of a very low face value, say one half¬
penny, and to pay these weekly to the patients—not, of
course, to the amount of the value of the work done, but in
some proportion to the value of the work, and with some
reference to the nature of the work. These tallies or tokens
or notes should be exchangeable at the stores of the asylum
for such various commodities as are valued by patients—for
tobacco, snuff, writing paper, pencils; for jam, marmalade,
cakes, sardines, saveloys, sugar, treacle, eggs, and other
eatables 5 for ribbons, cheap lace, neckties, handkerchiefs,
artificial flowers, and a hundred and one other things which
experience and inquiry would soon suggest. I should pro¬
pose that the jams and other eatables, divided into portions
of the value of one token, and each portion just sufficient for
eating with one meal, should be arranged at tea time on a
table in the dining hall, and the patients should be able there
and then to purchase additions to their meal. For other
commodities a shop should be opened once or twice a week.
Supposing that the face value of ten tokens or notes were
fixed at a half-penny, this sum would purchase, of the
qualities ordinarily used in asylums, a quarter of a pound of
jam, a quarter of a pound of sugar, a quarter of an ounce of
tobacco, a quarter of an ounce of snuff, two quires of note
paper, or a quire and eight envelopes, half-a-pint of beer,
and so on.
The present payments in kind should be altogether
abolished, and patients should be allowed ,to purchase if
they pleased the same quantities as are now allowed to them.
The same rule would hold as regards tobacco, and the pay¬
ments made to the patients should, of course, be sufficient to
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48 The Payment of Asylum Patients for their Work , [Jan.,
enable them to purchase as much as they now receive by
allowance, and something over.
The collateral advantages of the system of payment here
advocated would be many and great.
1. It would supply a disciplinary agent of the most direct
and effectual and often least obnoxious character, for it
would enable fines to be imposed upon patients for mis¬
conduct, a punishment that they would feel as keenly, and
that would be without the manifest objections of the punish¬
ments now in use. If the associated entertainments, for
instance, are to be regarded as a means of treatment, then
certainly no patient, who has shown by derangement of
conduct his need of treatment, should be excluded from
them as a punishment.
2. It would enable some extra advantage and reward to
be held out to those patients whose occupations are of
a repulsive nature, such as those employed in the foul
laundry.
3. It would contribute enormously to the well-being and
contentment of the patients, for it would supply, at any
rate in some degree, what is now so conspicuously lacking
in their lives, viz., an object, an aim of some sort. Too
much stress can scarcely be laid upon the utter emptiness of
the lives of the great mass of patients in asylums. Any¬
thing that would give them an object in life, an incentive to
exertion, something to which they could look forward, some¬
thing in which they could feel a close personal interest,
would be the greatest amelioration of which their lives are
capable, and this end would certainly be, to some extent,
attained by the system that is here advocated. It would
give them an incentive to exertion; it would place within
their reach opportunities of obtaining things that they may
now perhaps dream of, but can never hope to possess. It
would afford to all the working patients the pleasurable
excitement of a daily or weekly visit to the shop. It would
give to them in their own eyes, and in the estimation of their
fellows, some degree of that consequence and importance
that is conferred by the possession of property. True, the
property is not large, but among the blind the one-eyed is
king, and among an assemblage of paupers, not one of whom
has a mag to call his own, the possessor of a very trifling
amount of purchasing power becomes a person of con¬
sequence.
4. An exception to the inconvertibility of the token coin-
Digitized by A^OOQie
1893.]
49
by Charles Mercier, M.B.
age might be made upon the discharge of a recovered
patient from the asylum. The value of whatever token
coinage he had earned and saved might then be presented to
him, and not only would such a plan be an incalculable boon
to pauper patients upon leaving an asylum, but there would
be added a very strong incentive to convalescent patients to
work while waiting for their discharge.
5. Lastly, the financial results would be found to be very
advantageous. Difficulty there might be, and probably would
be, at first with the financial authorities of the asylum, but
this difficulty would be overcome when it was brought under
the notice of the authorities that a system of payment of
patients, similar in principle to that here proposed, though
differing in the details of its working, has actually been in
force in the criminal asylum at Broadmoor for the last 25
years, and has been found not merely beneficial, but actually
financially profitable in its working. Of this system, the
initiation of which was due to the foresight and energy, and
the working details of which were settled by the adminis¬
trative ability of Dr. Orange, the then superintendent of
Broadmoor, I was in total ignorance until the notice that I
was to read this paper appeared on the agenda of this meet¬
ing. Upon seeing that notice Dr. Nicolson, the present
superintendent, was kind enough to invite me to visit
Broadmoor, and to examine the system that Dr. Orange had
so successfully devised. I find that at Broadmoor the value
of the patient's labour, of whatever kind that labour may be,
whether that of skilled artisans, of needlewomen, or of ward
cleaners, is estimated, either by time, at rates varying from
2d. per hour upwards, or by the piece. However estimated,
the patient is given, in two books of the asylum, credit for
the value of the work that he does; not for its full value, but
for a value strictly proportionate to its full value, that is to
say, for every shilling that his labour is worth he is credited
with l^d. A pass-book is issued to him containing a complete
statement of the amount to his credit, and this amount he
may expend in anyway he pleases, subject to the sanction of
the superintendent. He may traffic with other patients, the
superintendent being satisfied that the price given and taken
is a fair one, or he may send in a requisition for any com¬
modity up to the value of his credit balance. There is no
coinage, token or other; the whole transaction is carried on
by means of book credits and debits entered against the
names of the patients.
xxxix. 4
Digitized by ^ooQie
50 The Payment of Asylum Patients for their Work . [Jan.,
The most important result of this scheme is that it is a
financial success. A sum of money exceeding £700 is
annually placed in this way to the credit of the patients, and
great part of this is expended for them, and it is estimated
By the asylum authorities—and let me suggest that the
officials of Her Majesty’s Treasury are not easily satisfied as
to the propriety of expending the national funds—it is
estimated that the sum thus expended is much more than
recouped by the increased value of the labour that the
patients are thus induced to perform.
CLINICAL NOTES AND CASES.
Cases of Hereditary Chorea (Huntington 9 s Disease). By W.
F. Menzies, M.D., B.Sc.Edin., M.R.C.P., Senior Assis¬
tant Medical Officer, Lancashire County Asylum, Rain-
hill. (Illustrated.)
(Concluded from p. 568 of Vol. xxxviii.)
A short account will next be given of the other cases I
have had the opportunity of examining.
Case II.—Tickle (D. 16), sister to the previous patient, was ad¬
mitted into Rainhill Asylum, 12th August, 1887, from the County
Asylum, Lancaster, where she had been for four years. History: Ten
years ago had a disappointment in love, and has ever since been
of a sombre and depressed temperament. Six years ago the
tremors commenced, and about the same time her mind became
doll and her memory poor, while depression was more marked.
The jerkings slowly increased, and fits of violence became
common, so that she was dangerous to herself and others. On
admission she was suffering from advanced phthisis, and was
very thin and weak. The chorea was almost in abeyance. She
was unable to stand, but could sit up. Pupils dilated and in¬
sensible to light; margins slightly irregular. Muscles of ex¬
pression paralyzed, has right ptsosis. Thyroid gland enlarged.
Patellar jerk increased, no ankle clonus, no superficial reflexes.
Dementia is far advanced. She can barely tell her name, does not
know her age, or where she is. Takes little notice of what goes
on around her, says she feels weak and ill, but has no pain.
Articulation most indistinct, lips and tongue tremulous. Heart
weak, no bruit, urine normal. Thus the general weakness cloaked
the usual signs, but Dr. Harbinson, of Lancaster Asylum, who
himself twelve years ago published the first English recorded cases,
Digitized by L^OOQle
Fig. 1.
Fig. 2.
Fig. 1 is a diagram to show condition of Clarke’s column between 11th and
12th dorsal.
Fig. 2 is copied from Obersteiner, and shows normal cord at 12th dorsal;
x, Clarke’s column.
Fig. 3.
Fig. 3 shows Clarke’s column as seen in a few sections just above 12th
dorsal on the left side. The bulging “ x ” in Fig. 2 seems here to be repre¬
sented by a process “ o ” from the posterior horn, containing a couple of
ganglion cells. Though this process is indicated in Fig. 1, it was too small to
be detected by the naked eye.
Fig. 4.
Fig. 4 shows areas of degeneration (dotted). It is not meant to indicate the
relative amount in different parts accurately.
Fig. 5.
Fig. 5.—Cervical enlargement, showing increase of connective tissue in
postero-median and postero-external columns.
To Illustrate Dr. Menztes’ Case.
Digitized by ^ooQle
Digitized by
Clinical Notes and Cases.
51
1893.]
told me that while tinder his care the woman displayed the
ordinary signs, but dementia was disproportionately advanced.
She died fourteen days after admission. Post-fnortem—besides
the pulmonary tuberculosis, slight renal cirrhosis, and a small
spleen, with fibrous capsule—there was nothing of note in the
trunk cavities. Dura mater normal. Brain 1,061 grammes. Con¬
siderable excess of subdural fluid. Membranes thickened all over,
general opacity of arachnoid. Brain, as a whole, unusually firm,
membranes strip everywhere with abnormal ease. Right hemisphere
425 grammes; left 443 grammes, both stripped. Much general wast¬
ing, no local atrophy. Grey matter about § normal thickness.
Striation well marked. Cortex and white matter both rather pale,
latter very firm, ventricles dilated, floor smooth. No noticeable
change in basal ganglia or cerebellum. Pons and medulla firm. No
microscopical examination was made. The brain was evidently
overgrown with sclerosis, and the grey matter atrophied.
Case III.—Tickle (F. 5), a boy of 13. The only abnormality is
an irregular jerking of the fore-arm and hand when he endeavours
to grasp an object, as in eating; the thumb turns downwards and
the object is often knocked over. When his attention is called to
it he can control it, but it recurs as soon as he forgets about it.
He is a decidedly intelligent lad. Knee-jerks normal. Whether
this case will develop remains to be seen, but in any case the
relationship here observed between the genesis of a habit spasm
and an organic disease of the higher motorial regions is of more
than passing interest.
Case IV.—Tickle (D. 48), male, an inmate of Prescot Union
Infirmary, where, through the kindness of Dr. Hall, the medical
officer, I was able to make an examination. He is totally confined
to bed, but can sit up. The muscles are flabby, but not wasted.
Subcutaneous fat abundant. The tremors marked in the thighs,
trunk, upper extremities, and face, especially the two last, but in
the legs have mostly given way to rigidity. He is continually
throwing his arms about, turning and twisting his hands in and
out, and going through every variety of movement. One or other
side of the mouth may be drawn up, the head rotated or extended,
the eyes blinked, or the corrugator supercilii thrown into strong
contraction. The abdominal muscles, intercostals, diaphragm,
and larynx all share, so that respiration is momentarily in¬
terrupted by a sharp snorting groan. Sensation is normal
—no history of pain. He can describe accurately where he
is touched, but cannot execute the movement of pointing
out the place, the endeavour ending in more violent jerkings than
usual. Cannot protrude his tongue at all. Knee-jerk and plantar
reflex excessive, ankle and quadriceps clonus strongly marked,
wrist and triceps jerk present, cremasteric, abdominal, and
scapular reflexes absent. The left lower extremity is somewhat
more affected than the right, and the same holds for the face.
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52
Clinical Notes and Cases .
[Jan.,
Right pupil 3*5 m.m., left 3 m.m.; latter irregular in margin, both
react freely. Vision, optic disc, and fundus normal. Hearing
normal. No R.D. Heart perfectly normal and regular, action
of bowels and digestion unimpaired. Urine normal. The cerebral
condition is one of demented contentment. He smiles and nods
his head in response to questions to which he cannot articulate an
answer. Seems to understand most that is said to him, and knows
where he is, but has a very imperfect idea of the flow of time.
Attention poor. The emotional element becomes prominent when
anyone gives him bad tobacco. He tosses it down, screams and
ejaculates incoherently, and endeavours to strike the donor, while
the movements become more tumultuous than ever. This is the
most advanced case I have seen, and the cortical atrophy, with
sclerosis in cord and brain, must be extensive.
Case V.—Dixon (C. 7), female, admitted into Rainhill Asylum,
10th September, 1887, aged 49. She has been married 30 years,
and has six children. The jerks have prevailed for ten years. It
does not certainly appear whether dulness and loss of memory
were concomitant or sequent. For two years she has been more or
less maniacal, and at last so violent that her relatives cannot keep
her at home any longer. The excitement partakes almost entirely
of the spasmodic emotional type. She has twice attempted suicide
(drowning and hanging). The weakness and jerkings have pro¬
gressed steadily. On admission she was too weak to stand alone.
The movements were of the usual type. Sensation and muscular
sense normal, plantar reflex absent, knee-jerk excessive, no ankle
clonus, triceps jerk present. Heart, lungs, and abdominal organs
normal, urine normal. She was weak-minded and happy, dull, un¬
interested in her surroundings. Memory very poor, attention
small, j udgment none. Probably the advanced dementia was the
most prominent feature. During residence she had frequent
attacks of emotional depression, and would cry aloud for hours.
Opposition to her wishes was a common cause of these outbursts.
On 9th February, 1888, she was seized with an apoplectiform
attack, in no way differing from those seen in general paralysis;
coma, stertor, and general flaccidity were present, all jerkings and
reflexes abolished. Temperature reached 103° F. She pulled
round in a few days, but remained permanently weaker and
thinner, and the movements were less under control. Articulation
was now unintelligible. This attack is of great interest, and is
the only one I have been able to hear of in any case of the disease.
The patient died 3rd March, 1889, of tuberculosis of lungs and
intestines. The brain and cord were removed for examination,
but there is no record of the result. I remember that there was
general increase of neuroglia, as evidenced by unusual firmness.
There was also a haemorrhagic membrane on the cord, which may
bear relationship to the apoplectiform attack.
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Clinical Notes and Cases .
53
Case VI.—Dixon (C. 14), male, 34, still living at home. He
began to be affected at 26, and has for long been unable to work.
The tremors are typical, but not very conspicuous. General
muscular weakness is more prominent, and the gait is slow and
unsteady. Sensation and muscular sense normal. He is a well-
nourished man with no muscular atrophy. Plantar reflex absent,
knee-jerk somewhat brisk, scarcely abnormally so. Tongue pro¬
truded in a jerky manner. Speech slow and dragging. He ex¬
periences a difficulty in starting his sentences, but these, when
started, are fairly coherent. Pupils equal and normal in reaction,
media clear, myopic shadow marked, disc and fundus normal,
Vision !*-§■. Fields of vision normal. No R.D. Mentally he is fairly
clear, but shows the same loss of apperception and attention as
the other cases. He is contented and careless. His wife says
his temper is most uncertain, but he has so far not been violent.
He lately went to the Royal Infirmary, Liverpool, but after a few
days grew restless and discontented, and refused to stay longer.
Case VII.—Dixon (C. 15), male, 32, younger brother to the last.
This is an incipient case. At present his intelligence is good, and
when I called to see him I found him engaged in solving quadratic
equations. Contrasted with this excellent grasp of present events
was his uncertain memory for the past. He was quite dubious as
to how long he had been married, the age of his children, and the
order in which they were born, and his wife remembered far
more about his own family than he did himself. He presented
a strange picture, aware that the fatal disease was com¬
mencing, yet most anxious to conceal it. He sat bolt up¬
right, and did not attempt to rise when I entered, his knees
were kept pressed together, hands clasped, and eyes fixed rigidly
on the opposite wall, thus making every preparation to control and
hide the slight jerks which were at intervals apparent in fingers,
forearms, and legs. His tongue is steady, pupils normal, knee-
jerks not exaggerated. During the conversation he frequently
lapsed into dreamy inattention, from which he woke with a start
when his wife spoke to him. I did not care to make a complete
examination, dreading an outburst of temper, but shall endeavour
to keep the case in sight.
. 'Remarks .— ^Etiology .—Huntington's chorea is probably one
of the most hereditary of all diseases. In one of my families 25
per cent, of traced individuals were affected, and 50 per cent, of
those over 12 years old; in the other, where the type was one
of later appearance, nearly one-third of the adults suffered.
Other observers have noted a higher percentage still. The
age at which it appears, generally speaking, precesses genera¬
tion by generation, but the exceptions are numerous,
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54 Clinical Notes and Cases . [Jan.,
and the rule far from strict. Those ascertained are here
tabulated:—
Sex .—The two families consist of 67 males and 71 females,
as well as 36 of sex unascertained. There were affected 26
males and 16 females. This superiority in the males is not
due to a preponderance of male patients, for those who had
children were 18 males and 23 females, and of the affected
members 14 males and seven females were parents, so that at
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1893.]
Clinical Notes and Cases .
55
least twice as many men are affected as women. There is no
tendency to alternation of the sexes in successive generations,
either parent being liable to bequeath the disease to son or
daughter.
Other points in the astiology are the absence of any
diathesis, especially a freedom from rheumatism.
Pathology .—The clinical signs of this disease are so
identical with those of ordinary rheumatic chorea that we
are driven to conclude that, whatever may be the nature of
the lesion, the position in the nervous system is the same.
Where may we reasonably seek for it P Hitherto the results
of post-mortems have been most unsatisfactory, for early
cases rarely die, and advanced ones show gross tissue changes
quite- sufficient to cloak the slight alterations presumably
responsible for the symptoms. A minute microscopical
examination of both hardened and fresh sections in an early
case is still a desideratum.
We can at once exclude the cord, for the knee-jerk is never
lost, and in early cases, sensation being normal, is not
increased. .Nuclear lesions of the medulla are always wanting,
the elements of speech are always perfect, letters are never
misplaced, syllables never omitted. The ataxia might
suggest the cerebellum; but in one case of an acute lesion,
which was for some days limited to one lobe, none of the
cerebral signs here seen were noticed. A thalamic lesion has
given rise to choreoid movements, but the association of
mental defect with these limit our choice to the cortex.
Possibly the large motor cells of the third layer are de¬
fectively inhibited, either by disease of the higher cells or
by interruption of connecting fibres. The latter is more
probable, for the cerebral phenomena of an early case
suggest no organic defect, but only a want of proper
control, as evidenced by the rise of the emotional element.
The simplest explanation thus assumes disease of the
terminal fibres of the “ cerebral segment,” just as primary
spastic paraplegia is the result of a similar lesion of the
upper cerebro-spinal segment. Functional over-action may
lead to the descending cord changes diagnosed in advanced
cases, as happened to the hysterical girl mentioned by
Charcot. Such a pathology reconciles the few facts of
morbid anatomy hitherto collected, the degeneration of
various cord tracts, with hypertrophy of the motor cells in
the anterior horn, found by Oirincione and Mirto; the
atrophy and sclerosis of the internal capsule with destruc-
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56
Clinical Notes and Cases .
[Jan.,
tion of the cornual cells in the cervical cord, described by
Harbinson; and the general sclerosis noted in my own
cases and those of others. One condition always found is
an overgrowth of the connective tissue element, giving
abnormal firmness. Now it is possible that this growth of
neuroglia may, by pressing upon the efferent, afferent, or
commissural fibres, so affect either the sensations which regu¬
late movement, the currents to the muscles themselves, or
especially the direction, inhibition, and co-ordination of the
large cells in the motor regions by those in the higher parts
of the brain, wherever these may be situated, as to cause a
partial dislocation of the muscle functions either by inter¬
ruption or irritation. The implication of motion without
sensation is just what we should expect in most cases, but
in the more advanced ones some disorder might reasonably
be looked for. It should be remembered that the special
senses are not involved at all, and that for years there is no
loss of the lower ideational centres, memory, judgment,
reason; but only of the highest inhibitory functions. So
with our present knowledge of brain function guesses at
localization are futile.
The theory that certain embryonal connective tissue
elements remain latent till late in life is one more easily
formulated than either proved or disproved. The sclerosis is
too slight and too wide-spread to render it probable, and the
theory is less likely to hold water in hereditary chorea than
in cancer, where it has been nearly proved to be false.
Evidence of a slowly acting micro-organism in the
environments at home or at work is wanting, for although
it be true that many of the unaffected leave the district
while the sufferers remain, and although if the affection
once cease it rarely reappears in a subsequent generation,
yet there is no case in which it has developed in the wife of
an affected husband, or vice versa , even after the lapse of
fifty years.*
# While this article was passing through the press, the woman Jane Tickle
died of tubercular peritonitis. A post mortem examination was made by Dr.
Wynne, Pathologist to Rainhill Asylum, and the notes are appended at the end
of the paper. It will be seen that general sclerosis of the brain was present,
but not to such a marked degree as in other cases. The atrophy (?) of the
occipital lobes was most marked, but seems to have produced no symptoms. The
myopia and nebulae accounted for the defect in vision, and the fields and colour
perception were normal. Probably the sclerosis of the antero-lateral ascending
tracts deserves special attention, but in other respects the result of a minute
microscopical search (over 100 sections) must be regarded as disappointing.
The other cases I saw post mortem had no occipital atrophy. With regard to
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Clinical Notes and Cases .
57
Summary .—One of the first points which strike anyone
reviewing the comparative literature is that different
families appear to affect different clinical types. All
writers agree that the disorder is essentially a chorea, that
the jerkings are at first partly under control, that the knee-
jerks are generally increased, and that cerebral defects are
common. Yet all are not agreed whether or not the move¬
ments cease during sleep. According to Waters, signs of
the ailment appear only after middle life, while Diller
mentions a generation where ten cases all developed before
twenty-five years of age. Huutington considered it more
common in men, Sinkler in women. Caviglia thought it
equally common in both. Therefore, with Dr. Reynolds, I
would deprecate dogmatism until some more extensive series
of cases have been collected, extending through more
generations. My own cases explain that some observed
differences arise from studying the disease at different
stages of development, e.g ., the persistence of spasms
during sleep. The essential points of the disease may be
summarized thus : At first there are only the jerkings and
the associated emotional state, leading to attacks of the
so-called mania or melancholia, then descending changes
cause increase of knee-jerks and general muscular weakness,
while the cerebral sclerosis results in true dementia. Lastly
the patient dies, not so much of the disorder itself as from
dome intercurrent affection, to which his paralyzed condition
lays him open. The most common of these is tuberculosis,
probably because he drifts into a workhouse hospital or
asylum infirmary, where unfortunately, the bacillus is but
too frequent.
To give in detail the results of other observers would
swell this article much beyond its proper limits. These
results can be obtained by reference to the original treatises ;
a relation of observed facts is of greater moment with our
Dr. Wynne’s account of the post mortem changes, there was, in addition, a
pronounced increase of connective tissue (almost a sclerosis) of the anterior § of
the postero-median columns in the cervical enlargement, and to a less degree of
the postero-external. The central canal was partially obliterated by connective
tissue overgrowth in the cervical region, wholly in the dorsal and lumbar. That
the processes of Clarke’s column were less conspicuous than normal is not
beyond the range of dispute. Other observers have met with sclerosis of the
antero-lateral ascending tracts. Is it possible that interruption of the muscle
sensations ascending to the cerebellum, causes erroneous reflex judgment, and
so sets the muscles into clonic spasm, this spasm then causing a second up¬
ward sensation, which now reaches the cortical areae of consciousness, and makes
the patient aware of the contraction ?
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58
Clinical Notes and Cases .
[Jan.,
present knowledge of the disease than protracted discussion
of theories more or less inadequate to account for the
symptoms.
I close with a request to asylum medical officers to collect
other cases. There cannot be many which do not, at some
period or other, come under the notice of relieving officers
of the various unions, through whose agency every affected
family in England could without much expenditure of labour
be traced, and thereby many questions regarding a morbid
entity not wholly devoid of interest could be finally disposed
of.
Summary of Post-Mortem Notes of Jane Tickle (Hereditary
Chorea).
Post-Mortem made seventeen hours after death. Age 33. Body
much wasted. No bed sores. No lividity.
Cranium. —The skull presented no abnormality either in shape
or density. The sinuses were fairly full of partly clotted blood.
There were no old thrombi. The main vessels were quite healthy.
Dura Mater. —A little above average thickness, but not adherent
either to skull or pia-arachnoid.
Subdural Space contained a little excess of clear fluid.
Pia-arachnoid was absolutely free from any opacity or thicken¬
ing and was nowhere adherent. There was a slight excess of
fluid, chiefly in the sulci. There was no hyperaemia.
Cerebral Hemispheres. —The whole brain weighed 1,132 grms.
The right hemisphere weighed 459 and the left 457 grms.
There was distinct, though slight atrophy of all parts of the
cerebrum, as evidenced by the rounding off of the convolutions
and widening of the sulci. In the temporo-sphenoidal lobes the
atrophy was scarcely noticeable.
The occipital lobes presented a symmetrical diminution in size,
which from the condition of the convolutions and sulci would
seem to be at least in part developmental and not due to atrophy.
The cuneus on the left side was very distinctly atrophied.
On the whole the atrophy was greater on the left than the
right side of the brain, and more distinct in the paracentral
region than in the frontal.
Cortex Cerebri. —The tint of the grey matter was quite normal.
Its consistence was in all parts rather firmer than in health. In
the temporo-sphenoidal lobes, it was, as is usual, less firm than
elsewhere. There was slight narrowing in all, except the
occipital lobes. The striation was rather more distinct than
usual. Vascularity normal.
Lateral Ventricles were not dilated. The ependyma was slightly
rough, hut not distinctly granular.
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Clvnical Notes and Cases •
59
Basal Ganglia presented nothing abnormal to the naked eye.
Cerebellum 139 grms. No abnormality.
Pons 15 grms. Rather softer than other parts of the brain.
The grey matter seemed less pigmented than nsnal.
Medulla Oblongata weight 6 grms. Rather small. The grey
matter of a paler tint than nsnal.
Spinal Cord. —Nothing beyond an nnnsnal firmness detected in
the fresh state.
Thorax. —The lnngs were tnbercnlar. Nnmerons small vomicss
in npper lobe of left, and small patches of consolidation scattered
through right.
Heart .—A little hypertrophy of left ventricle.
Abdomen. — Spleen .—Capsule thickened. Increase of connective
tissue.
Liver. —Fatty.
Kidneys .—Capsule thick, very adherent. Fibrotic kidney.
Intestines. —Matted together, and the whole peritoneum covered
by tubercular deposits and lymph. The tubercles varied in size
from the ordinary “ miliary ” to masses the size of marbles.
Microscopic Examination. —In considering the changes found in
the brain it must be borne in mind that the patient was a fairly
advanced phthisical subject, and for some time before death had
tubercular peritonitis with diarrhoea.
Fresh sections from various parts of the cerebrum were examined,
and all showed the same changes, differing only in degree accord¬
ing to the amount of atrophy present in the different regions.
The changes noted were :—
1. A slight coarseness of the neuroglia in the first layer.
2. A slight thickening of the vessels.
3. Degeneration of the cells in all layers. The degenerate
cells were characterized by loss of processes, a granular
condition of the protoplasm, and very often vacuolation
of the nucleus or cell-body. This vacuolation did not
specially affect any particular layer of cells, but was more
abundant in the deeper than the more superficial, or at
least was more readily detected.
4. In hardened specimens spider cells were detected in very
small numbers near the vessels in the white matter, but
neither in fresh nor hardened specimens was there any
appearance of miliary sclerosis.
Sections of the medulla showed a thickening of the ependyma,
and an undue coarseness of the connective tissue beneath. Sections
of the cornu ammonis and gyrus hippocampi showed vacuolation
of the large pyramidal cells, and the presence of “ colloid bodies ”
in the endothelial lining of the fimbria.
Spinal Cord. —In hardening, a one per cent, solution of bichro¬
mate of potash was used for twenty-four hours, followed by a two
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60
Clinical Notes and Cases .
[Jan.,
per cent, solution frequently changed until the cord was ready for
catting. No alcohol was used until after the sections had been
stained.
In staining, Weigert’s, Pal’s, and Marchi’s methods were used,
and some sections were stained with picrocarmine or with Ehrlich’s
hamatoxylin alone. The results obtained by all the methods were
the same.
White Matter.—In all parts of the cord Gower’s tracts and the
direct cerebellar tracts showed scattered groups of degenerated
fibres. In the lumbar region a zone bounding the periphery of the
cord from the anterior commissure to the exit of the posterior roots
showed an almost entire absence of healthy fibres.
Qrey Matter .—The cells were everywhere unusually pigmented
and granular. Picrocarmine sections treated with osmic acid and
those prepared by Marchi’s method showed intensely black clumps
of granules in nearly all the cells. This was most conspicuous in
the cervical regions.
Clarke’s column appears distinctly abnormal, especially in the
lower dorsal region, where it should be most conspicuous. Sections
from between the eleventh and twelfth dorsal nerves did not
exhibit the characteristic swelling of the posterior horn produced
by this group of cells. In some sections no cells at all could be
seen; in others one or two highly pigmented oval cells with no
processes. Sections at the junction of the dorsal and lumbar cord
showed the cells of the column being displaced by growth of con¬
nective tissues, and their proper area encroached upon. Just below
this the column was represented by an isolated cell, or not at all.
Throughout the upper and middle dorsal cord the column was
ill-developed, and very often no cells were found. When cells
were present they were always more numerous on the left side;
that is, if there were two or three on the left side there would be
one or none on the right.
Vessels .—Here and there distinctly thickened vessels were
present in the anterior horns; elsewhere they were dilated and
full of blood.
Medulla Oblongata .—Nothing abnormal was detected in sections
prepared like the spinal cord. I was unable to make certain of any
degenerated fibres.
From these observations it would seem that the degeneration of
the cerebellar tracts and Clarke’s columns was the characteristic
lesion in this case.
There was undoubtedly a widespread though slight sclerosis, as
evidenced by the unusual firmness of the brain and spinal cord.
Fibrotic changes were also noted in the kidney and spleen. As
regards the brain, the evidence of disease was abundant, but the
changes met with were of a very common character, and presented
as far as I could see nothing characteristic. The absence of
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Clinical Notes and Cases .
61
1893.]
thickening, opacity, and adhesion of the soft membranes excludes,
I think, any inflammatory origin of the cortical degenerations.
What effect the bodily condition of the patient may have had on
the cortical grey matter cannot be estimated, but I think a good
deal of the cell degeneration may be set down to that cause.
I do not see any sufficient ground for assuming a cortical lesion
for this disease. May it not more probably be a slight sclerosis
sufficient to hamper but not abolish the control of movements ?
Such an obstruction might be situated in the cord.
At any rate, in future cases it would be well to search for the
lesions here shown in the spinal cord. If these lesions are found
to be constant it will be time enough to construct a theory of the
pathology of hereditary chorea.
In view of the recent experimental work on the spinal cord, it is
interesting to note that the patient in this case, though carefully
examined, exhibited no alteration of sensation.—E. T. Wynne, M.B.
BIBLIOGRAPHY.
1. C. O. Waters.—Dringligon’s Practice of Medicine, 2nd edition, Vol. ii., p.
245. Letter written 1841.
2. Irving W. Lyon.—American Medical Times, 19th December, 1863.
3. George Huntington.—Medical and Surgical Reporter, Philadelphia, 13th
April, 1872.
4. Landouzy.—Socidtd de Biologie, 1873.
5. Alex. Harbinson.—Medical Press and Circular, 18th February, 1880.
6. Ewald.—Zeitschrift fiir klin. Medic., Band vii., 1884.
7. West, Stoke-on-Trent.—British Medical Journal, 5th January, 1884, and
26th February, 1887.
8. Peretti.—Berliner klin., Wochenschr., 1885, Nos. 50 and 51.
9. Clarence King.—New York Medical Journal, 1885, p. 468.-
10. Clarence King.—Medical Press of Western New York, 1886, Vol. i., p. 674.
11. Huber.—Virchow’s Archiv., C. viii., p. 267; also Amer. Jour. Med. Science,
October, 1887.
12. Oppenheim.—Berliner klin. Wochenschr., 1887, xxiv., 309.
13. G. Seppilli.—Riv. sper. de freniat. Reggio. Emilia, 1887-8, xiii., 453, 459.
14. Zacher.—Neurolog. Centralbl., 1888, No. 2, and Amer. Jour. Med. Science,
April, 1888.
15. Hoffman.—Virchow’s Archiv, oxi., 3, 513.
16. Lannois.—Revue de M3dic., 10th August, 1888.
17. Lenoir.—Etude sur la Choree Her^ditaire, Lyons, 1888, 96 pp., 8vo.
18. Klippel et F. Ducellier.—Enc6ph&le, Paris, 1888, viii., 716, 723.
19. Wharton Sinkler.— Jour. Nerv. and Ment. Dis., New York, February,
1889, p. 69.
20. Diller.—Amer. Jour. Med. Sc., Dec., 1889, p. 585.
21. King.—Medical News, 13th July, 1889.
22. Suckling.—Midland Med. Soc., 16th October, 1889, and Brit. Med. Jour.,
1889, ii., p. 1039.
23. C. M. Hay.—Universal Medical Magazine, Philadelphia, 1889-90, ii., 463,
472.
24. Korniloff.—Vestrick. klin. i. sudebnoi psichiatu i. neuropatol, St. Peters¬
burg, 1889, vi., No. 2, 38-56.
25. Bower.—Jour. Nerv. and Ment. Dis., New York, 1890, p. 131.
26. Pietro Caviglia.—Arch. Italian, di clinic. Med., June, 1890.
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62
Clinical Notes and Cases .
[Jan.,
27. E. Biernacki.—Berlin klin. Wochen»chr., No. 22, p. 485, 2nd June, 1890.
28. G. Cirincione and G. Mirto.—La Psichiatria, vii., faao. 8 and 4 , and
Giornale neuropatologia, vii., fasc. 4, 1890.
29. E. 8. Reynolds.—Med. Chronicle, April, 1892.
30. Greppin.—Neurolog. Ceotralbl., 1st October, 1892.
Case of Abnormal Development of the Scalp . By T. W.
McBowall, M.D., County Asylum, Morpeth. (With
Plate.)
The accompanying illustration represents what is believed
to be a hitherto undescribed abnormality of the scalp. The
condition was discovered accidentally. I observed an atten¬
dant cutting a lad’s hair, and remarked that he was not doing
it very well, as there appeared to be numerous scissor-marks.
It was explained that the marks were due to the arrangement
of the hair. This led to careful examination of the whole
scalp. Its condition is very well represented in the illustra¬
tion. On each side there are five deep furrows, passing from
behind forwards. Those nearest the middle line are straight;
the others slightly curved, and they are the more curved the
further they are removed from the middle line, and at the
same time they diminish in length. When the hair is of
ordinary length the condition of the scalp -would not be
suspected; it is only when the hair is very short that the
furrows become evident. For the purpose of preparing the
accompanying illustration the hair was cut as short as possible,
but the hair growing in the furrows was necessarily left some¬
what longer than elsewhere, with the result of indicating with
great clearness the course and arrangement of the depressions.
The furrowing of the forehead is not abnormal, but is produced
by the patient whenever he is annoyed, as he was when the
photograph was taken.
The patient is an epileptic idiot, aged 22 years, and has
been resident in the asylum nine years. He exhibits only
slight traces of intelligence. He is above the average stature,
and in good bodily health. The whole right side of the body
is wasted, and the limbs contracted. He is stated to be the
eldest of six children, and to have been epileptic since he was
one year old. He is distinctly but not markedly microcephalic.
Since this congenital deformity of the scalp was discovered I
have examined the heads of all the male patients, with the
result of discovering another example, but not so marked.
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JOURNAL OF MENTAL SCIENCE.
Jan. 18 93.
To i llask' ate D r Me Dowall's Case
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Google
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1893.]
Clinical Notes and Cases.
63
This patient is also a microcephalic idiot. I have made wide
inquiry in order to discover whether such a condition had ever
been described before, and also to obtain some information as
to its nature. All my research proved fruitless, except in one
direction. Dr. Carlyle Johnstone informed me some six months
ago that he had discovered two such cases, and he has been so
good as to favour me with a photograph of one.
Professor Unna, of Hamburg, to whom I forwarded a photo¬
graph and description of the case, favoured me with a reply.
He was of opinion that the condition of the scalp had not been
previously described. He suggested the electrical stimulation
along the sides of the scalp to see whether muscular contrac¬
tion could produce folding of the skin in a similar direction.
In his letter he continues :—“ A series of stimulations along a
corresponding line, producing a series of contractions and fold¬
ing of the skin, would thus indicate a high development of
the skin muscles, the contraction of which may account for
the rest of the furrowing. As regards the comparative
anatomy, I have examined several apes in the Zoological
Gardens here, and found that they possess a very muscular
scalp, but no amount of irritation succeeded in making them
fold the skin along the lines of the folds in the scalp of your
case. It would perhaps be advisable to consult an anatomist
or zoologist upon this question.” Professor Unna’s suggestion
to stimulate the scalp by means of electricity was tried, but
the result was absolutely negative.
A friend was so good as to forward a photograph to Professor
Kaposi, of Vienna, and I was favoured with the following com¬
munication :—“ I have delayed answering your letter because
I wished first to consult the opinion of the Professor of Patho¬
logical Anatomy of the city, Professor Kundrat, who has been
absent for some time. I have now, however, seen him, and
he says that he considers the folds to be partly hypertrophic.
He has observed hypertrophies in microcephalies and in other
deformities of various parts of the body.
u In this case one might conceive that the brain had not
advanced in growth, but the skin was sufficient for a normal
skull, and had developed independently in accordance with its
own capacity for growth. But because the contents to be
surrounded remained too small, the normally large skin was
forced to arrange itself in folds over the small skull, and in
parts became atypic, i.e., hypertrophied during development.
I fancy, too, that the folds chiefly correspond with the cleavage
of the skin (Langer’s lines).
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64
Clinical Notes and Cases .
[Jan.,
“This, after my conversation with Professor Kundrat,
coincides with my ideas on the subject. 1 do not know what
else to say about it.”
Were Professor Kaposi’s suggestion correct it is probable
that such a condition of the scalp would be seen much more
frequently, seeing how common microcephaly is. If one may
venture to offer a suggestion,it appears to me possible that we
have here a retrogression to a lower type. I have not had
opportunities of specially examining the heads of the animals
in the Zoological Gardens, but I have seen a somewhat similar
condition in dogs, and my impression is that it is very marked
in lions, tigers, and animals of that class. When a dog pricks
his ears the furrowing can be seen very distinctly, especially
when the hair is thin.
It is probable that the exact nature of the condition will not
be ascertained until a case has been minutely examined after
death.
Since writing the above I accidentally came across the
following passage, which clearly shows that the condition
was observed many years ago, though not by a medical
expert:—
“ But the idiot, B6n6si, inspired me with no repugnance,
because he was always good and always clean, with his grey
coat and his coarse shirt, whose collar cut his enormous ears,
adorned with rings. I would scarcely even ridicule his
stammering when it took him two minutes, in speaking to
my uncle, to say, ‘ Monsieur Bi6bi6oniface.’ He had a strange
appearance, however, with his large nose, wide mouth, and
head the size of one’s fist, close-cropped, and streaked with
furrows like a potato-field.
“ What solicitude, like that of a faithful dog, he mani¬
fested for his blind sister, whose guide and careful guard he
always was!
“ Therefore it was that we protected B6n6si, and defended
him against the street boys, who threw stones at him and
made fun of his insane but harmless fits of anger.”
(“ The Life of an Artist,” by Jules Breton. Translated
by Mary J. Serraon. Sampson Low, Marston & Co. 1891.)
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65
OCCASIONAL NOTES OF THE QUARTER.
Tennyson as a Psychologist .
That Tennyson touched the finest chords in our nature
none will dispute. But there are poets who have done this
without being what the lamented Laureate* unquestionably
was—a psychologist. “ In Metnoriam 33 is full of psychology
as well as feeling. He went deep down into the springs of
human thought and action. “ Lucretius 33 is psychological
if any poem in the language is.
It was our purpose to analyze Tennyson’s works from our
standpoint and to show how much true metaphysics can be
found, if looked for, in the marvellous prolucts of his grand
brain, with which he has enriched our literature for ever.
On glancing back, however, at the old volumes of our
Journal, we found an article by its first Editor which
appears to us to present Tennyson as a psychologist in so ad¬
mirable a manner that we decide upon reproducing it. The
article, which consists chiefly of a review of “ Maud, 33 is
besides historically interesting, if for no other reason than
that it marks the time when the term “ psychological 33 was
supplanting that of “ metaphysical. 33
It is seldom, indeed, that a physician finds occasion to review a
work so far removed from the dominion of scientific literature as
a poem. Prose, and that of the driest sort, is the bone upon
which the medical critic is for ever destined to whet his fangs;
and from poetry he is so debarred by the custom and opinion of
his profession, that he dare scarcely make use of a line or two for
the purposes of illustration or ornament, except under fear of
meeting the reproach of flippant absurdity. Yet physicians have
been poets, and good ones too ; and poets the true artists of man¬
kind have, in all ages, been our best instructors in many of the
secret springs of human action, and of the maddening emotions of
the soul.
Not to speak of classic writers, in what pages can we find the
phenomena of insanity portrayed with more vivid truthfulness
than in those of Shakespere. There is more real mental science
to be learned from the teaching of this demigod of poets than in
all the metaphysical rubbish which was ever delivered from pro¬
fessional chairs. The study of mind in its irregular developments
* Died at Aldworth House, Surrey, Oct. 6, 1892; buried in Westminster
Abbey, Oct. 12th. ‘
xxxix. 5
I
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66 Occasional Notes of the Quarter . [Jan.,
appears to have as great a charm for the great English poet of the
present day as it had for that prince of song. The writings of
Tennyson are peculiarly metaphysical, or, to use the new term,
psychological. His “Two ¥ 01008 ” and “Palace of Art” display
wonderful psychological insight, and his new poem is neither
more nor less than the autobiography of a madman. The critics
have found great fault with Mr. Tennyson for choosing so dis¬
agreeable a hero, and have designated the wild poetry, wonder¬
fully true to nature, in which the inner life of this morbid mind
is depicted, as spasmodic and unpleasant. With purely literary
criticism we have nothing to do; but the subject which Mr.
Tennyson has chosen is one of peculiar interest to ourselves and
our readers. It is the history of a madman depicted by the
hand of a master, and we shall attempt to give an analysis of it,
so far as it comes within our domain as mental pathologists. Let
others criticize the beauties of the poetry or the irregularities and
novelties of the metre; the point of view we take is, the power¬
fully and faithfully drawn mental history.
True to psychological probabilities, the author represents his
hero as the scion of an unsound stock. His father committed
suicide, or at least was strongly suspected to have done so, by
precipitating himself from a rock.
“ I remember the time, for the roots of my hair were stirr’d
By a shuffled step, by a dead weight trail’d, by a whisper’d fright.
And my pulses closed their gates with a shock on my heart as I heard
The shrill-edged shriek of a mother divide the shuddering night.”
The father of his future mistress, Maud, is pointed at as the
cause of this ruin of his house, and the death of his own parent.
The hero grows up a morbid misanthrope, hating himself and
all mankind; he snarls and sneers at everything, but most of all
at himself. The whole race of man seems to him too base to
live, or at least to continue; the earth is a “ sterile promontory,”
the heavens a “ pestilent congregation of vapours.”
He is introduced to us full of morbid emotion, a constant
mental sufferer, a true example of Guislain’s theory of the psycho¬
pathic origin of insanity. The utmost extent of his hopes is a
philosopher’s life of passionless peace, far from the clamour of
the slanderous world,
“ Where each man walks with his head in a cloud of poisonous flies.”
But most of all he would “ flee from the cruel madness of
love; ” he is not destined to escape this peril. Maud, the
daughter of the “ lean grey headed old wolf,” who had ruined his
father, returns with her brother to the hall, preceded by the
report of her singular beauty. Maud had been his playmate in
the days of childhood, and he retains in his memory an impression
that their fathers had affianced them.
t
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Occasional Notes of the Quarter.
67
He sees her, and finds his peace in little danger from her
beauty, which is faultless ; but with a “ cold and clear cut face,”
“ she has neither savour nor salt.”
But the cold and clear face haunts him by day and by night.
He meets her on the moorland, and at church, and in the
village street. The tender poison steals into his veins, but he
resists and strives earnestly to think ill of her. He felt from the
first “ my dreams are bad, she may bring me a curse.”
He suspects her of pride, then of falsehood, and of the baseness
of endeavouring to gain his favour for the political purposes of
her brother.
As the hopes of love open to him, he sees a prospect of joy in
the world, which had hitherto presented to him so dark and
dreary an aspect.
But if Maud prove all that she seems to be, it were different.
He still however suspects and resists, a raven ever croaking at
his side, “ keep watch and ward, keep watch and ward.” Last of
all he torments himself that her sweet and tender tone comes
from her pitying womanhood, for his forlorn and unhappy con¬
dition.
As usual, the catastrophe of downright love is precipitated by
jealousy, jealousy of a young coal-mine lord, whose suit is
favoured by the Assyrian bull. He feels that this rival is rich
enough to buy anything.
At length brighter prospects open, as he feels that the sweet
girl truly loves him.
The sweet poetry which attends the avowal is not psycho¬
logical, and we must therefore pass it over. Yet even in the
happiness of first love his mind displays its unsound tendencies.
A white curtain drawn at night makes a horror creep over him,
prickle his skin, and catch his breath, because it suggests the
sleep of death.
This extreme and unreasonable sensitiveness to painful impres¬
sions is often, indeed, the warning sign of mental disease.
The consciousness of an evil fate hangs over him like a pall,
and excites some alarm in his mind for the happiness of his
mistress. In spite of that which ought to have made him
supremely happy, he continues to torture himself.
He feels that the love of this most lovely girl may rescue him
from the dark path of despair in which his mind was progressing.
The love scenes are exquisitely drawn, and produce a most
happy change in the misanthrope’s mind and feeling. He is
no longer splenetic, personal, base; his blood flows gently,
sweetly on.
His present happiness enables him to look into the future* 5
the very stars seem brighter and closer to him, since he had
“ climbed nearer out of lonely hell: ” he feels himself perfectly
blest.
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68
Occasional Notes of the Quarter.
[Jan.,
The woe quickly comes. The haughty brother finds the lovera
together; heaps upon her disgraceful terms, and strikes him in
the face; for which, according to the Christless code that must
have life for a blow, the 44 Assyrian Bull ” is quickly called to
account, and shot in a duel. Maud breaks upon the scene, “a
ghastly wraith, uttering a cry, a ory for a brother’s blood.”
When sense returns he exclaims,
“ Ig she gone ? my pulses beat—
What was it ? a lying trick of the brain ?
Yet I thought I saw her stand,
A shadow there at my feet.”
This spectral appearance formed the foundation of subsequent
hallucination ; he fled to Britany, 44 sick of a nameless fear.”
" Plagued with a flitting to and fro,
A disease, a hard mechanic ghost
That never came from on high
Nor ever arose from below,
But only moves with the moving eye,
Flying along the land and the main—
Why should it look like Maud ?
Am I to be overawed
By what I cannot but know
Is a juggle born of the brain ? ”
Notwithstanding his hallucination, he nourishes his love, he
hears her songs and sees her beauteous form, hallucination mixes
with memory, he dreams of Maud and happiness, but is awakened
by the hallucination of her cry, and finds as usual the ghastly
wraith by his bed-side.
u In the shuddering dawn, behold
Without knowledge, without pity
By the curtains of my bed
That abiding phantom cold.
“ Get thee hence, nor come again,
Mix not memory with doubt,
Pass, thou deathlike type of pain,
Pass and cease to move about,
* Tis the blot upon the brain
That will show itself without.”
The shadow flits and fleets before him wherever he passes;
through the hubbub of the market, through the streets and
squares of the wide sounding city he steals, a wasted frame; but
no where, and in no manner, can he get rid of his ghastly com¬
panion.
The twenty-fifth division of the poem is indeed an interesting
one to the alienist reader. The sufferer has passed from halluci¬
nation to actual delusion, fancying himself dead and buried in a
shallow grave.
The dead men chattering around are the other inmates of a
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lunatic asylum, in which there is no secrecy, but idiot gabble and
babble, where everything comes to be known.
" See, there is one of us sobbing,
No limit to his distress;
And another, a lord of all things, praying
To his own great self, as I guess;
And another, a statesman there, betraying
His party-secret, fool, to the press;
And yonder a vile physician, blabbing
The case of his patient—all for what P
To tickle the maggot born in an empty head.
And wheedle a world that loves him not*
For it is but a world of the dead.”
The coal-mine lord finds him out, and pays him a visit, which is
not agreeable. The hallucination of his mistress’s form still
haunts him, but now the last spark of love is gone.
This mixed state of reason and of delusion, and of wild emotion,
partly the natural sequence of the latter, partly arising from
agonizing memories, is depicted with terrible reality. At last his
mood changes,
“ My life has crept so long on a broken wing
Thro* cells of madness, haunts of horror and fear.
That I come to be grateful at last for a little thing.”
The immediate cause of the change is attributed to a dream, in
which his mistress speaks to him of the hope arising from the
coming wars. It was but a dream, but it yielded a dear delight.
New hopes banish the old delusions, and he finds mental restora¬
tion in the activity of thought and feeling aroused by the transi¬
tion from peace to war.
He becomes sane, and enters heart and soul into the excitement
of battle against what he calls the dreary phantom of the North,
but which happily for him is no phantom.
Such is this remarkable sketch of poetic mental pathology. It
must be pronounced wonderfully true to nature. The hereditary
tendency, the early and terrible shock to the emotions, caused by
the father’s suicide, the recluse mode of life, in which morbid
feeling and misanthropic opinions are nourished to an extent pro¬
ductive of hallucination even at that early period of the malady ;
in which mid-day moans are heard in the wood, and his own sad
name is called in corners of the solitary house. All this is most
true to the frequent course of events, in that period when insanity
is threatening and imminent, but not actually present. Another
point touched upon with the singular delicacy of this exquisite
poet is the apprehension which the sufferer evidently entertains,
that he will become mad. “What matter if I go mad,” he
exclaims, “ if once I have been loved; ” and in another mood he
says his mistress’ sweet influence may save him from madness or
suicide. This knowledge of the impending fate is by no means
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70
[Jan.,
- Occasional Notes of the Quarter •
uncommon among educated persons who have strong tendencies to
mental disease. We believe indeed that it frequently exists even
when it is sedulously concealed.
It forms a constant source of most painful reflection, and in this
manner it tends to verify its own forewarning voice.
The gradual outbreak of actual madness after the catastrophe
of the duel is depicted with so masterly a touch, and in so simple
a manner, that any scientific comment from our pen would be
superfluous and bad taste. The madhouse canto (page 89) is
wonderfully graphic and powerful. The hallucination of his
mistress* form,t ever present to his eye, “ a hard mechanical
ghost,” is followed by the delusion of his own death and burial
under the city pavement. The suffocative agony of sensations in
a living grave are portrayed with terrible earnestness of belief;
yet the power of attention and of shrewd reasoning is represented
to be in great measure retained; the coal-mine lord is recognized
in his visit to the asylum, and the misanthropic sarcasm is still
keen and intelligent. The common medley of reason and unreason
is truthfully given. A less skilful artist would have left this
portion of the picture without any light, and would thus have
missed the truth.
In the recovery a little poetic license is taken, since it is not
probable according to pathological likelihood that he would have
dreamt the dream to which it is attributed, until his cure had
been considerably advanced. It may, however, be argued that
patients who have recovered from insanity very frequently attri¬
bute their restoration to causes which have had little enough to
do with the result. They are apt to recognize the last step of the
change and not the first: so we may with fairness remove the
burthen of this apparent inconsistency from the shoulders of the
poet to that of the patient. How much of his restoration to
mental health we may attribute with scientific probability to the
strong emotions caused by the outbreak of the Russian war, it is
not quite easy to determine.
This concluding part does not appear to us quite so true to
nature as all the former portions of this intensely interesting
mental history. There is more of the poet’s license in it, which
may be attributed to the absorbing interest of that great event,
which he rather appears to drag in for the purpose of expressing
political opinions. On the whole we are astonished and delighted
at the profound knowledge of mental pathology displayed by the
great poet of the age. If it were possible to enhance in dignity
the study of mental disease, the deep interest which the noblest
and purest of minds take in it would be attended with that
effect. Let us feel ourselves fellow-students in the most deeply
absorbing objects of human interest and research which have
occupied the greatest minds of the human race, and we shall be
the more likely to strive to be worthy labourers in that noble field.
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Occasional Notes of the Quarter .
71
If any of onr readers would desire to have a standard, or rather
a foil, by which to appreciate the truthfulness of Mr. Tennyson’s
poem, we recommend him to compare it with another autobio¬
graphy of a madman, namely, that of Sir Eustace Grey, by
Crabbe. To say nothing of the poetry or the want of poetry in
the latter, we venture to affirm that it is highly improbable, if not
impossible, for any person in the state of mind in which Sir
Eustace is represented to be, to give so clear, connected, and cir¬
cumstantial an account of himself as that which Crabbe puts
into his mouth. It is, in fact, a fancy sketch; but Maud is a
photograph.*
J. C. B.
Medico-Legal Aspects of NeilVs Case .
The case of Neill, the Lambeth poisoner, recently sentenced
to death and executed for a diabolical murder, raised several
points of medico-legal interest. (1.) The highly technical
character of the chemical evidence which Mr. Justice
Hawkins and the jury ex necessitate rei accepted from Dr.
Stevenson without being able, as the learned judge very
frankly admitted, to follow the elaborate tests by which that
distinguished expert arrived at his conclusions, has once
more brought to the public notice the position of scientific
witnesses in the Courts of Law. Dr. Cook, of Bristol, in a
notable letter to the “ Law Times/ 5 has suggested a new
solution of the vexed and inveterate problem, How should
scientific facts be established in juridical proceedings ? Let
the tribunals, says Dr. Cook in effect, recognize their own
incapacity and a fortiori that of jurymen to understand
scientific processes, and let a commission of experts be
appointed to inquire into and report upon issues referred to
it by the judge presiding over the trial of any complicated
medico-legal case. This commission would consist of, say,
three members. It would have power to call before it the
expert witnesses for the prosecution, and, if there were any,
for the defence; to examine and cross-examine them; to
hear counsel on the matters in dispute, and possibly to see
the crucial tests performed before preparing and presenting
its report. This scheme, which is partly borrowed from the
continental system of preliminary reports, seems to us, how¬
ever, to lie open to two objections. In the first place it
* “ Journal of Mental Science,” Yol. ii., 1856-56.
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72 Occasional Notes of the Quarter. [Jan.,
would involve expense. The members of the scientific com¬
mission, unlike the arbitrators of a tribunal de commerce in
France or Belgium, would have no career before them as the
goal of their labours, and could not be expected to act
gratuitously. Dr. Cook estimates that an annual sum of
£2,000 would cover the working expenses of his proposal, and
the British taxpayer could no doubt be induced to make this
sacrifice if he were convinced that it contributed to the
interests of justice. But a more serious objection remains
behind. Suppose that the commission differed in opinion,
could the judge safely advise the jury in a case of life
and death to act upon the report of a bare majority?
Would the jury take such advice even if it were given, and
in every such case would not the tribunal be thrown back
upon that very weighing of scientific testimony and balancing
of scientific authority which it is Dr. Cook’s great object to
avoid? We venture to think that there is a more excellent
way. The law has given many hostages to the principle
ubique in qua arte credendum. The Admiralty Division
hardly ever disposes of a difficult question of shipping law
without the aid of the elder brethren of Trinity House as
nautical assessors. Every court, from the highest to the
lowest, that possesses jurisdiction in patent cases has power
to summon expert assistance. In the High Court of Justice
itself judicial references are scarcely less common than
public trials, and under the Rules of Court the judges are
enabled to call in scientific experts in every cause other than
a criminal prosecution by the Crown. . If this power were
simply made universal the end in view would be attained
without expensive or elaborate machinery. The task of
advising would belong to the assessor; the responsibility of
deciding would rest, as at present, with the judge and the
jury. (2.) On the trial itself we do not propose to dwell.
The prosecution was conducted by the Attorney-General, Sir
Charles Russell, with great ability, and in the main with
exemplary moderation. The defence was all that could be
expected under the circumstances, but the learned counsel
for the prisoner—Mr. Geoghegan—like Serjeant Shee in
defending Palmer, was, metaphorically speaking, placed in a
cleft-stick. He had both to impeach and to uphold the
scientific accuracy of the expert of the prosecution. The
symptoms of Matilda Clover's death, said the learned gentle¬
man in substance, may not have been due to strychnine
poisoning, for Dr. Stevenson is fallible, and his tests may
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have yielded wrong results. But Ellen Donworth’s death
(with which Neill was not charged) must have been caused
by strychnine, for Dr. Stevenson found it in her body, and
Dr. Stevenson could not have been mistaken. A short
interval of time, of course, elapsed between the use of these
mutually destructive arguments which Mr. Geoghegan was
compelled by the weakness of his case, and, indeed, by the
very logic of his position, to employ. But their glaring
inconsistency did not escape the eyes of the jury, and must
have told heavily against the prisoner’s chances of acquittal.
There can be no doubt that Neill was properly convicted.
No direct evidence of administration, indeed, was forth¬
coming, and the evidence of identity was so weak that we
can readily understand the anxiety with which the counsel
for the Crown are said to have watched the progress of the
case. But the circumstantial evidence was strong enough
to justify the verdict of guilty which the jury unhesitatingly
returned. The alleged inadequacy of Neill’s motive need not
greatly concern us. To a well-regulated mind no such thing
as an adequate motive for the commission of a crime can
possibly exist, but on the unstable mental equilibrium of
persons like Neill, the slightest and most obscure motive
may operate with even more power. The old story told by
Count Cenci to Cardinal Camillo throws some light on such
judicial enigmas:
“ I love
The sight of agony, and the sense of joy,
When this shall be another’s, and that mine,
And I have no remorse and little fear,
Which are, I think, the checks of other men;
This mood has grown upon me, until now,
Any design my captious fancy makes
The picture of its wish {and it forms none
But such as men like you would start to know )
Is as my natural food and rest debarred
Until it is accomplished.”
Moreover, it is by no means clear that Neill did not act
from at least an appreciable motive. He attempted to levy
blackmail, and although he mistook the characters of his
intended victims in England, this circumstance merely points
to his ignorance of English society, and he may possibly have
fared better in America. (3.) The plea of insanity which
was set up on his behalf was hopelessly feeble, and was
properly rejected by the Home Secretary. We have reason
to believe that the American evidence contained no allega¬
tion that raised any doubt in Mr. Asquith’s mind or rendered
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74
Occasional Notes of the Quarter. [Jan,,
an examination of the prisoner by one of the Crown experts
necessary. We are no advocates of the indiscriminate use
of the last penalty of the law, but we do believe that there
are criminals for whose wickedness the only proper remedy
is the scaffold, and that Neill belonged to this terrible
category, and we have no hesitation in saying that the com¬
mutation of this scoundrel’s sentence on the kind of testi¬
mony that was presented to the Home Office would have
been an insult to the intelligence and a standing menace to
the safety of the community. (4.) The mode in which post¬
trial pleas are now dealt with by the law is highly unsatis¬
factory. A prisoner is tried for murder; not a whisper of
insanity is heard at the trial when the worth of the plea
could be publicly determined. He is convicted, sentenced to
death, and assured by the judge that he is already civilly
dead. Forthwith the air becomes tremulous with rumours as
to his mental state, and discharges its vibrations far and
wide. A petition for a reprieve is set on foot; a secret and
informal investigation by eminent experts takes place, and
when the convict’s days of grace have all but expired he is
either left, like Neill, to go to the scaffold or reprieved, like
Laurie, the Arran murderer, and sent to a criminal lunatic
asylum, without any information being vouchsafed to the
public as to the grounds on which the descending arm of
justice has been arrested. It matters not which of these
events occurs. Both are equally discreditable to the law. A
condemned murderer’s days of grace should not be agitated
by hopes and fears of a possible commutation, but should
“ run ” from the time when the fate of any plea or petition
brought forward or presented on his behalf has been finally
determined; and if a sentence of death solemnly and publicly
passed in pursuance of a verdict solemnly and publicly
returned by a jury is not carried into effect, the community
is entitled to know the reason why. We trust that the
belated Court of Criminal Appeal, which the judges recom¬
mend the Legislature to establish, will be empowered to
exercise jurisdiction in open court over post-trial, as well as
ordinary pleas, and that in any event the medico-legal
reports on which capital sentences are commuted will in
future be published in extenso in the Press. It is satisfactory
to know that in this matter the interests of the public and
the desire of the medical profession coincide.
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75
PART II-REVIEWS.
Thirty-fourth Annual Report of the General Board of Com¬
missioners in Lunacy for Scotland . Edinburgh , 1892.
During the year 1891 the total number of officially
recognized lunatics in Scotland has increased from 12,595
to 12,799. This increase is considerably less than that of
the previous year, which was 282. As regards the distri¬
bution of the insane, the following changes have taken place
during the year :—In royal and district asylums there is an
increase of 12 private and 219 pauper patients; in private
asylums there is an increase of 11; in parochial asylums
there is an increase of 7; and in the lunatic wards of poor-
houses of 7 pauper patients. The population remains the
same in the lunatic department of the general prison, and
in training schools for imbecile children there is an increase
of three private and 12 pauper patients. In private dwell¬
ings there is an increase of one private and a decrease of 54
pauper patients. Excluding inmates of training schools and
the general prison, the whole increase of registered lunatics
during 1891 is 24 private and 105 pauper patients, a total of
189. The number of lunatics on 1st January, 1892, and
their mode of distribution is given in tabular form on
next page.
One of the distinctive features of the Scotch Lunacy
Report is the broad distinction of all lunatics into two
classes, namely, those who are accommodated in establish¬
ments and those provided for in private dwellings, and it is
useful to consider these separately. As regards establish¬
ments, an increase has taken place in both the private and
pauper class. In the first, the increase of 23 is below the
average annual increase of 35 for the five years 1886-90,
while in the second the increase is above it, the figures
being respectively 219 and 123. The number of private
patients admitted (excluding transfers) during the year was
573, or 51 more than during the preceding year and 96
more than the average during the five years 1886-90, and
the number of pauper admissions was 2,353, or 140 more
than during 1890 and 291 more than the average for the five
previous years.
Digitized by ^ooQle
Number of Lunatics at 1st January, 1892.
76
Reviews,
[Jan.,
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Reviews.
77
The provision by which persons may voluntarily enter
asylums for treatment is apparently being taken advantage
of to an increasing extent, for the statistics show that the
number, 77, admitted during 1891 is 13 over the average for
the 10 previous years, and, in view of this fact, the Commis¬
sioners, while not expressing other than favourable views of
the working and usefulness of the statute, have thought it
advisable to remind asylum superintendents of the provision
as to the mental condition of persons who may be legally so
received and retained, and as to the extent of their responsi¬
bility in such cases.
The returns show that 226 private patients were dis¬
charged recovered , which is 27 above the number for the
preceding year and 40 above the average for the five years
1885-89, and that the number of pauper patients so dis¬
charged was 959, which, though 16 below the number for
the preceding year, is 30 above the average for the five
years 1885-89. The proportion of recoveries per cent, of
the admissions in each class of establishment is shown in
the following table :—
Classes of Establishments.
Recoveries per cent, of Admissions.
1885 to 1889.
1890.
1891.
In Royal and District Asylums .
39
38
35
„ Private Asylums.
34
35
28
„ Parochial Asylums .
42
46
42
„ Lunatic Wards of Poorhouses.
6
11
13
The year under report has been marked by an increased
death-rate , due apparently to the effects of the influenza
epidemic, which was extensively prevalent throughout the
country. The number of deaths of private patients is 152,
or 12 more than during 1890 and 51 more than the average
for 1885-89, while in the case of pauper patients the number
of deaths was 778, or 138 more than in 1890 and 185 over
the average of the years 1885-89. The death-rate for
private and pauper patients per cent, of the average number
resident, and the corresponding rate for the different
classes of establishments, are shown in the two following
tables:—
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78
Reviews .
[Jan.,
Death-rate in all Classes of Establish-
Classes of Patients.
ments per cent, of the Number
Kcsident.
1883-89.
1890. | 1891.
Private Patients .
66
8*4 j 90
Pauper Patients .
81
8-1 ! 9-6
Classes of Establishments.
Proportion of Deaths per cent, on
Number Resident.
1885-89.
1890.
1891.
Royal and District Asylums .
7*8
8-5
9‘5
Private Asylums .
8-0
7*8
51
Parochial Asylums .
8*9
8*9
12*7
Lunatic Wards of Poorhouses .
5*5
4-0
4-4
Of 117 reported accidents , 11 ended fatally. In five the
death was suicidal; one, that of a voluntary boarder, due to
phosphorus poisoning by sucking the ends of matches, one
by strangulation, one by belladonna poisoning, one by
hanging, and one by leaping from a window. Of the six
non-suicidal fatalities, one was due to fracture by a fall, one
to accumulation of hair in the stomach, two to asphyxia in
an epileptic fit, one to rupture of the bladder during an
attempt to escape, and one to a fall on a stone floor. In
addition to these, injuries were sustained in three cases
shortly before death, the injury being self-inflicted in one
case, but in none did death appear to have been due to the
injury, though in the case of one patient death may have
been hastened by it. Fractures or dislocations were involved
in 44 instances, received in 21 cases by falls, in seven by
assaults by fellow-patients, and in 10 cases by struggling
with patients or attendants; in three cases the injury was
unintentionally self-inflicted, and in three the causes were
not ascertained.
In the section devoted to the present condition of establish¬
ments, frequent reference, as in the Keport of 1890, is again
made to overcrowding, and the necessity for increased accom¬
modation. Important additions to existing asylums are
being made or contemplated to meet the requirements in
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1893 .] Reviews. 79
several districts, and in others new asylums are in course of
erection. One of the most striking features of recent years
in the arrangement of new asylum accommodation is the
increasing prominence which is given to the provision of
adequate hospital departments, and the Report for the year
under consideration affords ample evidence of the very
general desire on the part of the authorities to enhance by
these means the efficiency of asylums as curative institutions
as distinguished from homes for the insane. The Board of
Commissioners, while recording with satisfaction this ten¬
dency to the separation of these two functions of an asylum,
which they regard as sure to lead to a more effectual dealing
with insanity as a disease, and to promote the contentment
and happiness of those not susceptible of cure, do not regard
with favour the idea of the complete separation of these
two sections into distinct institutions under different superin¬
tendents. This, they point out, has been tried in various
countries, but has never been found to work satisfactorily,
and has never come up to the expectations of the promoters.
Such an expression of opinion on this important point, lately
so keenly discussed, coming as it does from such a source, is
of the highest value, and ought to possess a considerable
amount of weight.
Each year continues to be marked by an increase of the
burden of pauper lunacy in Scotland, and the question of
making adequate provision for its accommodation is one that
is becoming more and more clamant. In ihe review of the
Report of 1890 doubt was expressed as to how much further
this could be met by the method of boarding-out in private
dwellings, and the facts disclosed in the present Report
rather tend to increase that doubt. Notwithstanding the
increase in the total number of pauper lunatics, the year
1891 has been marked by a distinct diminution in the num¬
bers who are provided for in private dwellings, and statistics
for the past three years show that the proportion of those
in private dwellings is diminishing, while the proportion
accommodated in asylums is increasing, as is shown by the
following figures, giving the proportion per cent, of all
pauper lunatics in establishments and private dwellings :—
In Private
1st January.
In Asylums.
Dwellings.
1890.
76-1
23-9
1891.
76-2
23-8
1892.
77-1
22-9
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80
Reviews .
[Jan.,
It is but right to state, however, that in the opinion of
the Commissioners this decrease in the numbers in private
dwellings is to be attributed mainly to a heightened death-
rate, 53 more patients having died in 1891 than in the pre¬
ceding year, but this, as regards the year 1891, applies, if
not equally, at least to a considerable extent, to asylums as
well as to private dwellings, and does not fully explain the
facts indicated. The difference of the cost of maintenance
in the two methods of provision which has been gradually
diminishing for some time has been still further lessened
during 1891, and this, as has been affirmed, may be to some
extent responsible for the change in the distribution.
The method of boarding-out in private dwellings continues
to be regarded by the Commissioners with unabated favour
as a useful and advantageous way of providing for a consider¬
able number of the insane, and as well adapted to promote
their interests. It has its merits, all will acknowledge, and
these are summed up by one of the Deputy-Commissioners
as home-life, individualization, liberty, and contentment, and
opportunities for remunerative employment under healthy
conditions. On the other hand, like all other systems, it has
defects, but there are some which may be regarded as more
or less peculiar to this mode of provision. Whether the
presence of insane individuals exercises a harmful influence
on the sane among whom they are placed is a point which is
not touched upon in the Report. One of the undesirable
things most likely to occur is what is euphemistically called
ct sexual accidents.” Two such occurred during the year,
and though it cannot be denied that these do occasionally
occur in institutions, the risk is immensely greater under a
system where so much liberty is granted. In some cases,
too, the removal of patients to such outlying and inaccessible
districts as the Western Isles and the West Highlands must,
one would think, preclude the possibility of visits from
friends, and this is usually regarded as a hardship.
In the section dealing with the increase of pauper lunacy,
the Commissioners indicate that it is much beyond what
would naturally result from the increase of population, that
it cannot be attributed to accumulation from longer residence
in asylums ; that it is only slightly due to a lowering of the
death-rate; that there is no reason for believing it to be due
to an increased tendency to insanity in the community; and
that it i s not due to any one cause, but to many causes
operating with different degrees of force in different localities
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1893 .]
and under different social conditions. Of the many causes
specific mention is made of the following:—The provision of
asylum accommodation in previously unprovided districts;
the easier accessibility of asylums; the dyiug-out of feel¬
ings of dislike and suspicion towards these institutions ; the
greater readiness to send relatives to asylums, partly due
to an increasing conviction of the difference between the
acceptance of parochial relief in cases of insanity, and its ,
acceptance under other conditions; the growing unwilling- !
ness to submit to all that is involved in keeping an insane i
relative at home; the greater willingness of parochial
authorities to recognize claims to relief on the ground of
insanity; the stimulus of the grant-in-aid, and the widening
of medical and public opinion as to the degree of mental
unsoundness which may be certified as luuacy.
As to the remedy for this increasing burden, the Commis¬
sioners indicate that it lies chiefly with the Parochial
Boards, and is to be found in the following:—Careful
scrutiny of applications, to ensure the granting of relief only
when necessary in the interest of the lunatic or the public;
the exercise of vigilance in seeing that lunatics are not
detained in asylums when their mental condition renders
such unnecessary ; that lunatics, whose relatives are able to
maintain them, are not kept on the poor roll, and that, in
the case of those who require aid, the relatives who are
liable contribute as far as they are able.
Considering the increasing gravity of this burden of
pauper lunacy, which affects, not Scotland alone, but the
whole country, these remarks, embodying, as they do, the
experience of years in dealing with this subject, are worthy
of the careful consideration of the authorities upon whom
rests the responsibility of making provision for it, and there
is, further, to the specialist interested chiefly in the scientific
investigation of the causes of this increase, much in the
Report that is instructive and will repay perusal.
XXXIX.
6
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82 Reviews . [Jan.,
Forty-First "Report of the Inspectors of Lunatics in Ireland .
(Report for the Year 1891.)
The registered insane in Ireland were thus distributed at
the beginning and at the close of the year reported on:—
—
On 1st January, 1891.
On 1st January, 1892.
Male..
1
Fe¬
males.
Total.
Males.
Fe¬
males.
Total.
In District Asylums.
| 6,194
5,294
11,488
6,359
5,375
11,734
„ Central Asylum, Dun drum
150
29
179
124
19
143
„ Private Asylums.
253
368
621
266
366
632
„ Workhouses.
1,566
2,395
3,961
1,656
2,524
4,180
„ Gaols.
2
—
2
—
—
—
1 8,165
8,086
16,251
8,405
8,284
16,689
An increase of 438 during the year is thus shown. The
Inspectors calculate that about 4,970 are resident in private
dwellings or wander at large. These, of course, are not
included in the table above given. The whole number of
the insane in Ireland is reckoned at 21,000. This figure
coincides with that at which the Census Commissioners
arrived in the Census Returns for 1891. The following
interesting extract is taken from the Census Commissioners’
Report:—
“The total number of lunatics and idiots returned in 1851
was equal to a ratio of 1 in 657 of the population; in 1861,
to 1 in 411; in 1871, to 1 in 328; in 1881, to 1 in 281; and
on the present occasion, to 1 in 222, the ratio in the Province
of Leinster being 1 in 202 ; in Munster, 1 in 197 ; in Ulster,
1 in 264; and in Connaught, 1 in 258. The counties having
the highest ratios were—Meath, 1 in 126 ; Carlow and Kil¬
kenny, each 1 in 149; Westmeath, 1 in 157 ; Waterford, 1 in
160; Clare, 1 in 168; and King’s, 1 in 173. The following
counties had the lowest ratios—Down, 1 in 333; Antrim, 1
in 310; Dublin, 1 in 284; Mayo, 1 in 282; Kerry, 1 in 270;
Galway, 1 in 269; Donegal, 1 in 257; and Louth and County
of the Town of Drogheda, 1 in 251.”
The Inspectors do not attempt any explanation of the re-
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88
markable variation of the ratio in different districts. It is
noticeable that those counties which are wealthiest and most
civilized—Down, Antrim, and Dublin—have the smallest
proportion of insane ; but Mayo, a county of small holdings,
where distress is chronic, approaches nearly to Dublin; while
Meath, a comparatively opulent county, with its large grass
farms and entirely without towns or centres of dissipation,
presents the largest proportion of insanity. All this is
rather contrary to the ideas prevalent just now as to the in¬
fluence of fast living in the production of mental disease.
A Return is given by the Inspector showing that the pro¬
portion of lunatics under care per 100,000 of the population
has increased from 249 in 1880 to 355 in 1891. “Such an
increase is a subject which deserves the fullest and most
careful consideration. It now appears from the return of the
Census Commissioners that this increase can only to a small
extent be explained by admissions to establishments from
amongst the number of lunatics at large. The large emigra¬
tion which has taken place during the past forty years
(amounting in all to 3,415,400 persons), tending to remove
the healthy and strong, both in mind and body, and leaving
the weak and infirm as a burden on the public rates, must
be considered as one of the principal factors in the explana¬
tion of this large increase. Hence it is safe to assume that
the present number of the insane in Ireland properly belongs
to a much larger population than that which now exists.
However, making full allowance for this cause, which tends
to show an apparent increase of insanity, we are still driven
by the facts before us to conclude that the large increase of
lunacy has been absolute as well as relative. . . . The rapid
increase of insanity in the country, in the face of a
diminishing population, ought, therefore, to engage the
attention of all who take an interest in the Social and
material progress of Ireland, in order to ascertain how far
such increase can be stayed by any means within the power,
of the State.”
District Asylums .~Three thousand and ten patients were
admitted into these establishments during the year. The
average number of patients resident was 11,644. The re¬
coveries bore the proportion of 40*4 per cent, to the admis¬
sions ; the deaths, that of 7*6 per cent, to the daily average
number under treatment. Twenty-four per cent, of the total
number of deaths were due to consumption.
“The cause of death was ascertained by post-mortem
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84
Reviews.
[Jan.,
examination in 134 cases. Small though this number still
remains, yet it shows an increase compared with the numbers
in previous years.”
The writers of this Report comment on the absurd mode
of admission generally adopted in Irish Districts in accord¬
ance with the so-called “ Dangerous Lunatics* Act/’ which
has the double disadvantage that it converts the lunatic into
a criminal, and that it prevents the asylum authorities from
recovering cost of maintenance.
The Inspectors note the fact that during the year 1890 a
Bill was passed assimilating the law as to pensions in
Ireland to that in force in England. They point out that,
under the law as it formerly existed in Ireland, the rate of
pension was very low (one-fortieth for each year of service),
but “ was looked forward to as a matter of right.” The
higher pensions now legalized as permissive, are granted at
the discretion of the Board of Governors, who may give
or withhold them as they think proper.
“ The low rate of wages paid to the subordinate staff of
Irish asylums should, in our opinion, entitle them to look
forward to a superannuation allowance after years of faithful
service. It is undoubtedly of the first importance to attract
well-qualified persons to the asylum service, to retain their
services so long as they are efficient, and when incapacitated
by ill-health or years to grant them a reasonable mainten¬
ance for the rest of their lives.”
We cordially concur in what we take to be the opinion
here suggested, that asylum pensions, whatever scale is
adopted, ought to be “ a matter of right,” and we think this
right ought equally to exist in all divisions of the kingdom.
A large portion of the Report before us deals with the
question of over-crowding. Of the twenty-two district
asylums in Ireland, eleven actually contained more than
their proper number at the end of the year. The vacancies
in many of the others were few. In Londonderry there was
but one. The Richmond Asylum, Dublin, contained 341
patients above its accommodation, the Mullingar Asylum
167, and the number in excess of the entire accommodation
in the various institutions provided amounted to 632. The
importance of making sufficient and liberal provision for the
insane is evidently very present in the minds of the Inspectors,
and they have clearly encountered great difficulties in bring¬
ing it home to the consciences of the local authorities.
“Now that the number of pauper lunatics has increased so
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1893.]
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85
enormously, and that their humane treatment necessitates a
much larger expenditure, it is often difficult, notwithstand¬
ing a capitation grant iD aid of 4s. a week from Imperial
sources, to persuade Asylum Governors and those respon¬
sible for the imposition of county rates that in asylum
management liberality is often real economy. They say,
plausibly enough, that while they wish to treat their
lunatics something better than ordinary paupers, they
cannot see the necessity for anything more than the plainest
buildings and simplest dietary for patients whose domestic
conditions and surroundings were in many cases previous to
their admission to asylums squalid and poor. The answer is
simple: liberal feeding, picturesque sites, attractive sur¬
roundings and amusements are recommended because they
are considered in many cases essential to the patient’s cure.”
The “Lancet” Commissioner’s Report of some twenty years
ago is pointedly quoted:—“ When the task is to build and
organize an asylum, even the great domineering passion of
selfishness should induce everyone concerned, as trustee of
public funds, or ratepayer, to see that it is in all respects
adapted to divert, to cheer, to comfort, and to invigorate;
because diverting, cheering, comforting the mind, and in¬
vigorating the body, are the methods by which a rapid cure
is to be effected, and the dependent lunatic transformed from
a burden to a bread winner. The perfection of these appli¬
ances at the outset often makes all the difference between a
long and costly case, liable at any critical moment to become
chronic and incurable, and a recovery speedily commenced
and happily consummated.”
Whether these words are to be taken as a suggestion to
asylum governors or as an implied defence of recommenda¬
tions which the Inspectors have been compelled to make, it
is evident that they are intended to convey ideas that are
new in Ireland.
The labours of the Inspectors appear happily to have been
already productive of much good in this direction. In a
great number of the asylums new works are being pressed
on. In some, addititional space for patients is being pro¬
vided; in others, much-needed improvements in heating,
in the structure of laundries, kitchens, store and sanitary
buildings are being carried out.
At Belfast “ the best means of providing separate accom¬
modation for the insane belonging to County Antrim has
been for a considerable time under consideration. It was at
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86
Reviews.
[Jan.,
last decided to divide the district, leaving the asylum at
Belfast for the use of the insane belonging to that city, and
to erect a new asylum for the insane of the County Antrim.
For this latter purpose an estate close to the town of Antrim
was purchased/ 1
At the Richmond Asylum, Dublin, “ the Board of Governors
have decided to obtain an estate in the neighbourhood of the
metropolis, and there erect a second asylum for the district.
No doubt before many years are passed it will be found con¬
venient for the Counties of Dublin, Louth, and Wicklow to
separate from the City of Dublin, as the patients belong¬
ing to the metropolis are increasing with such rapidity as to
render, it likely that a separate institution will be found
essential for their treatment; but in the meantime the
scheme adopted by the Governors has the advantage of pre¬
senting the fewest difficulties in its accomplishment and of
affording the greatest facilities for speedily supplying the
accommodation so much required.”
Suicides , etc .—It is creditable to the general management
of the asylum that but three suicides during the year are to
be recorded. The number of accidents amounted to forty-
six, of which three proved fatal. In neither class was there
any case of special interest. Five cases of cruelty to patients
on the part of attendants are recorded. In one of these the
attendant was prosecuted.
Dundrum Criminal Asylum .—To the vacancy occasioned by
the death of Dr. Isaac Ashe, a talented and accomplished
member of our Association, “the Lord Lieutenant was pleased
to appoint Dr. Revington, a young Irishman, and a distin¬
guished Graduate of the University of Dublin, who had
been for some years Senior Assistant Medical Officer at the
Lancashire County Asylum, Prestwich. Since his appoint¬
ment we are happy to be able to report that the management
of the institution has distinctly improved, discipline has
been upheld, complaints of irregularities and misconduct on
the part of attendants and inmates have decreased, and
escapes, which had become a scandal, and had repeatedly
necessitated the intervention of the police to aid in guard¬
ing the outside of the building, have ceased.”
Private Asylums .—The reports made at the various private
asylums are kindly and generally favourable. Nevertheless,
it has been found necessary in one case to obtain a revoca¬
tion of license, and, as the offender was contumacious, even
to institute legal proceedings. The Inspectors again draw
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attention strongly to the lamentable lack of any proper
provision for patients of the poorer middle classes in Ireland.
In this connection they say :—“ The best way of providing
accommodation for the class who can only afford to pay
small stipends is manifestly in public institutions and not in
houses maintained for profit, and we trust that in any fresh
lunacy legislation provision will be made to enable the
local authorities to furnish separate accommodation for
this class of private patients in connection with their
asylums. Such provision has already been made in England
by the 241st section of the new Lunacy Act of 1890.”
The Insane in Workhouses .—In strong but temperate
language the Inspector described the unsatisfactory condi¬
tion of the insane in the Irish workhouses. The utter
unsuitability of the provisions existing may be gathered
from this passage :—“ It has been our duty to call the at¬
tention of Guardians to the absence of cleanliness, general
and personal, in the lunacy department of many workhouses.
In the majority of these institutions there are neither baths
nor suitable lavatory arrangements for the use of the insane,
and in the absence of these it is impossible to expect that due
cleanliness can be observed and that the patients can be kept
free from vermin and dirt.”
In concluding the text of their Report, the Inspectors again
appeal for a grant either out of the Irish Church surplus or
some other Imperial fund for the endowment of suitable
institutions for the care and education of idiots and imbeciles.
Appendix F. consists of reports of visitations made by the
Inspectors at the various institutions which contain lunatics.
We note the absence of reports on six district asylums. The
reports are very careful and courageous, and in many of the
particulars dwelt on they exemplify, like those of the
preceding year, the heavy task that is laid upon the Inspectors
in educating public opinion iu Ireland on the requirements
needed in modern times for the care of the insane.
We are glad to say the tabular and statistical statements
in this Report are, on the whole, accurately done.
From the perusal of this and their former Reports, as well
as from their countrymen, we believe that the present In¬
spectors of Lunatics in Ireland are justifying the hopes we
ventured to express when they were appointed, and are
carrying out their extremely difficult work in an excellent
manner.
Without undue precipitancy and without a delay that
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[Jan.,
might seem compliant ohne Hasten ohne Rasten 55 ) they
press forward the work of reform so much and so long needed.
In a remarkably short space of time their influence has been
generally felt, and felt to much purpose, and this is the most
conclusive proof of their earnestness and usefulness. We
wish them God speed in their labours, and we are sure that,
however unpleasant their task may often be now, they will
eventually enjoy the satisfaction of seeing an ample harvest
for their toil.
Philo8ophische Studien , January . 1892.
The first number of the “ Philosophische Studien ” of
1892 brings an interesting paper from the pen of the first
living representative of psycho-physics, Professor Wundt,
on “ Hypnotism and Suggestion/ 5 The article in question
is the more remarkable, because in it a decisively forward step
is taken in the explanation, and, above all, in the proper
valuation of hypnotism. Although much has been done by
Bernheim, Forel, and Moll to divest hypnotism of the
mysteries in which it was enwrapped—voluntarily or in¬
voluntarily—by those who knew and practised it, Wundt
goes still further than any of the authors mentioned, and,
throwing aside anything not conformable with the well-
known laws of nature, i.e., all occult relations which make
hypnotism so interesting, especially in the eyes of lay-people,
puts hypnotism on a thoroughly scientific basis. We are
well aware that there are still uninformed men, even in the
medical profession, who doubt the phenomena of hypnotism;
for such Wundt does not write. The phenomena in question
are indisputable to him, as they are to everybody who has
watched them with an unbiassed mind, and he therefore
does not go into the description of the symptoms, but only
mentions those which are of importance for the physio¬
logical and psychological explanation of hypnotism, as
automatism, somnambulism, post-hypnotic suggestion, posi¬
tive and negative hallucinations, the purely physiological
effects as the production of blisters, etc. After having
briefly touched upon these, Wundt treats in his second
chapter of the physiology and psychology of hypnotism
and suggestion, introducing at first and criticizing the
various attempts of explanation—physiological and psycho¬
logical — advanced by eminent observers. Heidenhain
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1893.]
thought the hypnotic condition to be due to an inhibition
of the ganglionic cells of the cerebral cortex produced as a
kind of reflex-inhibition by weak but constant irritation.
A similar view was propounded by Charcot, who, in addi¬
tion to the inhibition, assumes a stimulating effect on the
motor and sensory centres (automatic movements and
hallucinations). These theories, however, entirely neglect
the influence of suggestion as a means of hypnotizing. In
fact, Heidenhain himself was not satisfied with regard to
his own hypothesis, since he found that the functional
inhibition, produced in animals by ablation of the cortex,
differed greatly from that observed in hypnotized indivi¬
duals. Wundt also dismisses briefly Forel’s* theory of the
dissociation of customary associations and their being
singly called into play by means of suggestion, and
then goes on to criticize fully the physiological explanation
advanced by Lehmann,f who founds his theory mainly on
the vaso-motor effect of hypnosis and suggestion, generaliz¬
ing this truly physiological phenomenon, and making it
responsible for most phenomena of normal mental life, and
especially for attention, this idea being based on the facts
confirmed by Mosso, that during sleep the blood-supply to the
brain is diminished. Therefore Lehmann concludes that if
attention is very intense the blood-supply to the one special
part which has been stimulated becomes more abundant.
In the hypnotic condition attention is directed to one side
only, this condition being produced by the monotonous stimu¬
lation or suggestion; hence, the very limited number of as¬
sociations and the amnesia on returning to the normal state.
Wundt’s objection to this theory is that Lehmann, when
explaining psychical conditions—normal or abnormal—does
not apply his physiological vaso-motor theory, but explains
all processes by association of ideas and limitation of atten¬
tion, i.e., purely psychical conditions. With regard to the
methods of psychical explanation, there are two kinds, the one
which looks upon hypnotism as quite a new phenomenon of
an enormous psychological importance, calculated to throw
fresh light on the human mind, and the other which
builds up the explanation of hypnotism on psychical facts
known and understood. The former method of making
things which are not quite clear the basis of psychology,
Wundt rejects at once as unscientific, and considers only the
* Forel, Der Hypnotismus,” Stuttgart, 1889.
f LehmaDn, “ Die Hypnose,” eto., Leipzig, 1890.
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latter kind of phenomena. There are two principal hypo¬
theses, that of sympathy and that of double consciousness,
the former represented by Dr. Hans Schmidkunz,* the
latter by H. Taine,+ Pierre Janet,J Max Dessoir,§ and to a
certain extent by Moll.||
Schmidkunz fares very badly at the hands of Wundt,
who considers his book as very instructive bow not to study
psychology, whilst he finds the ideas of the other authors
mentioned anticipated in the ecstatic and somnambulistic
literature of former days, with one difference, however,
viz., that formerly the abnormal consciousness was con¬
sidered to be the highest, and to be gifted with extraordinary
power, whilst it is now, generally speaking, regarded as a
lower stratum of the human personality. On the whole,
Wundt considers the hypothesis of double consciousness as
an example of those imperfect explanations in which a new
name only is introduced for the phenomenon to be explained,
without making the matter any clearer to the critical
inquirer. Self-observation during the hypnotic condition
would be of great importance, but is, for obvious reasons,
extremely difficult, if not quite impossible. Forel mentions
in his book (p. 81) an interesting case of self-observation,
and Wundt also relates at some length a similar experience
of his own. When in 1855-56 a house-physician under
Professor Hasse, at Heidelberg, he had for a time very heavy
night-work to do, so that in the end he was over-fatigued,
and when called he performed his duties in a mechanical
manner, whilst only half-awake. One night he was called to
a patient who was suffering from typhoid fever, and was
very delirious. He went into the ward in a dream-like state,
although talking quite reasonably to the nurse and several
other patients. Suddenly he noticed in an open cupboard a
bottle of tincture of iodine, and at the same moment the
idea became predominant in his brain that iodine was the
medicine required in this case ; he ordered the nurse to fetch
the bottle, and gave the patient one teaspoonful, a few drops
of which were taken, but at once rejected, a circumstance
which greatly surprised him at that time- It was customary
in such cases to give a teaspoonful of laudanum liquidum
Sydenhami (G.P.); the colour of the tincture of iodine
* Schmidkunz, “ Psychologie der Suggestion,** Stuttgart, 1892.
t Taine, “ De Pin tell i gen ce,” Yol. i. (preface).
J Pierre Janet, “ Rdvue philosophique,” Yol. xxii., p. 577.
§ Max Dessoir, “ Das Doppel-Ioh.,” Berlin, 1889.
|| Moll, “ Der Hypnotismus,” 2nd Ed., Berlin, 1890.
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reminded him of laudanum, and in his condition at that
time, which he considers to have been one of spontaneous
somnambulism, he associated with the iodine the properties
of laudanum as an anodyne, and was so perfectly convinced
of the correctness of his idea that even the astonishment of
the nurse could not make him change his mind. After
having returned to his room he became perfectly awake, and
then only became aware of the mistake he had made. He
remarks that in the state mentioned objects seemed to be
further away than usual, and words seemed to come from
a greater distance, a condition which resembles that at the
commencement of a fainting fit or a narcosis. Altogether
there was a certain numbness of the sensorium. From this
interesting experience Wundt concludes that his condition
was one of “ auto-suggestion; ” the word “ suggestion,”
however, not having yet found a psychological explanation.
He defines it as u an association with complete limitation of
consciousness to the ideas produced by this association; ”
hence, the diminished sensibility in the hypnotic condition,
in consequence of which the phenomenon mentioned above
with regard to vision and hearing is observed. This ex¬
plains, to a certain extent, why a slight narcosis favours the
hypnotic state, viz., by the insensibility produced towards
outside stimuli. In order to explain certain processes of
the normal condition, but especially the events of dreams
and hypnosis, Wundt formulates a law “ of functional com¬
pensation If a greater part of the central nerve-organ is
in a condition of functional inactivity in consequence of
inhibitory influences, the excitability of the part which
remains in functional activity is increased towards any
stimulus directed against it. It stands to reason that
this increase is the greater, the less the energy previously
expended from the amount stored up in a condition of
latency in the central nervous organ in general. As the
physiological basis of this law we may assume a twofold
action—one neuro-dynamic, and the other vaso-motor. With
regard to the former, it seems probable, considering the
manifold connections which the nervous elements have with
each other, that the excitability of a central nervous
element depends not only on the condition in which it
happens to be itself at the time of stimulation, but also on
the state of the nervous elements with which it is connected,
in such a manner that by stimulation of the neighbouring
elements the excitability of the nervous element in question
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is decreased, while if the neighbouring elements are at rest,
the one element acts the more energetically. This we may
consider proved by the fact that cerebral activity is the
more energetic the more one-sided it is, and that the
excitability of all other cerebral elements is diminished by
energetic and one-sided activity of one area. The ganglionic
cells, in addition to their nutritive function, must be con¬
sidered places in which a constant accumulation of latent
energy takes place, which under certain conditions is con¬
verted into actual energy and conducted along the nerve-
fibre. The accumulation of energy takes place constantly,
its conversion into actual energy, however, only at times
under the influence of stimuli; during sleep, therefore, in
consequence of the absence of stimuli, there is a general
storing up of energy in all central nervous elements. We
know from the degeneration following section of nerves,
extirpation of ganglia, and section of the cord, that the
nerve-fibres are not only paths of conduction, but also serve
as channels for the nutrition of the nervous substance, by
means of which the substances, which are the chemical
equivalents of the latent energy, pervade the whole central
nervous system, constantly keeping up an equilibrium of
energy throughout in such a manner that energy used up at
one point is at once supplied again from neighbouring
points. If, therefore, a cerebral nervous element is stimu¬
lated during sleep, the excitement produced will be very
great, partly on account of the great energy present in the
element itself, and partly in consequence of the rapid supply
from the other resting elements. The effect produced by
this neuro-dynamic action is increased by vaso-motor com¬
pensation. According to the principle that the greater the
function of a part the greater its blood supply, and vice
versa , the blood supply to. the various parts of the brain is
regulated in such a manner that one part, which is active,
will receive more blood, while others necessarily will receive
less; and, on the other hand, the less active some parts are
the more their vessels will contract, thus allowing and
even forcing more blood to flow into the part which is in
functional activity. The neuro-dynamic and vaso-motor
compensations go hand in hand—it is impossible to assume
one without the other. Hypnosis is not, like sleep, the con¬
sequence of fatigue of the nervous system, but is produced
by the neuro-dynamic and vaso-motor changes in the brain;
the increase of function, therefore, is much more intense
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than in sleep, even passing over to the motor-centres, thus
causing the hypnotic condition to resemble the waking state.
Hypnosis has its origin in suggestion, supported by other
factors, which produce one-sided direction of the mind.
Consequently, while in dreams the ideas and illusions fly from
one thing to another, the hypnotized mind can only be
influenced by stimuli connected with the suggestion, but by
these it is very strongly affected. The conditions mentioned
plain without difficulty the general phenomena of hypnotism.
Here we have reached the climax of a most interest¬
ing paper, and therefore we have given it more fully than
perhaps a review requires. In the rest of his article
Wundt treats of the value of suggestion, and comes to the
conclusion that if it is of minor use for the advancement
of psychology, judiciously used it may be of great value in
therapeutics. He demands, however, that by law medical
men only should be allowed to practise hypnotism on
account of the dangers and disadvantages connected with
its abuse.
We cannot conclude this review without expressing our
pleasure that Wundt’s paper is the protest of science
against the occultism at present in fashion amongst us,
which stands in the same relation to real psychology that
astrology does to true astronomy.
French Hypnotic Literature .
Grand et Petit Hypnotisme . Par J. Babinski. Paris: E.
Lecrosnier et Babe. 1889.
This monograph deals with the relations of hypnotism
to hysteria, and, faithful to the traditions of the Salpetriere
school, M. Babinski, a pupil of Charcot, endeavours to prove
that the views of Bernheim and the Nancy school are, if
not erroneous, much exaggerated.
The objective signs of the hypnotic state—neuro-muscular
hyperexcitability, cataleptic plasticity, musculo-cutaneous
hyperexcitability—are discussed, and the characteristics
distinguishing them from simulated phenomena emphasized.
“ Grand hypnotisme” includes those cases only which
exhibit Charcot’s three classical stages of lethargy, catalepsy,
and somnambulism; “ petit hypnotisme ” includes those in
which one or more of the stages is or are deficient, or in
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which they are ill-defined, and in which there is often an
absence of physical or objective signs.
Patients with “ grand hypnotisme ” are always hysterical,
and most of the cases of “petit hypnotisme” belong also to
the hysterical class, although Babinski acknowledges that
one may find in many no stigmata of hysteria. The Nancy
school is accused of putting down all hypnotic phenomena to
the effect of suggestion; the tendency with the Salpetri&re
school is to call it all hysteria.
Charcot’s views (and his adherents’), are briefly :—
1. The objective signs of hypnotism are of fundamental
importance, and in their absence simulation cannot be
properly eliminated.
2. “ Grand hypnotisme ” is characterized by its three dis¬
tinct stages.
3. The objective signs of hypnotism may appear indepen¬
dently of suggestion.
4. Hypnotism, when well developed, is a pathological con¬
dition.
Bernheim, on the other hand, says that “ grand hypno¬
tisme ” is an artificial creation; no importance is to be
attached to objective signs; and hypnotism is a physiolo¬
gical condition. What is white in Paris is black, at Nancy,
and vice versa.
But Babinski pertinently asks : “ Since the true objective
signs cannot be simulated, whether due to suggestion or not,
are they not trustworthy evidence of the hypnotic con¬
dition ? ”
What guarantee, on the other hand, have we that
Li6bault’s and Bernheim’s slight cases are genuine ? Have
we any proof of the reality of purely psychical phenomena?
Bernheim cannot induce “ grand hypnotisme ” in his
subjects, and, therefore, denies its existence. Charcot and
his followers reply that it is because the subjects are not
selected, they are not “ grands hyst6riques.” Charcot began
his inquiries without any preconceived ideas; the three
states were simply observed; the patients were, so to speak,
virgin subjects as regards hypnotism. Let Bernheim,
therefore, select a subject, not hyperexeitable to begin with,
and prove that by suggestion he can induce “ grand hyp¬
notisme.”
Tamburini and Seppili, Bummo, Yizzioli, Oct. Maira and
David Benavente, Ladaine, etc., have confirmed the Salpe-
triere observations.
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In conclusion, Babinski dwells on the points of affinity
between hysteria and hypnotism (contractions, varieties in
attacks, alternation in phenomena, etc.), and looks upon
hypnotism as belonging to the large family of neuropathies.
Hypnotisme et hysterie ; du role de Vhypnotisme en therapeutique.
Par J. Babinski. Paris : G. Masson. 1891.
This is a natural sequel to the preceding monograph, and
the author dilates at greater length upon the similarity
between hypnotism and hysteria :
a. As regards physical manifestations, motor paralysis,
contracture, anaesthesia;
Psychical phenomena, exaltation of suggestibility, etc.;
y. The therapeutic benefits of hypnotism are almost solely
observed in hysterical cases ;
8. Hysterical and hypnotic phenomena are often inter¬
changeable or alternate;
€. Hypnotism may produce an hysterical attack.
Hence Babinski concludes: “We might almost say that
hypnotism is a manifestation of hysteria.”
Bernheim's views of hypnotism and hysteria are certainly
widely different from Charcot’s, and no doubt this explains
much of the discrepancy in their results. Bernheim doubts
the existence of hysteria in men, which is very common
according to the Salpetri&re school. Bernheim defines
suggestibility as “a condition in which the subject is
influenced by an idea accepted by the brain, and realizes it.”
“ But then,” says Babinski, “ we are all suggestible ; and if
hypnotism is merely a degree of suggestibility, where are we
to draw the line ? 99
As regards the therapeutical effect of hypnotism in nervous
cases (nearly always hysterical), Babinski arranges these in
five groups:
1. Those in which there is no improvement;
2. Those in which the improvemept is slight;
3. The improvement is rapid, but not permanent;
4. The improvement is slow, but permanent;
5. A few cases where the cure is rapid and complete.
In cases of organic disease associated with hysteria, the
hysterical element may be cured by hypnotism, and occa¬
sionally certain symptoms of organic disease may be
relieved by it, e.g., the lightning pains of locomotor ataxy.
If we examine 208 cases mentioned by Bernheim (“ De la
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Suggestion,” etc.) we find only 32 entered under the head of
hysteria ; but Babinski points out, and apparently with
very good reason, that many cases included in the groups
traumatic neuroses, neuropathic affections, neuroses,
dynamic paralysis, neurasthenia, organic affections of the
nervous system, are purely and simply hysterical. And he
adds: “ Can we accept the statements that lateral sclerosis
and cerebellar tumour are cured by hypnotism, or by the
application of a magnet, without the evidence of a post¬
mortem examination ?”
With regard to the treatment of mental diseases by
hypnotism, many competent observers—Magnan, Forel of
Zurich, Briand—are not sanguine about it; Percy Smith and
others in England, we might add, are of the same opinion.
Dr. Babinski’s monographs are well worthy of perusal by
all who are interested in the question of hypnotism.
Further researches are needed to place the subject on a
surer basis, and, considering the wide divergence in the
views of such observers as Charcot and Bernheim, the only
attitude of the unbiassed scientific student must be one of
expectancy and research.
Les suggestions hypnotiques au point de vue medico-legal .
Par Gilbert Ballet. Paris : G. Masson. 1891.
The main purpose of this pamphlet is to show that the
dangers of hypnotism, the fear of crimes arising through
suggestion—much spoken of in novels and in the press—
have been enormously exaggerated. While admitting that
attempts have been made upon the person of subjects in
the state of lethargy, or catalepsy, and somnambulism, the
author fails to see in the annals of crime any genuine
instance of a person committing a crime suggested during
the hypnotic state by another person. The cases of La
Ronciere, Benoit, Jacquemin, etc., analyzed by Liegeois (De
la Suggestion et du Somnambulisme, etc.), he points out are
not examples of suggestion.
“ But as regards the future,” Ballet remarks, “ are sug¬
gested crimes possible ? And, if so, can they be done with
ease or with impunity ? ” From the experience of the
laboratory we might reply in the affirmative; but the condi¬
tions here, we must remember, are different; moreover, the
patients are never purely passive automata; most of them
retain some individuality. Only one in twenty of hypno-
tizable subjects, Liebault observes, will faithfully carry out
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post-hypnotic suggestions; and, to quote Bernheim, “ educa¬
tion constitutes in itself a primitive suggestion capable
of neutralizing ulterior ones.” Certain subjects, when
criminal suggestions are made to them, refuse to, or do not,
wake; some fall into the lethargic state; others get a
hysterical attack. The criminal must, therefore, choose a
suitable subject for his purpose and train him. This in
itself may lead to exposure; and, in addition, the passive
criminal (the suggested person) would be more easily detected
than an ordinary being.
With regard to the signing of cheques, of wills, the giving
of false testimony by persons acting under hypnotic sugges¬
tion, here, again. Ballet thinks the dangers are more
imaginary than real.
He questions the advisability of hypnotizing a criminal
suspected of having acted under suggestion, to ascertain the
truth. Can we be sure of the results ? Many subjects are
known to mislead and even deliberately lie under the cir¬
cumstances.
When Bernheim says “la suggestion est dans tout,” he
alters, as Ballet remarks, the standpoint of discussion. If
Troppmann, Gabrielle Fenayrou, Gabrielle Bompard, etc.,
are all irresponsible, where are we to draw the line ?
One can imagine a clever criminal, familiar with the
subject of hypnotism, making use of another person to
accomplish a criminal act by suggestion, but the chances of
eluding detection are only slight, and common sense will often
come to the rescue in these cases in tracing the true culprit.
As a corrective to the credulity of many who see in
hypnotic suggestion a new scourge to society, and as a clear
and brief exposure of the medico-legal aspect of the question.
Dr. Ballet’s pamphlet is well worth perusing.
Uric Acid as a Factor in the Causation of Disease . By
Alexander Haig, M.A., M.D.Oxon., F.R.C.P. London:
Churchill. 1892. Pp. 272.
Nine years ago Dr. Haig set himself to investigate the
causation and treatment of a headache from which he suffered
periodically. But his investigations led him farther than he
expected; the horizon gradually expanded until now it seems
to him that if his conclusions are correct he has revolutionized
a large part of the field of medicine, including epilepsy, mental
depression, gout, rheumatism, diabetes, Bright’s disease, high
xxxix. 7
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arterial tension, etc. He received his first stimulus from sug¬
gestions in the works of Sir A. Garrod and Dr. Liveing, and
he has carried on a number of investigations which have been
published in various medical journals, and have attracted con¬
siderable attention and criticism. This volume the author
regards merely as a preliminary statement of his results.
The main points of Dr. Haig’s teaching may be very easily
stated. Excess of uric acid in the system is due, not to
increased formation, but to retention. It may be present in
excess either when in course of excretion in the blood, or in
the joints, liver, etc. When uric acid is in course of excretion
there is a tendency in susceptible persons to headache, lassi¬
tude, and depression, with slow pulse and high arterial tension;
when, on the other hand, the uric acid is driven into the joints
these symptoms at once disappear, but give place to tingling
in the joints, and in susceptible persons to symptoms of gout,
rheumatism, etc. Now Dr. Haig finds that either of these
two sets of symptoms can be produced at will. By giving
acids, morphia, etc., he can at once diminish the excretion of
uric acid, and clear up the headache and mental depression,
producing instead shooting and pricking pains in the joints;
and by giving alkalies, salicylic acid and its compounds,
quinine, etc., he can increase the excretion of uric acid, and
produce the opposite set of symptoms. Practically, in order
to cure his headache, he finds it necessary to follow up a small
dose of morphia (£ gr.) by a dose of salicylate; for if the uric
acid is merely driven into the joints it will come out again next
day, and produce the same symptoms again. But he has found
prevention more important than treatment, and he achieves
prevention by returning to the doctrine of former days, and
fighting uric acid by diminishing the income of nitrogen.
Since he has excluded butcher’s meat from his dietary he has
lowered the uric acid consumption and cured his headaches,
and he finds that this treatment—the prevention of urates so
far as possible and their rapid expulsion from the body—is the
key to the treatment of gout and many other disorders.
Alcohol he finds in itself harmless, and so far as it is not so its
action is merely due to the acidity of most wines and beer,
which drives the uric acid into the joints; and even when so
acting it is, so far as mental depression is concerned, beneficial.
“ If my premises are good,” Dr. Haig remarks, “ and ray
deductions sound, and if uric acid really influences the circula¬
tion to the extent which I have been led to believe .that it
does, it follows that uric acid really dominates the function.
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nutrition, and structure of the human body to an extent which
has never yet been dreamed of in our philosophy, and in place
of affecting the structure of a few comparatively insignificant
fibrous tissues in which it is found after death, it may really
direct the development, life-history, and final decay and disso¬
lution of every tissue, from the most important nerve centres
and the most active glands to the matrix of the nails and the
structure of the skin and hair.”
Dr. Haig works out, or suggests, the application of these
views in various fields. He points out, for instance, that the
phenomena of epilepsy frequently present a close resemblance
to those of the uric aoid headache. There is the same mental
well-being, with scanty excretion of uric acid before the fit,
the same excessive excretion of uric acid and mental depres¬
sion accompanying it, followed by the same subnormal surface
temperature, and often slow faltering pulse. Both come
on in early life, and recur at more or less regular intervals;
both are met with in members of the same family, or even
alternate in the same patient; while the action of drugs is
parallel in the two disorders, and the treatment—especially by
diet—becomes more promising.
Dr. Haig is not able to say in what proportion of cases
epilepsy may be due to this cause, nor to speak very positively
as to the results of the treatment he suggests. These questions
could, however, as he remarks, be speedily settled in an asylum
where many epileptics are under observation, and it is to be
hoped that someone will investigate the matter.
Dr. Haig also finds that uric acid counts for much in hysteria.
Its action here and elsewhere is largely due to its effects on
the arteries and capillaries, more especially in the brain. Uric
acid in the vascular system produces high arterial tension;
clear the blood of uric acid by the use of any of the drugs
which produce retention of it, and as the pulse tension is
reduced its rate quickened, and the urine increased, the mental
condition alters as if by magic.
Dr. Haig makes the interesting suggestion—which he tells
us he is endeavouring to work out—that the excess of suicides
and of criminality during the summer months is caused by uric
acid. During the cold months there is a tendency to the re¬
tention of uric acid; with the return of warm weather there is a
fall of acidity, and the uric acid held back and stored during
the winter begins to be dissolved in the blood. “ I believe that
the above-mentioned physiological fluctuation in the excretion
of uric acid, and the concomitant uric-acidsemia, completely
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account for the observed fluctuations in the incidence of mental
depression, suicide, and murder.” He also believes that alco¬
holism, morphinism, and cocainism have their starting point in
the temporary well-being these drugs produce through driving
the uric acid out of the circulation into the liver, spleen, joints,
etc., from which it emerges in the “ alkaline tide ” of the follow¬
ing morning.
Dr. Haig's book is altogether very interesting, and well
worth the consideration of the alienist. It is written in a con¬
versational manner, without attention to style. His unfalter¬
ing earnestness is aptly shown by his solemn treatment of a
venerable joke: u ‘ Is life worth living ?' That depends on
uric acid. The orthodox answer is ‘That depends on the
liver,' but as the liver is only one of the sources of uric acid I
cannot regard the answer as sufficient.” Some criticism has
been directed against Dr. Haig's use of Haycraft's method of
estimation by other workers who have arrived at different
results, and his conclusions require confirmation. We cannot
yet decide if he is like Saul, the son of Kish, who went forth
to seek his father's asses and found a kingdom.
Die Psychopathischen Minderwertigkeiten. Yon Dr. J. L. A.
Koch, Zweite Abtheilung. Ravensburg: Otto Maier.
1892.
Dr. Koch has now concluded his study of the border¬
lands of insanity, the first part of which we noticed in the
Journal for last April. This second volume deals chiefly
with acquired psychopathic conditions. He divides and
subdivides his subject in what is, perhaps, a somewhat
arbitrary way, but deals in an able and suggestive manner
with the mental and constitutional characteristics of various
morbid conditions, including, among others, morphinism
and cocainism, the chronic abuse of coffee (of which, how¬
ever, he is rather sceptical), and the neurotic conditions
accompanying puberty, pregnancy, masturbation, etc. In
justification of the title of his work. Dr. Koch criticizes the
wide extension sometimes given to the conception of neuras¬
thenia, as a %t comfortable pillow of self-satisfaction ” which
hinders progress. He considers that Beard is largely
responsible for this, but, at the same time, does full justice
to the American author as a genuine scientific worker, who
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1893 .]
initiated the study of many anomalous mental conditions.
The book ends with a discussion of prophylaxis and treat¬
ment, and with a few well-selected cases.
AudAtion Coloree. By Dr. Jules Millet. Paris s Doin.
1892. Pp. 81.
This interesting pamphlet is the latest contribution to a
subject to which little attention has been given in this
country, although it was in England that the expression,
“ colour hearing 99 or “ coloured hearing,” now generally
accepted as most convenient, was first used. Dr. Millet, a
young medical man of Montpellier, is fairly well acquainted
with the copious literature of his subject, to which he gives
frequent references, and is also interested in the bearing
which the works of various recent poets and novelists
(Baudelaire, Huysmans, Gautier, etc.) have on the matter,
although, with the exception of a famous sonnet by
Rimbaud, he attaches little value to these literary con¬
tributions to our knowledge of coloured hearing. He has
himself since childhood associated colours with the various
vowels, and been conscious of other similar associations.
Colour hearing is not common in Dr. Millet's experience;
much rarer than Bleuler and Lehmann found it, though this
may be due to the former’s rejection of cases which were
clearly not spontaneous, but acquired by suggestion. He con¬
firms the experience of other observers that the fundamental
colour of acute sounds (such as the English e) is red or
yellow, while the deeper sounds are associated with sombre
colours. Unfortunately, colour-hearers are not sufficiently
unanimous to enable us to found a science on their abnormal
sensations.
Dr. Millet presents, in a tabular form, the experiences of
92 cases, drawn from various sources, of persons to whom
vowel sounds are coloured. It appears that yellow is the
colour most frequently seen (in 68 cases), while orange and
violet are the colours least commonly seen (by eight and five
persons respectively). The French a is most usually black,
the English e is most usually heard white (i.e., by more
than 50 per cent . of those who hear it coloured). 0 is
usually red, but nearly an equal number of persons see a
red. The English sound a is usually yellow, while half the
persons who see green associate it with the French u .
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Dr. Millet has not much light to throw on the theory of
coloured hearing, but he invokes Luciani’s doctrine of the
partial confusion of cerebral centres, and also considers that
Charcot and Binet’s four types (indifferent, visual, auditive,
and motor) of mental process aid in making the phenomena
comprehensible, the subjects of coloured vision being all, he
believes, of the visual class. He considers that coloured
audition, far from being in any' way associated with neuro¬
pathic symptoms, marks a new stage of progress in the
perfectibility of the senses, and he urges us to penetrate the
mysteries of the ultra-violet rays. How those of us who are
not colour-hearers are to penetrate these mysteries the
author fails to explain.*
Le Type Ciiminel d’Apres les Savants et les Artistes . Par le
Dr. Edouard Lefort. Paris: G. Masson. 1892.
This is one of the “ Documents de Criminologie et de
Medicine Legale 99 which we owe to the enthusiasm and
industry of the Lyons school. Charcot and some of his
pupils had already exploited the field of art to illustrate the
demoniacal and ecstatic forms of hysteria, and the happy
idea occurred to Dr. Lefort that the same method might be
used to illustrate criminal anthropology. He has no
difficulty in showing what many of us have already
realized, that artists have always been familiar with those
signs of low and degenerate organization which recent
investigation has shown to be common in criminals. Dr.
Lefort takes the Italian, Flemish, Spanish, and French
schools in turn, and the book is fully and excellently illus¬
trated.
The British Guiana Medical Annual and Hospital Reports.
Edited by J. S. Wallbridge, M.E.C.S., and E. D.
Bowland, M.B.Edin. Demerara, 1892.
This little volume contains thirteen papers by medical
officers in the Guiana Government service, besides some
clinical notes and the reports of interesting discussions on
the papers read to the Guiana Branch of the British Associa¬
tion. The contributors prove that they have made good use
* It may be mentioned that an able article on “ Pseudo-Chromesthesia,” by
Dr. Krohn, has just appeared in the “ American Journal of Psychology,” (Oct.,
1892.) A fall bibliography (containing 85 entries) is given at the end.
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of ;the field'for original observation in the colony. Three
papers are of especial interest to the readers of this Journal—
“Cases of General Paralysis of the Insane,” and “Patho¬
logical Appearances seen in the Insane Dead in the Berbice
Lunatic Asylum,” both by T. Ireland, and “ Notes on Racial
Physique,” by P. B. T. Stephenson, M.B., C.M.
Dr. T. Ireland observes that “general paralysis occasionally
occurs in the negro, but seldom or never in an Indian coolie.
As one would expect in a race whose mental development is
as yet imperfect, and in which the finer mental emotions are
to a considerable extent latent, cases are occasionally seen in
which mental symptoms are almost entirely absent, or so
slight as to escape the notice of the patient’s relatives,
possibly only a slow gradual change in the character and
disposition taking place, without the appearance of the outre
ideas or extravagant behaviour so characteristic of the disease
as seen in the white race. Others, however, appear in which
all the symptoms, mental and physical, are perfectly typical.
The absence of exciting causes, such as anxiety of mind,
overwork, and over-excitement, in a country where it is so
easy to earn a livelihood, and where the struggle for existence
is comparatively slight, leads us to regard sexual and
alcoholic excess with syphilis as the most probable cause of
general paralysis.”
Six cases of general paralysis in negroes are described at
length. The first was a negress aged thirty.
Dr. Ireland remarks that in 1891 the health rate of the
public lunatic asylum fell from 104, about which it had stood
in the two preceding years, to 70, giving a percentage of a
fraction over 10 in the average number of patients daily
resident. As usual, Bright’s disease or cirrhosis of the liver
and kidneys was the most prolific cause of death, being fatal
in 25 cases. In a considerable number of those examined
after death anchylostomata were found, although in none of
them could the cause of death be assigned to these parasites.
Dr. Ferguson gives us a careful study of the anchylostoma
duodenale and the effects which it produces in the human
body. Anchylostomiasis is the cause of a great mortality in the
villages and plantations of Assam. It was no doubt brought
by the coolies to Guiana, where it infests the workers in the
sugar factories. It produces death by anaemia and effusion
into the serous cavities. Towards the end of the disease
mental changes are observed, which are thus described by
Dr. Ferguson :—“ His memory is impaired, and also his will ;
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he has become more dependent on and yields more easily to
others. His cerebration is sluggish; he cannot think closely,
and he makes no effort to do so. Not only are there these
mental alterations, but strange, often transient, sensory and
motor phenomena are observed, ill-defined and variable,
which seem to depend on the anaemia and consequent
deficiency of nutrition of the whole nervous system. Later
on he becomes stupid, will remain by his bedside for hours
with a listless expression, and taking little interest in any¬
thing. Where there is any congenital mental instability
this shows itself in irritability of temper, or in silly or un¬
called-for destructive acts. Ultimately he becomes drowsy
and lethargic, and is constantly sleeping, a sleep from which
he can be awakened without difficulty into a heavy, stupid
mental state, to fall back again as easily into drowsi¬
ness.”
Dr. Stephenson in his “ Notes on Racial Physique ” accepts
as a rule the axiom that the weight of the body in pounds is
proportionate to the square of the body in inches. The
mean coefficient for the adult Briton is 30; for the negro
31 for the men and 30 for the women, and for the coolie 34
for both sexes. The smaller numbers indicate the more
favourable body weight. He finds that the negro has about
the same size and weight as the British labourers, but the
coolie is two inches smaller and 22 pounds lighter than the
negro. Dr. Stephenson has some careful observations on the
loss of weight in mania and melancholia. He observes that
“ a gain in weight coincident with mental improvement is
most hopeful, while increase of weight without this is of bad
omen, and indicates the onset of dementia.”
The most important of the other papers in the volume are
the Address of the Surgeon-General to the branch of the
Medical Association, “ On the Determination of the Time of
Death from Post-Mortem Changes,” by C. Young, M.D., on
“ Bright’s Disease as seen in Malarious Countries,” by E. D.
Rowland, M.B., and a “ History of the Leper Hospital,” by
W. S. Barnes, M.D. In the last paper Dr. Barnes holds that
the proofs of the spread of leprosy through contagion are
not sufficient to justify the compulsory segregation of lepers.
He does not believe that the diminution or extinction of
leprosy which has taken place in some countries can be
attributed to segregation. In this view he is supported by
Dr. Grieve, the Surgeon-General, a man of great experience
and sagacity.
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Altogether these reports afford pleasing proof that the
energy of our race is exerting itself to advance medical
science in a relaxing tropical climate.
On the Origin of Arithmetic (Tiber den Ursprung des Zahdhe-
griffs aus dem Tonsinn und uber das Wesen der Prim -
zahlen ). Yon W. Preyer in Berlin. Hamburg and
Leipzig. 1891.
Professor Preyer, of Berlin, lays down as the foundation of
his inquiry that all mental conceptions come through the senses.
Arithmetic is the science of pure time, as geometry is the
science of pure space. Preyer regards the ear as the organ of
the sense of time, and the eye as the organ of the perception
of space. How can a man who has no conception of time
arrive at the conception of numbers ? Children, he says, count
and make estimates without a knowledge of numbers. It is
sometimes assumed that all numbers are evolved through the
addition of units, but this hypothesis assumes that they already
know two numbers, and the knowledge of a method, that is of
addition. These must first be acquired. Preyer thinks that
the perception of numbers comes in the first place through
hearing and the comparison of tones, and then becomes sup¬
ported by seeing and touch. The sensation of intervals in
musical consonance seizes upon the attention of children and
uncivilized people. The lower numbers are learned through
the feeling of pleasure at noting the intervals in musical tones
—the first 1-1,-the octave 2-1, the fifth If, the major third If,
and the natural seventh If, which goes between the fifth and
the octave. The major third itself is not so primitive a sound
as the fifth, because it lies between it and the first. The first
indicates the repetition of a single tone with no rising in
height. All the tones used in singing and in music are com¬
pounded of the octave, the fifth, the major third, and seventh.
The other consonances are not needed to bring out the most
pleasing harmonic tones, but they go to add more force to
them. Preyer then holds that the lower numbers are at first
names which indicate the recognition of the intervals of the
tones which are most universally pleasing.
The learned Professor pursues his analysis through a pam¬
phlet of thirty-six pages. I cannot subscribe to his assumption
that arithmetic is the science of pure time. When a person
recognizes four or five small objects at once there is a simul-
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taneou8 recognition of so many points in space without any
succession in time. The sense of hearing, however, brings us
into closer relations with time than with space. Helmholtz
has shown that in sound the number of the vibrations
in the air and in the nerve fibres of the ear are identical.
These vibrations in musical tones have a numerical relation
to one another. No one will deny that numbers may be
learned through the ear, that is, through the perception
of the repetition of sounds, or in the Intervals in the
jnusical scale. But the power of abstracting numbers from
these is an inherent quality of the human intellect, and this
capacity can be exerted by those who never heard a sound,
by the blind, and even by those who are both blind and deaf,
that is numbers might be learned through touch. Some
people rest their conceptions of numbers upon visual objects;
others upon sounds. Inaudi, the arithmetical prodigy lately
exhibited in Paris, made his calculations through heard num¬
bers working in his mind. Other great calculators work their
problems through visualized ciphers, aiding their mental opera¬
tions by counting on their fingers. The arithmetical faculty
is not dependent upon any one sense, although it could not be
evolved in the absence of sensation.
A Dictionary of Psychological Medicine , giving the Definition ,
Etymology , and Synonyms of the Terms used in Medical
Psychology , with the Symptoms , Treatment , and Pathology
of Insanity , and the Law of Lunacy in Great Britain and
Ireland . By D. Hack Tuke, M.D. Two vols. J. & A.
Churchill, London. 1892.
The production of the “ Dictionary of Psychological
Medicine” is an event which ought not to be passed by
without mention in the “ Journal of Mental Science.” For
in two large volumes of 1,400 pages of this work nearly
one hundred and thirty writers, besides the Editor, have
contributed from their special sources of information the
latest views and researches on all that concerns psycho¬
logical and neurological medicine and jurisprudence. The
indefatigable editor has gathered together a band of workers,
not only from our own and other English speaking countries,
but from the continent, and from almost every nationality
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1893.]
eminent physicians have sent articles on such subjects as
they have made their own. Thus Charcot has written on
Hysteria and Hypnotism, Professor Ball on the Insanity of
Doubt, Ribot on the Disorders of Will, Bouchereau on
Erotomania, Collin and Gamier on Homicidal Monomania,
Ritti on Circular Insanity, Legrain on Alcoholism and
Dipsomania, Motet on “Les Cerebraux.” From Germany
there are valuable contributions. Arndt writes on Electricity
in Insanity and on Neurasthenia, Erlenmeyer on Morpliio-
mania, Cocomania, etc., and Nostalgia, Kirn on Influenza
and Insanity, Mendel on Diagnosis, Ludwig Meyer on Chorea
and Insanity, Neisser on Katatonia and Verbigeration,
Tuczek on Ergotism and Pellagra. From Austria Benedikt
sends contributions on Craniometry and on the Brains of
Criminals, and Schwartzer on Transitory Mania. There are
also valuable accounts of the state of the insane in various
countries. Mierzejewski describes the Provision for the
Insane in Russia, Cowan that of Holland, Pontoppidan that
in Scandinavia, Morel in Belgium, Tonnini in Italy, and the
last physician and Tamburini send articles on the Insanity
of Ancient Greece and Modern India. From America also
Dr. Tuke has gathered the experiences of several noted
observers. Dr. Chapin, the well-known head of the
Pennsylvania Hospital for the Insane, contributes an
account of the insane in the United States. Dr. Cowles, of
the Maclean Asylum at Boston, writes, as we should expect,
on Nursing. From the pen of the late Pliny Earle we find
a paper on the Curability of Insanity. Dr. Donaldson,
formerly of the Johns Hopkins University, sends a valuable
article on Psycho-Physical Methods, and Professor Jastrow
one on the Reaction Time in the Sane. Dr. Lombard writes
on the Temperature of the Head, and Mr. Sanborn on the
Boarding-out of the American Insane in Private Families.
When we turn from foreign writers to those of our own
country we find that a very large majority of our psycho¬
logists have contributed to the Dictionary, and in addition
many who are not alienist physicians have brought their
stores of knowledge to the elucidation of neurological or
physiological problems. Thus, Dr. Clifford Allbutt writes
on Insanity in Children, Dr. Wilks on Delirium, Dr.
Bristowe on Stammering and other Affections of Speech,
Dr. Barnes on Climacteric Insanity and Ovariotomy in Rela¬
tion to Epilepsy and Insanity, Sir Andrew Clark on the Con-
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volsive Cough of Puberty, Dr. Playfair on Functional
Neuroses, Dr. Janies Anderson on Epilepsies and Insanities,
Professor Horsley on Cretinism and on Trephining, Dr.
Buzzard on Peripheral Neuritis, Drs. Ringer and Sainsbury
on Sedatives, Mr. Dent on Traumatism and Insanity, Dr.
Thudichum on the Chemistry and Dr. Beevor on the Physi¬
ology of the Brain. The Editor contributes a number of
valuable papers, and his colleague, the co-editor of this
Journal, sends also a long list. The other contributions of
our own psychologists it is difficult to specify when so many
are excellent, but mention may be made of Dr. Orange’s
paper on the Criminal Responsibility of the Insane, Dr.
Clouston’s on Developmental Insanities, Dr. Bevan Lewis’s
on Psycho-Physical Methods and Reaction Time in the In¬
sane, Dr. Mickle’s on General Paralysis, and Dr. Duckworth
Williams’s on Baths.
Alienist physicians are brought much into contact with
law, and the Editor has enlisted the services of a legal
gentleman, who has fully and yet concisely expounded
various points which came under this head. The law of
trusts in relation to lunacy, testamentary capacity, marriage
in relation to insanity, the law of partnership in the same
relation, these and many other questions are treated by Mr.
A. Wood Renton and the legal authorities cited. These
will be found extremely useful, and will obviate the necessity
of having recourse to legal text-books. There are also
papers on the New Lunacy Law, by Dr. Outterson Wood,
and on certificates by Dr. Hayes Newington.
Besides the more lengthy articles, the Dictionary abounds
in definitions and explanations of words, including those
which are obsolete or little known. And besides these there
are four features which deserve to be mentioned. The first
is an Historical Sketch of the Insane, by the Editor, which
goes back to the earliest ages and traces the history of the
disorder from the Egyptians and Israelites to the Greeks
and Romans, and thence through the middle ages to our own
time. The whole sketch is most interesting.
The second feature is a paper on the Philosophy of Mind,
by Mr. W. C. Coupland, which places before the reader the
latest theories and views on the subject, and gives a clear
resume of the writings of the two chief living exponents of
psychological science in this country, Professor Bain and
Mr. Herbert Spencer.
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The third feature is the Bibliography of Dr. Urquhart,
compiled with great care and labour, which gives in chrono¬
logical order, beginning with the year 1584, every book,
treatise, or paper which has been written on insanity in the
English language not contained in the psychological
Journals. As we approach our own times the value of
this becomes very apparent. Besides this bibliography it
should be said that to many of the papers is appended a
bibliography of the special subject with references to home
and continental literature bearing thereon.
The last feature, but not the least, is the very full and
complete index, which is invaluable to the student, and con¬
tains not the words already given in the Dictionary sub voc .,
but references to every kind of subject touched on in the
various papers, and the whole of the names of contributors
and others, with the titles of their articles and references
to subjects treated by them elsewhere. So full is it, com¬
prised in 65 double column pages of very small type, that it
is of the greatest possible assistance to the reader, and it is
much to be desired that all dictionaries should be provided
with so useful an adjunct. Great credit is due to Dr.
Pietersen for his labour in the construction of it.
Dr. Tuke may well be proud of his work. It is doubtful
if there is such another dictionary of any special branch of
medicine. All must heartily wish it success.
G. Fielding Blandford.
Festschrift zur Feier des Funfzigjahrigen Jubilaums der
Anstalt lllenau , herausgegeben von den jetzigen und
fruheren IUenauer Arzten: Schiele, v, Krafft-Ebing, Kirn,
Neumann, Fr. Fischer, Eickholt , Wilser, Landerer, Dietz .
Mit einem Lichtdruckbilde von lllenau und zwei litho -
graphierten Tafeln. Heidelberg. 1892.
These essays form a worthy commemorative contribution
to the interesting occasion in honour of which they were pre¬
pared. Dr. Schiile’s article is a Jubilee discourse, and consists
of a glance at present and future questions in psychiatry.
We regret that we are unable to give even an abridgment
of the historical events connected with this admirable insti¬
tution, superintended as it has been by able men, and
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directed at the present time by the distinguished alienist
who is so altogether worthy of the associations and reputa¬
tion of Illenau.
Krafft-Ebing contributes a paper on the differential
diagnosis of dementia paralytica and of cerebral neurasthenia.
Kirn, of Freiburg, writes on insanity and crime.
Neumann, of Badenweiler, records observations upon
fracture of- the skull, concussion of the brain, and shock.
Fischer, of Pforzheim, describes changes in the cornu
Ammonis in epileptics.
Eickholt, of Grafenberg, writes on the acute form of
so-called Verriicktheit.
Ludwig Wilser, of Karlsruhe, on the transmission of
mental peculiarities.
Landerer gives the results of treatment by Duboisin in
mental excitement in women.
The last article is by Dietz on the simulation of insanity.
It will be seen from these titles that subjects of the
greatest psychological interest are treated by the able men
who have been or are on the medical statf of Illenau.
These memoirs are not only valuable in themselves, but
they bear witness to the influence exerted by this institution
upon the psychological medicine of the present day. This
is the second Jubilee, the first having been celebrated when
the asylum attained 25 years of age, and Schiile concludes
his glance at the past history of Illenau in these words :
Heute, an diesem zweiten Jubeltage, sei der festlich hohe
Wunsch, in dem alles enthalten ist, wiederholt, und—innig
wie am Schluss des ersten—Illenaus Wohl unserm treuen
Gott befohlen.
We sincerely trust that the future of Illenau may be as
distinguished in humanity and science as the past, and that
when, in the order of events, it celebrates its centenary, the
historian of the course which it has run may be able to
present a yet more splendid record, if possible, of results,
scientific and humane, than that which its estimable director
has been able to present in the article from which we have
quoted.
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Die Literatvnr der Psyckiatrie im XVIII. Jahrkundert. Fest¬
schrift zum Fiinfzigijdhrigen Juhildum der Heilanstalt
Illenau , Baden , am 27 September , 1892. Yon Dr.
Heinrich Laehr, Geh. Sanitatsrath u. Professor. Berlin,
Georg. Reimer. 1892.
Dr. Laehr seized the occasion of the Jubilee of the Illenau
Asylum to prepare and present the above production. It
forms a valuable contribution to psychological literature.
From no one could it proceed so fittingly as from its author,
who has accumulated during his lifetime a mass of
references to works published, not only in Germany, but in
other countries, on mental disorders and allied subjects. The
present contribution is preceded by a brief but interesting
sketch of reforms in the treatment of the insane in various
countries.
This publication and Dr. Laehr’s former work, entitled
“ Gedenktage der Psychiatrie und ihrer Hiilfsdisciplmen in
alien Landern,” of which a third edition has been issued,
ought to be in the library of all medical psychologists, to
whatever nationality they belong.
Atlas of Clinical Medicine . By Byrom Bramwell, M.D.
Vol. II., part 1.
We welcome the first part of the second volume of this
important work. Among the subjects dealt with, two specially
concern the nervous system, viz., certain cases of Friedreich’s
disease, and the clinical significance of alterations in the fields
of vision. The high quality of the plates illustrating the part
is fully maintained.
The cases of Friedreich’s disease—hereditary ataxy—are
two in number, and they supplement a previous article in Vol.
I., in which the disease is described in detail. The peculiarity
of these two cases consists in the retention of the knee-jerks,
which, though slight, were distinctly present. In other
respects, the cases conform to the usual type. The patients
were brothers. There is no mention of the alcohol question,
whether the father was addicted to the glass or not, though this
point appears to have considerable bearing on the etiology of
the disease.
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A chapter of considerable length deals with the alterations
in the fields of vision. The earlier part of this is, perhaps, a
little lengthy and introductory, and might invite to Hamlet's
ejaculatory comment on the actor's preamble, but we have no
cause for complaint when the subject-matter is seriously
tackled. Dr. Bramwell insists that hemianopsia, like optic
neuritis, should be looked for in every case of suspected brain
disease; this as a matter of routine. That most intricate
subject of the visual representation in the cortex is very
clearly dealt with, though we must say that, with every visual
centre, we gaze regretfully at Professor Michael Poster’s brief,
but insufficient, resume of the subject, viz., “ that the hind
portion of the cortex is in some way intimately concerned
in vision.’' A protest is entered against the confusing dis¬
tinction made between the terms hemianopsia and hemiopia.
As the writer very justly remarks, if one term—hemianaesthesia
—will suffice for a defect in general sensation, why should two
be required for the special sense ? Of course, we are not
suggesting that in any case the specialist’s fee should be less
than two guineas, and if hemiopia do not seem quite long
enough for the purpose, then, by all means, hemianopsia, but
not both !
Among the subjects of general medicine, there is an article
on scrofula. We are delighted to see that the term still
survives, and that Dr. Bramwell defines it as a constitutional
state, which exhibits a special vulnerability of the tissues
towards the insults of the tubercle bacillus ; in other words, it
recognizes that it takes two to play at the game of tuber¬
culosis, a fact we are beginning to recall to mind. A beautiful
plate illustrates this disease. Dr. Bramwell does his work
very thoroughly.
Diseases of the Nervous System . By J. A. Ormerod, M.A.,
M.D.Oxon., F.R.C.P. Churchill. 1892. Students' Guide
Series.
Students' manuals are very numerous in these days/but we
consider that Dr. Ormerod has really rendered a service to
students of nervous disease with this short treatise. Nervous
disease, as depicted in the heavy tomes of our libraries, is really
a “ monstrum horrendum . . . ingens," and by the time the
student has waded through their pages it is he who lacks
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sight. Neither whole nor half-vision centre retains any clear
image, and the word-visualizing centre is quite blinded. The
author of this manual puts matters very clearly before us in
good plain English, and the diagrams, to help out the text,
are well-planned and well-selected. An anatomical intro¬
duction is followed by a section on the methods of examination,
including those of the special senses—eye, ear, smell, etc.—
and of special mechanisms, such as the larynx. The exami¬
nation of the eye is excellently handled. Electrical examination
and the interpretation of results is also well given. The special
diseases are compressed into very portable compass (we refer
to cranial capacity), no attempt being made to discuss
moot points or to illustrate by cases. Dr. Ormerod wishes
essentially to teach the better-established facts of nervous
disease, and in this we think he succeeds admirably; at the
same time, he does not blink exceptional records, e.g., under
Friedreich’s disease. Whilst accentuating the fact of the
absence of the deep reflexes, he does not omit to say that in
some very rare cases they may be retained or even exaggerated.
The writer is, of course, himself an authority, and we can take
in knowledge, therefore, with a sense of security. We are
confident that this manual will prove very helpful.
The concluding chapter deals with diseases of which the
organic basis is not known. This list includes chorea, as
well as hysteria and neurasthenia. We must confess we
regret that Neurasthenia should receive official recognition;
till this trouble crystallizes into something more definite than
its present formlessness, we should deny its claim to a separate
individuality.
On Education from the Medical Standpoint. By G. E.
Shuttleworth, B.A., M.D., etc. Inaugural Address as
President of the Lancashire and Cheshire Branch British
Medical Association , June 29 th, 1892.
Annual Reports of the Royal Albert Asylum , 1890 and 1891.
Those who are interested in the education of the idiot will
find much that will repay their perusal of the annual reports
of the Royal Albert Asylum, and also of the Address on
education, given by Dr. Shuttleworth. He considers the
relations of heredity to it; the relation of education to
development; the manual training in schools; the role of
xxxix. 8
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technical education in school life; education in relation to
sexes. Everything that the medical superintendent of the
above institution writes is characterized by common sense,
and implies too a vast amount of practical knowledge of weak-
minded children.
Our space does not allow of our entering upon the many
important subjects to which Dr. Shuttlewortli alludes. Our
chief object is to draw renewed attention to the case, and so
far as possible the improvement of the feeble-minded. We
may add that during 1890 and 1891, 137 patients were dis¬
charged, their mental condition being as follows:—Re¬
covered, 1; much improved, 43; slightly improved, 35; not
improved 12.
Mental Science and Logic for Teachers. By Thomas Cart¬
wright, B.A., B.Sc. (London), Principal of the Birkbeck
Training Classes. London: Joseph Hughes and Co.
1892.
This is an unpretentious but useful little book. It contains
a brief sketch of mental science, and of training of the senses,
and of memory, etc. Some good observations are made on
the cause of the misconception which arises in debate and
discourse, some of it being due to employing words alike in
sound but different in spelling, and words alike in spelling
but different in sound, but much more from the equivocation
springing out of identity in both sound and spelling.
A number of answers to questions in mental science and
logic are appended.
Elementary as is this brochure, it would be well if advanced
students would form as clear a conception of the meaning of
the terms they employ as Mr. Cartwright’s book would
afford them.
The Colonization of Epileptics. By Frederick Peterson,
M.D., New York. Reprinted from the “ Journal of
Nervous and Mental Disease,” December, 1889.
The subject of the above article attracts increasing atten¬
tion. In 1887 Dr. Peterson gave an account in the New
York Medical Records of his visit to the Bethel Epileptic
Colony at Bielefeld, near Hanover, and in this paper he gives
a very interesting account of its history and condition.
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He comments on the inadequacy of the institutions in his
own country to meet the needs of this unfortunate class, and
he hopes to arouse public sentiment in their favour, desiring
that some religious sisterhood, private philanthropist, or
public official may provide for their wants a colony, which
may prove to be a “ home for the homeless, a place of refuge
from many miseries, an educational institute for those who
are forbidden the public schools, an industrial college for
those to whom the ordinary avenues of trade are closed, a
hospital where cure or palliation shall be possible, and where
the highest scientific minds may be able to discover some¬
time a specific against one of the most woeful of human
ills; in short, a prosperous, industrious, and thriving com¬
munity, to serve as a model for many other such yet to
be founded on this continent.”
Dr. Ewart, in his article on “ Epileptic Colonies,” in this
Journal, April, 1892, gives a sketch of the same institution,
and acknowledges the assistance afforded him by Dr.
Peterson in regard to the steps now taken in the United
States in regard to the provision for epileptics. As is well
known, the Charity Organization Society in England is
interesting itself in the subject, and we may hope that
England will not be long behind hand in their care of the
epileptic by colonization and otherwise.
Illustrations of the Nerve Tracts in the Mid or Hind Brain and
the Cranial Nerves arising therefrom. By Alex. Bruce,
M.A., M.D., E.R.C.P.Ed. Edinburgh and London:
Young J. Pentland. 1892.
This admirable Atlas, intended for students in Neurology,
is deserving of all praise. The Plates are taken from the foetal
brain, with one exception, inasmuch as the course of the tracts
and cranial nerves can be followed with greater facility than
in the adult. We wish Dr. Bruce's labours the success they
so richly deserve.
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116
[Jan.,
PART III.-PSYCHOLOGICAL RETROSPECT.
1. English Retrospect,
Asylum Reports for 1891.
Aberdeen ,—The directors have devoted much attention to the
consideration of the best means to improve the character of the
accommodation for the poorer class of patients, and they hope to
be able to produce fully-matured plans and proposals at an early
date. When it is remembered that the older buildings date from
1799 it can be easily believed that they are considerably behind the
times and require numerous and extensive alterations to bring them
up to modern requirements.
Dr. Reid records the following case:—
A female, aged 40, was admitted on June 23rd in a weak and emaciated
physical condition, labouring under active melancholia, and with a fractured
arm, caused by her having thrown herself from the second flat of a tenement
house. Great vigilance had to be exercised owing to her suicidal tendencies.
Everything went on as satisfactorily as could have been expected until the 27th
July, when she was seized with great vomiting and great pain in the epigastric
region. Without entering on full medical details it may be briefly stated that,
from the aforesaid date to the second week of October, the patient passed no
fewer than 125 pins and sewing needles, with, in addition, many darning
needles and hair pins; also a pair of spectacles in pieces and a crochet needle.
Although she had lost much flesh, at the end of October recuperative power set
in, and she was slowly and gradually recovering both in body and mind when
an attack of pneumonia supervened, and she died on the 13th December.
Berkshire .—It is impossible to peruse this report without
experiencing great regret at the untimely death of Dr. Douty. He
had done good work since his appointment, and it seemed as if he
had many years before him during which to carry out his ideas.
The Visitors report that although strongly urged by the Com¬
missioners to appoint a second assistant medical officer they had
declined to carryout the recommendation from motives of economy.
But since the passing of the new Lunacy Act they find that the
time of the medical superintendent has been so much taken up with
clerical work that it has become necessary to make the addition
to the medical staff.
The church services have been improved by the substitution of
an organ for a harmonium.
Concerning the causes of insanity, Dr. Douty says in his
report:—
An idea is prevalent amongst the public that intemperance in drink is the
cause of a majority of the cases of insanity which occur amongst both the upper
and lower orders of society; I have even heard a man make a definite statement
to the effect that the patients in public asylums are worthy of faint sympathy,
because they were “ pretty well all of them there through drink.” I desire
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1893.] Asylum Reports. 117
again to take the opportunity, provided by my annual report, to say that such
statements could be made only by those ignorant of facts, that they are untrue,
and constitute therefore a great injustice to those afflicted with mental disease
in this country. No one is more cognizant of the disastrous effects of the abuse
of alcohol than the members of my profession, and we make, therefore, as careful
inquiries as we can, when taking the history of a case, to discover the previous
habits of the patient. Of the persons sent to us during 1891 only four could be
suspected of having been addicted to the abuse of alcohol. The remaining 84
were, on the other hand, persons who had led sober and hitherto industrious lives,
had been held in respect by their neighbours, and were sent to the asylum
because their health had failed through no fault of their own. I think I may
safely say as a rule 90 per cent, of our cases have no connection whatever with
alcohol. In some agricultural counties the abuse of alcohol appears to be more
common than it is here; and in the larger towns, as well as in the thickly
populated districts of the midland counties, drunkenness is, I believe, a more
frequent cause of insanity.
Bethlem Hospital. —The female attendants are now provided with
uniform, and it is reported that the result has been a most satis¬
factory and gratifying improvement in their appearance.
Dr. Smith points out the great improvement that would be
effected by the erection of a suitable hall for entertainments. It
must be admitted that the present arrangements for associated
amusements are not worthy of this important hospital.
Early in 1891, in response to the representation made by Dr.
Smith to the Governors, as to the'increase of work and respon¬
sibility entailed by the ill-advised Lunacy Act, 1890, an additional
assistant medical officer was appointed,
Birmingham. Winson Green. —A severe outbreak of influenza
occurred. It continued about three months and attacked 160
persons in all, 120 being patients. In no fewer than 24 cases the
disease was complicated by the occurrence of pneumonia, and of
these 23 died.
Nearly the whole of the drainage has been reconstructed, with
marked benefit to the general health.
A second assistant medical officer has been appointed. Dr.
Whitcombe continues the instruction of his nurses and attendants.
His Visitors presented each successful candidate at the examina¬
tion for certificates of proficiency in nursing, twenty in all, with a
silver medal.
Birmingham. Rubery Hill. —During the influenza epidemic only
two patients and two nurses were attacked—a remarkable contrast
with the other borough asylum.
One nurse and one male patient suffered from typhoid fever, the
cause of which could not be discovered.
Bristol. —In accordance with the recommendation of the Com¬
missioners a second assistant medical officer has been appointed.
It is expected that the administrative and residential block,
which for the last two years has been in course of erection, will be
shortly ready for occupation.
Cambridge. —The important structural additions and alterations
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118 Psychological Retrospect . [Jan.,
begun a year ago are still in progress, and, so far as they are com¬
pleted, are reported to afford excellent accommodation.
Cheshire. Parkside. —Additional buildings for the accommodation
of 96 patients and 10 nurses are now in use. The best means of
heating and ventilating the asylum are under consideration. A
second assistant medical officer has been appointed. A sitting-
room for nurses when off duty has been provided and suitably
furnished.
Argyle and Bute. —Various structural improvements have been
carried out during the year. Land formerly rented is no longer
available, and the asylum estate now extends to only 50 acres, an
amount evidently too small, and the Board has hitherto failed in
obtaining more.
In his report Dr. Cameron remarks :—
Some difficulty is occasionally experienced, especially in the case of private
patients, in obtaining accurate information as to the duration of insanity, and in
some instances patients are represented as having been insane only for a few
days or weeks when, in fact, they have been so for months or even years. For
example, in one case the duration of insanity was entered as one week, and in
another as ten days, whereas it had lasted in the former case for one year and in
the latter for three. It has been observed that in almost every case of general
paralysis affecting a native of the district the patient has for some years lived in
a large town.
Bedford , Hertford , and Huntingdon. —The mortality was markedly
increased by the occurrence of influenza. It is mentioned by Dr.
Swain that:—
Of the causes of death pneumonia occurred in the unusually large number of
22 cases; 17 occurred to male patients, and probably 10 of them were attribu¬
table to influenza. In the early part of May there were 11 successive deaths
from this disease, which was of a peculiarly fatal character. The duration of the
attack was very short, and treatment did not appear to produce any amelioration
of the symptoms.
It may be pointed out that the report by the Commissioners in
Lunacy is not given.
Carmarthen. —After due inquiry the Visitors resolved to dispense
with the services of one assistant medical officer, thus reducing the
medical staff to two—the medical superintendent and one assistant.
Against this reduction the Commissioners strongly protest, and
with very good reason. Had the staff been strengthened by the
appointment of one or two clinical clerks the absence of a second
assistant would have been made good, and no objection could be
raised to the arrangement made by the Visitors. A laboratory for
pathological and photographic work is in course of erection.
A female patient, when warming herself at an open fireplace in
the observation dormitory, accidentally set fire to her clothing and
sustained fatal injuries. The Commissioners suggest a slow com¬
bustion stove to obviate the risk of future accidents.
The wages of the attendants and nurses appear small and the
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1893.]
Asylum Reports.
119
amount of leave scarcely up to tlie average. Dr. Hearder suggests
that when these subjects are considered by the Committee the
scheme should include the erection of cottages for married atten¬
dants.
Cheshire. Upton .—A new steam laundry has been erected and the
washhouse enlarged. After inquiry as to the best system of drying,
Blackman’s has been introduced.
With reference to the recommendation of the Commissioners in their last
report as to the more frequent holding of post-mortem examinations, a question
arose as to the legality of such examinations without the consent of the friends
of the deceased, and it was decided to take the opinion of the Commissioners on
the subject, and also to ascertain the practice at other institutions. As the
result of such inquiries it has now become the rule of the asylum to hold a post¬
mortem examination in all cases, unless the friends of the deceased express their
objection to such examination being held. The friends of all patients have been
advised of this rule.
In connection with the above paragraph, which is an extract
from the report of the Visitors, we would venture to point out that
such a notice, given to the nearest relative when a patient is
admitted, may greatly distress the feelings of the friends.
Surely, when a man is removed to an asylum his wife and children
are sufficiently grieved without receiving an official notice that
a post-mortem examination will be held in case of death. Such
notices are forwarded by several asylums, but it is within our
knowledge that they have excited much mental distress, and have
been strongly denounced as an unnecessary addition to the suffer¬
ings of the relatives.
A second assistant medical officer has been appointed. The
asylum is quite full, and the question of providing further accom¬
modation cannot be delayed. The report by the Commissioners is
not given.
Derby. Borough .—On admission and on discharge the patients
are photographed. As the Commissioners remark, these portraits,
inserted in the case books, will prove a valuable addition to the
history of each case. As is now done in many asylums, Dr.
Macphail has instituted classes for the instruction of attendants in
nursing the sick and in their general duties. The death-rate con¬
tinues very high. It seems to be due solely to the unfavourable
nature of the cases admitted. Dr. Macphail points out that one
unfortunate effect of the new Lunacy Act is that of precipitating
the discharge of patients who, at the end of a year’s residence,
though technically not insane, were merely convalescent, and would
certainly have benefited by a little longer residence in the
asylum.
Derby. County .—Many structural improvements are in progress
in this asylum. These include reconstruction of the drainage,
overhauling the ventilation, and many minor though important
pieces of work, but Dr. Lindsay points out that much remains to
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120 Psychological Retrospect • [Jan,,
be done if the asylum is to be thoroughly equipped and rendered
efficient for the cure and care of the insane poor of the county.
In the opinion of the Commissioners the most pressing want is
the provision of better infirmary accommodation.
Concerning phthisis, Dr. Lindsay remarks :—
Pulmonary consumption comes next in frequency, accounting for 13 deaths,
one less than in 1890, which must undoubtedly be considered a large mortality
from this disease. An analysis of the deaths from pulmonary consumption
shows that only two had resided under a year; the other 11 had been resident
from one year and seven months up to 11 years and a half, the average duration
of residence of each case having been four years and eleven months. These
facts are significant.
Our high mortality from this disease, though doubtless not entirely due to
insanitary conditions, would tend to indicate some defect in the sanitary condi¬
tion of the asylum, such as overcrowding, insufficient air space, impure air from
inadequate renewal, and defective ventilation and wanning, evils from which
this institution has suffered in the past, and some of which the Committee are
now endeavouring to grapple with and remedy.
Devon .—A new block for female patients has been completed
and is in occupation. In what is described by Dr. Saunders as
“ a characteristic caustic and choleric report,” the Commissioners
indicate other additions and alterations which they deem necessary.
He recommends the erection of a properly equipped infirmary for
men, mess-rooms for attendants and nurses, and better and
adequate provision for the resident quarters of the medical officers.
An increased amount of leave for the attendants has been
sanctioned, in the hope that it may contribute to their content
and well-being, ]but some doubt is felt as to whether this will be
successful.
It is mentioned that it has been the practice for many years to
discharge patients on trial for one month, with a weekly allowance
of seven shillings, which is a great advantage to convalescents or
those seeking employment.
Dundee Royal Asylum .—In his report Dr. Rorie remarks :—
It is Btill supposed by many that the treatment of patients in an asylum
differs entirely from that pursued in a general hospital, but such is far from
being the case. A certain difference will, no doubt, always exist, but every
year this asylum at least is becoming more and more an hospital for the treat¬
ment of mental and other allied and nervous diseases, and less and less a place
for the mere detention of patients. The diseases treated in asylums are of
much longer average duration than those admitted into general hospitals. In
the latter the physical conditions may vary from day to day; but although in
the former, in the chronic insane, weeks and months may pass without much
marked alteration, the recent and acute cases require constant medical super¬
vision, as the symptoms may rapidly change. The duties of the medical staff
in regard to those closely resemble, therefore, those required in an ordinary
infirmary. Thus on the admission of a patient into the asylum a careful
examination is at once made, with the view of ascertaining whether injuries
exist, and at the same time as full an account as possible is obtained of the
patient’s previous history from those who accompany him. ... As complete a
history of the case as possible having thus been obtained, and all the deviations
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1893 .]
121
Asylum Reports.
from the normal standard having been noted, attention is then directed to the
means of treatment; and, in the great majority of cases, as in ordinary
diseases, the first thing that has to he attended to is the bodily condition of the
patients. Few patients approach the popular idea of a lunatic. Some, no
doubt, are violent, destructive, and dangerous enough, but the great majority
are weak, ill-fed, and suffering from various physical ailments, requiring the
administration of medicines as well as nutritive food. If serious illness exists
the patient is kept in bed, and the changes in pulse, temperature, etc., recorded
twice a day on the clinical chart placed at the head of the bed. Up to this
point then the treatment is practically that pursued in ordinary hospitals. It
is in the subsequent treatment of the patient, when, after the bodily functions
have been as far as possible restored to their normal condition, and attention
directed to the moral treatment in the employment of the various modes of
occupation, amusement, etc., as means directly influencing the mental faculties
or powers, that any differences are found in the practice of the two institutions.
Dr. Rorie continues to devote considerable attention to the
special training of his attendants and nurses.
Dumfries. Crichton Royal Institution .—The following is an
extract from Dr. Rutherford’s report:—
This very exceptional state of matters—a diminution in the number of
lunatics chargeable to Dumfriesshire parishes within the last ten years, when in
all other parts of the country there has been an increase in pauper lunacy, so
great that many of the district asylums have had to be enlarged—is directly
attributable to the discharging from the institution of every pauper lunatic
who can properly be allowed to live out of it. Many people have not the
slightest compunction in accepting parochial aid for the maintenance of a near
relative in the asylum, who would not think of asking such aid to help them to
keep that relative at home. Another great cause of the decrease of pauper
lunacy in this district is the action of the directors in extending the benefits of
the reduced board fund—the special charity of the institution—whereby persons
not of the pauper class, and anxious to avoid becoming pauperized, have then-
relatives treated in the institution at, in many cases, almost nominal rates of
board. During the past year the benefits of the reduced board fund were
granted to 47 applicants. The recipients were admitted at ordinary rates, vary¬
ing from £25 to £60, and the average sum allowed to each from the fund was
£20, so that, in certain deserving cases, all that was paid for the patient was at
the rate of £5 per annum. Many of the new cases recovered within six months,
so that the burden upon the friends was very small.
New farm buildings are being erected. They include accom¬
modation for 80 patients—thus forming a small detached asylum.
The open door system continues in full operation and apparently
with much success. On this subject Sir Arthur Mitchell
observes:—
There is only one entry in the register of restraint and seclusion, referring
to the restraint in a strait-jacket for two hours of a patient who was so
violent as to be dangerous to the attendants and patients. In the management
of this large institution restraint and seclusion do not appear to be often found
necessary, but it is understood that they are resorted to without hesitation
whenever the necessity arises. So far as can be ascertained, the patients
admitted into the asylum labour under forms of insanity which do not
differ from the forms under which the patients admitted into other asylums
are found to labour, and the rareness of the need of restraint and seclusion
does not seem to have its explanation in a prevalence of the milder forms of
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122 Psychological Retrospect. [Jan.,
insanity among the inmates. Something perhaps may be due to the quietudo
induced by the absence of such signs of loss of liberty or restraint as exist in
high walls or fences, in the frequent use of a key in opening and shutting
doors, in irksome discipline, etc. There is a manifest effort in the manage¬
ment to do away, as far as possible, with all such things as are suggestive of
loss of liberty. Several sections of the two main buildings were visited
without having any door opened or shut by a key. Indeed the matron
of the first house completed the visit with the reporter, not only with¬
out opening any door with a key, but without having a key in her pocket. In
all the branch establishments the doors, without an exception, were found un¬
locked. The whole of the boundary walls have been taken down, and an open
fence has been substituted. In various other ways an effort is made to prevent
the patients from feeling that they are detained or confined, and it is difficult
to see how this can fail to result in an increase of tranquility and contentment,
or, in other words, in a diminution of excitement. Everything that was seen
during a long visit seemed to show that the inmates enjoy a large amount of
liberty, larger indeed than would be indicated by the record in the daily
register of those on parole within or beyond the grounds.
.The report is embellished by some excellent photographs of the
asylum buildings.
Earlswood Asylum for Idiots .—The following are short extracts
from Dr. Jones’s report:—
A question often asked is, which is the most suitable age for admission ?
I am inclined to think that six or seven years of age is the most desirable time
to receive children at Earlswood, although your Board has in special circum¬
stances received them as young as three years. Imbecile children of tender
years are extremely helpless, and each child requires almost the undivided
attention of a nurse. About a year ago, with your sanction, I started an
electrical department for those unable to walk. Galvanism of the strength of
from five to ten milliamp&res was applied, and in my opinion with satisfactory
results. Three out of four helpless children are now able to walk; and (with
perhaps too limited an experience to make dogmatic statements) I am inclined
to regard electricity as a valuable therapeutic aid, although the time and
patience required in its application are not likely to add to its credit. The
experience of others with whom I have communicated is less encouraging than
that which I have recorded.
Its (idiocy) pathology, especially that of microcephaly, has aroused an un¬
usual amount of interest of late, and in view of justifying the severe operations
which have been recently performed upon cases of this kind, too much attention
from scientific men cannot be devoted to the subject. If the operation of
craniectomy be followed by the encouraging results anticipated of it, a heroic
step in treatment will have been inaugurated which must gratify the most
expectant physiologist. I speak with but little experience of the operation,
but I have seen some of Professor Lannelongue’s cases in Paris, and have
assisted at the operation in England, and I am not favourably impressed with
the results. I look upon it as one that is always attended with considerable
risk, even when performed under the strictest antiseptic precautions; take in
addition the difficulty there is in making an exact diagnosis of so general a
disease, and we are face to face with what seems to me a rash, if not unjustifiable,
procedure when undertaken as it is without a reasonable and due guarantee for
success.
Edinburgh. Mavis Bank .—Nearly all tbe reports for 1891 con¬
tain references, more or less detailed, to influenza. This is a sub¬
ject which has been largely written about of late, and in our notices
Digitized by L^ooQle
1893.] Asylum Reports . 123
of the various asylums we have not considered it necessary to refer
to the accounts of the epidemic, but the following paragraph from
Dr. Keay’s report may be given :—
Depression of mind during and after influenza is, of course, very common,
but without pre-existing mental instability it would not pass into actual
insanity. In almost all the cases a tendency to mental disease was found to
have existed, and the influenza must have acted simply as the exciting cause of
the attack. Insanity following influenza is quite a curable disease, and in its
treatment nourishing food, warmth, good nursing, tonics, and stimulants are
specially indicated. The curability does not appear to be lessened because of
the existence of a predisposition to mental disorder, but this renders the patient
more liable to similar attacks. If we should unfortunately be subjected to
repeated visitations of the plague, it is to be expected that mental breakdown
following the attack wifi be of much more frequent occurrence, for neurotic
individuals who pass apparently unscathed through one attack will be unable to
resist the depressing effects of repeated doses of the poison.
Edinburgh Royal Asylum .—The extensive buildings in progress
are approaching completion. One villa, for the accommodation of
15 ladies, is occupied. Externally it is very handsome, and it has
been furnished and equipped in the very best style.
In his official entry Sir Arthur Mitchell remarks :—
There is now a resident pathologist, and no opportunity is lost in advancing
the knowledge of insanity by examination after death. This is not a new thing
in the asylum, but a step onward has been taken by the appointment of a
resident pathologist. The records of pathological work in the asylum have
long been full, and they are constantly and diligently discussed and studied.
Indeed, no visit can be paid to the asylum which does not leave a strong and
most pleasant impression as to the character of the medical management. A
patient coming to the asylum has his condition as carefully and minutely
studied as patients have who enter our large general hospital's or infirmaries,
and whatever medicine can do to benefit him is done. Exercise out of doors,
good food, warm clothing, comfortable beds, pleasant and cheerful surround¬
ings, and a kindly forbearance are as much a part of treatment in this asylum
as anywhere, but it cannot be visited without one being impressed with the
attention which is bestowed on the strictly medical treatment of the patients.
The separate hospital, which has been so much commended, and which is being
widely copied, is an outcome of this feature of the management, which is due,
of course, to the Physician-Superintendent, but it is right to add that he is ably
assisted in his researches by his three assistants.
Concerning drink as a cause of insanity, Dr. Clouston writes:—
In regard to the causes of the disease, there are this year one or two rather
striking facts. No less than 96 of them, or 26 per cent., are said to be due to
intemperance. This is a very unusual proportion, for during the previous
fifteen years only an average of 161 per cent, had been due to this cause. It
is my opinion that a physically strong and sound population is on the whole
much less likely to take to excessive drinking than one that is weak, and that
has from any cause a lowered nervous tone. Now it has been notorious that the
years 1890-91 were attended by much disease of various kinds, by a very high
mortality among the aged and weak, by an epidemic of influenza of a virulent
and deadly type, with many serious complications, accompaniments, and effects.
There seemed to exist, too, such prevalent influences for evil, that patients did
not do so well as usual after surgical operations, that low asthenic types of
inflammation were prevalent, and there was a very greatly increased general
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124 Psychological Retrospect. [Jan.,
death-rate. The psychology and causation of excessive drinking are no doubt
complicated questions, but it cannot be doubted that one cause of drinking in
many cases is a feeling of bodily and mental weakness, a conscious inability to
do daily work, or to cope with difficulties, and a languor and want of enjoyment
in life, florae people begin to feel in that way as they get old, others do so
when they are below par in vitality, others after having suffered from disease,
others at certain seasons of the year or in certain kinds of weather, and others
when things go against them. Now it is mere folly to deny that alcohol gives
a temporary stimulus and strength to most people when they are in this state.
In such persons it relieves for the time the distressed and hopeless feelings, and
it dulls the sense of helplessness. As human nature is at present constituted,
an easy cure for misery or conscious weakness is to the majority irresistible,
even though it is known that an after penalty will be rigorously exacted that
will far outweigh the immediately pleasant effects. I am satisfied that some
of my patients took to an excessive use of alcohol this year on account of a
feeling of depression and inertia due to the causes I have indicated. In one
case this was very evident. She was a poor man’s wife, but most respectable,
and ordinarily quite temperate in her habits. She got run down, she was
nursing a child, and she found that a glass of whisky gave her a pleasant feeling
of relief from depression and weariness. Once she had tasted of this Lethe,
Bhe craved for more and more, and her very bodily weakness destroyed her
power of resistance. So this sober, decent woman, from this cause alone, drank
bottle after bottle of whisky, until she became insane, and it did not take much
to do this in the low state of health she was in. It needs only a small know¬
ledge of human nature and the dependence of mind and morals on soundness
and strength of body, to make one’s feelings far more those of pity than of
blame for such a woman.
Another case was that of a man, who, after an attack of influenza, was
prostrate in mind and body, with a weakly acting heart, and a stomach that
had no craving for food. Work was a trouble and pleasures were intolerable.
Alcohol certainly roused him from the feeling of prostration, strengthened the
heart’s action, and seemed to brighten life. Is it surprising if it was craved,
and soon its excessive use could not be resisted, and that in no long time it
upset the highest of the brain functions—the mental ? During the past two
years the nervous vitality of the community has been manifestly lowered, and
such cases were therefore more common than usual.
When one reads the following paragraph one may ask, Why is
boarding-out not tried in England as at least a partial remedy for
the ever-increasing number of patients confined in asylums ? We
cannot, however, give the reason here.
There can be no doubt that but for the boarding-out of quiet and incurable
cases by the two Edinburgh parishes, we should long ago have been so over¬
crowded by chronic cases that we should have been unable to. admit all the new
cases from our district. This year 24 such cases were boarded out, and eight
more were sent to the lunatic wards of the poorhouses. The number of pauper
lunatics of our district not in the asylum was about 70 more at the end of the
year than it was at the beginning. In 1881 St. Cuthbert’s parish had only 26
cases boarded out; now it has 258. Altogether there are about 350 cases
boarded out from our district. Whatever other advantages this method of
caring for the chronic harmless insane, who are paid for out of the rates, has, it
undeniably has this economical result, that no capital is sunk in providing
asylum accommodation for them. In this way something like £50,000 has been
saved to the ratepayers of Edinburgh.
Exeter .—-Concerning the medical treatment of patients in
asylums, Dr. Rutherford writes : —
Of late there have been many ill-natured attacks made on asylum medical
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1893.]
Asylum Reports.
125
officers, in the medical press and elsewhere, by irresponsible persons, who state
that the treatment of the insane by asylum medical officers does not keep pace
with the treatment of other diseases. In making this statement they seem to
have lost sight of the fact that the large number of incurably insane patients
sent to asylums have passed through the hands of "the medical profession on
their way thither, and have had the benefit of their treatment.
A large proportion of the admissions into asylums is made up of worn-out
brains, and wrecks of humanity, for whom there is no recovery, and who weigh
heavily against the recovery-rate of the recoverable few. I have tabulated
below the probabilities of recovery, in four classes, of all the patients admitted
into this asylum up to 31st December, 1891. In each case the prognosis was
made within a week of admission.
TABLE OF ADMISSIONS AND RECOVERIES.
Nature of
Prognosis.
Number of
Cases.
Percentage.
Recoveries
in each
Class.
Rate per
Cent.
Hopeless.
343
55*7
—
-
Unfavourable ...
123
20*0
12
97
Doubtful.
27
4*3
4
148
Favourable
122
19*8
96
78-6
In no less than 55*7 per cent, was the prospect almost hopeless, 20 per cent,
unfavourable, and in no more than 19*8 was the prospect really favourable. In
the latter class the recovery-rate was 78’6 per cent., and this does not include
the cases which have not yet recovered, but which still have a good prospect of
recovery. I do not think that the results of the treatment of any serious disease
will show a higher percentage of recoveries than this. [But more relapses.]
Glamorgan .— It has been decided to enlarge the accommoda¬
tion by erecting workshops and wards for 104 sick and chronic
males.
The following paragraph from Dr. Pringle’s report is an
interesting contribution to the statistics of insanity :—
In my report for 1887 I submitted certain facts as to lunacy in Glamorgan,
in the remainder of Wales, and in England and Wales generally, which showed
in a most striking manner the relatively small amount of lunacy to the sane
population in the first as compared with the other two, and now, with the
returns of the recent census, I find the position of Glamorgan well maintained
as ohe of the sanest counties in the kingdom. Whilst England and Wales has
one pauper lunatic to 383 of the sane population, Wales (excluding Glamorgan)
has one to 340, and Glamorgan has only one to 535, or, to put the matter in
'another form, instead of having 1,301 pauper lunatics in Glamorgan, we should
have 510 more, or 1,811, were the ratio of insane to sane population the same as
in England and Wales generally; or, in other words, we have 28*2 per cent,
fewer lunatics to the sane population. From a ratepayer’s point of view this
means, I need hardly say, an immense saving. If interest on capital expendi¬
ture, cost of keeping up buildings, and maintenance of patients are considered,
it represents at least £16,000 a year. The explanation I gave in my former
report as to the singular and happy condition of Glamorgan as regards lunacy
I still think is the true one, namely, that it is perhaps the most mixed county
in the kingdom. Owing to its mineral wealth, abundance of work and high
wages, it attracts the healthiest and most enterprising men of other countries
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126 Psychological Retrospect [Jan,,
and districts. This is well illustrated by the nationality of the admissions of
the past year. Out of 308 persons admitted 156 were born in Glamorgan and
other Welsh counties, and 152 elsewhere, namely, 115 in England, 26 in
Ireland, three in Scotland, and eight in foreign countries.
Govern .—The asylum is much over-crowded, but as the new dis¬
trict asylum is in course of erection there is now a prospect of this
inconvenience being removed. The admissions included many
feeble cases, with the result that the mortality was unusually
high.
Glasgow , City of, Govan and Lanark .—During the year 10 cases
were admitted for merely temporary detention by certificate of
emergency, to allow time for removal to a more distant asylum.
With the approval of the Commissioners this expedient was
adopted in cases of extreme urgency, where the police declined to
take charge of them, and pending negotiations for admission to
out county asylums.
Gloucester. Bamwood House .—The extensive structural im¬
provements begun in 1890 have been completed. Although the
space in the dayrooms and dormitories has been doubled, the
number of patients has not been increased. As Dr. Needham has
now ceased to direct the working of this splendid hospital for the
insane, he may be heartily congratulated on the great work he
has carried out there. In his report he says :—
The percentage of recoveries upon all the admissions for the last 15 years has
averaged 46 # 8 per cent., and for the last five years 57*2 per cent. When it is
remembered that patients are received practically without selection, and in the
order of their application, and having in view the obviously incurable character
of many of the cases on admission, there would seem to be no justification for
the statement that this and other hospitals and asylums for the insane are not
as successfully combating disease as other institutions which have as their
object the cure of diseases which are more entirely physical in their nature.
This is a fact which, in justice to our specialty, cannot be too strongly or too
frequently insisted on. [Relapses ?]
Gloucester .—From Dr. Craddock’s lengthy report we extract the
following:—
In this connexion (the causation of insanity) I wish to call attention to
what, after careful observation of all classes of the insane for many years, I
regard as an undoubted, though hitherto undescribed if not unrecognized, cause
of insanity. There is no word which completely embodies what I wish to
convey, the nearest to it being “ over-indulgence; ” by this I do not mean
indulgence in any one direction such as drink, sexual passions, and the like, but
simply the fact and the mental condition resulting from having everything
one’s own way, and never having been crossed. I can recall numberless
instances, and I believe they become more common yearly, where the early lack
of parental restraint and correction, it perhaps would be more correct to say the
deliberate abstention on the part of the parents from such restraint, the desire
to let a child have its own way, and an unwillingness on the part of parents to
displease, have developed the egotistic faculties so greatly to the detriment of
the altruistic, that the first sharp shock of opposition to a will hitherto owning
no superior authority has been fatal to the maintenance of the mental balance.
This is unfortunately no theory: several instances in both sexes during the past
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Asylum Reports.
127
year have impressed me so strongly that I have carefully inquired into the past
history from the relatives. Unwillingly and hesitatingly the sad story is
unfolded; the details may vary, hut the inherent fault, a weakly parent con¬
stantly giving in to an obstinate and often passionate child, is ever the same.
An abnormal development of the ego has been long recognized as a feature of
the insane diathesis, and the obtrusive patient full of talk, discontent, and
complaints, who so persistently thrusts his personality forward, has in many
cases been the pasha of the family circle. I would not pose as a laudator
temporis acti 3 but I do think that 40 or 50 years ago children would never have
been allowed the licence they are now; in such cases as I have described there
certainly has been “ a bridle for the ass,” if not, as is still more probable, “ a
rod for the fool’s back.” The humanitarian tendencies of the age frown on
what used to be known in Tom Brown’s day as a “ good sound thrashing ” to a
disobedient child; but I am not sure that the age is any the better for it.
Anyway the number of lunatics is increasing, and I record my deliberate
opinion, not formed hurriedly, and not with any diffidence, that a faulty system
of home education, and a kindly, though, I think, weakly and mistaken con¬
ception of parental duty is now playing no inconsiderable part in filling our
asylums.
Hants .—Notice has been given that the Isle of Wight must
make separate provision for its lunatic patients. Arrangements
are in progress for the erection of an asylum in the island.
Three cases of typhoid fever occurred, but the origin of the
disease could not be discovered. In the case of a female patient
the fever is described as a most acute attack, with extremely high
fever. It proved fatal on the fourteenth day.
Hereford .—In the hope of securing a good class of attendants
and nurses, and of retaining them in the asylum service, four
cottages are being built for married attendants, and mess-rooms
and bedrooms are being provided. The scale of wages and
amount of leave have been revised.
In the hope of postponing, for a time at least, the necessity for
additional buildings, the Visitors met representatives of the
Guardians in conference. The following resolution was passed:—
“ That the majority of the delegates do not feel' themselves in a
position to receive pauper lunatics from the Burghill Asylum
further than as at present, the harmless imbeciles, for want of
proper accommodation, and for want of proper attendants.” The
setting apart of one workhouse for the reception of pauper
lunatics was brought before the Conference, and the Committee
wish to call the attention of the County Council to this as a
possible way of utilizing the present excess of workhouse accom¬
modation.
Dr. Chapman recommends the erection of a good infirmary to
accommodate about 20 patients.
Holloway Sanatorium .—This large hospital seems to prosper in
every direction. Dr. Rees Philipps reports that no less than one-
fourth of the gentlemen admitted in 1891 suffered from general
paralysis. The female mortality was unusually high, about one-
half of the cases having succumbed to a low form of pneumonia,
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128
Psychological Retrospect .
[Jan.,
of which there were distinct outbreaks in February and June.
Though doubtless infectious in its nature, as shown by the almost
epidemic prevalence of pneumonia in London during the first six
months of 1891, the limitation of the outbreaks in this hospital to
the ladies’ infirmary would appear to point to some predisposing
local cause, probably to overcrowding and unfavourable situation
of that building.
Extensive structural alterations were carried out during the
year; others are in progress, and others are mentioned as more or
less urgently required.
Lectures to the nursing staff have been continued, and nine
candidates received the certificate of the Association. For the
next examination 23 candidates have sent in their names.
Dr. Philipps further reports that several patients have been
boarded out with employes of the Hospital in cottages either
inside the grounds or within easy reach of the Hospital, and are
visited daily by the assistant medical officers. The experiment
has been attended by satisfactory results.
A lady is now junior assistant medical officer on the ladies’ side.
We sincerely hope this appointment will prove successful.
Hull .—The extension of the asylum buildings is under con¬
sideration, as is also the erection of cottages for the employes.
The cases admitted were of an unusually hopeless character. The
very high death-rate is accounted for by the great prevalence of
general paralysis and other forms of brain degeneration among
the men.
Inverness .—The crowded condition of both day-rooms and
dormitories is under consideration. It is considered that the
time has now arrived when the accommodation must be increased,
especially for the sick and acute cases.
Isle of Man. —Dr. Richardson is not idle. Two cottages for
artisans are in process of erection. A billiard-room and shoe-
room have been completed. A course of lectures on “ First Aid
to the Injured ” was delivered to the officers and attendants.
Kent. Maidstone .—It having been proposed that Kent and
three neighbouring counties should unite in providing an institu¬
tion for idiots, it was decided that it was not desirable that Kent
should join such a scheme.
Kent. Chartham Downs .—After a service of seventeen years,
Dr. Spencer retires on a pension, gratefully acknowledged by him
as liberal, but the amount is unfortunately nowhere given. We
wish to continue the Pension List given in this Journal some time
ago.
(To be continued .)
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1893.]
German Retrospect.
129
2. German Retrospect .
By William W. Ireland, M.D.
On Loss of Consciousness following Cutaneous and Sensory
Ancesthesia.
Professor A. Pick, of Prague, has a paper of fifty pages on the so-
called muscular consciousness of Duchenne (“ Zeitschrift fur Psy¬
chology und Physiologie der Sinnes-organe,” 8 October, 1892). This
seems to consist of a knowledge of the position of the limb and of the
force of the muscular contractions expended to produce a designed
movement. There must also be in the mind a conception of the
designed movement. When through anaesthesia a person is
unaware of the position of his limbs, he cannot, without the use of
his eyes, ascertain where his limbs were when the movement
began, and what point they had reached in a given time. He
thus must use his eyes to guide the motions of his limbs. This
assistance of the visual sense is generally afforded more or less
in all complicated movements, even where the cutaneous and
muse alar sensibility are intact. The visual and muscular senses
act together and support one another. We may execute move¬
ments with the aid of the cutaneous and muscular sensibility
alone as in the dark, and, on the other hand, we may execute
movements guided by sight alone. In 1848 Dr. Duchenne made
observations upon three patients in whom there was a complete
loss of cutaneous sensibility. He found that, when these patients
were hindered from seeing their own limbs, they had lost the
capacity for voluntary motion. On the attention being diverted
from the execution of the designed movement, even when the eyes
were left open, the movements were arrested, or were performed
in an embarrassed manner in proportion to the degree of distrac¬
tion. Such extensive anaesthesia is a rare affection. It sometimes
follows severe epileptic attacks, or it may supervene after chronic
epilepsy, or alcoholism complicated with fits. Sometimes in
addition to the loss of cutaneous sensibility there is the sup¬
pression of taste and smell, and concentric narrowing of the field
of vision. Sometimes the anaesthesia is confined to one side, or
to one region of the body, and in such cases the phenomena of
transfer have been observed. It is thus a functional affection
occasionally attending hysteria. Drs. Thomsen and Oppenheim
have minutely described eighteen cases of sensory anaesthesia
occurring amongst lunatics (“ Ueber das Vorkommen und die
Bedeutung der gemischten sensorisch sensibeln Anaesthesie bei
Geisteskranken.” “ Archiv fiir Psychiatrie,” xv. Band, 2 Heft,
und xvii. Band, 2 Heft.)
As we shall see, complete anaesthesia of the cutaneous surface?
xxxix. 9
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130 Psychological Retrospect. [Jan.,
with sensory deficiency may occur with individuals who are quite
sane.
It is curious that some patients affected with anaesthesia should
remain capable of executing movements without the association of
vision, while others are quite incapable ; but this can be easily
proved. We can, in fact, arrange a series of cases where the
dependence of the patient upon one sense approaches more and
more to completeness. Gley and Mariller have described an
anaesthetic patient who could execute movements when the eyes
were shut, through a species of motor memory, but more slowly
and imperfectly than when the movements were seconded by the
vision.
On examining the handwriting of anaesthetic patients, in many
cases the writing was found unaffected ; in others there was more
or less disturbance. It appeared that with some patients the
impulse to write came through visual images ; in others through
impressions of muscular sense and touch (Kinaesthetischen
Vorstellungen). Binet observed that in some hysterical patients
affected with anaesthesia, the closing of the eyes or the privation
of light still leaves them in possession of all their motor powers,
while in others the motions are rendered slower. In other cases
closure of the eyelids produces almost complete motor incapacity,
while in others again the suspension of vision brings on a clouding
of the memory and of the intellectual faculties in general.
Professor Pick himself describes a case of the kind: a woman
of twenty-one years of age, who worked in a sugar manufactory.
She was brought to his asylum in a maniacal condition, suffering
from hallucinations, aphonia, hystero-epileptic convulsions, and
slight hyperaesthesia, which later on passed into complete
anaesthesia and analgesia. There was narrowing of the field of
vision, so that her hallucinations seemed to be fragments of
figures. When she shut her eyes the sense of position was lost.
She thought that she was standing when she was really sitting,
and when she was only using one arm she thought she was using
them both. On this patient Dr. Pick performed a number of
thoughtful experiments. He found that sleep could be induced
by closing the eyes and ears to external excitations. His paper
contains references to analogous cases which have been described
in German and French medical literature. Some of these we
have studied in the works cited.
In cases of extensive anaesthesia there is a marked tendency on
the part of the patient to stagger and fall when the eyes are shut.
This, however, does not always happen.
Krukenberg (“ Deutsches Archiv fur klin. Med.,” xlvi. Band,
p. 210) describes the case of a sailor forty years old, afflicted with
complete cutaneous and sensory anaesthesia. The manner of walk¬
ing was much affected when the eyes were shut; but there was no
falling. This man could be put into the hypnotic state by fixing
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1893 .]
German Retrospect .
131
the gaze with a glittering object, rubbing of the eyelids, and the
suggestion of sleep. The illness ended in death; but no lesion
could be found in the brain.
Dr. Schiitz showed to the Berlin Society for Psychiatry
(“ Neurologisches Centralblatt,” No. 237, 1883) a patient twenty-
three years old, suffering from paranoia with hallucinations, and
ideas of persecution and suicide. This man had convulsions of the
recti abdominis muscles without loss of consciousness. When
shown to the Society he had complete anaesthesia of the whole
cutaneous surface save the muscles of the right ear, the lips, and
the fingers of the right hand. To touch, pain on pricking or
pressure, cold, heat, and the interrupted current, he was equally
insensible. The muscular sensibility was also gone save in the
fingers of the hand in which feeling remained. When asked
to execute a movement with shut eyes his limbs remained
motionless.
In his “ Lemons Cliniques sur l’Hysterie,” Pitres remarks, in
reference to some cases of anaesthesia of the muscular sense, that
the shutting of the eyelids had a disturbing effect on the function
of muscles which were not usually under the control of vision.
Thus when both eyes were shut, the patient could neither speak
nor put out the tongue, nor swallow some water already put into
the mouth. When one eye was shut, he could still speak or
swallow, but with much difficulty. When both eyes were closed
the patient was as it were stunned, unable to comprehend what
was said to him.
The case described by Dr. Striimpell (“Deutsches Archiv fur
klin. Medicin,” Band xxii., s. 321) is so often cited that a short
resume may here be given. A lad fifteen years old was admitted
to the Clinique at Leipzig complaining of giddiness, headache,
and other nervous symptoms. A loss of cutaneous sensibility was
soon noted, which in about three months progressed into complete
anaesthesia. The patient was insensible to painful impressions, to
cold, and to heat. Weights of from 15 to 20 lbs. laid on the arm
were not felt, and a powerful faradic current could be passed
through the limbs or body without the patient feeling anything.
The conjunctivas and the mucous membrane of the nose and throat
were equally insensible. The senses of smell and taste were also
wanting, and he neither felt hunger nor thirst. The lad had lost
the sight of the left eye and the hearing of the right ear. Thus
the right eye and the left ear were the only sensory organs
remaining in function. When food was put into the patient’s
mouth he did not feel it, but he could voluntarily carry on the
action of chewing, and he had a sensation which let him know
that the action of swallowing was accomplished. The muscular
system was weaker than formerly; but there was no paralysis
save in the extensor digitorum of the right arm. The gait was
peculiar and irregular, but could not be called ataxic, as in tabes.
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132
Psychological Retrospect .
[Jan.,
The intelligence was diminished. By degrees the anaesthesia be¬
came less marked, when the intelligence was observed to improve.
On Dr. Striimpell starting the question, what he would do if
the power of vision were cut off, the youth answered, “If I
cannot see, I am nothing.” The experiment was tried. The right
eye was bound up, and the ear stuffed with wax. He uttered
exclamations of wonder, and tried, by striking with the hand, to
arouse impressions of hearing. In two or three minutes he fell
fast asleep, the pulse and respiration being quieter. The sleep
continued after the bandage was removed from the eye. and, under
favourable conditions, might last for some hours. He could only
be wakened by sounds in the ear, or a light flashed on the eye, or
similar excitations. Dr. Striimpell considers that this condition
resembles ordinary sleep. He is inclined to believe that the
waking state can only be sustained by the stimulus of outward
impressions, conducted to the brain by the peripheral nerves. He
observes that there was no anaemia of the brain to be detected,
assigning as reasons for so thinking that the pulse became harder
when the patient was put into a cold bath, and that the redness of
the skin after stimulation took as in a healthy person.
Dr. Gilbert Ballet (“Le Progres Medical,” 25 Juin, 1892)
had under observation for about four years a similar case. His
age was thirty-six. He had a neurotic heredity. The exciting
cause was a fall from a rock into the sea. After this there were
symptoms of neurasthenia and exophthalmic goitre. The thyroid
was enlarged. There was trembling, and the pulse was from 120
to 160 in the minute. He had previously suffered from hysteria.
There was anaesthesia, absolute in degree and completely covering
all the skin and all the accessible mucous surfaces. Neither by
touching, pinching, pricking, nor burning could the least sensation
be excited. Though the patient could feel hunger, food was
swallowed without any sensation. The muscular sense was
entirely abolished on both sides of the body. He had no con¬
sciousness of the movements of his limbs and of the position in
which they were. He was obliged to look at his arm or his leg to know
where they were. Taste and smell were completely suppressed,
and the sense of hearing notably diminished. There was a double
concentric narrowing of the field of vision, especially of the left
eye. His perceptions of the outer world only came through the
senses of sight and hearing. Thus visual images played the
principal part in his perceptions. He had often hallucinations,
such as that he was in a forest surrounded by animals and armed
men. As there was no way of comparing these appearances with
his other senses, especially touch, he could not resist believing
these hallucinations. “ When I am with you,” said he to the
doctor, “ I see well that all that is false, but, when I am alone, I
believe in my nightmare and my dream.” Dr. Ballet found the
patient to yield gradually to suggestions like a hypnotized person.
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1893 .]
German Retrospect.
133
I introduce, lie goes on, a little wadding into the ears in a
manner to close them as completely as possible. Nothing is yet
changed in the attitude and the physiognomy of the patient.
Then I lower the eyelids, and immediately the situation is quite
changed. Aim sinks down. He is extended on the floor like an
inert mass. I raise his limbs, they fall back a dead weight.
When I take away the wadding which shuts the ears, the patient
does not appear to hear any longer. It seems as if the little
auditory sensibility which remained had been extinguished by
shutting the eyes. In this case the waking state was promptly
succeeded by the sleeping or lethargic condition. The rapidity of
the pulse and the number of inspirations diminished. He found
that this condition could be brought about by putting something
in front of the eyes as well as by closing the eyelids. The
patient could be awaked by opening the eyelids, when he rose
and looked round in a confused manner, asking what had
happened, for he professed to have no remembrance of this phase
of his being.
M. Ballet discusses at length whether this condition was one of
hypnotic lethargy or of sleep. He thinks that Aim’s condition is
rather a form of hypnotic sleep, from the intermittent contractions
of the orbicularis palpebrarum , and from the resistance of the
muscles of the jaw. By some cleverly devised experiments, he
made out that the patient could be made to perform actions
suggested while he was yet awake, and even that he could receive
suggestions while in the lethargic condition. This, however,
leads into subtleties for which we have at present no space. Even
when it is granted that this singular condition resembles the
hypnotic rather than the sleeping state, there is much that is
mysterious and unexplained.
At the end of his paper, Dr. Pick cites a case reported by
Liegeois, in which this strange species of insensibility and
apparent loss of consciousness was induced by closing the ears,
instead of shutting the eyelids. Dr. T. Grainger Stewart has
allowed me to examine a patient, whom he has repeatedly shown
to his clinical class and also to several medical societies. This
woman had lost the sense of smell and the sight of the left eye
through basal meningitis. There were evident traces of paralysis
of one leg, but no general anaesthesia. Her hearing was good, and
her intelligence did not seem to have suffered ; but on closing the
seeing eye, or on interposing some object between the eye and the
light, she promptly fell into a condition of unconsciousness, which
was ushered in by a loud snoring, and passed away in less than a
minute, with a blowing through the half-closed lips.
This woman has been the subject of careful observation and
experiments. She has recently died. The case will be published
at length when the microscopic examination of the brain is
completed. No doubt the observations and comments of the
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134 Psychological Retrospect . [Jan.,
learned professor will throw some light upon this obscure, though
interesting field of inquiry.
Depth of Sleep.
Edward Michelson (Dis. Dorpat, 1891, quoted in “ Allgemeine
Zeitschrift, ,, xlviii. Band, 5 Heft) has studied the depth of sleep
at different times. For the first quarter-of-an-hour the sleep is
not deep; then the torpor increases and reaches its maximum
after three-quarters-of-an-hour. This lasts for half-an-hour and
then diminishes. After two hours the depth of the sleep is
diminished, and continues in about the same degree of intensity
for five hours longer.
3. Retrospect of Criminal Anthropology.
By Havelock Ellis.
A Museum of Psychiatry and Criminology.
The deeply interesting and instructive Museum of Criminal
Anthropology, founded by Lacassagne in the noble university on
the banks of the Rhone, is well known to all medical visitors to
Lyons. It is now proposed by the Faculty of Medicine at Turin
to establish a museum somewhat similar in character, though of
wider scope, at the university with which Lombroso has so long
been connected. All the material, so far as it can be collected,
for the study of the causes, symptoms, and therapeutics of insanity
and criminality will here be brought together. The medical man,
the lawyer, and the philosopher will be able to examine the
“ palimpsests ” of the asylum and the prison, the data concerning
the aetiology of crime and mental perturbations, the geography of
crime, etc., and the skeletons and brains of the insane and criminal
will demonstrate the close connection between mental aberrations
and corporal abnormalities. Such a museum must form a most
valuable source of instruction in psychiatry, and it is to be hoped
that the initiative of France and Italy may before long be followed
in England. I may add that a Museum of Psychology—not of
morbid psychology especially—was founded a few years since at
Florence by Professor Mantegazza.
Lombroso and the Natural Distory of the Criminal.
Dr. H. Kurella, the well-known editor of the u Centralblatt
fur Nervenheilkunde,” has just published, as one of Virchow’s
“ Sammlung gemeinverstandlicher wissenschaftlicher Vortrage,”
a pamphlet which is perhaps the most judicial statement in brief
compass of the position of criminal anthropology which has yet
appeared (“ Cesare Lombroso und die Naturgeschichte des Ver-
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135
1893 .] Retrospect of Criminal Anthropology .
brechers,” Hamburg, 1892). Lombroso is accustomed to unbounded
admiration and equally unbounded contempt from incautious par¬
tisans or ignorant opponents. But both are usually in the wrong.
The discoverer of a new continent is not necessarily fitted to
survey the territory he has discovered, foot by foot; while there
are many excellent and careful surveyors who are not exactly
fitted to discover new continents. Dr. Kurella is fully able to
discern Lombroso’s merit in opening up the scientific study of the'
criminal, and discovering new sources of evidence concerning the
nature of criminality, while at the same time he perceives that he
is often lacking in critical discrimination, and in the accurate use
of statistics. He especially insists on the importance of Lombroso’s
method of studying the poetry and art of criminals (as shown in
the marginal notes of books, on walls, utensils, etc.), as in the
very first rank of contributions to modem morbid psychology.
“ Lombroso here shows himself as a genuine interpreter of Nature,
and as a genius only equalled by Dostoevski among the modems,
and that wonderful criminal psychologist, Shakespeare, among
writers of older date.” Dr. Kurella finally reaches, after glancing
over the whole field of evidence, the conclusion, which is con¬
stantly becoming clearer, that the criminal is related to the idiot,
that criminality must be regarded as one of the branches of the
family group of degenerations called idiocy. “ It is the merit of
Lombroso to have shown that most incorrigible professional
criminals show the type of so-called moral insanity, and that this
type exhibits a multitude of characters—partly atavistic and due
to inhibition of development, partly pathological—which enable
us to recognize moral insanity as one of the groups of imbecility.”
In passing Dr. Kurella refers to the Italian painter, Luini, as a
murderer. There is, I believe, no reason to suppose that Luini
was a criminal; it is possible that the author was thinking of
Latini.
Examination of Ten Criminals .
In the “ Archivio di Psichiatria,” 1892, fasc. ii.-iii. (“ Esame
di Dieci Delinquenti ”), Dr. Moraglia presents the results of the
detailed examination of ten criminals in the prison of Finalborgo.
Three were convicted of rape, one of theft, five of murder; the
last was a woman imprisoned for corrupting children. The
woman was a “magnificent case” of sexual perversion. It is
worthy of note that all the nine men examined presented without
exception dark and scanty hair, irregular teeth, a massive jaw,
more or less prominent but always pronounced cheek-bones, and
defective or altogether absent moral sense. “ These characters,”
concludes the author, “ which may almost be said to be peculiar
to the criminal man, are rarely found united in the normal man;
still more rare is it to find them in the normal man united to the
other special abnormalities observed in the subjects examined.”
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Psychological Retrospect .
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The Feet of Criminals , etc .
Ottolenghi and Carrara (of Lombroso’s Medico-Legal Laboratory
at Turin), by their recent investigations of prehensility of the feet
in the insane and criminals, have burdened the alienist with a new
anthropological character (“II Piede prensile negli Alienati e
nei Delinquent,” u Archivio di Psichiatria,” 1892, Fasc. iv.-v.).
Stimulated by Regnault’s investigations of the prehensile foot in
Indians, they have examined 100 normal men, 200 criminal men,
31 epileptics, 62 normal women, 50 prostitutes, 64 criminal women,
and (to a more limited extent) 36 idiots; all were over eighteen
years of age, A drawing of the foot and the space between the
two first toes was taken, the subject standing erect and the toes
in repose, and then another drawing was taken after the subject
had been requested to abduct the first toe to the greatest extent
possible. In both conditions the extent of the space between
the toes was measured at the base and also at the periphery (t.e.,
from the centre of the extremity of the first toe to the centre of
the extremity of the second). The space was found to be smallest
in normal men; a space over three millimetres (it is very com¬
monly below this) was found to be three times more common in
criminal than in normal men. The epileptics closely resembled
the criminals in this respect. The proportion of normal female
subjects showing a wide space was much larger than of male, but
there was little difference between the normal and the criminal
women. The prostitutes, on the other hand, were much more
abnormal in this respect, and ranked with the criminal men. The
idiots were the most abnormal of all, although in their case it was
not possible to take measurements during forcible abduction. In
the course of the investigations two cases of true prehensile
power were met with. One was a criminal, a gymnast, and the
son of a clown; although he had made no previous experiments
he was found to possess great skill in taking up small objects
between his toes. The other was an epileptic criminaloid, who
from childhood had spontaneously used his feet in the same way as
hands in dressing himself, picking up the most minute objects, etc.
It will be seen that the results of these investigations fall
harmoniously into line with the various investigations as to the
anthropological degeneracy found among prostitutes, epileptics,
and idiots which have been made by Lombroso, Sollier, Mme.
Tamowsky, etc.
Abnormalities of the Ear in Criminal Women.
In order to complete his careful studies on the chief abnor¬
malities of the pinna among normal persons, the criminal and the
insane, -Professor Gradenigo, of Turin, has now given the results
of some further investigations on 245 criminal women (“Sulla
Conformazione del Padiglione dell* Orecchio presso le Donne
Delinquent,” in “Archivio di Psichiatria,” Yol. xiii., fasc. I).
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137
In 133 cases he found the pinna normal; in the remaining 112
cases 282 abnormalities were found (29 each person). The most
frequent abnormalities were prolongation of scaphoid fossa into
lobule, adherent lobule, and prominent antehelix. As in previous
researches he finds that unilateral anomalies are more common
on the right side (40 to 22), if we except the outstanding pinna
(ad ansa), which is found 11 times on the left side for twice on the
right. He concludes that criminal women show a greater number
of abnormalities of the ear than women belonging to the general
population, but a smaller number than insane women. An
exception must be made in the case of the ear ad ansa , which is
most frequent in criminal women.
Yali has confirmed Gradenigo’s conclusions by a series of
observations on normal and insane persons in Austria. His
figures are somewhat lower than Gradenigo’s, as concerns normal
persons, though not on the whole lower as concerns the insane ; he
did not examine criminals.
The Confessions of a Thief.
I have received, by the kindness of Mr. Ardill, Director of the
Sydney Rescue Work Society in New South Wales, Part I.
(without title page) of “ The Confessions of a Thief ” by Joe
Bragg (alias Albert Bourke), a pamphlet published in Sydney.
It is a genuine and remarkably truthful document (the language
liberally besprinkled with criminal argot), and is of singular
interest to the psychological student of criminality. Joe Bragg’s
paternal grandmother, as we incidentally learn, had been in a lunatic
asylum a great many years, and “ had been of the same violent
disposition as myself.” His mother “ had always a strong pro¬
pensity to religion. She told me that when a girl in the service of
Sir John Franklin, who was the Governor of Tasmania, she had
once fasted from meat for forty days, and that during the whole of
that time she had been afraid even to swallow her spittle.” From
the remark that in old age she was “then sober,” it may be
inferred that she had also been given to drink. Thus on both
sides Bragg came of insane and neurotic stocks. He was born
about 1851. Up to the age of thirteen, though suffering much
from neglect and hunger, he had. “ always been disposed to
honesty; ” at that age, “ being left homeless and destitute by
parental drunkenness and stung by the pangs of hunger,” he
stole a loaf of bread. He was imprisoned for three months in
Darlinghurst gaol, and was thus enabled to have frequent inter¬
course with many hardened criminals. On the very day of his
liberation he began a career of crime which lasted for twenty-two
years. He was soon again imprisoned for three months, “ and the
instructions I received during these three months considerably
improved me in my profession. The Government had placed me
in a position to learn a trade, and, having learnt it, I was deter-
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138 Psychological Retrospect. [Jan.,
mined to work at it.” He practised it successfully. “ Before I
was seventeen I had committed thousands of robberies, and had
been convicted about a dozen times.” Once, when he was in
Parramatta gaol, he heard much praise of a young man who
had recently received twenty-five lashes for knocking a warder
on the head with a pick handle. Bragg resolved to emulate him.
A few days after, when a warder spoke sharply to him, he struck
him on the head with a billet of wood ; this was the first of a
long series of violent outrages, each followed by severe punish¬
ment. It is remarkable that during one period of solitary confine¬
ment he taught himself to read a little; he had previously only
known the alphabet. Without sufficient food, suffering from
scurvy, and addicted during long periods of solitary confinement
to masturbation, he was reduced almost to a skeleton, and his
mind became disordered. He was affected for a time by an
obsession of somewhat the same kind as his mother had suffered
from. “ For a time I tried to be religious and prayed often. If,
when I thought of prayer, I did not immediately kneel down and
pray I accused myself of laziness; and, thinking that God was
displeased with me, I had no rest till I prayed.” During a
subsequent term of imprisonment he was pronounced insane by
the Medical Board and sent to Gladesville Asylum. Here he
pretended to be “a quiet simpleton,” and ingratiated himself with
the keepers, who reported favourably of him to Dr. Manning ; he
thus received privileges which enabled him to escape. He was,
however, recaptured, although finally discharged in a month, and
was enabled to thieve for several months “ in an orderly and discreet
manner.” Shortly afterwards he was sent to Berrima Model for
six months when still only twenty-six years of age. He came
out “ an honest and religious man,” and received religious instruc¬
tion from some nuns. The story of his relapse is curious. He
saw a man on his back asleep. “ Instead of going right on I
stopped and sat on the top rail of a fence over against him. No
one was about. I thought to myself ‘ There is a gift if I were on the
cross, but I am religious now, and cannot touch him.’ I resolved,
however, to have a close look at him. When I got close beside
him I noticed a bulge in one of his trousers’ pockets. ‘ That I
may know what a chance I am throwing away,’ I said to myself,
‘I’ll just see what he has in that pocket.’ I there found nine
pounds ten in gold. Taking a sovereign I put the rest back into
his pocket. I intended to take this pound merely as a loan, and
closely examined his features that I might know him again, to
return it to him when I should be in better circumstances. When
I had reached Harris Street, which was only a short distance from
where he was lying, I looked back at him. Pulling the catechism
and prayer-book out of my pocket I looked at them. I cast my
lamps [eyes] over their pages and became sceptical. There was a
sink close at hand. Throwing them both into the sink I danced
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about, and swore and blasphemed like a maniac. I then went
back to the brig and got the eight pounds ten. I also took a little
silver he had in his other trousers’ pocket, and his boots, which
were new ; and, only I saw a man at a distance coming towards us,
I should have taken his trousers.” He recommenced thieving,
spending the proceeds in public-houses or brothels. “I had
become uncontrollably irritable, and was perpetually gambling.”
A furious attack on a constable led to a sentence of imprisonment
for five years, and wild outbursts of violence frequently occurred
while he was undergoing this sentence. Once he received fifty
lashes. “ The fifty lashes took no more effect on me than a shower
of rain could take on a bullock.” When in prison at the age of
twenty a new and curious passion arose in him. He wished to be edu¬
cated and to become an author, and studied Murray’s “ Grammar ”
for ten hours a day, until he was able to read and write. At tho
same time he became thin and melancholy, and was considered as
semi-insane by the authorities, who placed him in a special yard,
and endeavoured to divert his mind from study. In order to gain
his own way he pretended to commit suicide by cutting his
throat, injuring himself, however, more seriously than he had
intended, and was more closely watched. After an ineffectual
attempt to escape he was placed in solitary confinement, and again
turned with ardour to his studies, even making a little progress in
Greek, Latin, and French. His imaginative and reflective facul¬
ties became active, but at the same time his mind became
weakened. He could no longer fix his attention on a book, and
had various delusions and hallucinations. He thought that people
owed him money, and also imagined constantly he was meeting
old enemies; he would immediately strike them or seize them by
the throat, only to find that he had injured himself against the
wall. He used to wrap his hands carefully in a scarf; before he
could get them loose the hallucination would vanish. At the
same time “ as I continued to reflect I discovered that my mind
was a field which had retained everything that had ever been cast
into it, and that it might be dug up with the spade of reflection.
For hours together I used to sit in the little shed in my yard
tracing back the events of my life. I clearly recollected all the
circumstances of my birth. ... To my astonishment I found
that I was alive a considerable time before my birth, and that my
body was not animated all at once, as I had thought, but that my
spirit strengthened with the formation of the body. I could
distinctly recollect the time when my body was not quite made,
and how fearful I was lest I should be fully vivified before I was
fully formed.” With the termination of this sentence Part I. of
these remarkable Confessions comes to an end. Bragg can scarcely
be called an instinctive criminal; he was an occasional criminal
who, in the usual way, by the contamination of prison became for
a time certainly a habitual criminal. At the same time, owing to
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Psychological Retrospect .
[Jan.,
physical and mental stress, there was a partial and incomplete
development in him of two strains of insanity he had inherited.
Mr. Ardill writes in a private letter : “ I regret that Parts II. and
III. are out of print. They were even more interesting than Part
I. Bragg is a remarkable character, a great student. Psychical
research is now absorbing his attention. He hopes to reach Eng¬
land before the close of the year. He is now endeavouring to
obtain sufficient to secure a passage, or to get a ‘ billet ’ to work
his passage.”
The Treatment of Habitual Criminals.
The “ Mitheilungen,” or “ Bulletin ” (it is, as usual, partly in
German, partly in French), of the International Association of
Criminal Law for April, 1892, is devoted to the meeting of the
Association at Christiania in 1891. Perhaps the most interesting
discussion was that regarding the habitual criminal and his treat¬
ment. In a report on this subject, chiefly founded on the statistics
of France, Germany, and Italy, Prof, van Hamel, the well-known
criminologist of Amsterdam, points out that the increase of
criminality in recent years is mainly, if not solely, due to the
increase of recidivism. The number of criminals is increasing,
especially in France, but it is the number of punishable acts com¬
mitted by each criminal which is especially increasing. In France
during thirty years the number of recidivists has increased 116 per
cent., the number of first offenders only 18 per cent. Similar
results are found in England, Germany, Italy, and elsewhere.
Yan Hamel proposes that every habitual criminal—a certain
number of offences being fixed to prove recidivism—should be
placed for observation during a period of twelve months in a
special establishment. He should then be brought before a special
court established for the purpose, which would hear the evidence
of doctors, officials, etc., and determine the method of treatment
to be applied to him. Uppstrom, of Stockholm, then took up the
question. He brought forward further evidence as to recidivism
in various countries, and insisted on the importance of never
liberating recidivists until there is reasonable assurance that they
will adopt an honest life. He also dwelt on the importance of
educating the will, and expressed agreement with van Hamel. A
resolution in the sense of van Hamel’s report was unanimously
passed. It was an interesting indication that lawyers are gradu¬
ally tending to fall into line with doctors where the criminal is
concerned, especially when taken in connection with the recent
Congress of Criminal Anthropology, when the lawyers mustered in
unusual strength, and on the whole rallied to the medical side.
Studies of Criminals.
Under this heading Drs. Lydston and Talbot have recently pub¬
lished one of the most important contributions to criminal anthro-'
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Retrospect of Criminal Anthropology .
141
pology which have come from America (“ Alienist and Neurolo¬
gist,” Vol. xii., No. 4). It is an abridgment of a larger work they
propose to publish, and deals chiefly with the cranial and maxillary
development of criminals. It includes studies of eighteen living
habitual criminals in the Joliet Penitentiary, chosen without
reference to physical development, and is fully illustrated.
The authors do not claim to have made any fresh contribution to
the subject of any importance. They regard the criminal class as
“ simply a part and parcel of that human flotsam and jetsam
which can be so aptly termed the world of degeneracy.” They
find, however, that this degeneracy is less marked in America than
in Europe, and the most pronounced criminal types they met with
were imported European criminals.
The authors find, as the Italian and other investigators have
found, that there is a tendency among criminals towards exaggera¬
tion of the natural racial type of the skull, the dolichocephalic
becoming more dolichocephalic, the brachycephalic more brachy-
cephalic. The more usual tendency among American criminals is
towards brachycephaly, while in America, as in other parts of the
world, there is a frequent tendency for the criminal skull to be
sub-microcephalic, platycephalic, oxycephalic, and plagiocephalic.
On this last characteristic, and on pronounced asymmetry in
general, the writers especially insist; “ the form suggests what
might result if the skull were taken while soft between the hands
and twisted in such a manner that all points of anatomical corres¬
pondence are thrown out of their normal relations; the result
would naturally be an asymmetry in all diameters.” And of the
face of one of the living subjects it is said: “ There is such a
marked disparity and asymmetry that it has the appearance of two
halves of faces of different sizes joined together, and by a bad
artisan.” The skulls studied by Dr. Lydston were not specially
selected, but fell into his hands by accident, having been collected
merely as curiosities by non-scientific persons. “ It is worthy
of comment,” as the authors remark, “that even the remarkable
series depicted in Lombroso’s ‘ Atlas ’ does not present such
markedly aberrant types as this comparatively small series of
studies; indeed, a search among several thousand skulls would
not be apt to bring to light such peculiar types of conformation as
the crania which we present.” This statement is fully justified
by the measurements and illustrations given in this interesting
paper.
Dr. Talbot is responsible for the examinations of jaws and
teeth. Here, although the writers were prepared for an excess of
malformations, they were surprised at their results, which, how¬
ever, fully confirm those arrived at by Dr. Clouston, and stated in
his “ Neuroses of Development,” though the classification adopted
by the American authors is not quite the same. They examined
477 criminal subjects, mostly males, and including 18 negroes and
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142 Psychological Retrospect . [Jan. f
three Chinese. Most of the deformities of the jaws and teeth
were confined to the upper jaw, and may be summarized by the
following percentages :—Normal, 36 06 ; large jaw, 15*72 ; pro¬
trusion of lower jaw, 3*56; protrusion of upper jaw, 1*04; high
vault, 14*67; Y-shaped arch, 2*70; partial Y-shaped arch, 16*56;
semi-V, 3*98; saddle-shaped arch, 12*36 ; partial saddle, 19*28;
small jaw, 6*29 ; semi-saddle, 5*03. All the (nine) women had large
jaws, but of normal development. The negroes had also usually
well-developed jaws.
Of the eighteen habitual criminals examined in the Joliet
Penitentiary (all males) a large proportion showed marked physical
degeneracy, as well as bad heredity, and it is worthy of note that
not less than three of them were paranoiacs with well-marked
delusions of persecution. Those who most nearly approximated
the normal were “ sporadic criminals ” (more usually termed
“occasional criminals”), of whom the most characteristic was a
bright, handsome, but neurotic lad of 17, sentenced for life for a
murder committed under the influence of liquor. No fewer than
half of the eighteen cases were foreigners, and it was these who
showed the most markedly aberrant type. Left-handedness was
found to be rare—only in one per cent, among 400 criminals in the
Joliet Penitentiary, and about two per cent, in the New York City
Prison.
PART IV.—NOTES AND NEWS.
MEDICO-PSYCHOLOGICAL ASSOCIATION OF GBEAT BBITAIN
AND IBELAND.
The Quarterly Meeting of the Association was held at Bethlem Hospital,
London, on Thursday, November 17, the President, Dr. Baker, in the chair.
The following gentlemen were candidates for election as members of the
Association, and on the ballot being taken were declared duly elected:—
Walter H. Atherstone, M.D., Surgeon Superintendent, Port Alfred Asylum,
South Africa.
Hubert Carpenter Bristowe, M.D.Lond., Second Assistant Medical Officer,
Somerset and Bath Asylum, Wells, Somerset.
Frederick St. John Bullen, M.B.C.S.Eng., Assistant Medical Officer, West
Biding Asylum, Wakefield.
Samuel Craddock, M.B.C.S.Eng., South Hill House, Bath.
James Francis Gemmel, M.B.Glasg., Assistant Medical Officer, County
Asylum, Lancaster.
James Holmes, M.D.Edin., Overdale Asylum, Whitefield, Lancashire.
W. Johnson Smyth, M.B.Edin., Army Medical Staff, Aldershot.
Charles Hubert Bond, M.B., C.M.Edin., Extra Assistant Physician, Boyal
Asylum, Morningside, Edinburgh.
The Pbesident called upon Dr. Walmsley, whose name was down on the
agenda, “ To advert to the observation attributed to Dr. Spence, and reported in
October number of the Journal as having been made at the Annual Meeting
held at York, viz., ‘ That the opinion of those Members of the Association of
great experience might be entirely swamped by the Assistant Medical Officers/ ”
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Notes and News .
148
After Dr. Walmsley had spoken at some length,
Dr. Whitcombe moved that the meeting proceed with the next business on
the agenda.
Dr. Rogers seconded the motion.—Carried unanimously (applause.)
ADJOURNED DISCUSSION ON DR. SAVAGE’8 PAPER ON “INFLUENZA AND THE
NEUROSES.”
(See Original Articles, Journal, July, 1892).
The President —All those who heard Dr. Savage’s interesting paper on
influenza will be glad to have the matter further discussed, and to hear the
remarks of those members who have not had the opportunity of expressing their
views. We must all have been more and more impressed with the difficulty of
the whole subject of influenza and its bearing upon people who have passed
through it. Just before coming to London I had to call and inquire after a
very valued member of our profession, who was suffering from the after-effects of
influenza, and whose condition was an exceedingly anxious one, and I am sure
we must all of us lately have had experience of the after-effects of this disorder.
Dr. Savage — I will read the results that have been arrived at by Dr. Leledy,
whose great experience coincides exactly with my own. He says —
Influenza, like other fevers, may set up psychoses. Insanity may oome on at various
periods of the disease. Influenza may start any form of insanity. No speoifio symptoms
result from influenza. The role of the influenza varies in the production of insanity. It may
be a predisposing or an exciting cause. In all cases in which insanity is developed there
has been noted some acquired or inherent neurotio predisposition. The insanity which
follows influenza probably depends upon altered brain nutrition, possibly toxic. The onset
of insanity is often sudden and bearing no relationship to the severity of influenza. The
curability of the psychoses depending upon influenza depends as a general rule on special
conditions. The insane appear to be less disposed to the attacks of the disease than the
sane. Rarely influenza has relieved or cured existing psychoses. The insane may have
mental remission during an attack of influenza. There is no special indication in the treat¬
ment of psychoses depending on Influenza. Influenza has led to crimes and to medioo-legal
Issues,
Mr. Richards —I can bear out the substance of what Dr. Savage has just now
read, from the fact that the insane, as a rule, when stricken with influenza do
not have their mental disease decreased or exaggerated. When I was superinten¬
dent of the Female Department of the Han well Asylum, numbering over 1,100
patients, during the first epidemic of influenza a very large number of the
patients suffered, very nearly one-third, and I cannot remember one single
instance in which their mental disease was either decreased or exaggerated.
At the same time amongst the members of the staff influenza was very rife, and
in several of the nurses I noticed that it had, perhaps, a more than usually
depressing effect upon them. Many of them became extremely melancholy,
and, in fact, had not the disease run a very short course with them, I am afraid
some serious mental symptoms might have developed. As regards the patients
themselves, in cases of recurrent mania, or melancholia, where the patients were
fairly well and were in the period of quiescence when the disease overtook them,
it did not bring on an attack of their malady. With regard to mental diseases
and obscure forms of nervous diseases being developed after influenza, I think
we must take it with some reservation that these neurotic cases are caused by
the influenza. For some time past, ever since the first and second epidemics of
influenza, it has become a very fashionable complaint. Patients have said that
they have had three, four, or five attacks, and all sorts of ailments have con¬
tributed to it. Consequently, if there was any nerve disease, either insanity or
neurotic affection, the friends of the patient immediately attributed that to the
influenza. I think, therefore, such statements must be received with consider¬
able doubt. I would, in conclusion, confirm what Dr. Savage has said, that
influenza does not increase insanity or bring back a recurrent attack of insanity
in the insane.
Dr. Ward — I should like to ask whether it has been found generally in the
asylums which have been visited by more than one outbreak of influenza that
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Notes and News.
[Jan.,
patients who were attacked with the disease in the first outbreak suffered in the
second outbreak as much as others who had not had it before. Though the
number of patients with whom I have to deal is small, still, so far as my experience
goes, I found that the disease was not generally taken the second time. We had
two outbreaks, one in 1890 and the other in the beginning of 'this year, and
scarcely any of the patients who had had influenza in the first outbreak had it
in the second. The attacks were confined in both cases chiefly to patients
on the ladies’ side, and they occurred in particular wards, without one being
able to decide that there was any decided infection, because they all occurred
so very nearly together. Again, I quite agree with Mr. Richards with regard
to there being no material change in the mental condition of any of the
patients who were attacked. I think some of them were, perhaps, a little
better and more amenable to treatment during the attack, and afterwards
perhaps some of them, for a time, until they recovered their usual bodily
condition, were a little worse. I found generall}' that the influenza amongst
the insane, with few exceptions, was almost entirely of the bronchitic type,
whereas, more particularly amongst the male attendants, who had it much more
severely than the females, the disease exhibited the more specific typical nervous
forms. I should like very much to know whether it has been found in other
asylums that any immunity was given by one attack.
Dr. White —In answer to Dr. Ward, I may say we had four distinct out¬
breaks at my asylum. The last outbreak consisted of nine patients, all occurring
at one time last July. None of those patients had previously had influenza. It
was of the distinct broncho-pneumonic type. The first outbreak was largely
limited to the staff rather than to the patients, and I undoubtedly traced it as
introduced from without. All the cases were isolated in the cottage hospital,
and in some instances the people communicating with the hospital contracted
the disease. I formed the opinion, from the first epidemic of 1891, that it was
distinctly infectious. I have observed in our admissions of this year a larger
proportion of general paralytics than it has ever fallen to my lot to notice, and
in very many of those cases there is a distinct history of influenza, contracted
some months previously, and in most cases of a severe type. I should like to
know the opinion of other medical attendants with regard to the association of
influenza with insanity, more especially with general paralysis. Of course, it may
take a year or more yet before we shall have the full explanation of the association
of influenza and general paralysis, but it is sufficiently interesting to collect
some statistics on the subject.
Dr. Murray Lindsay —We had two outbreaks of influenza, one very severe,
and one not so severe. I cannot remember one single case of those attacked the
second year that had previously had influenza. They were all cases of first
attack. In the first outbreak the patients were largely attacked as well as the
attendants. As I have said, the second outbreak was much less severe, and in no
case had a patient or a member of the staff who was affected had a previous
attack. Dr. Savage says that there is no connection with influenza and any
specific form of mental disease. That may be so, but I think from the nature of
influenza that one would probably find on investigation that as a depressant
disease it is more frequently followed by melancholia. I have lately seen a
professional brother who had a very severe attack of bronchitis followed by
pneumonia, and this has been followed by melancholia of a very unfavourable
type, his delusions being fear and suspicion of a very fixed and persistent nature,
and the case is a very serious one with regard to recovery. I think if an investi¬
gation were instituted, it might be found that when insanity has supervened
upon an attack of influenza melancholia was the most frequent form.
Dr. Thompson —I think we are wandering from the point. The principle
adopted by Dr. Savage in his paper was this, that influenza had a distinct
bearing on the amount of insanity produced, that is to say, that it was a direct
cause in the production of insanity. I said a few words at the former meeting
and I have only to repeat them now, that if that had been so we have un-
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Notes and News.
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1893.]
doubtedly had sufficient time and opportunity to see whether the admission
rates of the English and Scotch County Asylums have visibly increased. From
the perusal of the Blue Books I do not think they have. Dr. Savage is now
altogether outside asylums. He has patients in his general practice, and he sees
the matter from a different standpoint from what we do. He gets cases of
insanity in persons who have suffered from influenza, and that he says is the
cause. We no doubt get patients suffering from mental disorder who happen to
have had influenza, but I hold that we have no right to assume that this
influenza, which has been so widespread, so universal, is a direct or a special
cause of insanity, or else we should have found a direct increase in the ad¬
missions, unless it may be supposed that all other exciting causes of insanity
were suddenly stopped, which is very improbable. I repeat the protest I made
at the last meeting, that we should be careful before we definitely assign
influenza as an important cause in insanity.
Dr. Macdonald —I am very glad that Dr. Thompson has raised the question
as to whether or not the discussion is going to embrace the whole field of nerve
troubles following influenza, or whether it is going to deal with Dr. Savage’s
paper, namely, that influenza is a very frequent cause of mental disease. The
two questions are totally different. If we go into nerve troubles we may go on
for six months discussing them. Everybody will have something to say, and
something new. What Dr. Savage has placed before us is the simple question
whether influenza is a cause of insanity more than might be expected from any
specific nerve poison, as I take it influenza is. That being so, I for one cannot
agree with Dr. Savage’s view that influenza is a marked cause of mental disease.
I have looked very carefully through our records, and out of 260 admissions I
can only find two cases w r here I think w r e should in any shape or form be
justified in saying that they were really due to influenza. I look upon this
wonderful poison, and I speak very personally and feelingly because I had three
distinct attacks, one severe and two mild, as one of those mysterious poisons
which produce a state of susceptibility much more than any distinct disease.
That is what I have found it in my own personal experience, and in my own
experience at the head of an asylum, and also in our neighbourhood, talking
the matter over with general practitioners, namely, that many of the patients
were rendered much more liable to the influence of ordinary causes after an
attack of influenza than they were before. That bears out what Dr. Savage said,
that it did act as a wonderful igniter, so to speak, of disease. But surely, just
because that is so, we are not to infer that it was the cause of the disease, which
has, perhaps, been caused by the other ordinary causes at work. I had two dis¬
tinct cases, the only two I had, one of a young boy of 16, who developed the
symptoms during the attack, and I think it might fairly be said that they were
caused' by the excessively high fever and the poison. The other was the case of
a young married woman who, I found afterwards, had a very strong hereditary
predisposition to insanity, and who, during the attack, had also a great deal of
mental worry and trouble. I am inclined to think, though she had influenza,
influenza was not so much the cause of the disease as her other trouble. It
certainly paved the way, but it did no more. At the last meeting, when this dis¬
cussion commenced, one member made use of the phrase “post-influenzal
insanity .” I must take exception to this coining new forms of mental disease.
I know no such disease as “ post-influenzal insanity .” Just because a few
symptoms of various forms may appear after an attack, surely we are not justi¬
fied in giving it that distinctive name. If so, I think we might begin with
“post-prandial insanity ” after this meeting (laughter). So I differ from Dr.
Savage in this respect, and I think if the discussion could be confined to this
one fact of mental disease following influenza, and the individual experience of
superintendents, we should gain much more than by .travelling over the wide
field of nerve troubles following the disease.
Dr. Weatherly —As a very isolated proof of what Mr. Richard says, only
xxxix. 10
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Notes and News,
[Jan.,
one patient had been admitted in my asylum with the causation of insanity put
down to influenza, and that individual case was a case of general paralysis un¬
doubtedly caused by syphilis and addiction to liquor quite independent of
influenza, although influenza followed.
Dr. Whitcombe —In our City Asylum we had two outbreaks of influenza,
and personally I had an attack each time, the second being much worse than the
first. During our first attack at Birmingham iu the winter we had a large
number of patients and officers who were affected, but the attack was very
slight and passed off without any deaths; but in the second attack the disease
raised our death rate to over 20 per cent. It was of a very virulent nature. I
was down six weeks with it, and the attack was very severe. But so far as to
the admissions as the result of influenza, I have only had during the two years
one single instance in which insanity was said to be due to it, and that was the
case of a young woman, I think a barmaid in a public-house, who was sent to
the asylum because she jumped through the bedroom window in a state of
delirium. That is the only instance in which I have found out that influenza
has preceded an attack, and I may say during these two years our admission
rate has been very much larger than previously. This year we have had nearly
400 admissions, and last year about 300, but amongst the whole there was not a
single instance ascribed to influenza.
Dr. Boweb — I think the difference of opinion that seems to exist between
superintendents of asylums and Dr. Savage may be accounted for in this way.
Undoubtedly influenza has attacked the upper and educated classes in far greater
proportions than the poorer classes, especially at first. We have to deal with the
poorer classes, and Dr. Savage has to deal with outside patients in the better
classes. Mine is a small asylum, but practically my experience agrees with his.
We had three epidemics. In the first nearly every patient suffered, and but
very few attendants. In the other two outbreaks no patients suffered and only
a very few of the attendants. Of the attendants who had it on the first occasion
I can remember three who had two attacks afterwards, and as far as I was con¬
cerned I found that there was no immunity. The spread of the disease in the
first case did not seem at all to be from contact; a case arose here and
there in the asylum, and almost all the patients were attacked within
about a week. Unlike two previous speakers, I have had a good many cases
where the cause was attributed to influenza. One case of general paralysis was
in precisely the same condition that Dr. Weatherly spoke of. In two cases of
melancholia I think I absolutely eliminated every other possible cause. We all
know that to get at the exact cause of insanity is very difficult, especially
amongst the upper classes, who try to conceal any hereditary taint.
Dr. Bonvtlle Fox —First of all, with regard to the immunity of patients
already insane, in our community we find that extremely marked. We had
two visitations of the epidemic, and in the last visitation no female servant of
the establishment escaped having very distinct influenza, but on neither occa¬
sion did any patient have anything approaching an influenza attack, although
there were a considerable proportion of young patients who ought, by age, to
have been susceptible when exposed to it. With regard to the increase of
insanity by influenza, I have seen (though I have seen no insane patient with
influenza) a good many patients who have become insane from influenza, and
that not because influenza was assigned as the cause by their relatives, but
because after all other possible causes had been considered and eliminated there
seemed to be no other cause. Of course, we allknow^os£/mc is not propter hoc,
and in these particular matters I do not think I was deceived, and I cannot
but think there has been, among some classes at all events—I am of course
speaking from what I have seen—a considerable increase of insanity due to
influenza. I am bound to confess that with regard to causation I cannot go as
far as Dr. Savage, and although it has not been my experience to find that the
patient’s friends are quite so deceptive as some have found them, I cannot say
I have found that every case of insanity produced by influenza has shown
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Notes and News ,
147
hereditary taint. I will ask Dr. Savage, and I will ask you, do you not think
there is something in the influenza poison that is especially obnoxious to the
nervous system, not only with reference to that part which presides over our
thoughts and other mental functions, but as regards the spinal oolumn and
the peripheral nerves—through every part of them—and if this is so, and I
think that we Shall all admit that we have in cases of peripheral neuritis and
disturbances of various organs over whose functions the spinal cord exercises
great influence, an effect marked from influenza, what is more natural than that
you should go a step higher and expect to find that the brain should be dis¬
turbed, and its functions disordered, and therefore that it is not at all a surprising
thing that influenza should increase the amount of insanity ? I have had some
personal experience of influenza myself in two very severe attacks. A former
speaker euphemistically described his condition as one of “ susceptibility ” after¬
wards ; I can only describe mine as one of the deepest and profoundest depression,
and although I hope it stopped within the boundaries of sanity, I believe my
nervous system was undoubtedly affected for the time being by the poison taken
into my frame. But there are two questions, one of which has not been touched
upon at all, and the other only slightly alluded to, and that is the form insanity
attributed to influenza takes. I have not had the fortune to see any general
paralytics. The larger number of cases I have seen have undoubtedly been
melancholic, though some were maniacal. There has been one point very
characteristic of most cases, and that was that the results were most favourable
and that before long they appeared to make good recovery. As to the result of
the treatment under which patients attacked by influenza have been placed,
whether they are sane or insane patients, whether I have found that the use of
tonics, such as strychnine and quinine, has done good or what other treatment
has been adopted, I can only say that in one or two cases of mania I saw a very
great practical improvement from the use of that remedy which is vaunted by
some of us as having all the charm of the wand of the magician—I mean hydro-
bromate of hyoscine.
Dr. Conolly Nobman —I may perhaps be allowed to give you my experi¬
ence in the Dublin Asylum. There was an outbreak throughout the whole
district, and it is extremely hard to say how many of our admissions were
medically due to the disease. We had the first outbreak in the winter of 1889-
1890, and then all the superior officers of the asylum were attacked, most of the
servants, and a considerable number of the patients. It occurred again in the
middle of 1890-91, and on that occasion fewer of the officers were attacked and
not quite so many of the patients. It occurred again in the spring of this year
and was chiefly confined to the patients, though not solely, and some of the
servants again had it. The type was chiefly of the broncho-pneumonio variety,
and many of our cases developed pneumonia. There were a very large number
of deaths from that cause. There was not only a great prevalence of pneumonia,
but also of pericarditis, and many cases were complicated with pleural effusion.
The staff were attacked most particularly in the first epidemic, and many were
certainly attacked twice. Some patients passed through two attacks in the first
two years and died in an attack in the third. I am, perhaps, less capable of
hunting out cases of insanity than other people, but from my experience I have
scarcely been able to satisfy myself that any admission was due to influenza.
Certainly it was attributed to it in a great number of cases, but nearly every¬
body in the City of Dublin was attacked in the earlier epidemic. Of course,
like a great many other medical superintendents, and I think like most of my
Irish brethren, I have had to record that of late years the number of cases of
melancholia admitted to asylums has been greatly on the increase, but whether
that is due to the depressing effects of influenza upon our clientele I am not
prepared to saj r .
Dr. Soutab— Several speakers have held that influenza has apparently little
to do with the introduction of insanity. Of course influenza as the cause of
insanity would be an exceptional one. There seems to me a co-operation of
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148
Notes and News.
[Jan. ;
causes before the attack. I have been waiting to hear from those gentlemen
who have had a large number of patients under their care some statistics which
will show an analysis of the causes which have produced the attack in those
cases in which influenza was described as one. I can only speak of a limited
number of cases. We have only had ten cases in Mr. Bond’s house of insane
patients in which influenza has been described by the friends as the cause of the
attack. On an analysis of those cases I found that out of ten, five had had a
strong hereditary tendency. Those five were between the ages of 20 and 23,
exactly the time when an attack of insanity very often occurs, where there has
been a strong predisposition. But apart from influenza and to liereditary^
tendency, there seems to have been nothing in the circumstances of their life to
produce an attack of insanity. In those cases the hereditary tendency would be
sure to be looked upon as a producing cause, and I think we have hardly any
right to reject influenza as one of the principal causes in producing an attack.
Of the other cases in which influenza was described as the cause of attack,
certain evidences of mental disorder were observed to have taken place previous
to the attack of influenza, but they advanced much more rapidly after the
patient was so affected, so that here we are justified in looking upon influenza as
having a distinct influence in developing an attack, which, without influenza, -
might never have come to a head or have required hospital treatment. One case
seemed to be absolutely a case induced by influenza. It was that of a lady who
had had several attacks of what was called “delirium,” every time she had a
feverish cold or almost any illness raising the temperature in the slightest
degree. During the influenza she had an attack of mania. This was the only *
one in all the ten cases in which the maniacal form of mental disease was
present. All the other cases were melancholic cases, and the great majority of
cases were in the habit of rubbing their skin as if there was some sense of irrita- ?,
tion. All the young cases speedily recovered, and no special form of treatment
was required other than is usual in ordinary cases of melancholia. Some of the
other cases seemed as if they were going to hang on. The delusions were rather
persistent, and the recovery was very gradual. The point is that my examina¬
tion of these different cases brings out, as far as I understand the debate, the
result that influenza, while not a very great cause in inducing insanity, is
undoubtedly an influential contributory cause.
Dr. Hicks— I can scarcely agree that there has been actually no increase of
insanity from the effects of influenza. We meet with such cases, certainly, in
private practice and in consultation. It seems to me that influenza lips been an
active cause in producing insanity of late years. We have in influenza very
much that which we have in puerperal fever—an actually exciting cause in a
susceptible person, and it is possible that some other cause would have produced
a similar number of insane cases as we have now from this more active cause. It
has started the case more rapidly, and that really seems to be the reason why,
in private practice, we have met with so many persons who have had attacks of
insanity produced by influenza. An immense number of these cases have no
doubt recovered rapidly. They have been treated at home, and have really
undergone an amount of medical treatment which has been the means, as it
were, of relieving the attack. The patient has recovered, but the patient has,
undoubtedly, passed through an acute attack of mania for the time being, as in
puerperal fever. I think this shows that there has been a wave passing over the
country producing an increase of insanity, that is, that a larger number of
persons pass through attacks of insanity, and this may tend to explain the
diverse opinions that are expressed on the subject.
Dr. Savage (in reply)— I am very glad to find there is such a very distinct
difference in our observations; it shows it is worth discussing and considering.
Mr. Richards did not quite understand what my contention was. I personally
have not found many cases in which mental symptoms were modified by influenza.
I think one point upon which we might enlarge at some future time is whether
other forms of neurosis have been modified by influenza. For instance, a person
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1893.]
Notes and News.
149
has been subject to megrims; those megrims have stopped for some considerable
time after an attack of influenza. People who had nervous twitchings about the
face, after an attack of influenza no longer had it. So with recurring spasmodic
asthma, there has been an attack of influenza, and for the time and for some
time afterwards the patient, is free from the asthma. In fact, I have seen
certain modifications of neurosis caused by influenza, and in a few cases, although
I have not met them myself, one has heard of persons suffering even from in¬
sanity, the symptoms of which have been modified for a time. Undoubtedly some
patients have had attacks of insanity as a result of or following influenza. I
have seen several cases in which a neurosis has followed influenza, and the
patient afterwards has had a second attack following the same cause and has died.
I have also, as Dr. White said, seen a case of general paralysis following on in¬
fluenza, and in one case there was no alcohol and no syphilis. I have seen every
form of mental disease following influenza. I have seen more cases suffering
from melancholia than any other form. Then as to there not being an increased
number of cases of insanity, I do not think we are quite in a position to judge
of that yet. I will give two dr three reasons against our summing up too
quickly upon that point. The patients who have suffered to a great extent have
been among the upper classes, and a very great number of these cases have been
cases of comparatively easily managed melancholia. There is another very
important element. The number of suicides that have occurred after influenza
has been very considerable, and I have heard from half-a-dozen medical men
who had influenza, that seeing what they passed through it was a wonder
that they had not committed suicide. Dr. Macdonald has seen very few
cases. Well, all I can say is that is a pity. At the same time I can only say
other people have seen them. I do not know how it is that those who are con¬
nected with large asylums have not seen so many cases, but the same thing
holds good of syphilis. In consulting practice you see general paralytics with
a distinct history of syphilis given at once; from the large asylums the superin¬
tendents come and say their cases of general paralysis have not a history of
syphilis. It is merely another example of differing in observation. Dr.
Weatherly has seen one case in which syphilis undoubtedly had played some
part in the development of general paralysis, as well as influenza. Dr. Whit-
combe, again, has only had one case. Dr. Fox is inclined to think that there is
sufficient evidence that it has a toxic nerve influence, and if it be a toxine,
whether it be called grippo-toxine or some other toxine, it prefers to attack the
nervous system. I have seen every form of nervous disorder follow distinctly
and clearly attacks of influenza. I have seen epileptic fits, and also diabetes.
One has met with sleeplessness, one of the common symptoms of all forms
of mental disorder; with intense depression and delirium; as well as with
varieties of neuralgia; one has met with crises of an especially nervous type,
and if one of these nervous symptoms almost certainly depends upon influenza
poison it seems to me a very extraordinary thing that these symptoms should
not pass over the line of what we call insanity. Of course, I was not a father,
nor hardly a god-father, to this idea of neurosis and insanity, and I must dis¬
claim anything about “ Post-influenzal insanity.” The term I used in reading a
paper before the Medical Society was “ Influenza and Neurosis,” and, therefore*
one is not answerable for the term “ Post-influenzal Insanity.” My experience
is that there is some relationship between the two, but what it is I do not know 1 .
“PAYMENT OF PATIENTS FOR THEIR WORK.” >
Dr. Mercier read the following paper. (See Original Articles).
Dr. Orange —I should like to confirm what Dr. Mercier has said-with regpd
to Broadmoor. It is 21 years since I brought the system before the kuthorities,
and like everything else which could be supported with some shdw'of Reason, it
was most cordially received by the Home Office, and by then! <passed on to-the
Treasury, who have, of Course, to be consulted in all these matters. Action was
not very long delayed; it only required a little more expEfc&tion and elucida*
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150
Notes and News .
[Jan.,
tion. The scheme was fully explained in the annual report which I wrote for
the year 1876. I had rather an unusually large number of those reports
printed, to the extent of 500, which were circulated as widely as we could.
That report contained also schedules and forms used to carry out the scheme.
The scheme was originally sanctioned by the Lords of the Treasury as a trial.
After it had been in operation for about two years the officials of the Treasury
paid a visit to the asylum, with a view of ascertaining and reporting how the
scheme worked. Their report was made in due time, and published in 1879.
It was very satisfactory as far as we were concerned, inasmuch as it stated that
the system had been attended with very good results, both as an inducement to
inmates to work and as contributing to the expenses of the asylum by obtaining
a considerable amount of work which could not otherwise have been done.
Having left Broadmoor some years I was a little interested to hear, after the
lapse of a few years, what was still to be said for it. Dr. Mercier has now told
you what Dr. Nicolson reports with regard to it—that it is still as much in
favour with the authorities there as it was during the time it was my lot to be
at Broadmoor. (Applause.)
Dr. Bowebs —I think no one can dispute the value of Dr. Mercier’s paper.
No doubt his proposal is open to considerable development. He suggested
“jam,” but there is no doubt the rewards of toil might also be utilized for play¬
ing “ poker ” and what not. [“ Why not ? ”] I think anything which will help
to get our patients to work is of very great importance, and that some little
payment should be made in all asylums. I was rather disappointed that Dr.
Mercier was not able to give some hints as to payments and inducements to be
offered to patients in private asylums. We cannot offer extra beer or tobacco,
because practically they have as much of all those sort of things as they want,
or certainly as is good for them. Perhaps Dr. Mercier might mention some of
the things he finds useful. I have had considerable experience in employing
patients in the upper classes with a moderate amount of success, but still I have
some refractory patients.
Dr. Spence —As superintendent of a County Asylum I desire to say that I do
not think anything troubles us much more than the difficulty of paying our
patients for the work they do. We give them tobacco—that is all right, but
also we give them beer, and I object to that very strongly. We do give beer in
the asylum over which I am superintendent, but I know there are a great many
evils that I should be glad to see wiped away. I know there will be a great deal
of difficulty in persuading our committees to adopt the course suggested by Dr.
Mercier, and also in obtaining the assent of the Local Government Board
Auditor, who would certainly surcharge any attempt to give patients money or
tokens instead of beer or tobacco. Of course, these difficulties might be over¬
come. The paper is a very practical one, and I wish we had more of the same
kind, which would be helpful to superintendents in carrying out the every-day
work of asylums.
Dr. Lindsay —Asylum authorities ought to be greatly indebted to Dr. Mercier
for his paper. I will not say “ practical,” because I think it is impracticable.
(Laughter.) It seems to me that if you are to pay patients on the one hand
you should debit them on the other hand, in common fairness. If they are to
be paid for their labour I see no sound reason for saying that you would pay
them three halfpence when the value of the labour was one shilling. [“ Board
and lodging.”] The more correct thing would be to credit them with labour,
and debit them with board and lodging. (Laughter.) I am quite aware that
payment was made at Broadmoor years ago, but on revolving the question in
my own mind I came to the conclusion that theory and practice cannot always
be harmonized. I very soon dismissed from my mind the practicability of the
scheme. I am sure the labour of the average pauper patient would not be worth
a shilling a day, and would not pay for his keep. If Dr. Mercier would take
the stick by the right end, and begin by educating County Councils, their
superintendents would have an easier task. At present I think it would be very
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1893.]
Notes and News.
151
difficult for superintendents to persuade County Councils—to say nothing of
the Auditor—to pay patients for their labour. Although I think it is a matter
deserving the greatest consideration, I think there are very considerable diffi¬
culties connected with carrying out the scheme, because, of course, you cannot
compare prisons with asylums.
Dr. Macpherson —There is one point that has not been mentioned, namely,
that for 35 years the French asylums have paid their patients for labour done
in those asylums, and I may say with most beneficial results. There is also this
other point. Patients very often find on leaving asylums that they cannot get
employment; they are mistrusted by employers of labour. I have over and
over again seen patients who were incapacitated by attacks of insanity, and
who when they left the asylum went out to find that their tools and, indeed,
their surplus clothing had all been appropriated. In the French asylums each
patient who works may have a small sum" to his credit when he goes out to the
world, and that, in addition to the help he receives from society, is a matter of
very great help. In this country, of course, we all know nothing of the kind is
done.
Dr. Mercier —With reference to the payment of good class patients, and the
way they were paid, I have overcome that difficulty with the greatest ease. I
have paid them in money, and I do not find that they dislike it at all. As to
expense, of course, if the matter is tried on a large scale it is financially successful.
That is settled by the experiment already mentioned. The difficulty will be
to persuade County Councils that it will be financially successful, but I submit
that with the token coinage I recommend, a beginning may be made virtually
without any expense at all. It simply means cutting off the tobacco and beer
the working patients at present get, and giving them tokens to purchase
tobacco and beer, and other things which may be purchasable also. Of course,
no auditor would at present pass an actual money payment made to patients,
but the auditor does not, I assume, exercise a very minute supervision over the
variety of provisions. (Yes, yes.) There may be a difficulty, but what do we come
into this world for but to overcome difficulties ? Dr. Lindsay says the patient’s
work is not worth a shilling a day. If so, why pay them a shilling? I do not
see that is any objection at all. The actual amount of payment does not
equal the value of the patient’s work. If the patient’s work is not worth one
shilling a day what I say is it will be very soon worth more than a shilling a
day if you pay him l£d. for it, and there you get a distinct profit of 10|d. on
the transaction. I did mention the point of payment of money earnt to patients
on their leaving the asylum. I said I thought it was a most desirable thing to
do, and I think it might easily be arranged.
SCOTTISH MEETING.
A Quarterly Meeting of the Association, Dr. Ireland in the chair, was held
at Edinburgh, in the Hall of the Royal College of Physicians, 10th November,
1892. The other members present were Drs. James Cameron, Campbell Clark,
Clouston, Elkins, Carlyle Johnstone, Keay, Mackenzie, Oswald, G. M. Robert¬
son, Ronaldson, Batty Tuke, jun., Turnbull, Watson, Yellowlees, and Urquhart
(Secretary). Dr. Middlemass was also present as a guest.
The minutes of the last meeting were read, approved, and signed.
Dr. Ireland made suitable reference to the death of Dr. Aitken, and the
Secretary was instructed to write to Mrs. Aitken expressing the sympathy of
the members.
Microscopic slides, illustrative of recent work on cerebral anatomy and patho¬
logy, by Drs. Bevan Lewis, Goodall, J. C. Mackenzie, and Middlemass, were,
exhibited.
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152 Notes and News . [Jan.,
Dr. G. M. Robertson then read a paper on the treatment of acute delirious
mania, which will appear.
Dr. Ireland said that he had been especially interested in Dr. Robertson’s
remarks on the value of artificial digestion in dealing with these cases. He
always advised the young men to pay more attention to therapeutics than to
pathology. They would have the favour of the public on their side, who were
obstinate in the notion that medicine was really designed to cure people of
their diseases rather than to study the way they died. He referred to his
experience of opium and tartar emetic in the treatment of the delirium of
fever, and some cases of acute mania. There was a tendency in mania to
sinking, which rendered the old physicians cautious in bleeding.
Dr. Ronaldson said that he had found it in the highest degree necessary to
obtain proper movement of the bowels, and had lately used glycerine enemata
in preference to the more ordinary enemata, with the best possible results, only
a teaspoonful of glycerine being necessary. If haemorrhoids existed they were
likewise benefited by this treatment.
Dr. Campbell Clark spoke of the necessity of diagnosing acute delirious
mania from typhoid fever. In his practice he had found several cases of
typhoid simulating acute delirious mania in every way, and at least one of these
oaRes had been proved by post-mortem and microscopic examination to be
typhoid. He laid special stress upon the liability of puerperal patients to
specific diseases. There could be no doubt that dietetics were most important,
and he confirmed Dr. Robertson’s experience in regard to the benefits to be
derived from the use of digested food. In order to avoid any mistakes in the
preparation of peptonized milk he ordered half-a-pint to be boiled, then half-a-
pint of cold milk to be added, by which method the temperature for peptonizing
was obtained without further trouble. In case of a difficulty of feeding by the
mouth he used zyminized suppositories of meat and milk. He confirmed what
Dr. Ronaldson had said about glycerine suppositories, and recommended mor¬
phia suppositories as an effective and safe manner of treating peripheral irrita¬
tions. Although there can be no doubt that sulphonal obtains a high place in
every-day practice, in these cases he preferred hyoscine.
Dr. Mackenzie briefly described a fatal case of acute delirious mania, which
was characterized by extreme exhaustion, high pulse, sighing respiration, and
nearly abolished reflexes of the eyes. He injected part of a grain of stro-
phanthin with 30 minims of brandy subcutaneously, and hot milk was adminis¬
tered by the stomach tube. At first the patient appeared to rally, but in a few
hours she died, with a maximum temperature of 109°. The strophanthin was
given with the idea of increasing the cardiac systole, but its effects were
evidently transient. At the post-mortem examination intense compression of
the brain and hyperaemia, especially in the cerebellum, were the chief features.
He believed that alcohol should be more frequently used to allay excitement.
Dr. Batty Tuke, jun., referred to two successful cases in which he had bled
to the extent of 10 to 12 oz., both being young and strong men. He could not
corroborate what had been said in favour of sulphonal. He preferred to create
counter irritation on the surface of the chest and back with turpentine, or
a blister or large mustard plaisters. This, along with the use of hot baths, he
had found in many cases procure sleep when hypnotics failed.
Dr. Oswald spoke of the value of paraldehyde, combined with bromide of
potassium, in obtaining sleep in these acute excited states. The addition of
bromide had this advantage, that it obviated the excitement that was apt to
occur as an after-effect of paraldehyde. He considered that the free action of
the skin was only secondary to the free action of the bowels in allaying irrita¬
tion and excitement and inducing sleep. Enemata containing turpentine were
in his experience valuable, and he recognized the importance of maintaining
the alimentary canal in as aseptic a state as possible. A case diagnosed before
admission into Gartnavel as one of mania was shown afterwards to be really
one of typhoid fever.
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Notes and News.
153
1893 .]
Dr. Carlyle Johnstone said that he would not again refer at length to the
value of snlphonal in these cases, but while he regretted that it remains necessary
for us to treat symptoms, there was no doubt in his mind that in sulphonal we
possessed a most valuable drug.
Dr. Clouston referred to the difficulty of classifying cases of mental disease.
He would ask if acute delirious mania were really a distinct disease from acute
mania ? He believed that there was no real distinction between the two condi¬
tions, although some authors were satisfied that such existed. Dr. Clouston
compared these cases of acute delirious mania with some cases of alcoholism
dying with very similar symptoms. There can be no doubt that certain cases of
epilepsy, and also general paralysis, pass into a similar state, and he had seen
puerperal, lactational, and even cases of mental shock exhibiting very similar
symptoms. He would urge that different pathological conditions should be
ascertained before mental diseases should be so divided, and it is a question if
such exists in regard to the cases now under review. It must be kept in mind
that in live cases of delirious mania out of six the disease began and ended
with ordinary mania. He sometimes asked himself if we should not allow
acute delirious mania to run its course without using soporific drugs, just as
we did the delirium of typhoid fever. The microscopic sections (prepared by
Dr. Middlemass) placed on the table to illustrate Dr. Robertson’s paper showed
i*he extreme degeneration of the nerve cells to be found in some cases of this
kind. Dr. Clouston was hopeful that even such degenerative changes might
be curable, and that the recuperative power might build up nerve cell contents,
even if the organic change had advanced to a similar stage of what has occurred
in this particular case. This case had deeply impressed him, for if a really
“ curable ” case could have such advanced cortical cell degeneration it gave
new hope where men were hopeless at present. Looking at those ceils, they
were more degenerated and changed than in early general paralysis. He would
emphasize the fact that up till the last the prognosis in Dr. Robertson’s case
had remained good. There was apparently no reason why the patient should
not have recovered until it was evident that death was very near at hand.
Replying to Dr. Ireland, Dr. Clouston could not say that the variety of acute
mania called delirious mania ran a definite course like an infectious fever; but
in some cases the course of the symptoms was fairly certain. As a matter of
fact they expected that these patients would recover within three months if
they recovered at all.
Dr. Urquhart agreed with Dr. Clouston in believing that acute delirious
mania or typho-mania w as not a distinct disease, but he held that it was a con¬
venient name for these severe cases which from time to time occur in asylum
practice. On looking over the records of Murray’s Asylum he found that only
one case of acute delirious mania had occurred out of four hundred, and that
would seem to be the usual proportion. That case did recover after an ex¬
tremely severe attack, but the patient had relapsed two or three times in the
intervening ten years, and the subsequent attacks were not characterized by
the very severe symptoms of the original seizure. Dr. Urquhart referred to
the benefits of the wet-pack, especially when the skin is dry and harsh, and
the necessity for the treatment of the urgent symptoms.
Dr. Turnbull concurred in the importance of studying the clinical history
of the disease. Certain forms of acute mania tended to run a definite course,
just like the specific fevers, and hence the necessity of watching for the different
symptoms as they arose, treating these as far as possible, and placing the
patients in the best possible conditions for weathering the storm. With regard
to sulphonal and hyoscine, he had found sulphonal more generally useful than
the other, but had also obtained good results with hyoscine in toning down
the attacks of excitement in recurrent mania.
Dr. Robertson briefly replied. He said he could not agree with Dr. Clark
as to the relative danger of sulphonal and hyoscine in these cases, for he was of
opinion that the latter was more depressing. He also believed it to be neces-
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sary to run some risk oven with sulphonal in trying to stop the motor oxcite-
ment when a patient was running down and exhibitiu» symptoms of exhaus¬
tion. He would be unwilling to adopt such remedies as hot baths and blisters.
After the conclusion of this discussion an informal conversation took place
regarding asylum dietaries, which will be reported by Dr. Turnbull to the com¬
mittee now engaged in considering that question.
Dr. Turnbull moved, and it was unanimously resolved, that the Secretary
should intimate to the Council at their next meeting the desire of the members
then assembled to hold the spring Quarterly Meeting in Liverpool, or some
convenient town in the North of England.
Dr. Watson then exhibited and explained the plans of the Govan District
Asylum now being erected, the chief feature of which was the separation of
acute and sick cases in a hospital block, placed at a convenient distance from
the building for chronic patients.
After the meeting the members dined as usual in the Edinburgh Hall.
THE INTERNATIONAL CONGRESS OP CRIMINAL ANTHROPOLOGY.
The third International Congress of Criminal Anthropology was held at the
Palais des Academies, Brussels, from the 7th to the 14th of August. Dr. Semal
very ably organized the Congress j M. Le Jeune, the Minister of Justice, presided
at the opening session, while the King of Belgium attended one of the meetings
and invited the Congress to meet him. Various prisons and asylums were
visited, and the papers and discussions generally were of great interest. A large
number of foreign Governments were officially represented at the Congress, in¬
cluding France, Italy, the United States, Russia, Holland, Denmark, Hungary,
Switzerland, Portugal, Mexico, Brazil, Chiua, Japan, etc., and many medical
and scientific societies sent delegates. A notable feature of the meetings was
the considerable number of lawyers present, and the harmonious manner in
which the medical and legal elements in the Congress worked together. The
prominent members of the Italian school were on this occasion absent; and
although the congenital “criminal type,” in a very narrow and rigid sense, is
not accepted by criminal anthropologists generally, on the other hand honour
was paid to Lombroso and his followers who have, indeed, created the study of
criminal anthropology. While in the narrow sense of the word there is no
definite and distinct “ criminal type,” the very frequent association of a large
number of anatomical characters with criminality is now almost universally re¬
cognized. At one of the meetings of the Congress a photograph was passed
round by M. Cuylits (who argued that crime is an exclusively social phenomenon)
as that of an “ honest man ” exhibiting a large number of the features usually
associated with criminality; this “ honest man,” however, was recognized by Dr.
Warnots as a hospital patient who had been frequently in prison. The incident
was an amusing illustration of the careless manner in which evidence is some¬
times brought forward in these matters.
It is impossible within the limited space at our disposal to give an account of
the various papers and discussions, but some reference may be made to a few of
the more important. At the first meeting Dr. Magnan, of Sainte Anne, presented
his report on “ Morbid Criminal Obsessions,” dividing them into homicidal,
kleptomaniac and kleptophobiac, pyromaniac and pyrophobiac, and sexual ob¬
sessions, giving several examples of each variety, and concluding that mental
degeneration is the soil from which all, though differently coloured, emanate.
Dr. Ladame,.of Geneva, followed with a paper on the special “ Obsession of
Murder,” as a division of the great class of hereditary insanity, like dipsomania
or kleptomania; he divides such subjects into those whose obsessions remain
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theoretic and those whose impulse leads them to murder or suicide. Dr. Gamier
criticized a portion of Ladame's paper, considering that he placed side by side
cases dependent on, and independent of, hereditary degeneration; the most
dangerous variety is that where the impulse is sudden and immediate, without
hesitation or struggle. Professor Benedikt accepted the conclusions of Magnan,
Ladame, and Gamier, and thought that the victims of obsession were very
numerous in prisons, especially among recidivists. He mentioned the case of a
reformed thief, who became a police official and led an irreproachable life for
seven years, when one day, to his immediate grief—and though he was well off—
he was unable to resist the temptation to appropriate a pocket-book full of bank
notes. Dr. Nacke, of Hubertusburg, considered that obsession was rare, and that
its diagnosis mingled with that of epilepsy, periodic melancholia, etc. This
was not, however, the opinion of most of the speakers. The Congress then passed
on to the discussion of the “ Functional Etiology of Crime.” This subject was
introduced by Dr. Dallemagne, of Brussels. He considered that the study of
crime is, above all, a study of the criminals’ psycho-physiology, and that there
are three orders of factors to be regarded—the nutritive, the reproductive, and
the intellectual—every act being the resultant of one or more of these factors.
M. Cuylits and M. Drill believed that more importance must be attached to the
social factor; to this Dr. Dallemagne replied by pointing out that in Denis’s
diagram the curve of crime is almost parallel to the curve of the price of wheat.
In the afternoon, after Mme. Pauline Tarnowsky htd read a paper giving the
results of her investigations on “ The Organs of Sense in Criminal Women/*
Professor Lacassagne, of Lyons, spoke on “ The Primitive Instincts of Criminals,”
expounding his well-known classification of criminals into the frontal, parietal,
and occipital groups. Dr. Nacke was not able to accept Lacassagne’s cerebral
geography; and M. Cuylits insisted on the importance of the environment. Dr.
Motet followed with a paper on the “ Motives of Crime in Children.” A com¬
munication was then read from M. Ou-Tsong-Lien, of the Chinese Legation,
regarding criminal administration in China. He pointed out that when a dis¬
trict had supplied no criminal for a certain period the local authorities were
recompensed, crime not being regarded as a purely individual concern. M.
Tarde remarked that this was a collective responsibility towards which we are
tending. This was also the opinion of M. Prins, who thought that the future
will bring judicial decentralization. On the following day M. Drill, of Moscow,
presented a report on “The Fundamental Principles of Criminal Anthropology.”
Among these are, as he insisted—(1) the old principle of punishment must give
place to the idea of social protection ; (2) the criminal must be studied, instead
of merely studying the criminal act; (3) there are two factors in crime—psycho¬
physical organization and external influences. Dr. Houz<$ expounded the con¬
clusions of the report he bad prepared, in conjunction with Dr. Warnots,on the
question : “ Is there an anatomically determined criminal type ? ” He showed
that, in the strict sense, this does not exist, the so-called “criminal type” being
a hybrid product composed of characters drawn from various sources, and that
even if it actually existed it was only found in a very small minority of criminals.
He pointed out that criminal anthropology was in no way bound up with the
existence of any rigidly anatomical “ criminal type.” Dr. Jelgersma, of Meeren-
berg, then presented a report, entitled “The Physical, Intellectual, and Moral
Characters of the Congenital Criminal are of Pathological Origin,” and concluded
that from whatever point of view we regard the instinctive criminal he is a
diseased person, that criminality is as much a disease as insanity. In the dis¬
cussion which followed the Abbe de Baets sought to reconcile the new anthro¬
pological school with the old classical school of jurisprudence; in the future, he
declared, it would be necessary for lawyers and priests to study the facts of
positive science. Subsequent speakers, generally, accepted the reconciliation
of lawyers and doctors on a basis of general agreement as to the importance of
anthropologic science.
On the 10th Dr. Nacke read a paper on “ The Signs of Degeneration in Insane
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Women, and in Criminal Women who have become Insane.” He showed that
among the former such signs were only wanting in about three per cent., and
were rather more frequent among the latter, but he was not able to accept a
criminal type in Lombroso’s sense. Prof. Benedikt explained the conclusions
of his report on “ Criminal Suggestion and Penal Responsibility.” He has no
belief in the possibility of crime by suggestion. Dr. Voisin then preseuted a
summary of his report on the same subject, in which he arrived at an opposite
conclusion—that the hypnotic method is a real means of cure, and also a very
dangerous incentive to crime. Dr. Bdrillon als > presented a report in the same
sense. A discussion followed which led to no unanimous conclusions. The
Germans (Mendel, Nacke, etc.) generally disputed either the criminal or thera¬
peutic efficacy of hypnotism ; the French and Belgians on the whole argued for
such efficacy. On the following day M. Gauckler, Professor of Law at Caen,
presented his report on the “ Respective Importance of the Social and Anthropo¬
logical Elements in the Determination of Penality.” He concluded that—(1)
The essential function of criminal law is to prevent crime by intimidation, and
that this function is conditioned by elements exclusively social; (2) A secondary
but still very important function is to ensure the harmlessness of a delinquent,
and this function is conditioned by anthropological data. Prof, von Liszt,
from the legal side, approved M. Gauekler’s conclusions. M. Prins contested
the essential function of intimidation in criminal law; Prof, van Hamel, of
Amsterdam, saw little difference between the point of view of the study of the
individual and that of the study of society; they could not be separated; and
M. Ploix remarked that even disagreement on principles did not interfere with
harmony in practice. Prof. Manouvier then presented his paper on “ Prelimi¬
nary Questions in the Comparative Study of Criminals and the Honest,” in
which he explained how it was that a commission appointed by the previous
Congress to make a comparative anatomical study of criminal and honest
persons had no report to offer. The difficulties in the way of strict selection
and of uniformity of method were found insuperable. M. Denis, the Rector
of Brussels University, then read a communication on “ Criminality and the
Economic Crisis.” He showed diagrams indicating parallel curves of famine
and criminality, and an inverse relation between marriage and the price of
wheat; he regretted that since Quetelet’s death the study of moral statistics
had been almost abandoned. M. Tarde then presented a lengthy and very
interesting report on the “ Criminality of Crowds.” He insisted that the
morality of crowds is inferior to that of the individuals composing them. This
may be true even of nations, and he instanced the English, who as a nation have
acquired a reputation for perfidy, though as individuals they are to a large
extent frank and loyal. Whether rural or urban, crowds are liable to folie des
grandeurs , or to persecutory mania and to mental hallucinations. It is, how¬
ever, specially among urban crowds that moral insanity is more frequent and
more profound. The question of the prevention and repression of collective
criminality was a very difficult one. Dr. Dexterev and Dr. Sarewski, from
observations of mob psychology during the recent cholera riots in Astrakhan,
did not agree with M. Tarde that mobs always had leaders. Dr. Gamier fully
accepted M. Tarde’s conclusions; there were always alcoholics and genuine
lunatics in mobs, and these led away the others. M. Tarde admitted in his
reply that a leader was not always necessary to a crowd. On the following day
a communication was read in which Dr. Debierre gave the results of some
anatomical researches concerning the vermian fossa, tending to disprove Lom¬
broso’s contention as to its connection with criminality. Dr. Gamier then pre¬
sented an important report on “ The Necessity for a Preliminary Psycho-Moral
Examination of Incriminated Persons.’* He showed that during the five years
1886-90 no fewer than 255 persons, or about 50 per annum, were found to be
insane almost immediately after judgment had been pronounced, and were thus
unjustly subjected to the disgrace of condemnation. He mentioned a few of
the numerous cases with which his official position brought him in contact^
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157
1893 .]
Dr. Gamier was supported by Dr. Winkler, Dr. Motet, and others. Prof, van
Hamel then presented his report on “The Measures Applicable to Incorrigible
Criminals.’* He argued that the detention of recidivists must be indefinite, the
criminal to be periodically brought before a court which would possess the power
of deciding concerning his future. Prof. Thiry, who was persuaded that indefi¬
nite detention could not be avoided, was in agreement with Prof, van Hamel,
but did not see the necessity of judicial intervention to prolong or interrupt
detention. M. Maus, in a paper on the same subject, advocated an indefinite
sentence (somewhat as at Elmira), considerable latitude being left to the prison
administration to individualize the treatment. Dr. de Boeck, of Uccle, and M.
Otlet, an advocate of Brussels, presented a report on “ Prison-Asylums and the
Penal Reforms they Invol ve,” formulating their conclusions in the shape of an Act
corresponding to those already accepted by the Parliaments of Italy and Belgium.
On the last day of the Congress, after a communication from M. Terawo-Tora,
the delegate of the Japanese Government, on the progress of criminal legisla¬
tion in Japan, M. de Ryckere brought forward his paper on Bertillon’s anthro¬
pometric system, which is shortly to be introduced into Belgium. Among
other papers brought before the Congress were two by Prof, von Liszt and Prof.
Benedikt on “ The Applications of Criminal Anthropology,’* two by Dr. de Rode
and Prof. Hubert on “ Sexual Inversion and Legislation,*’ arguing that before
trial there should always be a medical examination in such cases, and papers by M.
dje Vaucheroy on “The Influence of Alcoholic Heredity on Insanity and Crimi¬
nality,** and Dr. Coutagne on “ The Influence of Occupation on Criminality.”
The excellent plan was followed at the Congress of issuing Rapports beforehand,
so that it was not necessary actually to read them at the Congress, thus allowing
ample time for discussion and for the reading of shorter communications.
Pending the publication of the “ Actes,” a fairly full account of the papers and
discussions will be found in the “Archives de l’Anthropologie Criminelle” for
September, the whole number being devoted to the Congress.
The next International Congress will be held at Geneva in 1896, but it is
expected that there will be a special session at Chicago during the present
year.
WEST LONDON MEDICO-CHIRURGICAL SOCIETY.
Dr. H. Sutherland read a paper on Nov. 1th on the “ Prevention of Suicide
in the Insane.”
Statistics showed that only one case out of 222 patients who were suicidal
on admission succeeded in committing the act, the remaining 221 having been
prevented from doing so by the vigilance of the attendants.
The duties of the superintendent and attendants of the suicidal insane were
to keep a careful and constant watch upon all medicines, plasters, and dis¬
infectants. To keep keys, razors, knives, forks, fireirons in places of safety.
To impress upon visitors the necessity of not leaving poisonous substances
about, or introducing scissors or edged tools into the asylum. Attempts at
hanging might be prevented by keeping out of the wards all nails, wires, ropes,
sash-lines, bell-pulls, tapes and string. Patients with homicidal and suicidal
delusions should not be allowed to work in the shops of the asylum, where they
have knives and hammers at their command.
The site of the asylum should be chosen as far as possible from rivers, ponds,
and railways.
In the asylum itself all doors should open outwards, windows should be
protected, w.c.’s should close with a ball let into the door, fireplaces must be
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[Jan.,
protected by guards, taps for gas secured under lock and key, and all windows
and gas jets bo placed out of reach.
Patients should bo watched at meals to see that they eat enough, and do not
take food in a dangerous manner.
Some curious weapons were exhibited, made by suicidal patients from pieces
of crinoline steel, firewood and string forming a knife, and from stones tied
up in a stocking forming a hammer, and other curious inventions.
The paper concluded by a tribute of praise to the attendants, by whose
devotion suicide in asylums is reduced to a minimum.
ILLENAU’S GOLDEN JUBILEE.
Since we received the “Festschrift,” issued at the time of the Jubilee, which
we have noticed in this Journal (p. 109), we have received from the Director, Dr.
Schule, an account of the proceedings which took place at Illenau on the 27th
September, 1892.
Our space allows us only to note that the occasion was a very brilliant one.
The Grand Duke and Grand Duchess of Baden honoured it by their presence.
The ceremony was partly religious, partly secular. A sermon was delivered by
the Chaplain. The Duke replied to a loyal speech in which he was addressed.
Dr. Schule, of course, spoke. Among other things a hymn, specially written
for the Ceremony, was sung at the Service, and a special poem eulogizing
the work performed at Illenau was recited during the proceedings. Altogether
the enthusiasm and the tributes paid to those who had been the making of the
asylum were of the warmest character, and the success was, we are glad to say,
as great as it deserved to be. Congratulations in regard to the past were com¬
bined with the expression of the hope that in the future still greater heights
would be reached in the treatment of the insane. We add our “ Amen! ”
Obituary.
THOMAS AITKEN, M.D.Edin. •
We regret to have to record the death of Dr. Aitken, of the Inverness
District Asylum, one of the senior members of the Medico-Psychological Asso¬
ciation.
Dr. Aitken was born in Dumfries, and was rocked in his cradle by the widow
of the poet Burns. After attending school in Birmingham he served as assis¬
tant medical officer under the late Dr. W. A. F. Browne in the Crichton Royal
Institution, and thereafter completed his medical education in Edinburgh. He
graduated in 1856 and then became assistant medical officer in Durham County
Asylum with Dr. R. Smith, before being appointed Superintendent of the
Inverness Asylum in 1859. That institution was completed in 1863, and was
designed to accommodate 300 patients. Since then it has been repeatedly
enlarged, and now contains over 500. ’ Further accommodation being urgently
required, Dr. Aitken was, until the time of his sudden illness, occupied in
designing a separate hospital block for the reception of acute cases. Although
it was well known that for some years his health was far from being robust, and
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Notes and News .
159
that at times he carried on his life-work under circumstances of painful
difficulty that would have daunted a less resolute man, his health had im¬
proved so much of ,late that Dr. Aitken’s death at Baden was a shock to his
many friends who had parted so recently from him in high spirits and the
prospective enjoyment of a holiday in Germany.
His loss will be widely felt, not only by those with whom he was more
intimately professionally connected, but also by the public in the north of
Scotland. Dr. Aitken did not confine his energies to the administration of
asylum affairs, but he was also a good citizen and a man of no ordinary
accomplishments, both literary and scientific. He was deeply interested in
archaeology and geology, and specially wrote on the Hill Forts so common in
the north of Scotland. All his life long he was an eager student. His collection
of books on the French Revolution was very complete ; and his study of Heine,
and the poetry of Keats and Wordsworth was both comprehensive and erudite.
Dr. Aitken had a full knowledge of French and German, and has left many
translations from works in these languages, not only from those dealing with
psychiatry, but also from such poets as Heine.
Dr. Aitken did not publish any work of note in psychological medicine,
although he was ever careful to keep abreast with the foremost knowledge of
the time. His conscientious reports have been noticed from time to time in
this Journal, and although his views did not always command assent, they were
respected as the outspoken accents of sincere conviction.
A. R. U.
M. PROSPER DESPINE.
Dr. Despine, of Marseilles, died there January 16th, 1892, at the age of
eighty.
He was an honorary member of the Medico-Psychological Association.
A native of Savoy, he commenced his medical studies in the Marseilles School
of Medicine; he pursued and finished them in Paris, where he obtained his
degree of M.D. in 1837.
Despine was interne at Bicetre under Ferrus and Leuret. It was under the
direction of these enlightened alienists and also by associating with fellow-
students, who were themselves afterwards distinguished masters of mental .
science, that Despine acquired a keen taste for the study of the problems of
psychology and medical philosophy. He was the author of several works of
profound erudition, in which he proved himself to be a mental philosopher,
and, in some respects, an able exponent of the Scotch metaphysical school.
Such are his “ Psychologie naturelle on Etude sur les facultes intellectuelles ou
morales dans leur etat normal, et dans leurs manifestations anormales chez les
altenes et chez les criminelles ” (1868): “ De la folie an point de vue philo-
sophique ou plus spdcialment psychologique chez le malade et chez l’homme ez
sante” (ouvrage couronnd par l’lnstitut ez 1874), ‘‘Etude scientifique du
somnambulisme ” (ouvrage recompense par la Socidte medico-psychologique de
Paris, 1877). He also published “La Contagion morale” (1870), “Limita¬
tion ou les principes qui la determinent ” (1871), “ Le ddmon alcool ” (1871),
“ De l’etat psycbique des criminals,” “ Un cas d’hyst^rie aigiie chez
l’homme,” etc. His last work was an interesting study on Moliere, in which
he studied the illustrious comedian as moralist and as philosopher. Its title
was “ La Science du cceur hnmain ” (1884).
Dr. Despine was an honorary member of the Societd Medico-Psychologique
of Paris, of the Acad^mie des Sciences, Belles Lettres et Arts of Savoy, and
of the American Society of Prisons. His great age did not allow of his taking
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[Jan.,
an active part in the proceedings of these different learned bodies, but to the
last moment he was interested in the questions which had been the object of
his researches. He died after a short illness. Very modest, very upright in
character, he was held in high esteem by all his medical brethren.
DR. PHILIPPE REY.
NURSING CERTIFICATES.
The following candidates were successful at the examination for the certificate
of proficiency in nursing held in November, 1892 :—
Winson Green Asylum , Birmingham.
Males. Females.
Yarnal, Alfred. Holden, Bertha.
Derby Borough Asylum .
MacDonald, Helen N.
Sanatorium.
Barrett, Lydia.
Cowling, Clara.
D’Arcy, Maud.
Greatbatch, Elizabeth Annie.
Gleeve, Kathleen.
Heraper, Elizabeth.
Hughes, Annie.
Julius, Minnie.
Pakenham, Emma Mary.
Crichton Royal Asylum , Dumfries.
McLeod, Jessie.
Kirklands Asylum , Bothwell.
Macaskill, John.
Sunningside Asylum , Montrose.
Dunbar, John. Duncan, Annie.
Emslie, Robert. Duncan, Christina.
Massie, John S. Findlay, Elizabeth.
McIntosh, Elizabeth.
Middleton, Margaret.
McCall, Mary.
The next examination for this certificate will take place on Monday, the first
day of May, 1893. Candidates can obtain from the Registrar a schedule, which
should be filled up and signed as required, and returned to him at least four
weeks before the date of the examination.
Letters of inquiry respecting this certificate should be addressed to Dr.
Spence, Burntwood Asylum, near Lichfield, Staffordshire.
Holloway
Aries, William.
Gouriet, Alfred.
Green, Edward John.
Jenkins, Lambert.
Ponsford, Henry.
Webber, John.
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Notes and News.
161
M.P.C. EXAMINATION.
Thursday, Dec. 8, 1892.
The following Candidates for the M.P.C. passed the Examination held at
Bethlem Hospital, Deo. 8:—
W. Andriesen, Maurice Craig,
Frederick G. T. Fox, H. C. Halsted,
W. H. R. Rivers.
THE SPRING QUARTERLY MEETING.
This Meeting of the Association will be held at the Medical Institute^
Liverpool, March 9, 1893.
FLETCHER BEACH,
Hon. Secretary.
Darenth, Dec. 12th, 1892.
ADDENDUM.
In the Occasional Note on “ Tennyson as a Psychologist,” there should have
been inverted commas, from line 20, p. 65, to J. C. B. inclusive (p. 71,
line 11).
In addition to Dr. Peterson’s article reviewed at p. 114, we have received r
“ Progress in the Care of the Colonization of Epileptics/* reprinted from “ The
Journal of Nervous and Mental Disease,” August, 1892; “ The Treatment of
Epilepsy,” reprinted from the “ Buffalo Medical Journal.” In the “ New York
Medical Journal/* July 23, 1892, Dr. Peterson gives “ An Outline for a Plan of
an Epileptic Colony.” These publications prove that the author has thoroughly
studied the subject, and has determined not to allow it to fade away from the
public mind.
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Note8 and 'Nem\
Appointments .
Bond, C. H., M.B., C.M.Edin. appointed Clinical Assistant to the West
Biding Asylum, Wakefield.
Griffith, Augustine, M.B.Lond., appointed Second Assistant Medical
Officer to the Nottingham Borough Asylum.
Jackson, Arthur M., M.D.Oxon., M.R.C.S.Eng., appointed Senior Assistant
Medical Officer to the Kent County Asylum.
Johnston, T. Leonard, L.R.C.P.., L.R.C.S. L.F.P.S.G., and L.M., appointed
Second Assistant Medical Officer Berkshire County Asylum.
Jones, Robert. M.D.(Lond)., F.R C.S.(Eng.), Medical Superintendent of
the Earlswood Asylum, appointed Medical Superintendent to the Middlesex
County Asylum, Claybury.
Mackenzie, J. C., M.B., appointed Medical Superintendent to the Northern
Counties Asylum, Inverness.
Macnaughton, G. W. F., M.S.Edin., appointed Third Assistant Medical
Officer at the Worcester County and City Lunatic Asylum.
Mathieson, George, M B., C.M.Glasg., appointed Junior Resident Medical
Officer to the County Asylum, Stafford.
Millard, R. J., M.B., Ch.M., appointed Junior Resident Medical Officer to
the Hospital for the Insane, Paramatta, New South Wales.
Murdoch, J. W t m. A., M.B., appointed Medical Superintendent to the Berks
County Asylum.
O’Mara, Francis, L.R.C.P., L.R.C.S.I., appointed Assistant Medical Officer
to the Limerick Lunatic Asylum.
Rouse, E. R., M.R.C.S.Eng., L.R.C.P.Lond., L.S.A., appointed Third Assis¬
tant Medical Officer to the London County Asylum, Colney Hatch.
Shaw, H. G., M.R.C.S., L.R.C.P., L.M., reappointed Assistant Medical Officer
to the Female Department of the London County Asylum, Colney Hatch.
Wilmott, C. C. Eardley, M.B.Durh., appointed Junior Assistant Medical
Officer to the Middlesex County Asylum, near Tooting.
Digitized by ^ooQle
THE JOURNAL OF MENTAL SCIENCE.
[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland .]
No. 165. * B !,o 8 m B8 ’ APRIL, 1893. Yol. XXXIX.
PART 1.—ORIGINAL ARTICLES.
On Psychoses after Influenza .* By Julius Althaus, M.D.,
M.R.C.P.Lond., Senior Physician to the Hospital for
Epilepsy and Paralysis, Regent's Park.
The discussion which I have been invited to open is on a
subject which is new to all of us, and which may, therefore,
simply on this account, claim a share of our attention.
Indeed, on searching the works of Clouston, Blandford,
Savage, and others, as well as the extensive periodical litera¬
ture which is at our disposal in the t( Journal of Mental
Science,” the “ West Riding Asylum Reports,” and similar
publications in Prance and Germany, the subject of mental
affections occurring subsequently to influenza has hardly been
mentioned with a single word previous to the epidemics of
that distemper which we have recently passed through. Nor
is there anything to be found on this subject in the numerous
books and papers descriptive of influenza which have appeared
before 1890. All that has been written on mental disorders
in connection with influenza previous to that date refers to the
febrile or initial delirium which may occur at any time during
the progress of the feverish attack, and may, indeed, precede
all other symptoms, setting in sometimes before there is any
rise of temperature. This initial delirium has been described
as long ago as 1510 by Sauvages, and later on by Huxham,
Ash, Haygarth, Gray, Smyth, Rush; more recently by Lom¬
bard, Bonnet, and P6trequin, and during the last epidemics
* Read before the Psychological Section of the Annual Meeting of the British
Medical Association, at Nottingham, July, 1892.
XXXIX. 11
Digitized by L^OOQle
164
[April,
On Psychoses after Influenza ,
by Ewald, 1 Joffroy, 2 GWynne, 1 Creagh, 4 Nicholson, 5 Van
Deventer,® Mairet, 7 and others. In the German Collective
Investigation Keport, edited by Leyden and Guttmann,® no
less than 276 such cases have been collated. It is, however,
not this initial delirium which we have met here to consider
to-day, but those better defined psychoses which are prone to
occur after the feverish attack is over, during, or some time
subsequently to convalescence .
The only remark relating to our subject which I have been
able to discover previous to 1890 is one made by Sir James
Crichton-Browne, 9 who states in a valuable paper on so-called
" acute dementia,” published in 1874, that he has seen a chlorotic
girl who had retained unimpaired intelligence until she was
attacked by influenza, when she rapidly lost the use of her
faculties, and became unable to think, speak, or move spon¬
taneously. These four lines, therefore, constitute all the
definite information which is extant on post-grippal psychoses
previous to 1890. Sir J. Crichton-Browne has kindly informed
me that the case just mentioned occurred after an attack of
genuine influenza, and not a mere feverish catarrh; and that it
was a case of certifiable insanity, and not mere initial delirium.
The case is, therefore, of historical interest, as being the first
undoubted instance of a real post-influenzal psychosis recorded
in medical literature.
It is, however, not simply because the subject is new that it
should claim our earnest consideration. To my thinking it
should do so even more on account of its own intrinsic interest
and importance, which become at once apparent, whether we
look at it from a purely scientific or a more practical point of
view. I believe it will be generally acknowledged that these
post-grippal psychoses possess considerable scientific interest,
inasmuch as they have been found to differ in many respects
from other post-febrile insanities, with the special features of
which we have long been more or less familiar; while on the
other hand the comparatively large number of cases which have
been met with, in general as well as in consulting and asylum
practice, greatly exceeding that of psychoses occurring after
other fevers, imparts to the subject naturally a higher degree
of practical importance than that of some analogous conditions
which are so rare that they may be considered as curiosities of
medical practice and literature. Such is, for instance, the case
with psychoses after measles, of which, as far as I am aware,
altogether only four cases have been reported.
Digitized by ^ooQle
165
1893.] by Julius Althaus, M.D.
The literature of psychoses following influenza has since the
recent epidemics become very large. Amongst the authors
who have written on this subject I would particularly mention
Savage, 10 Clouston, u Hack Tuke, 18 Flint, 13 Harrington, 14 Paine, 15
Richardson, 10 Kraepelin, 17 Jutrosinski, 18 Pick, 19 Ahrens, 80 Bar¬
tels, 81 Becker, 88 Mucha, 88 Solbrig, 84 Fehr, 85 Schmitz, 88 Weyner-
owski, 87 Mispelbaum, 88 v. Holst, 88 Krypiakiewicz, 80 Muller, 81
Munter, 88 Ladame, 88 Bidon, 84 Leledy, 85 Yoisin, 38 Mairet, 7 Mor-
selli, 87 Frigerio, 88 Christiani, 89 Lojacono, 40 Cantarano, 41 Hoge, 48
Ayer, 48 ana myself. 44
In approacning the study of psychoses after influenza it
occurred to me that it might be useful to consider these affec¬
tions in connection with other better-known post-febrile
insanities. Mental diseases coming on after rheumatic fever,
pneumonia, intermittens, the acute exanthemata, erysipelas,
cholera, and whooping cough have, indeed, attracted the
attention of numerous observers, more especially during the
last forty years, in this country, as well as in Germany and
France, and I need only remind you of the writings of Russell,
Greenfield, Handfield Jones, Wilson Fox, Murchison, Clouston,
Blandford, Savage, Tuke, Hermann Weber, Scholz, Jolly,
Kraepelin, Boileau, Berthier, Christian, and others who have
done so much for the elucidation of this subject. Indeed, the
psychoses following rheumatic and intermittent fever were
already known to Sydenham, Boerhave, Van Swieten, Mus-
grave, Hofmann, the elder Monro, and other physicians of the
last century. In order to illustrate certain points in the
natural history of all post-febrile psychoses, I have constructed
a table based chiefly on Kraepelin’s 45 collection of cases, on
which are shown :—
1st. The number of well-observed cases which have been
utilized;
2nd. The influence of sex, age, and general and special
predisposition;
3rd. The duration of these affections; and
4th. The eventual result, whether cured, uncured, or
fatal.
I shall have frequent occasion to refer to this table in the
course of my address, and now proceed to submit to you the
more important points connected with our subject, which are
still to some extent sub judice , and on which I would invite
discussion by the eminent experts here present.
Digitized by
Googl
Table showing the number of Cases, Influence of Sex, Age, and Predisposition, Duration and Result
in all Post-Febrile Psychoses.
[April
166
On Psychoses after Influenza,
Result.
Died.
^ i4 t* e
®S°g2S" o; -
Un-
oured.
0
0
0
0
0
0
30-6
0
5*8
Cured.
93*6
895
100
80
87
80
71 8
100
56*6
Duration.
Years.
«o © © © ©
38
0
0
Twelve
months.
00 CO
3 • 8 S °’
sag
One
month.
W) CO
g j °
M tO
So 3 s 8
One
week.
16
70-7
24
71'4
87
63
17
18*8
12*5
§
1
i
5
Alcohol.
?
16
?
?
?
?
?
?
10 8
General.
30
41*4
31
10-7
19
54
34*5
21
72*7
Of Age.
Above
30.
23
60
52
42*9
42
50
29*5
62*5
61
Up to
30.
77
40
48
57.1
58
50
70*5
37*5
39
Influence of
Sex.
Female.
39-7
18
24
39*3
40
27
435
31-8
43-6
Male.
603
82
76
60*7
60
73
56*5
68*4
56 4
Number of
cases
utilized.
96
43
39
41
16
11
87
19
113
Acute Infectious
Diseases.
Rheumatic Fever
Pneumonia .
Intermittent Fever ...
Variola.
Scarlatina .
Erysipelas .
Typhoid Fever.
Cholera.
Influenza .
Digitized by L^ooQle
167
1893.] by Julius Althajjs, M.D.
1. Are psychoses after influenza more frequent than those
which occur after other fevers ?
In one sense this question has already been answered in the
affirmative. There is no doubt that the cases which have been
recorded by various authors are absolutely much more numerous
than those which have been described as following any other
acute diseases. On ray table the number given is 113, the
next highest numbers being 96 for rheumatic fever, and 87
for typhoid fever. That number (113), however, does not
approximately represent the whole of the cases which have
been mentioned or cursorily described by authors, for I have
only selected those which have been related with full detail.
Thus the table does not include one of the 170 cases of post¬
grippal psychoses which have been at the disposal of the
compilers of the German Collective Investigation Report, 8 and
which, I regret to say, do not appear to me to have been as
much utilized as they might have been.
Individual observers have seen many more cases of post¬
grippal psychoses during the last year or two than of other
post-febrile insanities during a lifetime. Thus Savage 10 has
reported upwards of fifty cases, Leledy, 85 twenty-two, Jut-
rosinski, 18 twenty, Hack Tuke, 12 eighteen, van Deventer, 6
eleven (in addition to twenty cases of initial delirium), Mairet, 7
eleven (in addition to six cases of initial delirium), myself, 44
nine, six of which I have reported, and many others a some¬
what smaller number—all within a comparatively short period.
Clouston, 11 indeed, states broadly that? the poison of influenza
destroyed the cortical energy to a much larger extent than any
of the continued fevers or zymotics—nay, that its effects on the
mental condition of Europe during the years of its prevalence
far exceeded in destructive powers all those diseases put
together. It left the mental tone of Europe lower by some
degrees than it found it, and no epidemic of any disease on
record has had such mental after-pains. There is thus good
evidence to show that the absolute number of cases of these
psychoses greatly exceeds that of other post-febrile insanities.
But is this frequency also relatively greater—that is, when we
compare it with the extremely large number of cases of the
parent affection which have occurred ? It is this latter ques¬
tion which I would submit more particularly to your con¬
sideration. Influenza has recently assumed the character of
a pandemic rather than that of an epidemic, and an element of
doubt is thus introduced which it would be desirable to clear
up. Jastrowitz, who has drawn up the report on 170 cases in
Digitized by L^ooQle
168
On Psychoses after Influenza , [April,
the German Collective Investigation Report, 1 is of opinion that
psychoses are not only absolutely but also relatively more
frequent after influenza than after other fevers, and from the
data which are at my disposal I have arrived at the conclusion
that the only other acute disease which can at all compare
with influenza in this respect is typhoid fever.
2. What is the influence of sex and age in the causation of
these affections ?
Kirn 46 states that females are more liable to them than males,
and Jutrosinski 18 thinks that both sexes are about equally prone
to them. A glance at my table, however, shows the male sex
to be throughout more liable to post-febrile psychoses than the
female. This difference is most marked for pneumonia, viz.,
82 against 18; and least so for typhoid fever, viz., 56 against
44. For influenza the numbers are 56*4 and 43*6.
The influence of age on the production of post-febrile
psychoses does not seem to be so uniform as that of sex, for
although persons below thirty years of age appear to be on the
whole more liable to them than those upwards of thirty, there
are exceptions to this rule. For influenza the numbers are 39
for the younger and 61 for the older set of persons. I have
compared the prevalence of post-grippal psychoses in the several
decades of life, and find the three decades between 21 and
50 years af age to be more prone to them than the five decades
at the two extremities of life (63 to 37). We find here a close
analogy to what happens in cerebral syphilis leading to mental
affections, which are also much more frequent between 20 and
50 years of age than at any other time of life; while, on the
other hand, after rheumatic fever, small-pox, scarlatina, and
typhoid fever patients are more liable to suffer before than
after thirty years of age.
3. What is the influence of predisposition ?
Hereditary or acquired predisposition is, from the table, seen
to play a considerable part in the production of all post-febrile
psychoses, and in none more so than in the post-influenza!
(72*7). Predisposition includes heredity, a history of previous
psychoses or neuroses in the patient himself, previous brain-
injury, alcoholism, anaemia, the presence of some degeneration
such as syphilis, or senile decay, the menopause in women, and
grief or shock after the feverish attack. The influence of a
neurotic tendency, however, has often been exaggerated, from
sheer force of habit rather than from accurate observation. Thus
Mairet* mentions the case of a woman who had no hereditary
or personal antecedents whatever, yet includes it in a series of
Digitized by t^ooQle
1893.]
by Julius Althaus, M.D.
169
others as strongly predisposed to brain disease. In nine cases
of post-influenzal psychoses which I have seen (six of which I
have reported), 44 predisposition existed only in two; of eighteen
cases reported by Hack Tuke, 12 ten were predisposed and eight
not so; of three cases described by Mucha 28 only one was pre¬
disposed ; and Kraepelin, 17 Ladame, 83 and Jutrosinski 18 evi¬
dently go too far in looking upon predisposition as the exclu¬
sive setiological factor in these conditions. On the other hand,
the gravity and duration of these insanities are unquestionably
increased by predisposition. The influence of alcoholism is
seen to have been active in 10’8 per cent.
4. What is the relative influence of the fever and the grippo -
toxine in the production of these psychoses ?
Fever and a special virus may be looked upon as the chief
causative agents of all post-febrile insanities, but their influence
differs remarkably in the different forms of these diseases.
The fever (that is, increased temperature and cardiac action) is
of the first importance in the delirium of inanition or collapse,
which follows upon the crisis in pneumonia and the acute
exanthemeta, when in consequence of a sudden fall of tempera¬
ture and simultaneous slowing of the heart’s action, too little
nutritive material is carried to the cortex, causing sudden ex¬
haustion of the highest controlling centres, and setting free the
uncontrolled energy of the lower centres, which is manifested
by maniacal excitement. In the production of post-typhoid
psychoses, on the other hand, the toxine of the malady seems
to be more important than the fever, and the same I believe to
be the case in influenza. In the latter complaint the fever is
habitually too short and too slight to have much influence upon
the nutrition of the cineritious matter; and the prostration of
mental and physical strength is habitually so profound as to be
utterly inexplicable except by assuming poisoning of the nerve-
cells by the grippo-toxine. Indeed we shall see presently that
in the majority of cases of post-influenzal psychoses the feverish
attack has been peculiarly mild. This holds good chiefly for
the melancholia and the general paralysis which occur after
influenza ; while for the delirium of inanition, which also occurs,
the fever must chiefly be held responsible.
Seeing how greatly cases differ in their clinical features, I
am inclined to think that there must be great differences in
the composition of the virus in different cases. Pfeiffer 47 has,
in his latest description of the influenza bacillus, laid stress
upon the circumstance that its size is found to vary consider¬
ably, some rodlets being very much larger than others; and it
Digitized by ^ooQie
170
[April,
On Psychoses after Influenza ,
is conceivable that in cases where the larger-sized bacillus pre¬
dominates, or shows particular vitality, the toxine secreted by it
may have a more deleterious influence on the nerve-cells of the
cortex than the smaller kind of bacteria. In the same way
Koch was enabled, in the beginning of the recent epidemic of
cholera at Hamburg, to predict, from the size and vitality of
the comma bacillus, or “ vibrio/” as some people now call it, that
the outbreak would be a particularly severe one. Another im¬
portant point is that psychoses are chiefly apt to occur after
slight cases of grip which have been neglected, showing an
analogy with some forms of syphilis, in which grave tertiary
lesions tend to appear where the primary and secondary
symptoms have been so slight as to attract little attention, and
have therefore been insufficiently treated.
5. What is the duration of post-influenzal psychoses ?
While insanities after the acute exanthemata, erysipelas, and
pneumonia tend to get well in a week, those occurring subse¬
quently to rheumatic, typhoid, and intermittent fever, and
influenza, have generally a longer duration. Only 12*5 per
cent, of post-grippal psychoses got well in a week, against 87
per cent, for scarlatina; 32*5 more had recovered within a
month, and 55 lasted beyond a month. The latter were chiefly
cases of the severer forms of melancholia in aged persons, and
of general paralysis, while those which lasted a comparatively
short time, were either cases of the delirium of inanition or of
the slighter forms of melancholia in young persons.
6. What is the proportion of cured, uncured 9 and fatal
COS68 ?
Insanities after intermittent fever and cholera show a hundred
per cent, of recoveries, while after small-pox and erysipelas we
have 20 per cent, of deaths, after scarlatina 13, after pneumonia
10*5, after typhoid 7*7, and after influenza 7*6. The per¬
centage of uncured cases after the latter is 35*8, and cured 56*6,
so that the prognosis of post-influenzal psychoses appears to be
tolerably favourable.
7. Is there any relationship "between the severity of the feverish
attack and the subsequent occurrence of psychoses ?
I have divided the available cases into three classes, viz.,
slight, medium, and severe, and have found that 55*2 of these
psychoses have come on after comparatively mild attacks of
grip, 27*6 after severe attacks, and 17*2 after such of medium
intensity.
8. What length of time may elapse between the feverish attack
and the outbreak of the insanity ?
Digitized by ^ooQie
by Julius Althaus, M.D.
171
1893.]
This is a very important point, involving the question of
post hoc erga propter hoc . Are we justified in attributing a
psychosis to influenza when it occurs, say, three or four months
after the feverish attack ? In former years insanity has been
referred to typhoid fever when there had been an interval of
five or even ten years between the two events. The effects of
injury to certain parts of the body, more especially as pro¬
moting the subsequent growth of tumours in the injured parts,
seem to corroborate this view. I think, however, that we shall
be more.safe in looking upon a psychosis as really consequent
upon some preceding infectious disease when it occurs:—
(1st) During convalescence from the latter; and
(2nd) Within six months after the attack, provided that no
other causes have been at work during the interval; and also
provided that the patient has, since convalescence, shown some
symptoms of disturbed balance of brain-power, even where this
did not amount to an actual psychosis.
A study of those cases in which the interval between the
feverish attack and the outbreak of the psychosis has been
accurately stated, has led me to the conclusion:—
(1st) That those psychoses which are characterized by
delirious exaltation and mania are prone to follow very close
upon the feverish attack, and begin, indeed, sometimes imme¬
diately after the crisis;
(2nd) That insanities distinguished by depression and melan¬
cholia are apt to appear somewhat later, viz., between a few
days and a few weeks after the attack; and
(3rd) That general paralysis of the insane may be the latest
of all, the interval between the attack and the first unmistak¬
able appearances of the psychosis having amounted to as much
as six months in a case recorded by Krypiakiewicz. 80
9. Is there any special form of insanity induced by influenza
which does not occur after other fevers ?
Kira 46 speaks of a typical grippal psychosis characterized by
acute mania and confusion, while Mairet 7 considers true “ folie
grippale ” to consist of melancholic delirium. Most observers,
however, have come to the conclusion that there is ho special
form of insanity which could be considered as connected with
influenza per se .
In the paper read before the Section I have fully described
the clinical features of the various forms of psychoses which
are apt to follow the feverish attack; but want of space pre¬
vents me from reproducing that description here. I will, there¬
fore, only state that there are three principal forms of post-in-
Digitized by ^ooQie
172
On "Psychoses after Influenza,
[April,
flaenzalinsanities,viz.: 1st. Acute hypochondriacal melancholia,
with lethargy and loss of volitional power (41*2 per cent.);
2nd. Weber’s 49 delirium of collapse, or inanition, and confusion,
with hallucinations, followed by stupor (27*2 per cent.) ; and,
3rd. General paralysis of the insane of an extremely rapid
(galloping) course (6*2). To these forms may be added—4th.
The pseudo-influenzal psychoses, that is, various forms of
mental disturbance, such as intermittent or circular insanity,
delirium tremens, mania, etc., in persons with a long history of
hereditary or acquired tendencies, in whom the feverish attack
is only the accidental exciting cause of a disturbance which
would also have occurred from any other cause, or perhaps no
cause at all (25*4 per cent.). While, therefore, no actual
specificity is shown to exist in post-grippal psychoses, they
differ from other post-febrile insanities by presenting a greater
variety in their clinical features; inasmuch as the first group
mentioned is similar to the mental affections occurring after
typhoid and rheumatic fever and whooping cough, while the
second group resembles the psychoses chiefly seen after the
acute exanthemata, pneumonia’ and the puerperal state. After
influenza, however, we see cases belonging to both groups in¬
discriminately, and, in addition to them, cases of general
paralysis, which is hardly ever seen after other fevers. Indeed,
Mickle 49 states that only in 12 out of 3,374 male general
paralytics, and in one female out of 910, fevers were assigned
as the cause, and that even these might perhaps be all explained
away.
10. How does influenza affect those previously insane ?
In some asylums the patients appear to have been much less
affected by influenza than the attendants and other sane persons
living in the institution, while in others no such difference has
been observed. Leledy 85 states that in the asylum of Beaure¬
gard, near Bruges, which contains 400 inmates, only 15
patients had influenza, while the attendants and other employes
suffered almost to a man. Of these 15 persons, only three were
men, and twelve women. On the other hand, Mucha 50 found
that in the asylum of Gottingen 15*3 per cent, of the male and
33*3 of the female patients had influenza. The attendants
there suffered in much the same ratio, viz., 13*3 per cent, of
males and 32 per cent, of females. Some light may perhaps be
thrown on this singular circumstance by what happened in the
hospital for the insane at Gladesville, New South Wales, where
Sinclair, quoted by Ashburton Thompson, 51 found that the
attendants suffered more in three different buildings than the
Digitized by ^ooQle
1893.]
by Julius Althaus, M.D.
173
patients, but that in the main building, where the percentage
of male patients attacked was only 0*5, the female patients
suffered to the extent of 41*5 per cent. This apparently un¬
accountable occurrence was eventually explained by the female
patients having been employed in a laundry, to which infected
clothing had been sent from another building. As soon as the
female patients began to wash this clothing their side of the
house began to suffer. The male side of the house being com¬
pletely separated from the female side, and males not having
been employed in laundry-work, they no doubt for this reason
escaped infection. What happened in Charenton 85 is again
different. There almost all attendants suffered, but not one of
them seriously, while amongst the patients only the aged and
those suffering from general paralysis, apoplectic and senile
dementia, succumbed to the epidemic. Insanity, therefore,
did not appear to be a protection against grip; but where the
insane were spared, this seemed to be owing to their being
isolated, and therefore less exposed to infection than others
who moved freely about.
The effect of the feverish attack on the insane appears like¬
wise to have varied very much in different asylums. The
mental condition has either been left unchanged, or improved,
or become aggravated. Mucha 60 tells us that in the asylum of
Gottingen the influence of influenza on the mental affection was
practically nil . On the other hand Leledy 86 states that the
fifteen patients at Beauregard, who had influenza, appeared to
be particularly lucid during the attack. Some who had been
violently delirious became quiet; there was no difficulty in
keeping them in bed, and they were altogether more manageable
than previously.
In some recent cases decided benefit appears to have occurred.
Metz 6 * mentions the case of a man, aged 33, who had been
eleven months in the asylum for maniacal excitement with
delusions, when he was seized with grip. The feverish attack
lasted two days, and almost immediately after the crisis the
patient became rational, and could be discharged a few weeks
subsequently. Journiac 86 speaks of a similar case which occurred
in a sister of charity, aged 48; but nothing is said about
the further progress of these cases. Leledy 86 reports the case
of a lad, aged 15, who was much improved by an attack of
influenza, but had to be readmitted three months after his
discharge, when he was as bad as ever. Van Deventer 11 has
described the case of a hysterical girl, aged 9, who had been
subject to attacks of confusion with occasional lapses of
Digitized by ^ooQie
174 On Psychoses after Influenza , [April,
consciousness, and appeared to recover after an attack of
influenza.
It seems possible that a condition of anmraia, with contraction
of the arterioles of the brain, may be improved by the sudden
congestion of the cerebral blood vessels which occurs during
the feverish attack; on the other hand it is even more easy
to conceive that a congestive or sub-inflammatory state of the
brain and its membranes may be aggravated by such an incident.
Cases of this latter kind appear, indeed, to have been much
more numerous than those in which improvement was noticed.
Instances in which the result was quickly fatal have been
reported by Van Deventer, 6 Bartels, 21 and Leledy. 65
11. What treatment should be resorted to in the different
forms of post-influenzal psychoses ?
Change of air and scene, and avoidance of excitement and
worry, are useful in the whole class of these affections. Insom¬
nia, which is generally present, should be combated by pro¬
longed warm baths, and such medicines as paraldehyde,
sulphonal, trional, and amylen-hydrate. For the anorexia
which is so common, bitter tonics and dainty dishes should be
prescribed, while for general debility a combination of strych¬
nine and arsenic is invaluable. In the depressive form of
insanity, alcohol, in the form of champagne or whisky and
Apollinaris water, is generally necessary; and the constant
current of electricity, applied to the prsefrontal lobes and the
bulb, tends to clear up melancholia.
In the delirium of inanition and confusional and delusional
insanity, hypodermic injections of morphine and atropine, fol¬
lowed by the free exhibition of alcoholic stimulants, are useful.
When collapse threatens, hypodermic injections of ether and
camphorated oil (1 grain in ten minims) should be employed.
Bromide of ammonium combined with strychnine is indicated
after the acute stage of this affection has passed off.
For general paralysis of the insane after influenza I can
recommend mercury, together with large doses of iodide of
potassium, while alcoholic stimulants must be strictly prohibited.
Avoidance of excitement and of physical and mental efforts is
in these conditions more especially important.
Where insanity after influenza appears to be grafted upon
pre-existing neuroses or psychoses, each case has to be treated
on its own merits. It is chiefly in this class of cases that
determined attempts at suicide are made, and the patients
should therefore be watched with special care.
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by Julius Althaus, M.D.
175
LITERATURE.
1. Ewald.—tJber Influenza. Deutsche Med. Wochenschrift, Jan. 23,1890.
2. Jcffroy.—D^lire avec agitation maniaque dans l’influenza, Meroredi
medical. No. 13, 1890.
3. Gwynne.—Notes of two hundred cases of influenza in Sheffield. The
Lancet, August 21,1891.
4. Creagh.—Suicidal tendency during an attack of influenza. The Lancet,
July 11, 1891.
5. Nicholson.—The complications and sequelae of influenza. Brit. Med.
Journal, June 13,1891.
6. Yan Deventer.—Uber Infl. verbunden mit Geisteskrankheiten. Central-
blatt fur Nervenheilkunde, May, 1890.
7. Mairet.—Grippe et alienation mentale. Montpelier Medical, Mai et
Juin, 1891.
8. Leyden and Guttmann.—Die Influenza, Epidemic 1889-90. In Auftrage
des Yereins fur innere Medicin in Berlin herausgegeben. Wiesbaden, 1892.
9. Sir James Crichton-Browne.—On Acute Dementia. West Biding Hospital
Reports, London, 1874.
10. Savage.—Influenza and Neurosis. The Lancet and Brit. Med. Jour, for
Nov. 7,1891, Journal of Mental Science, July, 1892.
11. Glouston.—Clinical Lectures on Menial Diseases, 3rd Edition, London,
1892.
12. Hack Tuke.—Mental Disorder following Influenza. In Dictionary of
Psychological Medicine, London, 1892, Yol. i., p. 688.
13. Flint.—Insanity attributed to la grippe. North Western Lancet, St.
Paul, 1890, p. 367.
14. Harrington.—Epidemic Influenza and Insanity. Boston Medical and
Surgical Journal, 1890, Yol. ii., No. 6.
15. Paine.—Epidemic Influenza and Insanity. Medical Standard, Chicago,
1890, p. 168.
16. Bichardson.—The Causation of Mental Disease in Relation to La Grippe.
Cincinnati Lancet, 1891, p. 600.
17. Kraepelin.—Ueber Psychosen nach Influenza. Deutsche Medic. Wochen¬
schrift, 1890, No. 11.
18. Jutrosinski.—Ueber Influenza Psychosen, Tubingen, Moser, 1890, also
in Deutsche Medicin. Wochenschrift, 1891, No. 3.
19. Pick.—Geisteskrankheit. nach Infl. Neurolog. Centralblatt, 1890.
20. Ahrens.—Beitrage zur Kasuistik von Psychosen nach Infl.; Tubingen,
1890.
21. Bartels.—Einfluss der Infl. auf Geisteskrankheiten. Neurolog. Central¬
blatt, 1890, No. 6.
22. Becker.—Geisteskrankheit. nach Infl. Neurol. Centrbl., 1890, No. 6.
23. Mucha.—Uber Psychosen nach Influenza, Inaugural Dissertation.
Gottingen, 1891.
24. Solbrig.—Neurosen und Psychosen nach Infl. Neurol. Centr., 1890, No. 11.
25. Fehr.—Infl. eine Ursache der Geisteskrankheiten, Hospital Tidende.
Copenhagen, 1890, p. 345.
26. Schmitz.—Infl. und Geisteskrankheiten, Allg. Zeitschrift fur Psychiatrie.
Berlin, 1890, p. 238.
27. Weynerowski.—Beitrage zur Casuistikvon Psychosen nach Infl.; Tubin¬
gen, 1890.
28. Mispelbaum.—Uber Psychosen nach Infl.; Allg. Zeit. fur Psychiatrie.
Berlin, 1890, p. 127.
29. Von Holst.—Psychosen nach Infl. Berliner Klin. Woch., 1890, No. 27.
30. Krypiakiewicz.—Uber Psychosen nach Infl. Jahrbuecher fur Psychiatrie.
Leipzig, 1891, Yol. x., 1.
Digitized by ^ooQle
176 On Psychoses after Influenza . [April,
31. Mailer.—Tiber Cerebrate 8tornngen nach Infl. Berl. Klin. Woch., 1890,
No. 37.
32. Munter.—Psychosen nach Infl. Allg. Zeit. f. Psych., 1890, Vol. xlvii., p.
156.
33. Ladame.—Des Psychoses aprfcs l’lnfl., Annates M6dico-Psychologiques.
Paris, 1890, p. 20.
34. Bidon.—Etude Clinique de Taction exerc£e par la grippe de 1889-90, sur
le systeme nerveux. Revue de M6decine. Paris, August and October, 1890.
35. Leledy.—La grippe et Paltenation mentale. Paris, 1891.
36. Voisin.—Iddes de persecution k la suite de la grippe. Gazette des
hdpitaux. Paris, 1890, p. 1012.
37. Morselli.—-Sui alcuni effetti neuro e psicopatici dele’ infl. Riforma
medica, 1890, p. 542.
38. Trigerio.—Alienazione mentale consecutiva alTinfl. Istituto Lombardo,
1890, Faso. 9.
39. Christiani.—Psicosi consecutive alTinfl. Riforma Med., 1890, p 962.
40. Lojacono.—L’infl. c la malattie nervose e mentale. Rif. Med., 1890, p. 932.
41. Cantarano.—Sui rapport! tra Tinfl. e le malattie nervose e mentale.
Psichiatria. Naples, 1890, p. 158.
42. Hoge.—Insanity following la grippe. Virginia Med. Month. Rich¬
mond, 1890, p. 369.
43. Ayer.—-Mental Disturbances of Infl. Boston Med. and Surg. Journal,
1891, Vol. ii., 12.
44. Althaus.—On Mental Affections after Infl. International Journal of the
Medical Sciences. Philadelphia and London, April, 1892.—Influenza, its
pathology, symptoms, complications and sequels, etc., 2nd Edition, London,
1892, pp. 84 to 126.
45. Kraepelin.—Uber den Einfluss akuter Krankheiten auf die Entstehung
yon Geisteskrankheiten. Archiv fur Psychiatrie, Vol. xi., pp. 137, 295 and
649; and Vol. xii., p. 287. Berlin, 1881-82.
46. Kirn.—Die nervosen und Psychischen Storungen der Infl. Leipzig, 1891.—
Munch. Med. Woch., 1890,17.—Allg Zeitschriftfur Psychiatrie, VoL xlviii., 1,
189L
47. Pfeiffer.—Weitere Mittheilungen ueber den Erreger der Influenza,
Deutsche Med. Wochenschrift, May 26,1892.
48. Hermann Weber.—On Delirium or Acute Insanity during the Decline
of Acute Diseases, especially the Delirium of Collapse. Med.-Chir. Trans¬
actions, London, 1865, Vol. xlviii., p. 135.
49. Mickle.—On General Paralysis of the Insane. 2nd Edition. London,.
1886.
50. Mucha.—Influenza—Epidemic in der Provinzial-Irrenanstalt zu
Gattingen (Prof. Dr. L. Meyer). Berliner Klin. Wochenschrift, June 27,
1892.
51. Ashburton Thompson.—Report on the Epidemic of Influenza in New
South Wales during 1891. Sydney, 1892.
52. Metz.—Heilung einer Paranoia nach Infl.; Neurol. Centralblatt, 1890,
No. 7.
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1893.]
177
Some Further Remarks on Expression in the Insane . By Dr.
John Turner, County Asylum, Brentwood, Essex,
( Illustrated ).
The following notes on expression are supplementary to a
paper on the same subject published in this Journal twelve
months ago.
Since that time I have collected a considerably larger number
of cases bearing on the subject, and the conclusions arrived at
from this larger number are quite in accord with those drawn
from the smaller number. There are, however, some points
which were only touched on in the last paper which will be
more fully discussed here.
Considering that the different phases of expression dealt with
are only capable of explanation by the theory of dissolution of
the nervous system—that apart from it they are unintelligible
and meaningless—I take it that the evidence their study
affords gives additional support to this doctrine, which has been
of great importance in the elucidation of nervous diseases, and
will in the future, if corroborated, be of still greater importance,
allowing us, as it alone does, to resume under one cause a vast
number of isolated and otherwise inexplicable facts,
A large number of our emotional reactions are looked upon
by some writers as of accidental origin, and although this may
be true in some cases, yet I do not believe to such an extent
as would include the “ entire aesthetic life of man ” (W. James*
“Text Book of Psychology,” p, 390). At any rate, when we
meet with tricks of expression habitual to many different
individuals, and, as seen in the adult stage, only occurring in
cases of mental disorder, it is more satisfactory to seek some
explanation of such expression than to regard them a's purely
accidental and of no great significance.
The doctrine of evolution, with its corollary of dissolutions
of the nervous system, enables us to give a perfectly intelligible
and rational description of insane expression, and to account
for all its numerous peculiarities and divergences from expres¬
sion in the sane.
Having in a previous communication attempted an explana¬
tion of the mechanism of asymmetrical muscular action in
expression, it will be unnecessary here to again refer to this
part of the subject, especially as such an attempt was merely
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178 Remarks on Expression in the Insane, [April,
provisional, and will probably require much modification and
alteration as our knowledge of the subject increases.
It is scarcely necessary to state that the whole group of
phenomena dealt with in these papers—both the symmetrical
and asymmetrical forms of expression—are referred to as
instances of dissolutions of the nervous system; the only
essential difference between them being that while in the former
case the disablement of the higher centres concerned is sup¬
posed to have been equally distributed over both sides of the
cerebrum, in the latter, one side of the cerebrum has suffered
more than the other in either its entirety or in some particular
part of it.
The first part of the following remarks will deal with some
further points in connection with asymmetrical, and the second
with some striking forms of symmetrical expression only met
with among adults in the insane:—
I.—The expression which I shall first deal with is difficult to
define—it most nearly approximates to sneering or snarling—
but beyond the elevation of one side of the upper lip there is in
most cases a distinct protrusion of the same not seen in the
sneer or snarl, and which recalls the pouting lips of angry
monkeys.
Darwin looks upon sneering as one of the most curious
expressions which occur in man; he considers that it reveals
his animal descent, and he looks upon it as the survival of the
habit common in animals of uncovering the canine teeth before
fighting (“ Expression of the Emotions,” p. 264).
As met with among the insane, it often seems to have little
or no evident relation to the mental states with which it occurs
in the sane.
I have in the last year or two come across twenty-two
instances of this asymmetrical elevation and protrusion of the
upper lip—on the right side in ten cases, and on the left in
twelve. All my most marked cases occur amongst idiots,
imbeciles, or general paralytics.
The portraits (3 and 4) are both of patients presenting this
feature. The one in whom it is the more marked is an idiot,
set. 36, and she is one of the cases where there seems to be no
extreme emotional state associated with it, although I am in¬
clined to think from the facts that I have never seen this action
without a corresponding contraction of the corrugator supercilii,
and also that on the days when she is very good-humoured it is
quite absent, and that her mouth when she is smiling is strongly
drawn to the left; that it is when she is displeased, or in an
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179
1893.] by Dr. John Turner.
ill-temper, that it is assumed. So habitual is this action with
her that it has mapped out a permanent furrow on her cheek
following the curve formed by the contracting muscle, and seen
when her features are at rest. This condition in her case is
only seen on the right side.
No. 4 is the portrait of a woman in a state of chronic in¬
sanity. Her tongue is seldom at rest, her talk is most inco¬
herent, the ideas following one another according to similarity
of sound in the words employed. She is an emotional old
lady, and very easily loses her temper, when she gesticulates,
almost invariably placing the left forefinger behind her left ear,
becomes abusive, and very distinctly elevates and protrudes the
right half of her upper lip, giving her face, which usually has
a pleasant aspect, a very repellent look. She is fond of reading
the Bible out loud, interpolating frequent remarks of her own,
and it was whilst so doing that the photograph was taken.
The condition, though well marked in her when very earnestly
engaged in expressing her views, is not nearly so well seen as
when out of temper. This old lady presents cerebral ptosis of
left eye, which of late years has become more marked.
I have already referred in my former paper to a female
general paralytic who presented this condition on the left side of
her face, and whose expression in consequence was one of
habitual snarling. I pointed out that in her case during her
seizures there was a marked exaggeration of the asymmetry,
and that the muscles affected were at these times the seat of
clonic spasm. This woman also presented other animal-like
propensities.
Before leaving this part of the subject let me just refer to
the expression of anger or rage; for obvious reasons it is seldom
that this expression can be photographed, and on this account,
perhaps, the portrait of the woman No. 2 will have special
interest. This woman was in a state of acute mania, extremely
excited, talking indignantly and rapidly, gesticulating, and
spitting in the faces of those about her. She was in the act of
turning round to abuse me when the portrait was taken. She
exhibits but in a symmetrical form the protrusion of the lips
before referred to, and which reminds one of the features of the
sulky monkey figured by Darwin. There is at the same time
seen the widely-opened glistening eyeballs, dilated nostrils, etc.
This woman, when not angry, had by no means a forbidding
cast of countenance, nor were her lips then protuberant.
The above-mentioned are a few examples of a condition
which, if it has any significance at all, seems to me only
xxxix. 12
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180
Remarks on Expression in the Insane , [April,
capable of being explained on the assumption that we have
here a return to a more or less primitive state, in which such
an action was habitual and useful. Its occurrence and com¬
parative frequency amongst the insane cannot fail to be of
interest in the study of the dissolutions of the nervous
system.
II.—The portrait No. 1 depicts a very marked condition of
asymmetry in the brow of a melancholic woman, set. 65. She
was a chronic case, with every few months periods of excite¬
ment, during which she would sit and wring her hands, groan,
and work her lower jaw from side to side in a most extra¬
ordinary manner, protruding it and touching her nose with her
lower lip. Her expression was one of misery, but quite sym¬
metrical. She began to refuse food towards the end of 1891,
and it became necessary to feed her through the nasal tube,
which proceeding she strongly objected to, struggled violently
whilst it was being carried out, begged and implored us
not to do it, as she was already “ full up and had no passage
for her food.”
Whilst being fed her forehead assumed the strongly-marked
asymmetrical condition seen in the photograph. There was
apparently almost entire paralysis of the right half of the
occipito frontalis; for whilst a well-marked series of transverse
furrows were seen on the left half of the brow sufficient to
partly mask the fan-like radiating furrows caused by the strong
action of the corrugator supercilii, these were quite absent on
the right, and on this side the corrugator supercilii is un¬
antagonized, so that the brow is pulled downwards and inwards
on the right side. On subsequent occasions, whenever she had
any reluctance to take food, it was only necessary to threaten
her with artificial feeding to call forth the above-mentioned
asymmetrical condition.
Besides this case I have met with three other almost equally
well-marked instances of a similar nature. It is by no means
peculiar to melancholic states, and strong depressing emotions
do not seem in every case to accompany it. The following are
a few particulars of these three cases:—
No. 1.—A. E., an imbecile, aet. 49; only capable of being
occasionally employed on simple jobs ; dirty in habits; gener¬
ally sits whispering and giggling to herself, and grimacing;
has outbursts of laughter for which there is no obvious cause;
sensibility of skin deadened, when pricked so as to draw blood
on hands or face, will either pay no heed or else grin, or occa¬
sionally assume the asymmetrical condition. With her there is
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1893.]
by Dr. John Turner.
181
very marked discordant action of the muscles of expression
frequently seen. I have a photograph displaying the lower
part of the face in a broad grin, whilst the forehead displays the
asymmetrical condition in full force. She is very imitative in
the matter of expression, and by frowning at her she generally
responds, but in an asymmetrical manner, and by these means
she was easily photographed; also, when smiled at, she grinned
in response or burst out laughing.
No. 2.—An old lady, a case of senile mania, with much
mental enfeeblement. The condition with her is not associated
with any marked emotional states.
No. 3.—A single woman, set. 69. Chronic insanity, prob¬
ably the result of intemperance. She has delusions of
grandeur; calls herself “ Queen Emma,” etc. Writes volumi¬
nously to various public officials setting forth her grievances.
Is a very excitable old lady, and it is when annoyed that her
forehead displays the asymmetry.
In all four of these cases the same side of the forehead is
affected.
In the female insane asymmetry of facial muscles (including
inequality of the pupils and lateral deviation of the tongue
when protruded) is met with in half the cases admitted. An
analysis of 549 persons shows that 278, or 50 per cent., present
some asymmetry distributed about the face as follows:—
No. of Oases.
Per cent.
Upper zone (oo. frontalis and cor. sup. m.).
123
22*4
Lower zone (mouth and nostril muscles) . :
36
6*5
♦Pupils unequal .
127
230
Tongue laterally deviated .
150
27*6
The lateral deviation of the tongue, I imagine, represents a
greater depth of dissolution of the nervous centres than the
paralysis of the muscles of expression, and this supposition is
borne out by the facts when we come to examine the gravity of
the cases in question judged by their liability to recovery.
Thus the largest percentages of recoveries is among the cases
which have asymmetry of the facial expression in the upper
zone, the lowest among those who present lateral deviation of
the tongue on protrusion.
* A Russian observer, Zwiaguinntaeff (“ Med. Basse,” Oct., 1887), finds
inequality of pupils in 10 per Qent t of healthy persons.
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182 Remarks on Expression in the Insane, [April,
The following table gives the percentages of recoveries,
deaths, and of those remaining amongst the patients present¬
ing asymmetry:—
The lesser percentage of deaths among the second and third
classes would at first glance seem to contradict the supposition,
but as a matter of fact it does not; the higher mortality is
largely due to intercurrent affections, not of nervous system.
The graver forms of mental disease which do not recover, but
end in dementia, form the bulk of all asylum populations, and
have a low rate of mortality.
These figures, which, with a very small exception, refer to
cases of acquired insanity, are quite in accord with the require¬
ments of the theory of dissolution of the nervous system.
Thus we find in recent cases that not only is the asymmetry
more fleeting and less marked, but that it is first seen in
muscles represented (for their emotional movements) in the
highest and least stable of the nervous centres, viz., the
muscles of the upper zone of the face. In more chronic and
graver cases, that the asymmetry is more fixed—that as the
disorder increases we get in succession the muscles of the lower
zone of the face affected, and then those of the tongue, the
implication of these latter representing the greatest depth of
dissolution (of the three levels considered), and consequently
met with among a less favourable class of cases. Eventually in
cases of long-continued insanity and secondary dementia, as I
pointed out in my last paper, even the trunk muscles are
affected, so that the body leans over to one or the other side
when the patient is in the erect posture.
So much for asymmetrical forms of expression. We have
now to consider some expressions common in the adult insane
which are normally peculiar to childhood. These are— (a)
Pouting; (b) Weeping as displayed by children. The former
is much the less commonly noted; indeed, I have only collected
five or six instances amongst a community of over 700 people.
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1893.]
183
by Dr. John Turner.
but we must recollect that it is rare in children, and probably
never seen in sane adults.
Darwin remarks on the subject of pouting that “ It prevails
throughout the world.”—“ It is not common with European
children, but commonly and strongly marked with most savage
races.”—“ It is noticed in adult Kaffirs of both sexes, very
frequently with the women of New Zealand.” He thinks it
results from the retention, chiefly during “ youth, of a
primordial habit, or from an occasional reversion to it ” (“ Ex¬
pression of the Emotion,” p. 242, ff). Under these circum¬
stances the fact that we get such an expression spontaneously
called up occasionally amongst the insane is significant, showing
apparently that actions habitual or useful to us in the past are
not readily forgotten. In the course of time and under vary¬
ing conditions there is a heaping up of fresh centres on those
already existing, whereby the lower ones have their workings
hampered or stopped, yet the tendencies of these lower centres
to react in certain specific directions still remain. Very prob¬
ably properties inherited are never entirely eradicated, however
long they may remain dormant, and if so each individual will
contain the latent instincts of the whole series of his pro¬
genitors, only the more remote his station from these progeni¬
tors, so much the more will he have developed other centres
and other properties, whereby his earlier and lower centres will
be smothered beneath the accumulation of later mechanisms.
Thus it is that under the influence of dissolution he first reverts
to infantile and then to savage and animal customs. That such
is the state of affairs is exemplified by a study of the insane,
both as regards their expressions and general behaviour. And
so also we find that the more rapid and superficial the culture
of a race, the more readily they revert to primitive ways, a
well-recognized fact which has become proverbial.
Among idiots and imbeciles, if I may judge from the few in
this asylum, I should say that pouting was an expressioil very
commonly met with in adult age. I have a photograph show¬
ing it distinctly in an idiot girl 13 years of age, and have
noticed it in other and older cases.
In acquired insanity I have seen it well marked in a woman
42 years of age, a well-educated, emotional lady of an irritable
disposition, who when displeased sulks like a child; gets by
herself in a corner, pouts, and puts her finger to her lips.
Also in a lazy, weak-minded woman 28 years of age.
In regard to the expression of childish grief and weeping it
is to be noted that—(1.) It is largely displayed by the action
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184 Remarks on Expression in the Insane , [April,
of the muscles of the lower zone of the face, (2.) That with it
there is a remarkable squaring of the mouth, often with
extreme eversion of the lower lip, (3.) There is also great
flushing of the face and tears. Now it is rare, if ever, that
this expression occurs amongst adult sane people except in a
modified form accompanying extremely painful bodily states,
but among the insane it is one of the commonest of all
strongly-marked forms of expression.
The portraits 5 and 6 show it in an imbecile, at. 35, and
a general paralytic. The latter (No. 6) exhibits very marked
eversion of the lower lip, her eyelids are tightly closed, tears
well out from between them and course down her cheeks, her
face flushes deeply, and she howls. The most trivial circum¬
stance is sufficient to call up this extreme distortion of the
features. The expression is, however, very transient; it is all
over in a few seconds, and her features resume their usual
calm, fatuous, and demented aspect.
In the case of the imbecile there is not any eversion of the
lower lip, but the mouth is remarkably squared and wide open,
two features very characteristic of children when they are
crying. With this woman, as with the former, the slightest
interference with her will cause her to assume this expression.
In both, especially in the latter case, it cannot fail to be
noticed that the lower zone of the face takes by far the larger
share in the formation of the expression. The forehead in
both women is quite smooth, with the exception of slight
furrowing caused by some contraction of the corrugator
supercilii.
The imbecile here referred to possesses the most striking
animal-like traits of any human being that I have ever seen.
Her behaviour is monkey-like; she will gaze in a fixed
manner, and suddenly blow out a lot of saliva in the faces of
those looking at her, quickly dart out her hand, claw-like,
viciously scratch and scream with rage.
It is a noteworthy fact that these grotesque forms of expres¬
sion are most common in idiots and general paralytics. In the
latter, a quickly progressive degenerative disease, it is most
interesting to watch the gradual obliteration of the finer and
more delicate shades of expression.
One other result in regard to physiognomy, of congenital
absence, impairment or destruction of the higher levels of the
nervous system is that we frequently get inharmonious action
of the muscles of the two sides of the face, very probably as
the result of deficiency in commissional fibres, etc. The muscles
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1893.]
185
by Dr. John Turner.
of each side of the face act independently, so that whichever
side the individual’s attention is attracted from, it is the muscles
of that side which respond only.
There is at present in this asylum an idiot woman who
exhibits this condition in a very extreme form. One notices
in her with different emotional states one-sided contraction of
muscles of upper or lower zone; the right or left half of the
forehead will be flung into furrows, or the mouth drawn up to
either side as the case may be. Two other cases have been
referred to in a former part of this paper, exhibiting crude
and incongruous forms of expression, as coming under this
category.
A large number of idiots of all ages are in the habit when at
rest of widely opening and shutting the mouth, and con¬
tinuously repeating this action, at the same time making slight
ejaculations. I have not noticed whether this is more marked
at certain times of the day, but it seems to me not unlikely
that possibly it is associated with feelings of hunger.
Inqwiries into a Variation of Type in General Paralysis . By
F. St. John Bullen, Assistant Medical Officer, West
Riding Asylum, Wakefield.
Under this heading I propose to make a few inquiries rela¬
tive to the principal forms under which this disease shows
itself, and more especially into the likelihood that it is under¬
going some modifications under various influences. This latter
possibility has impressed me for some time, and, on addressing
several specialists on the subject, I find that no few share the
same opinion. So far as the question of modified type is con¬
cerned, the difficulty which presents itself at the outset is that
it is uncertain whether the older writers recognized general
paralysis under the Protean aspects now known to us—sup¬
posing them to have existed—and it may be an error to assume
that its now varied forms are extensions of, or deviations from,
a more concise and specialized group of symptoms. If, on the
other hand, we can rely upon the observations of those who
have spent a considerable number of years in lunacy practice,
and can at the same time by statistics indicate that noteworthy
differences are becoming apparent between recent and former
cases of general paralysis, some basis for belief in a variation
of type may be assumed.
It seems that very prominent distinctions in the forms of
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180
A Variation of Type in General Paralysis , [April,
general paralysis found in different asylums are evident, and
varying opinions held by competent observers, so that it has
appeared to me that a short paper might serve some purpose in
calling forth discussion on, and further elucidation of, this sub¬
ject. At the outset I must express my gratitude to those
f entlemen, whose names are hereafter to be mentioned, who
indly gave me the results of their wide and valuable experience.
I have myself abstracted over 250 cases of general paralysis
from the case-books of the Wakefield Asylum, taking a period
of ten years, from 1880 to 1890, and subdividing this into
halves for purposes of comparison. I am prepared to allow,
without prevarication, that a considerable latitude must be given
to statements on some particulars afforded by case-books, and,
with the exercise of the closest scrutiny, no results can have
anything like scientific accuracy. I have only selected male
cases and those which terminated in death. The points upon
which I propose to dwell are the following:—
1.—The relative frequency of certain recognized types of
general paralysis, and the prominence or predominance of any
one type.
2.—Evidence that locality—this including questions relating
to urban or rural life, occupations, modes of life, etc.—has any
notable influence on this change of type.
3.—Whether any alterations are observable in (1) the age at
which patients are attacked; (2) the duration of the disorder,
and (3) its distribution as to sex.
4.—Whether convulsive and apoplectiform seizures bear the
same relation to each other, and to the disorder, now as
formerly, in (1) frequency of, and (2) period of, occurrence,
and what is their present significance in prognosis.
5.—Whether there are any changes to be noticed in the
coarse post-mortem features.
1.—It is not necessary to allude to the many varieties in type
recognized at the present—they are described at length by
both Meynert and Dr. Mickle. We have to deal here with the
relative frequency of the principal types. The former belief
in the predominance of a maniacal form, with optimism, etc.,
has undergone an approved revisal, but as to what form of
general paralysis has filled the gap left by the withdrawal of
this “ classical 99 form, there is yet a difference of opinion. In
France, Messieurs Calmeil, Camuset, and Lunier have sever¬
ally emphasized a greater prevalence of the melancholic type of
general paralysis, the latter two recognizing in this a modifica¬
tion. Amongst several English asylum superintendents of the
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by F. St, John Bullen.
187
present day I have found no corroboration of this view to the
extent held by the forementioned authors. Drs. Merson (of
Hull Borough Asylum), Revington (late of Prestwich), Robert
Smith (of Durham), Saunders (of Exeter), and Samuel Lyon
(of Bloomingdale, New York) all inform me that the maniacal
type is far in excess of the melancholic, although Dr. Revington
thinks that there is an increasing proportion of the latter to the
former.
In my own statistics the cases in which excitement or ideas
of exaltation and bien^bre are found constituted 64 per cent, of
the whole; those with depression and hypochondriasis only 13
per cent. Acutely maniacal characteristics (proving fatal
before dementia overclouded) were present in but 5£ per cent.;
acute depression only in four cases. So far as my own experi¬
ence goes, I, whilst fully recognizing the melancholic form of
general paralysis, can only give it as forming a very small
share of the total cases. Of all varieties, however, the primary
demented type occupies a prominent place, and it appears to
me that, at any rate in some localities, this type is on the in¬
crease, and is largely existent at the present. One aspect of
this form Dr. Clouston alludes to under the'title of “non-
delusional,” and asserts u that nearly one-third of his cases
were of this character,” and that it is a type very common in
the female sex. Without adhering to his limitations in de¬
scribing this special variety, and merely defining the class as
primary progressive dementia, the following evidence may be
quoted:—
Dr. Claye Shaw writes me: “ I have no doubt that we get
more cases of the demented and paralysed form than we used
to, and that the percentage of these is not only greater, quoad
other forms of insanity, than formerly, but that amongst
general paralysis cases it is the most common form'.” With
this, however, Dr. Shaw opines that the old classical form,
whilst more rare nowadays, is yet to be met with, and exhibits
no change in its course.
Dr. Merson writes: " Not only do I not see now the
boisterous maniacal type I used to, but that in most cases
there is marked dementia before the patients come under my
care, and that without any previous history of melancholic or
maniacal stages.”
Others support this view. Dr. Leon Arnaud (Abstract,
“ American Journal of Insanity,” July, 1891) says “ that
primary paralytic dementia is the most common variety of
precocious general paralytic forms.”
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A Variation of Type in General Paralysis, [April,
Dr. Folsom, in the same periodical, writes concerning the
prodromal stage of general paralysis : “ This early stage is
most marked in Meynert’s 1st Class, the demented type to
which the recent great increase in general paralysis belongs.”
On the other side we find Dr. Mickle expressing himself in
his text-book thus :—“ In a few cases of general paralysis a
dementia begins and includes the entire range of mental
symptoms throughout the whole course.” This, however, I
take to apply to cases of the same class as Clouston’s “ non-
delusional” form. Dr. Smith, of Durham, characterizes cases
of dementia throughout as being rare, and the reports of the
asylum bear this out plainly.
From my statistics I find that dementia occurring at the
outset, or within a month of the earliest symptoms, is observ¬
able in 28 per cent, of all cases. By the end of three months
nearly 38 per cent.; by the end of a year no less than 62 per
cent, of all cases show dementia. Of the primary demented
cases 7 per cent, more belong to the second period of five
years than the first. As regards the stage of fatuity, out of
125 cases in which this was fixable in time, roughly speaking,
23 per cent, were fatuous within a year from the earliest
symptoms, 53 per cent, by the end of the second year, and 79
per cent, by the end of the third. Cases of the “ non-delu-
sional” form I have met with in 15 per cent, of all cases of
dementia.
I am unable to offer much evidence as regards the influence’
of locality, occupation, and degree of mental evolution on the
type of general paralysis in such a short paper as this. More¬
over, in such a question there are too many fallacies where
only a limited selection of statistics can be studied to make
positive statements of any value. I have analyzed a large
number of asylum reports. Certain features become prominent,
and might lead one to make inference were it not for the
number of side-issues that can be raised. However, stating
them (and they are probably familiar enough to us) must not
be taken as equivalent to laying any stress on their importance.
I quote simply as having a suggestive significance.
The admission-rate in general paralysis varies greatly in
different asylums, and seems to move up with the diminution
of rural occupations and the increase of such employments as
are found in number in great centres of population, or colliery,
iron-working, and pottery districts; so that we see in the
asylums of Leicester and Rutland and Hereford, for instance,
that the general and agricultural labouring class form nearly
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189
by P. St. John Bullkn.
40 per cent, of all occupations, whilst their admission-rate of
general paralysis is but two per cent, and three per cent,
respectively. In the Staffordshire asylums the rate of general
paralysis runs up; so does the percentage of colliers and
pottery-workers in the occupation-list. Again, at Derby
County, where the general paralysis rate has been increasing
for some years, and is now 20 per cent., we find the agricul¬
tural labourer contributing only six per cent., the colliery-
workers 16 per cent to the trades-list. Durham County also
breeds the general paralytic in quantity, the average admission-
rate for the last three years being 17 per cent., and the deaths
from general paralysis nearly one-third of the total. At the
North Biding Asylum the death-rate is even in excess of this.
In these asylums the proportion of inmates formed by colliery
and iron-workers is very large. The great centres of Lanca¬
shire also furnish an immense proportion of general paralytics
to their asylums.
Besides variations in numbers produced, there are very
marked disproportions evident between the types of general
paralysis found in different districts. Dr. Smith, of Durham
County, tells me that he finds the former boastful, elated
characteristics replaced by violent and aggressive tendencies,
and the reports of his asylum show that by far the larger pro¬
portion of general paralytic admissions and deaths are returned
as mania of general paralysis, whereas of sixty-six cases admit¬
ted by me at Wakefield between 1890 and the present time
over 50 per cent, were demented on admission (and that with¬
out history of previous excitement), and only about half-a-
dozen really excited cases were received under care. Dr.
Clouston allies the calm, demented type with quiet, rural
districts. Dr. Claye Shaw writes me concerning the pre¬
sumed numerical increase in the demented variety to the effect
that he considers such to point towards a lower order of
development in the classes from which are drawn the inmates
of county asylums, and that the present form more resembles
what is seen in insanity amongst races of inferior development,
so that it would seem that owing to competition, large families,
insufficient food, etc., amongst the lower orders, a less ener¬
gizing nervous condition has of late prevailed, and this, of
course, in the diseased state would show itself in a less evolved
form of grouped symptoms.
It would be interesting to know what proportion of cases of
early dementia is met with in private asylums. Dr. Lyon, of
Bloomingdale, New York, which receives the upper classes of
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190 A Variation of Type in General Paralysis , [April,
society, informs me that he does not notice any change in the
type or course of general paralysis now, as compared with
former years, and apparently there is no striking proportion of
demented cases. Dr. Savage has expressed himself to me as
decidedly doubtful about any variation in type, and thinks that
the apparent change is due to the further inclusion of previously
unrecognized forms, and especially of syphilitic cases.
With regard to the age at which persons are affected with
general paralysis I find the average of all the cases of this
disorder admitted between 1880 and 1890 into Wakefield to
be 42| years (on admission). From 1880 to 1885 the mean age
was 41 years, and from 1885 to 1890—nearly 45 years—
seventy-two per cent, of all cases were between 30 and 45 years
of age, of which 21*5 per cent, occurred between 30 and 35;
25 per cent., 35 to 40; 26 per cent., 40 to 45; and 5-J- per cent,
were between 25 and 30. So that here, at any rate, no alteration
in the ages, generally considered as most attached to general
paralysis, is obvious. However, Dr. Arnaud ( loc . cit.) and
Dr. Mickle both mention a lowering of the mean age. This
subject of age is too lengthy to be discussed here, and, apart
from statistical reckoning, any alteration in the way of an
extension of the ordinary limits of age will be only apparent
to individuals by the recognition of a notably increased
number of very youthful or senile cases.
With respect to the duration of this disease, Drs. Burman
and Newcombe, in the West Biding reports, gave the average
(respectively) duration as 15 months (males) and 21£ months.
Dr. Mickle says the average was 28 months at the date of the
first edition of his book, and 40 to 42 months at the second.
Dr. Ascher, of Daldorf Asylum, Berlin, gives 14£ months as the
mean, after admission; 16*8 per cent, surviving the second year
of treatment; and 26 months as the total duration in nearly
half the cases. Opinions on this subject vary; some superin¬
tendents believe the disease runs a shorter course, others a
tardier one. Each appears to me correct as regards the local
varieties of general paralysis, but their views are conflicting
when applied to general paralysis as a whole.
The average total duration in my cases was years, and
there was but little difference in the mean between the first
and second periods of five years. I find that one-seventh of
the total cases die by the end of the first year; three-sevenths
by the end of the second; five-sevenths by the end of the
third; and nearly seven-eighths by the end of the fourth, so
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191
1893.]
that a considerable portion live till the fourth year. The cases
of primary demented type had an average of 2^ years.
A pretty general impression appears to exist that the ratio
of female to male general paralytics is on the increase. In
Wakefield Asylum the ratio in admissions for 1859 to 1860,
1863-64 (the only tables available) was, on average, as one to
six; from 1886 to 1890 inclusive, as one to five (this latter
average is that of the Staffordshire Asylums), and one to 4£
that of the Wilts County. At Prestwich (report 1889 and 1890)
the ratio is one to three; at Rainhill (report 1887-89, 1890)
rather more. In the former place the females are considerably
in excess of the men. Dr. Wiglesworth remarks, in a recent
report, that, " whether or not general paralysis in women has
increased of late years is difficult to prove, but it is certainly
by no means uncommon now amongst women of the lower
class.”
Next we have to consider the relationships of convulsive
and apoplectiform seizures to each other and to general
paralysis. I am informed by Dr. Merson that convulsive
attacks occur in about half his cases, mostly in well-advanced
stages of the affection. They are much more frequent than
apoplectiform seizures. In regard to their characters Dr.
Smith, of Durham, states that he misses nowadays the out¬
bursts of convulsions, accompanied by rapid, bounding pulse,
profuse sweating, and fever, and although the number of fits
remains the same, or even higher (200 to 300), death is not so
frequent a result, and temporary recovery often takes place.
He also finds epileptiform more common than apoplectiform
seizures. In Bloomingdale Asylum, New York, of 21 general
paralytics admitted during the last twelve months five had con¬
vulsions and two apoplectiform attacks. Dr. Lyon writes to
me: “ The first convulsive seizures are not usually fatal, but
they are generally followed by others, which are primarily or
remotely so.” A former assistant physician there has also
spoken to me of the rapid, sthenic character of the general
paralytics in New York, together with an almost invariable
convulsive termination, the fits being often the first ones
occurring, and not to be stayed by drugs. Dr. Newcombe
found convulsions to occur in half his cases of general paralysis.
Dr. Saunders, of Exeter, states that in his patients the disease
rarely runs its course without the occurrence sooner or later of #
convulsions, but that these attacks are not frequently fatal.
I note amongst my cases, 272 in all, that eighty-six (or
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192
A Variation of Type in General Paralysis , [April,
81 per cent.) had convulsions, and seventy-five strokes, i.e., a
much smaller percentage of convulsive seizures, and a greatly
increased one of apoplectiform over Dr. Newcombe’s figures,
and also a larger proportion of the latter than I gather from
the opinions given to me is usual. In some asylums the import
of the convulsive seizure would seem to be graver than in
others; for instance, I note that in Prestwich Asylum, of the
deaths from general paralysis in 1889 and 1890, 42 per cent,
took place, accompanied with convulsions, according to the
reports. In Wakefield Asylum the convulsive attacks are
apparently becoming more infrequent. During the past two
years not more than twenty cases of convulsions have been
met with, though we have always over 50 male general
paralytics in residence. Moreover, many of these instances
were slight and localized seizures. And not for several years
has there been a severe run of fits in any case.
The total duration of cases in which convulsive and apoplec¬
tiform attacks occurred, in 122 instances, was two years and nine
months, or rather longer than the mean duration of all cases—
this period alike for both forms of seizures.
The mean age of those of my patients who had convulsive or
apoplectiform seizures was 40 years, or somewhat less than that
of the total cases. Dr. Newcombe’s results were similar. I
find the average age at which seizures of both kinds occur to
be about 42 years. Newcombe also states that nearly half the
total number of male patients affected by seizures died within
a month after the occurrence of the first pronounced attack.
My figures bear this statement out, nearly 37 per cent, of the
cases dying at the first attack, and nearly 12 per cent, more
dying during the ensuing month. In a quarter of all the cases
there was more than one attack of convulsions. There was no
difference in the proportion of fatal convulsive attacks between
the first and second periods of five years. Dr. Newcombe’s
cases died during 1870 to 1875, or before presumably, so that a
comparison instituted between his cases and mine from 1885 to
1890 shows that after the lapse of fifteen years no variation
has taken place as regards this asylum.
As to the period at which convulsions supervened, nearly
half the cases having them had them during the first year;
three-quarters of the total occurred by the end of the second.
In the second period, from 1885 to 1890, however, the fits
were more spread over the later years of general paralytic
life.
Nearly two-thirds of the apoplectiform seizures happened by
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1893.]
by F. St. John Bxjllbn.
193
the end of the first year, and the first attack is not postponed
beyond the second year but in very few cases.
The last question I wish to raise is whether there is any
change in the frequency or degree of the meningo-encephalic
adhesions found post-mortem in general paralytics. In a
former paper I stated them to occur in 61 per cent, of all
general paralytic brains. In 136 cases (from April, 1886, to
January, 1892) I found adhesions in 61 per cent, also, so
that the number of cases remains unchanged. But the
adhesions themselves appear often during this latter period of
less extent and degree; and out of twelve cases dying this
half-year, in six the adhesions were very slight or absent. All
these were cases of early dementia except one. The others
were old-standing cases, all of whom had had convulsive
seizures except two, who were markedly of the melancholic
type. I believe Dr. Wiglesworth’s impression concerning a
possible variation in these morbid changes is the same as mine,
but he would decline to make any positive expression of opinion
without careful investigation.
To sum up, it seems that although in every particular the
type of general paralysis cannot be said to have universally
changed, yet it is probable that in some feature or another
alteration is to be noted very generally, and that in some
localities prominent changes are apparent in the whole form,
and that in the following details we may especially look for
evidences of variation :—
1. Less pure and sthenic type of mania, with more infre¬
quency of occurrence.
2. Greater frequency of primary demented cases, and an
earlier onset of dementia in cases where emotional manifesta¬
tions are primary.
3. Possible increased ratio of melancholic to maniacal
symptoms.
4. Modification in the ages of patients attacked, in the
duration of the disorder, and in its distribution as to sex.
5. Variation in the relative frequency in occurrence of con¬
vulsive and apoplectiform seizures; in a less sthenic character
of the former, and in diminished frequency and fatal significance
of them.
6. A possible concurrent change in the meningo-encephalic
adhesions (post-mortem).
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194
[April,
The Effect upon Mental Disorder of Localized Inflammatory
Conditions . By Edwin Goodall, M.D.Lond., B.S.,
M.R.C.P., Pathologist and Assistant Medical Officer,
West Riding Asylum, Wakefield.
Is the beneficial effect often produced in a case of recent
and acute insanity by local inflammation (cellulitis) mainly
due to the local disturbance or to a general, systemic disturb¬
ance ? This question appears to me to have more than a
mere theoretical interest, for the following reason:—If the
effect noted be due mainly to the local inflammation we may
go on applying blisters and equivalent chemical irritants on
a sufficiently large scale to the skins of patients; but if the
result is to be ascribed solely or largely to the accompanying
general disturbance, it will be advisable to consider whether
such cannot be evoked with greater certainty and thorough¬
ness than is possible with the means now employed. I
much doubt whether local inflammation, the result of
chemical irritation, can be compared, from the point of
view of influence upon existing mental disorder, with
cellulitis* of unknown origin, such as occurs in the insane.
Upon this point it would & instructive to hear the opinions
of experienced observers. No one probably will deny that a
more profound general disturbance is associated with
idiopathic cellulitis than with inflammation due to chemical
irritation. If, then, cellulitis is capable of producing the
more striking mental alteration, it seems legitimate to
ascribe this to the more profound systemic disturbance
referred to. The qualitative difference in the nature of the
irritants in the two cases possibly entails some difference in
the modes of local reaction; even if this be so one would
still, I think, be justified in adhering to the conclusion
reached, i.e., that the greater mental effect produced by
cellulitis is due to the greater systemic disturbance.
If inquiry be made into the causes of the latter, in the
case of cellulitis, it is at once apparent that they differ
essentially from those operative in the case of “ chemical 39
* The occurrence of this cellnlitis is a matter of great interest. In cases of
general paralysis we may suppose that the vitality of the tissues is so mnch
reduced as to permit the entry (by surface-wound or by the normal passages)
and the development of organisms incapable of flourishing in the healthy
body. In other cases this explanation is far less plausible. May not the
ordinary otheematoma be the product of bacterial activity ?
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1893.] In/lammatory Conditions and Mental Disorders . 195
inflammation. In cellulitis there is more than fever: toxic
products are being conveyed through the body. With the
degree of toxicity we are not now concerned—all that it is
necessary to point out here is that pyogenic cocci are
present at the site of inflammation, and are there produc¬
ing a toxine, which we must suppose to be diffused over the
system. In inflammation aroused by blisters, croton oil,
etc., the question of an organism does not arise; we have
not to do with a circulating toxine. A rise of temperature
may occur, and this may or may not be an indication of fever.
The question as to the extent to which the circulation of
toxic products is concerned in the production of the mental
alteration often noted in cases of cellulitis amongst the insane
is one capable of scientific determination. The necessary
procedure involves a minimum of risk, for the amount of
toxine introduced into the body can be absolutely estimated.
Here is no question of the multiplication to an incalculable
extent of a living organism. The quantity circulating is
the quantity introduced, and no more. The direct transfer¬
ence from one patient to another of inflammatory exudate or
pus from an acute abscess might be regarded as unjustifiable
on the ground that, for all we know, the organisms produc¬
ing these disorders are capable of causing pyaemia. But
until it is shown that the toxines or metabolic products of
these organisms are capable of producing inflammation and
abscesses at parts remote from the seat of inoculation, the
argument just mentioned cannot be urged against the pro¬
posal to inject the product of metabolism, freed from the
organisms themselves. The chances of grave septicaemia
must be but slight, otherwise we should meet with this
complication oftener in cases of spontaneous cellulitis. By
preliminary animal experimentation, by attention to
technique, and by the injection, in the first instance, of
minute doses, the risk of untoward consequences would, I
believe, be rendered insignificant.
The material used for injection should be the product of
organisms proved to be capable of provoking well-marked
cellulitis. In a case in which the writer injected the pro¬
ducts of metabolism of staphylococci from an acute and
rather large boil into a patient there was practically no
general disturbance; the slight rise of temperature (100°)
and the malaise were adequately explained by the local
inflammatory condition. The material injected was probably
incapable of producing noteworthy systemic disturbance,
xxxix. 13
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196 Inflammatory Conditions and Mental Disorders . [April,
but some swelling and brawny induration around the seat of
injection, with pain on pressure, bore testimony to a local
reaction, though one mild in degree. This was not antici¬
pated, as the culture had been carefully filtered, so that the
presence of organisms was extremely unlikely. JEven had an
organism or two been present it is, I think, very improbable
that such could have produced the local disturbance noted
within the time which elapsed between injection and the
appearance of local reaction (about 20 hours). But the
likelihood is that the latter—which was but slight—was
due to some irritating property of a chemical kind of the
fluid injected, which, I believe, was quite sterile.
The following is in brief the procedure adopted in this
case to obtain the products of growth of the micro-organism.
It is not new, but may be of use if mentioned here. Pus
was obtained from the boil after its surface had been cleansed
(sublimate, alcohol, and ether). A cover-slip preparation of
the pus showed diplo- and staphylococci. Tubes of broth were
inoculated and kept in the incubator until they showed
well-marked growth. Pure cultures of the cocci were
obtained from these after the ordinary method of Koch,
and from them a large quantity of broth was inoculated.
After a couple of days in the incubator abundant growth
was manifest in this. The bulk of the turbid broth was
then filtered through a Kitasato porcelain filter, which had,
of course, been sterilized. In this method the glass vessel
surrounding the hollow porcelain cylinder is exhausted of air
by a water-pump. The sterilized fluid falls from the porcelain
at the rate of about five drops a minute. This is fast enough.
A rabbit was injected with the filtrate (after cover-slip
preparations of the latter had been made and shown to be
free from bacteria) on two successive days. Altogether 25
min. were introduced. The animal seemed to eat less, but
otherwise there was no evidence of local or general distur¬
bance. The patient was then injected subcutaneously with
14 min. of the filtrate, the syringe (improved pattern used
for tuberculin injection) having been properly cleansed.
The object of this paper is to put the question whether, by
imitating what may be termed the method of nature, as dis¬
played in the particular instance in point, we may not hope
to bring about or accelerate cure in recent and acute cases
of insanity, and to suggest that the imitation hitherto
attempted is very imperfect and capable of considerable im¬
provement.
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1893.]
197
Some Remarks on the New Farm of the Omagh Asylum .* By
Dr. George Francis West, Assistant Medical Officer of
the Omagh Asylum.
The amount of land originally belonging to the Omagh
Asylum amounted to fifty-two acres. This land surrounds
the asylum, and is bounded partly by a wall and partly by a
river.
Some time ago the authorities purchased an additional
farm of about eighty-four acres for the use of the asylum.
As this purchase has been viewed favourably by some and
unfavourably by others, and as the question of buying land
has been discussed in other asylums, I think it will be
interesting to consider how this farm has worked, and how
far it has succeeded.
The Omagh District Asylum for the counties of Tyrone
and Fermanagh contains 306 males and 261 females. Both
Tyrone and Fermanagh are agricultural counties, neither
possessing large towns nor many manufactories, consequently
instead of there being (as there are in the English asylums)
a large number of tradesmen, the greater part of our male
patients are farmers or agricultural labourers.
We have at the present time 306 male patients, and yet we
have only one carpenter, one mechanic, four tailors, and two
shoemakers working in the shops.
Under these circumstances it is evident that the best way
of providing work for the patients to which they are
accustomed would be by having a large farm, and about a
year-and-a-half ago the asylum authorities purchased about
84 acres of additional land lying immediately outside the
boundary wall, being separated from it by a country road.
Of this land about 35 acres were rough land or bog, which
required to be broken up and reclaimed. The rest of the
land was in a very bad state; it all wanted drainage and
manure very much.
The patients were set to work at once, and in addition to
the men employed on the old farm, a number varying from
60 to 80 men were constantly employed on the new, the total
number employed on the farm being 110.
We have found this work very advantageous to the
* Read at the Quarterly Meeting of the Irish Branoh of the Association, held
at the Mullingar Distriot Asylum, October 27th, 1892.
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198
The New Farm of the Omagh Asylum , [April,
patients. Greater numbers can be employed than hereto¬
fore, and some patients that refused to work before now go
out regularly. Many of the patients appear to like working
on the new farm better than on the old one. I suppose the
fact of being outside the boundary wall gives them a sense
of freedom, and many of them take quite an interest in the
way the work of improvement is getting on.
The amount of work done during the past eighteen months
has been very considerable. About seven acres have been
thoroughly drained. Most of this work was done during the
autumn and winter months, when there was little agricul¬
tural work. At present the men are engaged in sub-soiling
the rough land and reclaiming the bog, a work which will
employ them for a considerable time.
A part of the farm is also a good place for the female
patients to go out on during the summer. There are some
large grass fields sloping down to a small brook, and
frequently the female patients come to these fields in fine
weather. I have often during the summer watchjed the
female patients in these fields. Some were sitting on the
grass knitting or sewing, others were walking about or
lounging near the brook. The worst and most violent
patients were comparatively quiet, showing what I am sure
many have observed, namely, the quieting effect of giving
patients plenty of elbow room.
The scene reminded me very much of a large picnic, and
compared very favourably with the old-fashioned airing-
yards once so much used.
I do not wish it to be understood that our patients were
always confined in airing-yards till within the last two years.
On the contrary, the patients for many years past were
accustomed to use the old grounds, which are very fine and
well planted, but in addition to the advantage of variety, the
fields I refer to being in the open country, and having an
extensive view, must afford great pleasure to the patients.
I may mention that the attempted escapes are very few.
During last year only two male patients tried to escape, and
no female succeeded in escaping off the asylum premises.
I will now say a few words from a financial point of view,
for I have heard some people criticize rather severely the new
purchase on the ground that it would not pay. Putting
aside the question that the farm is intended for the benefit
of the patients, I could show that even as a business specula¬
tion it is a success.
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199
1893.] by Dr. George Francis West.
When all the land is reclaimed it will make a great dif¬
ference in the amount of provisions supplied by contract.
Much of these will then be produced by the farm, which will
constitute a two-fold advantage—first, a saving of money, as
the provisions will be produced cheaper; second, a superiority
in the quality of the articles over the same supplied by con¬
tract.
For instance, in the case of potatoes. On talking over the
matter with the land steward, and taking a rather low average,
I found that 19 acres would supply us for a year with potatoes
at our present rate of consumption. Also with reference to
milk. The consumption of milk last week was 625 gallons.
Of this 370 gallons were supplied by the contractor, and 255
gallons by the fourteen cows kept by the asylum.
The Governors are building another byre, which will hold
eighteen cows, thus largely increasing our supply of milk,
and I hope they will soon see their way to build another of
such a size as to enable us to keep a sufficient number of
cows to supply the asylum with all the milk it requires the
whole year round.
With reference to the meat supply, we consume five sides,
or two-and-a-half cows per week. Nearly the whole of this
is supplied by contract, and I do not think the present farm
is large enough to assist much in keeping cattle for killing,
but with 150 additional acres of land it could be easily
managed. I fear the Governors, having so lately bought a
farm, would not care to indulge in a new purchase for some
time to come, but nothing succeeds like success. A short
time will prove that farming pays, and I hope before many
years to see a stock farm added to the asylum capable of
supplying us with all the meat we require.
I have endeavoured in this short paper to show that the
new farm is of great advantage :—
1st. To the patients, as affording a healthy occupation which
is of great advantage to them physically and mentally.
2nd. As a means of supplying the asylum with provisions
more cheaply and of a better quality than could be done by
contract.
3rd. As a business speculation. The net profit of the farm
last year was £498 5s. 9d., and the profit will increase every
year as we continue to improve and reclaim the land.
Under these circumstances I believe I am justified in con¬
sidering the new farm of the Omagh Asylum to be, from
every point of view, a decided success*
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200
[April,
Systematic Dress-fitting for Female Inmates of Asylums .*
By Arthur Finigan, Medical Superintendent, District
Asylum, Mullingar.
In accordance with a resolution adopted by the Irish
Branch of this Association in November, 1888, we are now
assembled in a District Asylum, and this being our first
provincial meeting I need hardly mention what a very great
pleasure it affords me to offer a hearty welcome to the
members who have been good enough to come to Mullingar
to-day.
Yon will permit me to express a hope that this meeting
may tend to permanently establish the practice (now so
well inaugurated) of holding at least one meeting annually
in an Irish asylum. Such an arrangement affords us an
occasional opportunity of exchanging ideas on much that is
interesting in the actual field of our labours, and in viewing
each other’s work we are enabled to draw comparisons with
our own, which may stimulate us to give our best attention
to judicious reforms for the asylum with which we may be
officially connected.
The subject of this short paper, encroaching as it does
upon the art of dress-cutting, is scarcely one that will admit
of much discussion by the members of a Psychological
Association, but when considered as a practical detail in
asylum administration, it will be found to involve many
interesting points bearing on the tidy appearance of female
patients, economy in expenditure on dress materials, and
the still more important matter of an agreeable employment
for the female inmates of asylums.
Medical superintendents who make a practice of visiting
public asylums for the insane, cannot have failed to observe
(even in asylums that are well organized) the very large
proportion of unbecoming and clumsy outer garments usually
worn by the female patients. Even the most casual visitor
can, as a rule, distinguish the insane inmates from their
personal attendants by that peculiar dress which is a
characteristic of public institutions (irrespective altogether
of the brands or numbers which ornament the clothing in
some asylums). Females under all circumstances are pro-
* Read at the Irish Quarterly Meeting, held at the District Asylum
Mullingar, Oct. 27,1892
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1893.] Systematic Dress-fitting for Female Inmates .
verbially fond of dress, it enters largely into their diurnal
anticipations, and our experience in asylums teaches that it
exercises a powerful influence in the matter of moral treat¬
ment. However well the insane woman may appreciate the
comfort of a luxuriously-furnished day-room, or a neatly-
appointed dormitory, her individual self-interest is much
more absorbed in her personal appearance, the character of
which she is ever anxious to improve and adorn, unless,
indeed, the feminine tendency lies altogether dormant, or be
perverted in the extreme by an acute insanity.
Most asylum officials are familiar with the very decided
objection occasionally offered by some recent admissions
(especially in cases of mild melancholia) to put on the
asylum clothing. Not unfrequently they look upon it with
suspicion, or perhaps develop the illusion that such clothing
is the badge of degradation or pauperism, with the result
that an obstinate resistance is continued, and, as in the case
of some of our famous political agitators, the patient elects
to remain naked, or in bed, rather than array in this regula¬
tion or very apparent institution dress. If you will admit
the possibility of such impressions arising in the mental
condition of our patients, it becomes a matter of some
importance in early treatment to rigidly avoid any cause
that might provoke misunderstanding. To this end we
should assimilate the regulation dress in asylums as closely
as may be to that usually worn by patients when in health
in their own homes. An attempt in this direction would
necessitate a marked improvement in the style and finish of
the dresses usually made up in public asylums. They should
be shaped with a view to fit individual patients rather than
be unskilfully cut out in dozens to replenish the institution
stock. The personal preferment of patients might with
advantage be consulted when their mental condition permits
it, and for this purpose a variety in materials should be
available.
To initiate and carry out a desirable reform of this kind
enormous employment is involved for both patients and
staff, as it necessitates each patient being separately
measured and fitted. Fortunately the work is of an engag¬
ing description, and females, if in the least disposed to be
industrious, are easily induced to attempt and persevere with
it to within the bounds of success. *
In illustration of the feasibility of such an arrangement I
cannot do better than give a brief outline of the method
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202 Systematic Dress-jUting for Female Inmates, [April,
which has been practised successfully in this asylum within
the last few years, and as you will have an opportunity of
seeing it in operation in each of the female divisions you can
form your own opinions as to its advantages or the reverse.
In this asylum, as in most others, the Charge Nurses are
directly responsible for the order and neatness of the
patients in their respective divisions, but as a qualification
for their position it is a sine qua non that they be thoroughly
acquainted with one of the systems of (so-called) scientific
dressmaking. I may state that there are many such systems
in vogue, but the Rapide tailor-cutting system is the best
and most simple. The Anglo-Parisian and American Chart
systems are also used by the more proficient nurses in this
asylum. When time is available the charge nurse imparts
her knowledge to at least two of her assistants, and when
these are competent to teach, they form classes of the most
intelligent patients, who take an active part in measuring,
drafting, cutting out, and finishing dresses for their own
individual wear. Encouraged in this way to take a personal
interest in the work, it is often a matter of surprise to
observe the number of indolent and even apathetic patients
who, stimulated by the object lessons practised in their
presence, are thereby induced to become voluntary pupils of
this modified school system of moral treatment.
It is obvious this work must be carried out in the separate
divisions of the female department, and such is rather an
advantage, as it gives rise to a spirit of emulation between
the various charge nurses who superintend to excel in turn¬
ing out the best dressed patients ; besides, it admits of the
mistress in charge of general sewing to devote her entire
attention to the making of nurses* uniforms and male under¬
clothing.
Apart altogether from the interesting employment which
this mode of dressmaking affords, it further secures a con¬
siderable saving of material in comparison with the older
plan of cutting out dresses in the gross. It has also been
noticed that robes last longer owing to the ease and com¬
pleteness of the fit, and patients are disposed to preserve
their garments in proportion to the comfort experienced in
their wear.
Systematic dress-fitting for the female inmates of asylums,
when viewed in another sense, has distinct and permanent
advantages, inasmuch as a moderately perfect knowledge
of it enriches its possessor by a trade which may be turned
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203
1893.] by Arthub Finigan.
to practical account beyond the precincts of an asylum.
More than one example of this is already within my know¬
ledge, but I may specially refer to the case of a homeless,
deluded girl who had been under treatment here for about
three years. She developed a striking taste for this work,
and by practice became proficient, so as to render material
aid in teaching her fellow patients. Eventually she re¬
covered, and on receiving her discharge, she obtained a
situation in a flourishing house of business, where she was
enabled to command a respectable livelihood, on the merits of
a calling she had casually picked up in Mullingar Asylum.
The Formation of Subdural Membranes , or Pachymeningitis
Hcemorrhagica .* By George M. Robertson, M.B.,
F.R.C.P.Edin., Medical Superintendent, Perth District
Asylum, Murthly, late Senior Assistant Physician,
Royal Asylum, Morningside, Edinburgh.
Part I.
Details of the Membrane Formation .
A discussion on the origin and nature of pachymeningitis
haemorrhagica at the present time is very desirable on account
of the remarkable difference of opinion of those who have
studied it. Two theories regarding its formation exist, and
the best pathologists and neurologists have ranged them¬
selves almost equally on either side. This fact of itself
betokens that each view probably has some elements of
truth in it, and that neither contains the whole truth.
What, then, is greatly to be desired under these circum¬
stances is a new theory that will combine the elements of
truth contained in each of the old theories, and supply the
deficiencies of both.
Both the inflammatory and the 'primary haemorrhagic theories
date back to the early part of the century, the former view
having been adopted by Calmielf and Bayle,J and the latter
by Abercromby§ and Andral.|| The haemorrhagic theory
was the one more commonly believed in till Virchow wrote
in support of the inflammatory theory in 1857.1 Through
* Essay for the Bronze Medal Competition of the Association.
f “ De la Paralysie chez les Alten&,” p. 394 (1826).
t " Traitd des Maladies du Cerveau et de ses Membranes,” p. 260 (1826).
§ “ Pathological and Practical Researches of the Brain and Spinal Cord,” 4th
edit., 1846, p. 231.
|| “ Clinique Medical ” (translated by Dr. Spillan), 1836, p. 6.
1 “ Wiirzburgh Verhandlungen ” (1857), ii., 134.
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204
The Formation of Subdural Membrane.s, [April,
the great reputation of Virchow as a pathologist, his account
became generally accepted as the correct one, but now the
haemorrhagic theory is again attracting considerable atten¬
tion, through the writings of Huguenin,* and the experi¬
ments of Labordef and Sperling. J
The details of the two theories, expressed in a few words,
are as follows:—Those who advocate the inflammatory theory
believe that there is a primary inflammation on the surface
of the dura mater, which commences with a hypermmia,
and which develops a “ false 55 membrane of inflammatory
elements, as in any other inflammation of a serous mem¬
brane. It is noted that the capillaries in this new growth
are very numerous and dilated, and show a great tendency
to rupture, but the effused blood is bound down by the
existing membrane, and prevented from escaping into the
subdural space. The fluid portion of the effused blood is
absorbed, leaving coagulated fibrine and pigment granules,
and each successive haemorrhage adds a layer, by which the
membrane becomes thick and stratified, and in course of
time fibrous.
The advocates of the primary hcemorrhagic theory , on the
other hand, believe that a haemorrhage pours out into the
subdural space—the so-called “ cavity of the arachnoid ”—
and that the dura mater at this stage is not inflamed. The
effused blood coagulates and a fibrinous membrane forms,
enclosing the more fluid portions, which afterwards become
absorbed. The fibrinous portion, containing much blood
pigment, may then organize, and blood-vessels sprout from
the dura into it. The subsequent changes in this membrane
are much the same as already described, but it is strongly
insisted that in this case the lowly organized “ false ” mem¬
brane is consecutive, and is secondary to the haemorrhage,
whereas in the former case the membrane was primary and
the haemorrhage into it secondary.
We shall not enumerate the various objections to the two
theories that have been brought forward, nor shall we offer
the explanations by which these have been met. To do so
would be to record the history of a war that has been waged
by the supporters of these two theories for nearly seventy
years, and in which upwards of ninety writers, mostly French,
* Ziemssen’s “ Cyclopaedia of the Practice of Medicine,” 1877, p. 386.
f “Contributions k l^tude des Conditions Pathogeniques des Kystes
sanguines, etc.” Comp. Eendus. Soc. de Biol., 1864, Par. 4, s. i., 70-74.
X “ Central, f. d. Med. Wissensch,” Berlin, 1871, ix., 449.
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1893.]
205
by George M. Robertson, M.B.
have been engaged. Instead of doing this we shall at once
enter npon an exposition of our own views of the mode of
formation and the nature of pachymeningitis hsemorrbagica,
or, as we prefer to call it, subdural membrane.
At the very outset we shall state the physical factor
which we believe to be the primary cause of this pathological
lesion. We believe that the all-important element in the
production of subdural membrane is sudden lowering of the
intracranial pressure, and that the effect of this is analogous
to a dry-cupping of the dura mater. If this factor be kept
in mind, and its physiological effects followed out, we believe
that all the essential facts in the nature and formation of
subdural membranes can be accounted for. Before proceed¬
ing we would mention that this lessened intracranial pres¬
sure of which we speak is something more than the u loss of
support ” which is referred to by most recent and some older
authors, and which in their opinion is due to brain atrophy.
Such a cause of diminished intracranial pressure must take
at least weeks to occur in the most exceptional cases, and
cerebro-spinal fluid to compensate for this loss can, we know
by experiment, be secreted by the choroid plexuses in large
amount, and with considerable rapidity. We believe that
diminished pressure sufficient to cause dry-cupping of the
dura must be produced by a much more sudden cause than
atrophy. The only agent that can do this is the blood in
the vessels of the brain, and we believe, therefore, that there
is either a constriction of the cerebral vessels producing
a sudden shrinkage of the bulk of the brain, or there is a fall
in the general arterial pressure, due commonly to an ex¬
hausting disease, whereby a deficient quantity of blood is
sent to the brain, and a similar shrinkage occurs.*
In 1878 Dr. Cloustonf wrote that he believed a sudden
shrinkage was the cause of membrane formation, and it is
noticeable that those most subject to subdural membranes,
as the senile and general paralytics, are well known to suffer
in a pre-eminent degree from vaso-motor derangements of
the cerebrum. Such a sudden shrinkage of the brain, con¬
sequent on the partial withdrawal of the enormous quantity
of blood which distends it at high pressure, must produce a
very considerable lowering of the intracranial pressure, as very
little will effect this result in a closed box like the cranium.
* We defer a much fuller consideration of this important subject of intra¬
cranial pressure to a later stage.
t “ Journal of Mental Science/’ 1878.
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206
The Formation of Subdural Membranes , [April,
The suddenness of this shrinkage we consider a most impor¬
tant element, as a sudden great demand for compensatory
fluid could not be met at once, and hence the results of a
shrinkage would tell with full force.
Should a sudden vascular spasm occur, as is supposed, the
ansemic brain will tend to shrink from the cranial walls, and
being fixed below by vessels, nerves, and the crura cerebri,
it will tend to shrink towards the base, and leave a vacuum
around it. In reality no absolute vacuum ever occurs under
these circumstances, but greatly reduced pressure must exist
around the brain, which in course of time may be compen¬
sated for by an increased effusion of eerebro-spinal fluid,
but till that happens the blood vessels on the surface of the
brain, and on the surface of the dura mater, are under very
abnormal physical conditions allied to dry-cupping. The
effect of this on the vessels of the pia-arachnoid is probably
to cause engorgement, especially of the large veins near the
surface, and this may in some cases go on to rupture. Dr.
Be van Lewis* and Dr. Wiglesworthf both believe that this
occurs, and we have occasionally found haemorrhagic areas
under the pia-arachnoid, as the latter points out, and also
blood pigment, the remains of old haemorrhage. We believe,
however, that this is a rare source of blood in the subdural
space, as the outer layer of the pia-arachnoid is a dense and
non-vascular membrane, which prevents blood from escaping.
So tough is it in health that it is known to retain the blood
when the internal carotid is ruptured, and in general
paralysis, in which disease subdural membranes are so
common, it is even more tough and fibrous than in health.
The results of this lessened intracranial pressure on the
vessels of the dura are probably much more serious. The
dura mater is a tough, inelastic, and slightly vascular mem¬
brane, but it is covered by an epithelial layer, under which
there are capillaries lying amongst a little loose connective
tissue. In former times this was believed to be the parietal
expansion of the arachnoid, and it was also believed to be
stripped off by large hsemorrhages, and to form the internal
layer of the so-called “ arachnoid cysts.” No one accepts
these pathological views now, and the parietal arachnoid of
the older anatomists is now regarded as only the superficial
layer of the dura mater. This structure, of great tenuity,
and consisting of epithelium, capillaries, and loose connective
# “A Text-book of Mental Diseases.”
f “Journal of Mental Science,” 1888.
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1893.]
207
by George M. Robertson, M.B.
tissue, is, however, very important to us, and we shall study
the effects of low pressure in its blood vessels.
The first effect of lessened intracranial pressure in these
superficial capillaries of the dura mater will be a disturbance
of the natural balance between the intra-vascular blood-
tension and the strength of contraction or tone of the
vessels. A source of considerable support to the vessels has
been taken away, and possibly even negative pressure pro¬
duced, hence it is probable that the blood-tension will over¬
come the strength of the vessel walls, and great dilatation
of the vessels, with engorgement by blood, will ensue. This
engorgement and dilatation of the vessels on the surface of
the dura mater, which we have deduced theoretically, is
found by investigation to be an extremely common occur¬
rence in those cases in which subdural membranes might be
suspected to be found, and it also frequently accompanies
these membranes. Out of 100 cases of general paralysis,
Bayle found more or less injection of the “ arachnoid of the
dura mater” in 25 cases, and subdural membranes in 18.*
The frequency of this vascular engorgement in these cases
and its association with subdural membranes we believe
points to a causal connection between the two, and, as a
matter of fact, in pachymeningitis hemorrhagica, according
to Yirchow, “ the first thing observed is hyperemia of the
dura.”f As regards the facts of the first stage of subdural
membrane formation, we are, therefore, in agreement with
those who hold the inflammatory theory, but we differ
widely as to the interpretation of these facts. Whereas
Yirchow and his followers believe the injection of the dura
mater to be the first stage of an acute inflammation, we
believe it to be a mere mechanical engorgement of the
vessels. The presence of this hyperemia of the dura as a
transient preliminary stage of membrane-formation has
not received the attention it deserves from the upholders of
the haemorrhagic theory, because they are at issue amongst
themselves as to where the haemorrhage comes from, and
perhaps because, being suggestive of inflammation, it has
suited them to ignore it.
The appearance of the dura mater is very striking, for
instead of being a pale glistening membrane, with a few
rosy streaks, it becomes covered with luxuriant ramifica¬
tions and dense meshworks of engorged cyanosed vessels.
* “ Recherches sur PEnc^phale,” Paris, 1838, p. 166.
f Althaus, “ Diseases of the Nervous System,” p. 188.
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208
The Formation oj Suldural Membranes , [April,
These are plainly visible to the eye, but can be best studied
under the low power of the microscope. If we examine a
fairly healthy region one sees few vessels injected, and they
form long anastomosing loops. They are of narrow diameter,
their contour is even, and they contain a small quantity
of blood of a rosy pink colour. When one passes to a con¬
gested region the whole field is covered with gorged and
dilated vessels. The vessels appear much more numerous.
The anastomosing meshworks are closer, and the diameter
of the vessels is from five to ten times greater. The vessels
give the appearance of being morbidly distended with packed
blood-corpuscles, as Cohnheim has described in passive
congestion, and their colour varies from a deep red to a
brownish hue, where deoxygenation has taken place owing
to stasis. Vessels will also be seen with aneurismal dilata¬
tion, as if they had been distended to the bursting point,
and in many cases the outline is very uneven, showing that
the limits of the normal calibre had been over-stepped.
Here and there in some cases minute haemorrhage may be
observed, and in the vast majority of cases some blood
pigment will be found, the remains of a similar hyper¬
distension of an older date. This hyper-distension, with
engorgement, may not pass on to a more advanced stage, but
may resolve, leaving behind only a few pigment granules.
The pigment is frequently found lying m a thin, broken
line on each side, and collected in a larger mass at the angle
of bifurcation of vessels which, no doubt, had extravasated
it, when previously hyper-distended. In other cases it is
found as a thick single line, evidently occupying the lumen
of a vessel, in which stasis had occurred. We have had
experimental demonstration, which has satisfied us that
great engorgement, and even rupture of vessels, may take
place on a serous surface, with reduced pressure, such as we
believe occurs on the surface of the dura mater. Dr.
Labor.de, head of the physiological laboratory at Paris,
dry-cupped the under-surface of the tendinous expansion
of a rabbit’s diaphragm, and produced great congestion,
tortuous vessels, and small haemorrhages, analogous to what
we have described on the dura. Though this does not
prove that engorgement of the vessels of the dura mater is
due to a similar cause, it nevertheless demonstrates that it
can be produced in this manner were the physical conditions
existing.
We have now given a description of what we believe to
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209
1893.] 6 y Geobob M. Robebtsoh, M.B.
be tbe first stage of subdural membrane formation. This
stage, as we have stated, may pass away, and only leave a
few grains of blood pigment, where complete stasis had
occurred, or where haemorrhage had taken place. It may,
however, pass on to what we describe as the second stage, if
the causes producing lessened intracranial pressure have not
passed off, or their effects been neutralised by compensatory
cerebro-spinal fluid. After the superficial blood vessels of
the dura have become over-distended, the fluid contents of
the blood will tend to transude through their walls, as
happens in all serous surfaces, for example, in the peritoneum
and pleura, when there is passive engorgement, caused by
cardiac failure. Now an increase of fluid in the subdural
space, where normally very little or none is found, it being
almost entirely confined to the subarachnoid spaces, is very
commonly found in cases in which we would expect to find
subdural membranes. Magendie* mentions, with some
detail, three cases in which he found great increase of this
fluid, namely, the general paralytic, the senile, and the
phthisical, and these are the very cases in which subdural
membranes occur most commonly. In some instances small
haemorrhages occur, which give the transuded fluid a
coloured tinge, but effusion of blood by rupture does not
necessarily accompany this stage, which, in the typical case,
should just stop short of this.
When the hyper-distension of the vessels has reached a
point beyond what has been described, the stomata on the
walls of the capillaries will gape, and blood serum of greater
specific gravity than before will pour out through these
openings. Leucocytes will also pass through with ab¬
normal readiness and in large numbers. This blood serum
will effuse around the capillaries among the loose connective
tissue, and it will be forced through the stomata on the
dura mater, over the surface of the epithelium. Under
certain conditions, sufficiently rare, but yet recognized by
Cohnheim in his description of passive congestion, the fibrine
in this effused blood serum appears to clot, and we find a
spider's web membrane of interlacing fibrine threads with
leucocytes, over the dura mater. As the stage between over¬
distension with effusion of serum and rupture of vessels
with haemorrhage is a very short one, and the special condi¬
tion, perhaps, exceptional, we can hardly expect to meet with
• " Lemons sur le System© Nerveux.”
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210
The Formation of Svbdwral Membranes , [April,
this purely fibrinous exudation often. We have, however,
met with two specimens of it without a trace of red-blood
corpuscles, or of pigment, and we are certain that it is often
overlooked. It is so thin and transparent that it can scarcely
be seen when held at right angles, but if it be glanced at
sideways, with the light shining over it, and if the surface be
scratched with the point of a knife, it will be seen distinctly.
It is so delicate that the best method of removing it is to cut
it into a square on the dura and with the blade of the
scapel to roll up the membrane from the edge like a carpet,
and then to spread it out in water on a slide. The first case
Brunet* describes appears to be similar to these we have
mentioned, and it was examined by a practised microscopist
like M. Ch. Robin. The membrane occurred in a general
paralytic and was “very thin, very soft, semi-transparent,
pale, with no red or yellow colour. 51 M. Robin found micros¬
copically “a granular appearance, finely striated, resembling
fibrine in the way of decomposition. This aspect is due
to numerous intercrossing flat fibres of very fine size, im¬
bedded in amorphous material.” “ The parietal arachnoid
deprived of this membrane is a little injected and is glisten¬
ing.” Brunet mentions specifically several times that no
trace of blood was found, and hence he attributes an
inflammatory origin to this formation, and he sums up as
follows:—“ The method of formation resembles that in other
serous cavities. Thus we have found the injected surface
from which the plastic exudation comes, etc. The first
fibrillation is fine and resembles the appearance of fibrine.
The resemblance is so close that it offers doubts to all but the
most experienced microscopists.” “ To the naked eye it also
closely resembles coagulated fibrine, spread out, but the
latter is more opaque and more elastic, and more difficult to
separate.” “ The addition of acetic acid, however, at once
settles any doubts on this question.”
It is just on this point that we differ from M. Brunet, for
the presence of cells which the acetic acid discloses does not
necessarily prove the formation to be inflammatory. These
cells in our specimens are of two kinds; there are a small
number of epithelial plates, and a much larger number
of leucocytes. These epithelial plates are scattered,
and simply appear to have been torn off the surface
of the dura mater, and are not in such numbers or
* “ Becherches but lee neomembranes et lea Eystes de Paraohnoide,” Par.,
1859.
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211
1893.] by George M. Robertson, M.B.
in groups as we would expect to find them were there
any cellular proliferation. The mere presence of leuco¬
cytes is not of itself sufficient to prove the .existence of
inflammation, as they are found in small numbers in all
serous fluids, and they would be certain to escape wherever
much transudation was taking place. Their numbers in some
parts of the membranes are extremely few, and on the whole
they do not exceed in number the leucocytes found in a
similar sized portion of the “ buffy coat ” of coagulated blood,
and, therefore, their presence in these numbers does not sug¬
gest inflammation to us. In fact, so alike are these two tissues,
this fibrinous membrane from the dura and a piece of washed
coagulum from the “ buffy coat,” that if only a small area be
examined microscopically no essential difference can be made
out in many instances. For these reasons, therefore, we
believe that this fibrinous membrane is nothing more than
coagulated blood serum, which has escaped from the blood
vessels, as we have already described. When the membrane is
spread out and stained it is found to consist of a felted mesh-
work of extremely delicate threads, in which are many leuco¬
cytes and an occasional large cell, with a deeply-stained oval
nucleus. There are no vessels and no species of organization.
In the dura mater, from which this membrane has been taken,
there can be seen the congested vessels, as a general rule.
On transverse section of the dura mater and the membrane
we see lying on the surface of the dura a stratified membrane
of short, transversely-cut fibrine threads and leucocytes. In
the deeper layers some epithelial cells can be seen, evidently
picked up from the surface of the dura, where some are still
to be found adhering to it. Below this line can be seen the
gorged vessels of the superficial layer of the dura, and around
them the loose connective tissues, much more open than in
health, and containing many wandering leucocytes.
The supporters of the haemorrhagic theory would explain
the presence of this fibrinous membrane by stating that blood
had effused from somewhere, and that the red-blood corpuscles
had become decolorized and washed away. Whether a
small quantity of blood extravasated from one bleeding
point could possibly be spread over such a large area in
such uniform and extreme tenuity, and finally if such com¬
plete lixiviation could occur, are matters of extreme doubt
and have never been demonstrated.
We have now concluded the second stage of the formation
of subdural membranes, and we have so far accepted the
xxxix. 14
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212
The Formation of Subdural Membranes, [April,
facts observed by the supporters of the inflammatory theory,
but we have differed in our explanation of them.
The third and last stage of subdural membranes formation
is that of hemorrhage. It is obvious that if low intracranial
pressure be still maintained the strain on the distended
and engorged capillaries will result in rupture with the effu¬
sion of blood. This hemorrhage, unless of the most minute
description, will rupture and escape through the sodden and
loose superficial layer of the dura and will dissect its way
under the fibrinous membrane. As a general rule these
primary hemorrhages, though numerous, are not much
larger than a pinVhead or a pea, and therefore they are easily
retained by the fibrinous membrane. The effused blood
soon coagulates, and then the membrane grows thicker and
stronger. Newly-formed membranes are sometimes got in
this condition, consisting of a large fibrinous expansion,
enclosing small coagulated haemorrhages, or, as Rindfleisch*
describes it, “ a lax, gauzy, yellowish efflorescence, studded
with innumerable bloody points/ 5 As a general rule, how¬
ever, these membranes are not seen till they are much older,
and they are .then found to be much thicker and in layers,
which alterations have been produced by successive haemorr¬
hages. In an old membrane, therefore, haemorrhages of all
ages may be found, some recent and resembling a blood clot,
some discoloured, and still others whose locality is betokened
by large collections of blood pigment, which give a yellowish
or brownish tinge to the membrane. No doubt some slight
irritation of the dura is now produced, and blood-vessels,
which may be seen as reddish threads when the membrane
is raised, pass into the membrane, “ where they break up into
stellate ramifications, 5, f and a low form of organization takes
place, the fibrine becoming fibrous and the cells spindle-
shaped. The newly-formed blood-vessels, being probably
subjected to the same lessened pressure as the superficial
vessels of the dura, also become very “ irregularly dilated,
bulging and twisted/ 5 and “ their calibre is, on an average,
from three to four times wider than that of ordinary capil¬
laries/ 5 ! The walls of these newly-formed capillaries consist
of nothing more than a delicate membrane and sparsely
scattered spindle cells. Under these circumstances it is not
surprising that they also are very liable to burst, and as the
* “Pathological Histology,” p. 302, * Syd. Soc. Tr.,” Vol. lviii.
t Op. cit.
X Op. cit.
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by George M. Robertson, M3.
213
membrane grows larger the vessels grow larger, and the
haemorrhages are sometimes of great sire. A haemorrhage
the size of an egg on the back of one’s hand is frequently seen
in the middle of an old membrane, and this is sometimes called,
when recent, a “ haematoma of the dura mater,” and when
old and containing brown serous fluid, an “ arachnoid cyst.”
According to the supporters of the haemorrhagic theory,
even large haemorrhages are not necessarily retained by two
layers of a previously existing membrane, for they believe
that when much blood is effused in the subdural space it may
be retained by coagulation of the fibrine on the external and
internal surfaces, and it subsequently adheres to and
organizes in the dura. The truth of this view has been
demonstrated by experiments by L&borde and Sperling, and
we have such a membrane experimentally produced in a dog
by M. Laborde. Although we have received complete confir¬
mation that this last mode of formation may occur, yet in
many instances there is a gradual beginning, such as we have
described. We have seen so frequently disseminated haemorr¬
hagic spots under a fibrinous expansion, which could not be
accounted for by a sudden profuse haemorrhage, we are con¬
vinced that membranes are certainly antecedent to the
haemorrhage in some instances. Some of those who uphold
the inflammatory theory strongly, but feel bound to admit the
facts of these experiments, get out of the difficulty by asserting
that the clotted blood irritates the dura, so that wandering
leucocytes and vessels enter the clot, and that, therefore,
despite its haemorrhagic origin, the organized membrane is
really of an inflammatory nature.* This, however, is an
evasion, for the question at issue was whether subdural mem¬
brane was produced by a primary inflammation with exudation
or by a primary haemorrhage with subsequent organization.
It will be seen that although we have accepted the observa¬
tions of the inflammatory school, yet we have demonstrated
that the whole membrane may be blood clot, as the sup¬
porters of the haemorrhagic theory assert. We stated at the
beginning that there was part of the truth in both theories,
and we have endeavoured to take what was true in each, and
attempted by offering a new interpretation of accepted faots
to satisfy aU objections.
(To bo continued.)
Note.—P art II. contains an acoount of the physical and general conditions
accompanying subdural membrane formation.
* Christian, “Ann. M6d. Psycholog.,” 1874, Juillet, p. 33.
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214
[April,
CLINICAL NOTES AND CASES.
Case of Endothelial Tumour of the Dwra Mater {with Illustra¬
tion). By F. Lishman, late Clinical Clerk, Northumber¬
land County Asylum, Morpeth.
The specimen to be described was obtained at the post¬
mortem examination of a patient in the Northumberland
County Asylum.
The patient was a man aged 65, who had been an especially
heavy drinker. He was admitted into the asylum on March 22nd,
1892, suffering from dementia due to organic brain-disease. He
was very aphasic and could only say a few words. He had, more
or less, general paraplegia, which resulted from apoplectic attacks
at different times during the few previous years. He died on
June 23rd, 1892, from an ill-defined apoplectic attack a few days
, previously.
On post-mortem examination the brain was found to weigh 44J
ounces. A large amount of fluid—about 6 ounces—escaped on
removal of the brain. The membranes were much thickened and
opaque, but stripped readily.* The vessels at the base were exceed¬
ingly atheromatous. Convolutions were atrophied, brain substance
soft and watery. Subarachnoid fluid considerable. Lateral
ventricles distended and containing slightly turbid fluid. There
was a huge softening in the tip of the left temporo-sphenoidal lobe,
and there were numerous other areas of softening over both hemi¬
spheres. The tumour was situated in the left middle cerebral
fossa, at its anterior part, about one inch from the middle line and
attached to the posterior border of the superior surface of the great
wing of the sphenoid. It originated in the dura-mater, and was
removed with a portion of that membrane. It was about the size
of a walnut, of a pinkish-grey colour and firm consistence; it might
almost be termed of cartilaginous consistence. Its surface was
irregular and somewhat cauliflower-like.
All the other internal organs of the body were carefully examined,
and there was no indication of any other secondary (or primary)
growth.
This case is recorded because of its pathological interest
and comparative rarity. From a clinical point of view it is
devoid of any importance because of the impossibility of
diagnosing the tumour before death, and because such gross
cerebral lesions as are mentioned above were undoubtedly
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Clinical Notes and Cases,
215
Fig. 1. *
* Magnified with Zeiss’ Apochromatic: Nnm. Ap. 0*95; equivalent foons
4 mm. x 250.
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21G
Clinical Note* and Cases.
[April,
capable of producing in themselves, and did produce, such
symptoms as would effectually conceal any that, under other
circumstances, might have added extreme clinical interest
to the case.
Under the microscope the section presents the typical ap¬
pearance of an endothelioma. The large amount of fibrous
tissue arranged in an alveolar-like manner enclosing groups
of cells, crowded together, concentrically laminated, and
which are endothelial in character; this, with the blood
vessels running in the stroma, gives us the pathological
picture of a true endothelioma. (See Figs. 1 and 2).
In using the term €€ endothelioma,” a confusion will
result if a distinction be not drawn between this and other
tumours into which endothelial elements enter ( e.g ., alveolar
sarcoma).
In endothelioma the endothelial cells are derived solely
from the serous lining membrane of the lymphatic vessels—
this is not the case in other forms. Ziegler in his latest
book has arrived at this conclusion, as a method of dis¬
tinguishing and defining the true epithelioma. He further
states that typical cases of the tumour show columnar pro¬
jections of these conglomerated endothelial cells, indicating
the course of the lymphatic vessels, and these, when cut
transversely, will show a lumen if it is not already
obliterated. There does not yet appear to have been
described a case in which the lumen of the lymphatic vessel
has been observed. It is specially interesting, therefore, to
observe in this section what is apparently such a distinct
demonstration of the above opinion expressed by Ziegler. In
parts of the section the columnar arrangement can be made
out where the vessel has been cut longitudinally, but these
can only be followed for a very short way, as they are
probably very irregular in their course. Very many columns
are seen to be cut transversely, and nearly all of these seem
to have a complete occlusion of their lumen; in the centre
of some few of these, however (which are shown in the
figure), there is a distinct lumen with its surrounding wall,
giving every evidence of an advancing proliferation of its
endothelial cell-elements, which would, no doubt, in time
completely occlude the lumen.
Endotheliomata are of a benign character and probably of
slow growth, seldom giving rise to trouble except by direct
pressure on vital parts of the encephalon.
In considering the diagnosis of endothelioma its resem-
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1893.]
Clinical Notes and Cases .
217
blance in certain points to the alveolar sarcoma and carcinoma
must be borne in mind. These three tumours present some
marked resemblances. All have the arrangement of alveoli
supported by fibrous tissue, and all have their blood vessels
not running in and anastomosing between the individual
cell-elements, as in most of the sarcomatous tumours, but
running in and supported by the fibrous tissue stroma.
In alveolar sarcomata each individual cell is surrounded
by a fine prolongation of the fibrous tissue forming the
supporting framework of the tumour. Further in this tumour
there is never seen the radiating arrangement nor the true
processes of the special cell-elements as observed in the
tumours under discussion.
In carcinoma there is not the concentric arrangement of
spindle cells around a central axis. The situation of the
tumour debars it from being a carcinoma, growing from a
fibro-serous membrane which contains no epithelial elements.
The presence and absence of secondary growth would, un¬
doubtedly, weigh in the diagnosis here.
The study of endotheliomata will ever remain a matter of
scientific and pathological interest and curiosity, but prob¬
ably it will never come to possess any measure of clinical
importance by reason of their comparative non-evidence
during life.
My thanks are due to Dr. T. W. McDowall for permission
to record this case, and also to Dr. Whitwell, of the West
Biding Asylum, Menstone, for the careful preparation of the
sections of the tumour.
Syphilitic General Paralysis .* By M. J. Nolan, L.B.C.P.,
M.P.C., Fellow Koyal Academy of Medicine, Senior
Assistant Medical Officer, Dublin District Asylum.
At the present time, when our fin de siecle knowledge of
“ general paralysis 99 enables us to recognize under that
generic term many types of the disorder, and when the
relation between it and syphilis continues a rather vexed
question, little apology is needed for introducing to notice
the following cases. They illustrate unmistakably some of
the instances in which syphilis is solely responsible for what
* Paper read at the Quarterly Meeting of the Medioo-Psyohologioal Assooia-
tion, held at the Mullingar District Asylum, October 27th, 1892.
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218 Clinical Notes arid Cases . [April,
is termed by Dr. Savage “ A process of degeneration which
ultimately produces the ruin we recognize as general
paralysis.”* Whatever may he hereafter formulated from
the present evolutionary crisis in the history of the disorder
there can be but little doubt that syphilis will be one of its
most intimate and important relations. The story of its
methods is briefly sketched in the following two short life-
histories—in one asserting itself in the offspring of its
victims by right of impure heredity, in the other, carrying
death direct into the vital centres by the force of its malig¬
nant virus.
Case I.— Hereditary Syphilis. —General paralysis due to congeni¬
tal syphilis.
History .—J. B., set. 18, admitted September 10th, 1891. Paternal
grandfather died in Richmond Asylum. Patient’s father had been
many years ago “ a show case ” of syphilis in the Dublin hospitals,
furnishing the subject matter for cliniques on nearly every mani¬
festation of specific disease. At present he is convalescing from
an attack of hemiplegia, and is pathologically exalted on every
point—family position, independence, etc.—but on none more than
the fact that he has been so favoured a victim of syphilitic virus,
which he proudly states he has transmitted to his wife and children!
In the case of the patient, the wretched old man would seem to
have watched and noted every evidence of the poison he trans¬
mitted with the interest and joy which a gardener takes in
regarding the successful unfolding and conformation of a prize
exhibit, and, stranger still, he has infected his wife—cachectic and
miserable through her husband’s misdeeds—with the same morbid
and revolting sense of satisfaction! The patient, it would seem,
as a small and sickly infant, had convulsions a few hours after
birth. Subsequently he enjoyed fairly good health to the age of
14, was active, intelligent, and gifted with rather more than
the usual musical talent. When 14 years old he had “ convul¬
sions ” for two days. These were followed by some degree of
mental deterioration. At 16 the fits returned, producing more
marked mental damage, insomnia, change of temper, and loss of
memory. Early in January, 1891, he had four very severe epilep¬
tiform seizures, and on the 27th March one fit, which left him
“ paralyzed,” and since that time to date of admission, a period of
nearly six months, he has had slight attacks, averaging about one
per month, which did not apparently increase the mental or bodily
breakdown.
On admission . —Physical condition .—Patient has the characteris¬
tic physiognomy of the victims of congenital syphilis. Head is
* Tuke’s (t Diet. Psycho. Med.,” Art. “ Syphilis and Insanity,” Vol. ii., p.
1257.
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1893.]
Clinical Notes and Cases .
219
small and misshapen, scars at angles of month, pegged central
incisors ; skin dry and wrinkled; hair scanty, short, and brittle.
Examination of the eyes showed interstitial keratitis. The nose
is depressed. He is miserably wasted, weighing only 7st. 71b. in
his clothes, though five feet five inches in height. His upper
limbs are out of proportion to his body, his lean, withered hands
being unduly long, the joints nodular, and the skin lying in
fissured folds. His pupils are unequal, and irregular in contour,
responding sluggishly to accommodation and light, and but very
slightly to the sympathetic reflex. There is general tremor, and
febrillar twitching of facial muscles. The plantar, knee jerk, and
cremasteric reflexes are very exaggerated. Ankle clonus is well
marked. His gait is hasty, uncertain, and tottering, There is
general cutaneous hyperesthesia. The tongue movements are
jerky, and its extrinsic muscles are very tremulous. The speech
has the most typical characteristics of “ general paralysis ” articu¬
lation.
Mental state. —Patient smiles and grimaces. It is difficult to
arrest his attention, as he is busily engaged in gathering up and
secreting any rubbish that is about. His responses to questions
evidence a marked dementia. Be can tell his name, but not his
age, residence, names or number of other members of his family.
He states that he is feeling “ very well ” and “ very happy,” and
in silly fashion spars at those about him; a moment later he
cringes as if in fear, and whimpers like a beaten cur.
Progress of case. —For six weeks subsequent to his admission
patient underwent very little mental or physical change. His
conduct was practically identical with that of many of the general
paralytics with him in the infirmary, and his physical signs and
symptoms (already noted) continue to correspond closely to their
similar conditions. His speech trouble seemed to increase more
rapidly, perhaps, than his other advancing infirmities, and his
mental state was almost uniformly a restless dementia.
November ls£, 1891.—Suffered from a slight epileptiform seizure,
which was followed by paresis of right side, and spastic rigidity of
his right side. Control over the rectum and bladder lost. Pupils
widely dilated, unequal, and very tardy reaction to light. A few
hours later decubitus acutus formed over sacrum. Is unable to
respond to any questions, or comprehend any direction. Very
weak; temp, 100*6; pulse 90. Mentally apathetic.
November 3rd.—General spastic rigidity. Marked fibrillar
twitching of all muscles, most pronounced on the vastus externus.
Increased hyperaesthesia over spine. Temp. 102° ; pulse 97. Con¬
dition in other respects unchanged.
November 4th. —Rigors. Deep flush over malar prominences.
Cardiac action feeble and excited. Pulse 110; temp. 104°.
Grinds teeth and makes masticatory efforts.
November 5th .—Pupils regular, with brisker reaction. Further
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Clinical Notes and Cases.
220
[April,
increase in patellar, plantar, and cremasteric reflexes. Temp.
100°; pulse 90.
November 12th , 1891.—Apparent slight improvement during
past week. Temperature ranged between 100° and 101°, pulse
about 90. Mentally has become excited, shouting, crying, and
destructive.
November 17 th. —Continued as last noted for past five days. To¬
day several petechial spots appeared on the chest, arms, and legs,
and large purpuric extravasations over the buttocks and abdomen.
He became very prostrate, refused food and medicine, and gradu¬
ally collapsed, his temperature falling to 97° on the 20th. He
died on the morning of the 21st, death being preceded by a succes¬
sion of slight convulsive seizures.
Post-mortem examination .—Calvaria thickened and asymmetrical.
Dura mater adherent, thickened and rough. Pia mater opaque
and thickened; when removed left the convolutions exactly as in
general paralysis. Cerebrum small, with badly marked and inde¬
finite fissures. Brain substance soft and watery; ventricles
distended with fluid. Examination of viscera showed large
syphilitic gumma of right pleura extending from the second to
the fifth rib.
Lungs and heart small, but healthy. Stomach small; intestines
diminished in lumen; mucous membrane opaque and jelly-like,
giving amyloid reaction. Liver, spleen, and kidneys were atro¬
phied, and gave amyloid reaction.
Remarks. —The physical signs and symptoms indicative of
“ general paralysis ” are fully confirmed by the post-mortem
appearances, which were absolutely typical of the most
characteristic lesions noted in that disorder.
Possibly cases of this kind are not as rare as asylum
physicians would incline to think from their intern expe¬
rience, as for many reasons they may not find their way into
these institutions. On the other hand, in general hospitals
they may very probably sometimes be confounded with the
“ juvenile dementia of inherited syphilis,”* with which it
has many points of contact in its symptomatology, but it
will be remembered that pathologically they are wide as the
poles asunder. Again, had this patient died at home his
terminal illness, so very suggestive of meningitis, would
have diverted attention from the real nature of the case
were not the full antecedent history known to the physician.
Case II. — Acquired syphilis .—General paralysis of local cerebral
origin (gumma in the right frontal lobe).
* See Tuke’s "Diet. Psycho. Med,,” Article “Syphilitic Disease*’ (Dm.
Barlow and Bury), Vol. ii., p. 1267.
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1893.]
Clinical Notes and Cases .
221
History .— A. B., set. 41, admitted 27th February, 1892. Van
driver. No hereditary history of insanity, or evidences of collateral
neuroses. Married 25 years; very industrious habits, anxious tem¬
perament, moderate sexual appetite, and remarkably temperate. Six
years prior to admission patient returning from a friend’s house late
at night, and fuddled by three glasses of whisky which he had
taken, had connection with a prostitute, from whom he contracted
a hard chancre. In recognition of his uniformly excellent character
and the exceptional circumstances that led to his offence, his wife
forgave him, so that their cordial relations remained unchanged.
He suffered in due time from all the constitutional evidence of
syphilis, which he gave to his wife, who became a victim of grave
specific uterine disease. At the end of three years all active
symptoms ceased, and for the two years immediately following
they enjoyed fair health. About thirteen months prior to his
admission Mrs. B. noticed that her husband, who had previously a
very acute sense of smell, could no longer perceive any odour, and
about the same time he became sleepless, dull, and very forgetful.
Later he complained of a fixed pain in the right antero-lateral
cephalic region, and this increased in area and intensity until it
invaded the entire right side of cranium, and was so severe that
he frequently screamed aloud, struck his head violently against
the wall, and at night, when its exacerbations were at their
maximum, he was accustomed to hold it under a water tap, and
tie cords as tightly as possible round the scalp. The apathy,
insomnia, and amnesia increased daily, and taste hallucinations
became prominent. His action became purposeless, his move¬
ments uncertain, and general tremor set in, at the same time that
he began to lose sexual power and desire, which latter had been
for a brief period abnormally strong. His broken slumber was
disturbed by dreams of a distressing character. Three weeks
prior to admission he dreamt that he had made a post-mortem
examination of his wife’s remains and removed all her viscera.
After this he became very violent, threatening, and obstinate*
Two days prior to his admission he recurred to the dream and
said, “ I have that post-mortem to make yet! ” Since then he
had been annoyed by visual hallucinations, “ seeing the room full
of men,” and was very much excited, struggling with his imaginary
assailants.
Diagnosis .—Syphilitic tumour of brain, with paretic dementia.
On admission.—Physical condition .—Patient is suffering from a
cachexia, which has already resulted in advanced marasmus. The
gait is tottering and the wasted limbs are ataxic in their move¬
ments. There is marked general tremor, and pronounced fibrillar
twitching of the muscles of expression, which are also flattened.
The patellar, plantar, and cremasteric reflexes are all exaggerated,
and there is well-marked ankle clonus. Cutaneous sensibility
much increased. Tongue clumsy and ataxic in its voluntary
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222
Clinical Notes and Cases.
[April,
movements; tremulous, indented, and flabby when at rest. The
pupils are small, irregular, and unequal; sluggish in their response
to direct consensual and light stimuli, and fixed to the sympathetic
reflex. The movements for accommodation are spasmodic and ill-
directed, the pupillary reaction being slow and incomplete.
Absolute loss of smell. Sight normal. He is unable to hold a
writing pen when placed between his fingers, likewise he fails in
efforts to button or unbutton his clothes. On close examination
the cicatrix of a chancre on the glans, the scar of a bubo in the
groin, and traces of characteristic specific eruptions are detected.
The respiration is quick and shallow, pulse small and feeble ; tongue
coated with a thick, dirty, creamy fur. His pronunciation is
blurred and chippy. Voice is broken, resembling a hoarse
whisper.
Mental state .—Patient stands or sits in an attitude of rapt
attention, gazing fixedly into distance; his features set and
immobile, tne want of expression indicating dementia. He re¬
sponded to questions in a low, awed, despondent voice, saying as
few words as possible to express his meaning. Now and again he
shook his head hopelessly, and repeated in a tone pregnant with
despair, “ I am done. A bad business. I am done.” When put
to bed his tremor increased, and a few minutes later he was seized
with a slight epileptiform convulsion, during which he passed
water involuntarily. Scrambling out of bed with repeated
clumsy efforts he remained with outstretched feet, swaying to
and fro, trembling violently all over, and almost unconscious of
his surroundings.
Progress of case .—For twelve days following there was rapid
mental and physical deterioration. He sat all day in one place,
limbs all flexed, neck craned forwards, eyes gazing into the
distance, and expression that of intent listening. He could be
roused with great difficulty from this state, and he could not tell
day of week, month, or year; but gave details of imaginary events
.of the previous day; of his supposed walks, visitors, and other
doings. On the 12th March he had a violent epileptiform seizure,
the convulsions causing him to fall out of bed. This was followed
by an increase of the dementia; he could no longer respond to
questions, nor could his attention be fixed. While confined to bed
he lay in a state of general flexion ; there was marked rigidity of
the limbs, tendency to acute bed-sores, spasmodic masticatory and
swallowing movements, and almost constant grinding of the teeth.
The reflexes became more exaggerated, and general hyperaesthesia
was well marked. On the 30th March bull© formed over the
metatarso-phalangeal articulation of the left foot, followed next
day by an acute diffused erythema extending to the knee. Three
days later the bull© burst, and exposed a sinus leading down to
diseased bone, and giving exit to exceeding foul pus. The sinus
was enlarged and dressed antiseptically, with the result that the
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Clinical Notes and Cases .
223
•
diffuse inflammation subsided, and Healed on discharging some
dead bone, but repair was slow. Meanwhile there was a very
marked remission of the dementia, he became bright, answered
questions readily, and even volunteered remarks. Gradually,
however, his expression became more and more “wiped out;”
general and facial tremor increased, yet on the 26th April he was
noticed to have spoken more intelligently than previously. Control
over the bladder was impaired, and he was out of bed and rolling
about the bedclothes at night. On the 30th he had slight but
frequent epileptiform seizures, after which his expression became
suddenly exceedingly fatuous; he could not be induced to speak, and
his tongue when protruded was deviated to the right side. On
the 1st and 5th of May he had several slight epileptiform and syn¬
copal seizures and became alarmingly weak. Mentally he was mute,
fearful, and emotional. He remained in this state until 8 o’clock
p.m. on the 7th, when he was seized with epileptiform convulsions.
The left side became rigid, the right relaxed; lower jaw drawn
down and back; tongue projected and directed to right side;
strings of thick mucus hanging from the mouth; pupils dilated
and insensible to light; plantar reflexes absent; temperature rose
suddenly from normal point to 102°; pulse 80, small and
compressible; conjugate deviation of head and eyes to the left
side. He died at 11 o’clock same night, six years from the
date on which he contracted syphilis, one year after the appear¬
ance of the first mental symptoms, and ten weeks from the first
convulsive seizure and committal to the asylum.
Post-mortem examination .—By the express injunction of the
relatives this was unfortunately limited to the cranial cavity.
Scalp and calvaria normal. Ho adhesion or thickening of
membranes over the vertex, but vessels of the pia mater were
engorged. The convolutions were normal in appearance, their
configuration being particularly well defined, the membranes being
readily separated from them. On the under surface of the brain,
over the region of the right inferior frontal convolutions, the
dura mater seemed adherent to the brain surface, and also to the
bone beneath. On separation from the latter, which was normal
in appearance, the condition was found to be due to the presence of
a firm tumour embedded in the substance of the brain ; its base
rather pear-shaped, pressing on the orbital surface of the frontal
bone. It bridged obliquely across the tri-radiate fixture, receiv¬
ing in its caudal and external end the roots of the olfactory tract;
the remains of the olfactory bulb were contained in the rounded
and distal extremity. The dura mater was closely adherent to
the presenting base, forming a dense fibrous floor for the support
of the tumour. This condition contrasted markedly with the
freedom of the membranes from attachment in any other region.
On removing the tumour from the nest of congested and partly
softened cerebral matter in which it lay, it was found to be about
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Clinical Notes and Cases.
224
[April,
the size and shape of a small walnut. It presented all the usual
characteristic appearances of a syphilitic gamma.
Remarks .—Apart from its resemblance in every detail to the
classic cases of gummatous cerebral growths (recorded by
Lancereaux and others) associated with mental disorder and
paralysis, some special points of interest may be briefly men¬
tioned.
(a.) In the absence of any history the case when it first
came under notice would have seemed identical with
“ general paralysis” of non-specific origin. The advanced
dementia rendered it very difficult to test smell, and even
when discovered that the sense was lost, the fact would
probably be attributed to widespread rather than a very
circumscribed brain lesion.
(b.) The fact that hallucinations of taste set in soon after
the anosmia would point in this case of local cerebral disease
to the close proximity of the cortical areas for the senses
engaged—a point yet unsettled by physiologists. The left
olfactory bulb, though apparently healthy, was quite
inactive, the patient having had complete loss of smell.
It is probable the destructive lesions were propagated into
the centric origins of the nerve roots.
(c.) The association of spastic spinal symptoms with
frequency of fits and mode of termination indicates very
probably degeneration of the pyramidal tracts of the cord.
This, unfortunately, could not be determined. Were it
demonstrated it would prove the co-existence of the two
classes of cases which Savage terms te true general paralysis
of local (syphilitic) cerebral orgin,” and 66 general paralysis
of syphilitic origin, with spastic spinal symptoms.”
(i d .) Prior to the development of the characteristic
“ hemicrania ” the pain of an intense neuralgic kind was
referred to a spot a little in front of the tip of the right ear,
the patient sometimes introducing his finger into the mouth
and pointing upwards to indicate its centric situation. Had
the case been seen at this stage it might have given way to
brisk specific treatment, which could not overtake the
ravages the disease had made when it came under notice.
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Clinical Notes and Cases .
225
Notes on a Case of Acute Insanity with Sexual Perversion . By
William C. Sulliyan, M.B., Clinical Assistant, Rich¬
mond Asylum, Dublin.
The case which, by the kind permission of my chief, Dr.
Conolly Norman, I am enabled to bring under your notice
to-day, is one of acute insanity occurring in a male adolescent,
and marked in its course by the somewhat unusual symptom
of sexual perversion.
Patient, J. D., a youth of 21 years. No insane or criminal
heredity; suffered three years ago from an attack of post-
febrile melancholia, with hysterical symptoms, from which
he made a good recovery. From that time up to onset of
present attack enjoyed good mental health; was not addicted
to masturbation, but indulged in sexual intercourse. For
some two months before admission had been intemperate.
Present attack, commencing with excitement, passed into
depression, verging upon stupor, in which condition patient
was admitted to the Richmond Asylum July 4th, 1892, pre¬
senting at this time the usual symptoms of deep melancholia.
His genitalia were normally developed, but his expression is
noted as effeminate, and the prominence of the pomurn
Adami was absent, partly owing to hypertrophy of thyroid.
Patient masturbated constantly.
Throughout July the case presented the appearance of an
ordinary melancholic attack, with numerous hysteroid
symptoms.
In August it is noted :—" Patient seems a little brighter.
Appears to have developed amorous feelings towards one of
the officers, Mr. X., gazing at him ecstatically, following
him about, and declaring that he c loves ’ him. Questioning
patient elicits that the feelings aroused are of a sexual
^ature.” This condition lasted about three weeks, passing
olff gradually as the other mental symptoms improved.
I On September 3rd it is noted :— “ Patient has now quite
m 'ecovered, and is able to give a clear account of his mental
* itate during attack. . . . Confirms statement that his feel¬
ings towards Mr. X. were of the above-mentioned nature;
such feelings were also excited by sight of certain of his
Eellow patients. . . . During his illness patient had suffered
irom frequent attacks of globus hystericus, followed by
jolyuria and profuse sweating.”
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Clinical Notes and Cases.
[April,
Remarks .—From this clinical history it will be observed
that the condition of perverted sexual reeling was merely an
episode in the melancholic attack. The patient, while in
mental health, had no unnatural desires, and in all proba¬
bility was not in the habit of masturbating; but only in his
disease he develops this habit, and subsequently manifests
feelings of sexual perversion—a sequence of symptoms which
rather suggests a relationship of cause and effect between
the masturbation and the perversion.
If such a relationship be admitted, this case would go to
support the view that ordinary cases of sexual perversion
may originate by a similar evolution, and that they are not
necessarily the result of any innate condition.
Hypertrophy of the Scalp in a Lunatic. By Dr. Pooai.
(Communicated by Dr. McDowall, Morpeth.)*
The subject who presented this anomaly of development of the
scalp was M. B., aged 66, a peasant woman from the province of
Comasca. Of medium height, regular conformation of body, dark
complexion, irides dark chestnut, thick and black eyebrows, hair
thick, strong, black, with only a few white ones, notwithstanding
her advanced age. Her mother, a brother, and a sister have been
insane. She suffered some years ago from puerperal mania, and
was finally admitted to the asylum at Como labouring under
simple lypemania, on 25th March, 1884. She died suddenly from
syncope on the 27th of the same month. The autopsy revealed
advanced fatty degeneration of the heart and liver.
The scalp covering the posterior and part of the upper portion
of the head is much thickened, and presents numerous and deep
furrows in a transverse direction, curved, with the concavity
upwards, produced by thick elevations of the skin, which seems
hypertrophied.
These folds and the resulting furrows are arranged with a
certain amount of symmetry round a. furrow which may be con¬
sidered central , running in a straight line from back to front, anjd
starting at the vertex, follows the direction of the sagittal sutuiU
for a distance of five centimetres, and has a depth of abour
three millimetres. Round this upper central furrow goes a
second, which, from being cut off in front at the level of the
anterior stem of the central furrow, has the shape of a U, ancj
limits a fold of about one centimetre in breadth. This firsll
* Dr. Karelia, of Brieg Asylum, Breslau, was kind enough to bring thii
case under my notice.
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Clinical Notes and Cases.
227
fold is in its turn similarly surrounded by a second, the second
by a third, and thus five others follow, always concentrically—
altogether eight folds covering the whole posterior portion of the
head.
The regularity of these furrows is only partially interrupted
between the fifth and sixth folds by the existence of some connect¬
ing folds at that spot.
The folds gradually become more voluminous from above
downwards, so that whereas the first, as before mentioned, is only
one centimetre broad, the lower ones measure two centimetres.
The same is true as to the depth of the furrows, which is greater
in the lower portion. The greatest depth is in the middle line,
and gradually diminishes, disappearing at the upper and lateral
parts of the head.
The skin of the folds reaches a thickness of twelve millimetres,
that of the furrows four millimetres.
The rough, coarse, and abundant hair followed the various
directions of the folds, and grew even on the lateral and most
hidden portions into the deepest part of the furrows.
To this very rare anomaly of the scalp, which gave the outside
of the head the appearance of a brain, there was no corresponding
important alteration either in the bones, the meninges, or brain;
nor were there special adhesions between the skin and the perios¬
teum, which might have caused such a genuine hypertrophy of the
skin as to force it into folds. Further, this anomaly having
existed from youth, cannot be attributed to tugging by combing,
and we must consider it congenital.
xxxix. 15
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Clinical Notes and Cases.
[April,
I must further refer to the skull, the cephalic index of which
was 76*5. It presented traces of the lambdoidal and sagittal
sutures, and a slight superior occipito-parietal platycephaly.
The occipital convolutions of the external surface of the brain,
two in number, were very voluminous, not much convoluted, but
rather simple in configuration. The lower posterior terminal
branch of each calcarine fissure was wanting. Each calcarine
fissure ended in a single sulcus; the right one turned obliquely
upwards, and the left continued transversely, for two centimetres,
to the superior occipital surface.—(From the “ Archivio di Psichi-
atria,” v., f. 2-3, 1884. Torino.)
OCCASIONAL NOTES OF THE QUARTER.
Mr. Irving 9 % “Lear 99
Shakespeare so clearly held up the mirror to nature that
every special student finds his specialty recognized by the
great dramatist. We do not for a moment suppose that
Shakespeare made a prolonged study of the insane or of the
mental defects associated with senility, yet when he came
to portray a weak-minded old man his observation in no
way misled him, and we have in his Lear one of the
most masterly descriptions of a demented king that any
literature, whether special or general, can provide.
Lear and Hamlet have been particularly looked upon
as psychological studies, and they will ever provide food for
further investigation. Here we are chiefly concerned with
a particular actor’s representation of one character. We
do not think with many—particularly German critics—that
Shakespeare is for the study and not for the theatre. We
should rather say he is for the theatre as well as for the
study, as much as the Bible is for the church and for the
closet.
We can add little to the criticism of the play itself, or to
the morbid psychology of Lear. These subjects have been
considered and reconsidered till they form a literature of
their own. Dr. Bucknill, in 1859, published in his “ Psy¬
chology of Shakespeare 99 a very careful study of King
Lear, and we would strongly recommend our readers to
consult this essay. Dr. Bucknill recognized, as a practical
psychiatric physician, that Lear’s reason was tottering
before his daughters’ misconduct produced a further de-
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229
Occasional Notes of the Quarter.
gradation of mind. It seems strange tliat so few appear to
have fully recognized this, and by some reviewers of Irving’s
acting his recognizing this has been looked upon as a dis¬
covery of his.
At the very outset Irving represents Lear as restless,
irritable, boisterous, and beside himself. The mannerisms
of the actor are marked in the earlier scenes, but either
they are suppressed by the actor himself, or are so '
masked by his deeply pathetic acting in the later scenes
that they can give offence to no one; Irving becomes the
fierce, generous King, who, having always acted in a head¬
strong way, as he loses self-control, becomes more and more
headstrong and wilful.
Perhaps the boisterousness of the first part is a little over¬
done, but it makes a very fine contrast to the misery,
at first half-dumb, then incoherently voluble, of the old man
who had discovered himself to be a fool. The eloquence of
Lear and his prolonged speeches have at times been looked
upon as being inconsistent with senile decay.
We, on the other hand, know that eloquence in old age
may outlast judgment, and may be associated with varying
degrees of moral and intellectual or sensory defects. Lear
is represented by Irving as being in a great hurry, being
restless and anxious to get rid of all his worries and to have a
good and easy time. He is certainly “ made up ”—to our
thinking—rather too old, and it is astonishing to the spectator
to see the physical energy of one so aged. In the scenes
where Lear discovers that he is deceived by his daughters,
Irving very finely represents the slow growth of his doubt of
Goneril and Regan, and his equally slow appreciation of
Cordelia. The scenes with Kent, with Gloster, and with the
Fool are all that could be desired. The King, formerly so
exacting, is seen to be losing his grip of the world; he is
passionate, but doubtful; at one moment tolerant of what
appears to be insolence, and in the next passionate at
ingratitude. We cannot go into each scene, but must pass
on to the shock of the death of Cordelia. The old man,
with tottering mind, is rendered insane by the griefs and
worries produced by his daughters; then the deeper grief of
the sense of his ill-treatment of his youngest daughter and
of her death produce a temporary return of reason before
the end. Irving does not over-act here; the restoration
of reason is felt to be a passing change, and one is led to see
the beautiful reconciliation of father and child in death.
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230
Occasional Notes of the Quarter.
[April,
Irving’s death scene is pathetic and natural, and is without
the ghastly realism which the French stage has used us to.
The whole character is well maintained, and we look upon
Irving’s Lear as one of the representations which will
live in the history of the stage.
We may, perhaps, add one or two points on the play
itself.
First, we have frequently been struck by the great increase
of appetite and, apparently, of digestion which may occur
with senility. Shakespeare represents Lear as being very
hungry. “ Let me not stay a jot for dinner. Go, get it ready.
Dinner, ho, dinner! ” This is probably of little moment,
but we think it is another point showing the precise know¬
ledge of the poet. We have a recollection of a proverb to
the following effect: “ Give a thing, take a thing, an old
man’s plaything.” We should like to know the source of
this; it represents Lear’s frame of mind, and we have met
with at least one case in which a man of near 80 gave
away his property to his heirs, and then accused them
of stealing it and of neglecting him. We have looked for
signs of loss of recent memory in Lear, and have not found
them, though we should have expected them.
There are several points in reference to the daughter’s
conduct which need notice. First, Cordelia, knowing as she
did her father’s mental weakness, had no business to behave
as she did. In Shakespeare’s time, beside punishing the
insane, it was considered necessary to humour them, and we
have always thought that Kate, in “ Taming the Shrew,”
really was not so weak as supposed, but was acquiescing in
what she supposed to be the delusions of a lunatic.
Cordelia ought to have known this much, and ought not
to have thwarted her old doting father. We are inclined to
think that she was the child of old age, and was probably
rather weak mentally herself.
Then as to the other daughters we do not intend to
whitewash them, but anyone who has had much to do with
senile dements knows that such people upset ordinary house¬
holds enough, and that in a semi-barbarous court they would
be not only intolerable, but they would lead to brawls and
license such as Goneril describes.
“ Every hour he flashes into one gross crime or another,
That sets us all at odds. I'll not endure it. 7 ’
(f His knights grow riotous,” etc. In this passage, too, is
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1893.] Occasional Notes of the Quarter.
the only suggestion that in Lear, as in many old men, there
may have been uncontrolled lust. “ One gross crime to
another” might easily bear this interpretation. The foolish
old man divided his property in the degeneratingly generous
way, only to regret it; when he finds his personal importance
lessened, he loses rapidly more self-control with each fresh
buffet of misfortune, and passes away naturally enough.
In the play we have also the natural fool and the pre¬
tended lunatic, and we think all the parts were well taken,
and the characters sustained, but as we really only intended
to refer to Irving we must refrain from further comments.
Roe v. Nix .
The facts of this remarkable and extremely narrow case,
which was tried by Mr. Justice Gorell Barnes and a special
jury, at the close of last year, are too fresh in the minds of
our readers to require or to justify recapitulation at any
length, and it may suffice to state that the point at issue
was whether certain testamentary documents executed by a
Chancery lunatic, Miss Ellen Roe, were or were not vitiated
by the alleged mental unsoundness of the testatrix. The
evidence was very evenly balanced. On the one hand, Miss
Ellen Roe had been found lunatic by inquisition ; no super¬
sedeas had been obtained. The Lord Chancellor’s visitors
were of opinion that she did not possess testamentary
capacity at the critical period ; the deceased lady had pro¬
posed to bequeath her property to the Dean of Norwich,
and to leave legacies to the Archbishop of Canterbury and
the Lord Chancellor, and a strong effort was made to show
that she was under the influence of an insane aversion
towards her sisters, and that the case, therefore, came
within the ratio decidendi of Dew v. Clark and similar
authorities. On the other hand, it was contended, and
evidence was adduced to prove, that the only form of
insanity from which Miss Roe had ever suffered was tem¬
porary alcoholism, and that her aversion to her sisters was
at first merely the indifference caused by long absence
from home, and afterwards the dislike which the inmate of
an asylum is apt to feel to the persons whom she supposes
to have put her there. It was also proved that one of the
Chancery Visitors had expressed an opinion that Miss Roe
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232
Occasional Notes of the Quarter . [April*
might be allowed to make a will—although, of course,
without undertaking to say that it would be valid—and that
the actual preparation and execution of the disputed
instrument were preceded and accompanied by every
possible precaution on the part of testatrix’s solicitor. In
the event the jury pronounced in favour of Miss Roe’s
testamentary capacity—a conclusion at which we might
not perhaps have been able to arrive—but which it was
perfectly possible for reasonable men to adopt under the
circumstances, and the verdict was received in Court with
the popular applause which the judicial obliteration of the
stigma of insanity never fails to elicit. The course of this
case was seriously impeded by the fact that all the reports
of the Chancery Visitors with regard to Miss Roe were pre¬
sumably destroyed at her death, and, at any rate, were not
forthcoming for the purposes of the trial. We trust that
Section 186 of the Lunacy Act, 1890, which renders this
absurdity possible and lawful, will receive the early attention
of the Legislature.
Morley v. Loughnan .
The case of Morley v. Loughnan is equally interesting to
the student of human nature, the lawyer, and the psycho¬
logist. The details of the strange and painful story on
which it turned are, no doubt, familiar to our readers, but a
sketch of the salient features may not be inopportune. The
late Mr. Henry Morley, from whom the defendant, Mr.
W. H. Loughnan, a prominent member of the Close Sect of
Plymouth Brethren, was alleged to have obtained sums of
money, amounting to about £140,000, by undue influence,
was an epileptic, possessed the exaggerated warmth of
sentiment, the liability to alternate depression and elation,
and the need for external guidance, which epileptics fre¬
quently display, and though not positively insane, passed at
least the greater portion of his life on the borderland
between the world of sane men and the realm of minds
diseased. Conscious of the risks to which his son’s mental
condition exposed his substantial fortune, Mr. Morley’s
father had placed him under the friendly control of “ com¬
panions ; ” and, when the narrative opens, this desirable
appointment had just fallen to the lot of Mr. W. H.
Loughnan. In the creed of the Close Sect of Plymouth
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1893.] Occasional Notes of the Quarter.
Brethren the duties of entire dedication of property to
religious purposes and sequestration from worldly society
hold a cardinal place, and Mr. Loughnan laboured faith¬
fully, and not without success, to imprint them upon the
mind of his impressionable ward. At no time, however,
was the balance between these great principles very accu¬
rately adjusted in Mr. Loughnan’s teaching. At first the
duty of dedication received excessive prominence, and Mr.
Morley was dramatically asked whether the luxury with
which he was surrounded was worthy of a disciple of Christ.
Then the duty of sequestration became the lesson of the
hour, and the imperative claims of dedication were somewhat
feebly insisted on. At length Mr. Morley, after having
written a letter of farewell to the world, went to live with
his protector. Mr. Loughnan lent himself nobly to the task
of making his self-invited guest’s seclusion from tempo¬
ralities complete, managing his business, conducting his
correspondence, accepting large donations from his super¬
abundant wealth, and drawing around him a close cordon of
associations, corroborative of his own influence, from which
Mr. Morley was only released by the hand of death. Then
it appeared that Mr. Loughnan had benefited by his ward’s
weak generosity to the extent of £140,000, and the executors
of the deceased gentleman properly subjected the nature
of the relationship that had existed between Mr. Morley and
his “ companion ’’to the searching scrutiny of the Chancery
Division. Into the miserable devices by which Mr. Loughnan
endeavoured to resist first, the executor’s claim, and,
secondly, the exposure which its prosecution involved, we need
not enter. Suffice it to say that Mr. Justice Wright, sitting
as an additional judge of the Chancery Division, held that
the gifts from Mr. Morley to the defendant were vitiated by
the undue influence of the latter, and that the plaintiffs
were entitled to receive the whole amount from him, and
even from the innocent subdonees into whose hands part of
the spoil had passed. We observe with surprise the state¬
ment in the pages of a legal contemporary that " this case
presented no new legal difficulties.” The inaccuracy of this
assertion is readily demonstrable. There are two classes of
cases in which donations are set aside on the ground of
undue influence; first, cases in which there is positive
evidence that coercion has been brought to bear upon the
donor; secondly, cases in which there existed a relation
between the donor and the donee, capable of giving, and
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284 * Occasional Notes of the Quarter . [April,
calculated to give rise to undue influence, and the donee is
unable to prove affirmatively that the donor had independent
advice. Mr. Justice Wright held that in the case of Morley
v . Loughnan there was positive proof of undue influence
having been exercised. But his lordship was also prepared
to hold, if necessary, that the relation between Mr. Morley
and Loughnan was such a relation as brought the defendant
within the second class of cases above referred to, and threw
upon him the onus—which he had utterly failed to dis¬
charge—of vindicating the voluntary character of the
gifts. This, if we mistake not, is a distinct advance upon
previous decisions, and it will render the law of undue
influence for the future much more difficult of evasion than
it has been in the past.
Compulsory Legislation for Habitual Drunkards .
In the year 1890 the late Dr. Henry Monro sketched the
following suggestions for a petition to Parliament on the
subject of habitual intemperance.
Compulsory powers required. —That medical men should sign a
statement that they consider certain forms of inebriety the result
of disease , and consequently that such cases need the only remedy
which is likely to prove of any real benefit, viz., compulsory seclu¬
sion in retreats or homes suitable for their treatment and cure.
Voluntary seclusion inadequate. —The present law permitting
voluntary seclusion is almost useless, as persons suffering from the
disease have a wholly enervated will , and are, in consequence,
usually incapable of the resolution necessary to take any such
steps of their own accord, for the purposes of their own cure,
however much they may desire from time to time to escape from
the overpowering impulse towards alcohol.
Method of certifying. —We would therefore earnestly entreat for
legislation on the special point of compulsory seclusion under some
such provisions as the following:—
We would suggest that one member of the family of the inebriate
(or two if deemed more desirable) should “ request,” two medical
men should “certify,” and some judicial authority should be
instituted, say a Commissioner for Intemperance, or Magistrate, or
any other officially appointed person, to “ authorize ” any such cer¬
tificate for seclusion.
Objection to ordinary lunatic asylums. —We do not deem it
desirable for the ordinary lunatic asylum to be assigned for the
reception of these cases, “ as, though such persons have lost
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1893.]
Occasional Notes of the Quarter,
235
ordinary moral control as regards alcohol, they are not deemed
insane in other matters.”
The kind of retreats desirable. —We think that retreats for these
cases should be public institutions, managed by Committees
possibly; but under medical care analogous to the existing
lunatic hospitals (payment being made by those capable of pay¬
ment) ; and it might be advisable further to suggest that the
same certificates should cover the seclusion in private houses, if
more acceptable to the relations of the inebriate.
Period of detention and leave i of absence clause. —We would
further suggest that the period of time covered by these certifi¬
cates should in no case be less than one twelvemonth; though
fixed periods of absence might be granted during that time, at the
discretion of the medical officer of the institution, on probation , as
is permitted by the Lunacy Laws, provision being made for the
immediate recall of such patient upon the least breakdown prior to
the specified time for the return of the case.
Security for sufferers under this disease. —We cannot help believ¬
ing that with some such provisions as those suggested above, all
possibility of any acts of injustice would be avoided, and a means of
cure provided for a daily increasing disease which it is impossible
for the medical profession to treat effectively without the support
of the State.
It has been thought well to carry out these suggestions,
the essential feature of which is the compulsory instead of
the voluntary seclusion of inebriates whose lamentable
habits are due to disease. An opportunity for making an
effort in this direction has occurred, in consequence of a
Departmental Committee having been appointed by the
Home Office. This Committee not having closed its sittings,
a memorial was drawn up for presentation to this Committee,
and a number of influential signatures were obtained in
support of its prayer. We think it well to place it on
record in the pages of this Journal, and trust that no long
time will elapse before compulsory restraint will become
legal, at once for the benefit of the inebriate, and in order to
mitigate the intolerable misery from which his family, in
countless instances, suffers.
Copy of the Memorial.
We, the undersigned, members of the medical profession, having
had experience of the great difficulty which now exists in dealing
with inebriates, respectfully urge upon the Committee the pressing
need of further legislation concerning them.
At present provision is made to a very limited extent by the
Inebriates’ Acts, the essential feature of which is that a person
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236
Occasional Notes of the Quarter,
[April,
may place Himself under restraint for a period not exceeding a
twelvemonth. This has been found to be of limited value, the
proportion of persons, especially ladies, who will go before magis¬
trates and voluntarily place themselves under restraint is small,
and we think that unless the clause is repealed which requires
appearance before two Justices, the Acts will remain of little
value.
We earnestly desire the compulsory restraint, with all proper
safeguards, of those men and women who cannot control them¬
selves in this respect. We are of opinion that much good may be
done to inebriates, if compulsory detention can be enforced for a
sufficient time, and if upon release and subsequent breakdown,
they can again be placed under control without delay or difficulty.
William Jenner, M.I
Henry W. Acland „
George Johnson „
Bichard Qnain, „
Edward H. Sieveking, „
William Munk, „
Alfred B. Garrod, „
John W. Ogle, „
Samuel Wilks, „
John S. Bristowe, „
Charles J. Hare, „
J. Bussell Reynolds, „
W. O. Priestley, „
George Harley, „
B. W. Bichardson, „
George Buchanan, „
J. Andrew, „
C. Lockhart Robertson, „
E. Symes Thompson, „
J. Langdon-Down, „
G. Fielding Blandford, „
W. H. Broad bent, „
W. S. Playfair, „
W. S. Church, „
W. B. Cheadle, „
Dyce Duckworth, „
J. Fayrer, „
Peter Eade, „
Thomas Buzzard, „
B. Douglas Powell, „
J. Frank Payne, „
Edward Liveing, „
W. Withers Moore, „
Robert Lee, „
T. Henry Green, „
D. Hack Tuke, „
T. Lauder Brunton, „
Charles Henry Balfe, „
Thomas Barlow, „
Joseph Ewart, „
M.D., F.B.C.P.
James Paget, F.R.C.S.
John Eric Erichsen, „
William S. Savory, „
G. M. Humphry, „
J. Spencer Wells, „
Henry Thompson, „
Thomas Smith, „
Alfred Willett, „
William MacCormac, M
John Langton, „
Howard Marsh, „
Harrison Cripps, „
F. H. Champneys, M.D., F.B.C.P.
James Sawyer,) „ „
William Carter, „ „
J. Gilbart Smith, „ „
J. A. Ormerod, „ „
Samuel West, „ „
G. H. Savage, „ „
J. Kingston Fowler, „ „
G. A. Heron, „ „
William Vawdry Lush, „ „
Theodore Dyke Acland, „ „
J. Bayner W. Batten, „ „
B. Percy Smith, „ „
Archibald E. Garrod, „ „
George Danford Thomas, M.D.
Arthur P. Luff, „
Bobert Baker, „
Norman Kerr, „
W. A. Brailey, „
. J. O. Adams, „
Henry Bayner, „
C. S. W. Cobbold, „
Outterson Wood, „
Theo. B. Hyslop, „
W. R. Howard Ealing, „
W. H. Blenkinsop, „
Edward J. Nix, „
George Henty, „
J. J. Atteridge. „
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Occasional Notes of the Quarter .
237
The Epileptic Colony .
It has hitherto been the rule in this country that epileptics
should qualify as lunatics before they could find a home.
The usual charitable institutions were for the most part
closed against them, and, save a few special hospitals, no
other place of rest could be found for them. Those “ subject
to epileptic fits ” are, by the rules of many homes, excluded
from them. Want of employment and the consequent worries
of poverty aggravate their malady, and the utter helplessness
of their condition leads to despondency and hastens their
descent towards dementia. According to Edith Sellers, in a
paper in “ The Medical Magazine ” for February, who quotes
the recently published statistics of the Charity Organization
Society, there are nearly 78,000 epileptics in Great Britain,
and 39,000 of these are still in the full possession of their
reason. Now it is a fact that the condition of life most
calculated to ward off epileptic attacks is that of healthy
occupation, and, under ordinary circumstances, this is the
most difficult to obtain. Thus the scheme so ably advocated
at the Mansion House, at a meeting* presided over by the
Lord Mayor, for the purpose of founding a home for those
necessitous epileptics who are able and willing to work,
meets an urgent and ever-growing want. The importance of
such a scheme it would be difficult to over-estimate; it is a
reasonable one, and it is based, to a great extent, upon the
successful colony established at Bielefeld, in Westphalia. It
is proposed to secure an estate of 100 acres within fifty miles
of London, easy of access, where additional land may be pro¬
cured when required, and to erect upon it appropriate build¬
ings. Through the munificence of Mr. Passmore Edwards,
the necessary funds for the purchase of the land and erection
of the buildings are promised, and an encouraging amount
of support from other quarters has been given.
In the early days of the colony simplicity will be the rule,
and the occupation provided will take the form of farm and
garden work, which is at once easy and healthy. Gradually,
as the scheme develops, other and more varied occupations
will be provided suitable to the more delicate members of the
community, thus monotony will be averted, and in suitable
workshops and in all weathers there will be work going on.
It is not intended to confine the benefits of the colony to the
* Jan. 25, X893.
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necessitous poor. Wealthy cases will be provided for and
freely admitted, for the terms they will pay will be high, and
will procure for them comfortable and even luxurious
quarters, so that the profits arising from their payments will
go towards defraying the cost of the poorer inmates. To a
great extent it is expected the colony will become self-
supporting.
We heartily wish the scheme all the success it most
rightly deserves.
Saint Amable.
During a holiday visit to the Auvergne last autumn we visited
the quaint little town of Riom, which has, as we shall see, a
certain interest for the alienist. It has always been a rival to the
more flourishing city of Clermont Ferrand, and although it has
had to give place to Clermont as capital of the district, it still
retains the Courts of Appeal for the whole neighbourhood. By
this means the town continues to hold its own and keeps some of
its past importance, although at the present time it can only boast
of a population of some ten thousand persons.
The first object which attracts one’s attention on entering
Riom from the Railway Station is the long fapade of the Courts
of Justice, built on the spot where in the 14th century once stood
the Palace of John of France, Duke of Berry and Auvergne.
Nothing, however, remains of the original building but the beauti¬
ful little Sainte Chapelle, with its 15th century windows.
Passing into the main street we noticed several houses of the
15th and 16th centuries, with fine sculptured fronts, also a belfry
tower of the time of Francis I. Continuing our route we reach
on our right the Church of Saint Amable, first consecrated in
1120, and retaining three apsidal chapels of the 12th or 13th
century, and a triple 12th century nave, which was, however,
reconstructed during the last century. The choir, transepts, and
spire were rebuilt in 1859. It is not so much, however, with the
church we have to do, as with the Saint to whom the church is
dedicated. He is represented to have had the power of healing sick
people, but more especially those who were insane. We cannot do
better than quote from a book by Monsieur Bernet-Rollande a few
further particulars of his life and work:—
“ According to tradition a chapel, or perhaps a church, existed
in Riom at the beginning of the 5th century, dedicated to Saint
Gervais and Saint Protais—twin brothers—who received the palm
of martyrdom at Milan in the days of the persecution of Nero.
It is in this church that we like to picture to ourselves a young
man on his knees—Saint Amable, the future priest of Riom.
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Gregory of Tours tells us that a priest of Riom existed, whose
tomb in the 6th century was an object of universal devotion in the
Auvergne. People made pilgrimages to it, and flocked thither at
all the Christian feasts. After having prayed at this holy
sepulchre sick people were relieved, those bitten by serpents were
cured, and the ravings of maniacs were appeased/’
The life of Saint Amable has been described in a manuscript
preserved among the Archives of the Church, which is said
to have been written in the 12th century by a priest of the name
of Juste. Prom this manuscript it has been gathered that Saint
Amable was born at a place called Chauvance, near Pontaumur,
about the year 400, and that he was a member of an important
family, which took its name from this locality. The house of
Chauvance figures amongst the aristocracy of Auvergne in the
middle ages, and was strengthened by an alliance with the house
of La Rochebriant. However that may be, the name of Amable
has been kept up from one generation to another in the house of
La Rochebriant Chauvance, and the oldest member of it exercises
the immemorial right of attending *the fete of Saint Amable clad
in canon’s robes, and takes his place in the procession close to the
shrine of the Saint, upon which he places his hand.
The village of Chauvance is marked to this day by a stone cross,
called the Cross of Saint Amable (apparently of the 15th century),
which is covered with carvings of little full-length figures,
heraldic designs, and inscriptions, which latter, however, it is im¬
possible to decipher. At some little distance from the cross an
enormous block of stone is to be found, which has always been
called Saint Amable’s Rock, and which, tradition says, bears the
mark of the Saint’s foot.
In the district which lies between Chauvance and Riom the
name of Amable has always been very widely known, and is given
to girls as well as to boys, but it is not to be met with in other
parts of the Auvergne.
During the 5th century a church dedicated to Saint Benigne
was built close to the Sanctuary of Saint Gervais and Saint
Protais. The general opinion is that Saint Amable built this
church at his own expense, and this well accords with the idea
that he belonged to a rich and influential family.
Juste’s manuscript contains the following lines concerning the
death and funeral rites of Saint Amable : —“ Monseignieur Saint
Amable of holy memory died the 1st of November, in the year 475,
after the Passion of our Lord, in the days of Childeric, King of
France. The news of his death spread from one part to another, and
coming to the ears of the clergy and the faithful of the town, which
we now call Clermont, they assembled with candles and torches at
the funeral of the Saint. They were joined by a mass of people
of all ages and conditions. They laid him to rest in the centre of
the Church of Saint Benigne, which he had himself built. The
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ceremony was most solemn and impressive, but its principal
distinction lay in the number of miracles God performed on all
ijhose sick people—-whatever the nature of their illness might be
—who had the good fortune to touch the shroud of the illustrious
dead.”
After mentioning the case of a man being cured who had been
possessed by a demon, Juste goes on to narrate that 44 it is well
known that if anyone has swallowed poison or any little venomous
insect whilst eating, or drinking, or sleeping with his mouth open,
there is an infallible cure in going to pray at the tomb of Saint
Amable.”
Three or four ancient hymns are still extant in which the works,
virtues, and miracles of Saint Amable are extolled. One line may
be quoted here —
44 Yous fuyez devant lui, feu, demon et serpent.”
An historian of the name of Chevalier, writing ‘in 1700, gives
the following account of a miracle worked by Saint Amable :—
44 A lady of high degree had the misfortune to discover that all
her children were bewitched through the wickedness of one of her
servants. These children appeared to be possessed by a demon
which sometimes flung them into the air. Their pitiable condition
was much augmented by their tender age—the eldest boy being only
seven or eight years old. The unhappy mother, finding no help
on earth, implored that of heaven. God heard her prayer favour¬
ably. A young monk, who knew of the power of Saint Amable,
advised her to visit the shrine of the Saint. She received this
advice with great joy, and made a vow to visit Riom with her
children. To lose no time, however, she had mass celebrated in
the chapel of her castle, and her intention made known. As soon
as the words were spoken to these poor afflicted children—- 4 O
Mon Dieu, voyez, voyez un si joli Saint *—they were immediately
free from the spell which had been cast over them, and were
themselves once more. Their mother, full of gratitude, and anxious
to fulfil her vow, travelled to Riom—a distance of full twenty
leagues. As soon as they entered the Church of Saint Amable,
these children, seeing an image erected above the table where the
holy relics were exposed, at once recognized their deliverer, and said
to their mother, 4 See, here is the Saint who healed us.’ ”
Not a vestige now remains of the Church of Saint Benigne,
44 but we may reasonably suppose,” says M. Bernet-Rollande,
“that the present Church of Saint Amable is built over the
original spot. Saint Amable still watches over the ancient town,
and every year, on the Sunday which follows the 11th of June,
the shrine, which contains the relics of the Saint, is carried in
procession by twelve husbandmen or vine-dressers, clothed in
white, after the custom of their ancestors.”
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From a trustworthy source we gather a few more particulars of
psychological interest:—
“ Every year on the Sunday following the 11th of June the
fete of Saint Amable is celebrated with great pomp. The people
attribute to the relics of this Saint the virtue of curing the
insane. On that day a numerous procession promenades the
streets. Peasants from the surrounding districts arrive in large
numbers, dressed in the ancient costume of the Brayands, which
consists of a vest, breeches, and gaiters of white woollen material
and a huge cocked hat. Some of them carry the Saint, and
others a huge wheel, profusely decorated with flowers, which,
whilst it is being carried, revolves constantly on its axis. During
the procession the insane are made to walk under it, and by that
process are supposed to recover their minds.”
PART II.—REVIEWS.
Lectures on Mental Diseases designed especially for Medical
Students and General Practitioners . By Henrt Putnam
Stearns, A.M., M.D. With illustrations. Philadelphia,
1893.
Any publication proceeding from the Physician of the
Hartford Betreat, Connecticut, is certain to be welcomed by
all who are acquainted with his conscientious work in the
field of medical practice to which he has devoted his best
energies for so many years.
Dr. Stearns traverses the whole ground of psychological
medicine in a methodical and exhaustive manner, beginning
with the physical basis of thought, and proceeding to the
study of hallucinations, illusions, imperative concepts,
delusions, melancholia, mania, folie circulaire, dementia,
adolescent insanity, senile insanity, climacteric insanity,
puerperal insanity, epileptic and alcoholic insanity, general
paralysis, and acute delirious insanity.
There is a chapter on the classification of mental diseases,
which he admits must be tentative in the present state of
our knowledge. The following is his own classification:—
A . Symptomatological.
1. Melancholia. 2. Mania. 3. Primary delusional in¬
sanity. 4. Folie circulaire. 5. Dementia.
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1 .
B. Etiological .
C Insanity of Puberty.
Epochal (Physiological).-? Climacteric Insanity.
2. Lymphatic (Sexual).
3. Toxic.
4. Neuropathic.
5. Pathological.
6. Other less frequent
genera and species.
( Senile Insanity.
I Puerperal Insanity.
< Masturbatic Insanity.
I Ovarian Insanity,
f Alcoholic Insanity.
\ Syphilitic Insanity.
(Epileptic Insanity.
\ Hysterical Insanity.
{ General Paralysis.
Insanity from Coarse Brain
Disease.
Acute Delirium (Typhomania).
Phthisical Insanity.
Eheumatic Insanity.
Post Febrile Insanity.
V
{
It is difficult to know what to extract from a work con¬
taining so much that was interesting. We cannot, however,
pass over the author’s opinion in regard to the term
“ paranoia.” He observes :—“ It is certainly difficult to
understand on what principles of nomenclature this term can
be applied to any genus of insanity. If the purpose was to
substitute a Greek word for one derived from the latter, and
by its use avoid the English term insanity altogether as the
name of an order of disease, all would be plain enough ; but
no such purpose exists. We have the term insanity as
descriptive of a class or order of disease, and we are now
seeking a name for a particular genus of that order, and it
becomes obvious at once that a name which comprehends all
that is understood by the name of the class or order under
which it is to be arranged, will convey, not only no accuracy
as to what is named, but is eminently misleading. It cer¬
tainly has relations neither with a symptomatological, patho¬
logical, physiological, or setiological basis of nomenclature,
nor has it even the merit of a neutral character, as is the
case when forms of disease are named after the discoverers,
as Gower’s disease, Addison’s disease, etc.”
We heartily endorse this opinion, and are glad that so
high an authority should have expressed himself in such
unmistakable terms.
For the term “ Monomania ” Dr. Stearns suggests the
phrase u Primary Delusional Insanity.”
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The author refers to a subject which has led to some
difference of opinion in our own country—whether insanity
following surgical operations is due to shock or the anes¬
thetic employed. Dr. Stearns observes that “ in the majority
of surgical cases the insanity seems to develop before a
condition of anemia and perverted nutrition has become
established, and it becomes necessary to look for other
causes. These may be found in the depressing influence
upon the nervous system of very sensitive persons which the
anticipation of an operation produces, the shock which is
more or less profound according to the nature of the opera¬
tion, and the subsequent uncertainty of a successful issue.
The importance of this last factor must be considerable in
some cases. Indeed, it has often been observed that cases
not followed by the development of insanity do well or other¬
wise largely as the element of expectancy and hope pre¬
dominates in the mind of the subject. In my own experience
I have never known of a case of systematized insanity which
apparently resulted from the use of anaesthetics; and after
surgical operations of a severe nature, insanity as a sequence
is certainly rare. Therefore other aetiological factors must
exist in the majority of such cases.”
Dr. Stearns cites from von Frank Hochwart 31 cases of
mental disorders following operations on the eve, divided
into four groups—1st. Hallucinations (confusional insanity);
2nd. Simple confusional insanity in old people; 3rd.
Psychoses in chronic alcoholism; 4th. Cases of confusional
insanity in very marasmic individuals, with other inter¬
current somatic diseases with fatal termination. It is
Hochwart’s opinion that mental disorder is more frequent
after eye-operations than any other.
We must content ourselves with a very inadequate notice
of this work, and with cordially recommending it to our
readers.
Introduction to Physiological Psychology . By Dr. Theodor
Ziehen, Professor in Jena. Translated by C. C. Van
Liew and Dr. Otto Beyer. Illustrated. London:
Sonnenschein. 1892. Pp. 277.
This is a translation of Prof. Ziehen’s “Leitfaden der
Physiologischen Psychologie ” (published in 1891), and we
may say at once that to some extent it fills what is, or should
have been, a long-felt want of the alienist. Unless we take
xxxix. 16
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into account Ladd's large and in many respects excellent
work, there was no book in English which presented in a
concise and handy form any statement of that general
science of experimental psychology of which medical
psychology is but a branch". Dr. Ziehen's book is well
fitted to fill the void for two reasons—he is in sympathy
with the English associational tendencies in psychology (in
opposition to Wundt's doctrines), and he was moved to take
up the general study of physiological psychology by the
problems that came to him in the course of medico-psycho-
logical work. Although not appealing exclusively to the
physician, this book is especially intended for (as the trans¬
lators call him) the “ psychiater.’'
Chapters I. and II. deal generally with the elements of
psychic action. In Chapter III. we approach the important
subject of stimulus and sensation. In the three following
chapters the sensations of smell, taste, touch, sight, and
hearing, their laws and measurement, are dealt with in
detail. Weber's law is considered in three chapters, and
Fechner's psycho-physical formula and the limits of its
application are clearly discussed. A chapter follows on
emotional tone, and the succession of sensations. The
important subject of the transformation of sensations into
conceptions, and the physiological basis of ideas is then
dealt with. The three succeeding chapters are concerned
with the laws of the association of ideas, with the rapidity
of mental action, reaction times, etc., and with a discussion
of attention, the ego, the physiological basis of memory and
forgetfulness. A chapter follows on morbid thought,
dreams, secondary sensations, hypnotism, illusions, and
hallucinations. The book concludes with chapters on
action, expression, speech, an analysis of the will, and a
very clear statement of the various monistic and dualistic
theories of mind and matter. The author's own position is
described as a critical monism, resting on the fact that our
first data are only those contained in the psychic series of
phenomena.
The author possesses an experienced teacher's lucid and
concise method of presentation, and (having clearly stated
his sympathy with the English school and opposition to
Wundt's theory of apperception) he discusses every question
that arises in a fair and open-minded manner. It may,
perhaps, be held that he sometimes accepts views of cerebral
localization which are still mb judice , and he is certainly
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1893 .]
hasty in concluding that because there can be no psychosis
of the will the conception of moral insanity is untenable.
The clinical phenomena of moral insanity may admit of
more than one interpretation, but are not necessarily bound
up with any theory of the will. On the whole it may be
repeated that the book is one which will prove useful, and
which can be warmly recommended. The old writers of
metaphysical psychology, except as furnishing studies of
human aberration, possess little interest for the medical
psychologist. He has reason to be grateful to the modern
and more scientific psychology of experiment which assigns
to his own studies an honourable and essential place, and
enables him to realize their significance.
It should be added that the book does not profess to be a
practical manual, and the question of instruments, methods
of psychological examination, etc., are not considered. In
this respect the book may be supplemented by various articles
in the “ Dictionary of Psychological Medicine,” especially
by the important article on “ Psycho-physical Methods.”
We have compared the translation with the original text,
and find that the translators have done their work in an
accurate and satisfactory manner, although they do not
write a very elegant or idiomatic English style. An index
has been added to the translation.
La Pathologie des Emotions . Etudes Physiologiques et
Oliniques. Par Ch. F^rA Paris: Alcan. 1892. Pp.
605.
This is a large book, but it cannot be said that there is
much unnecessary padding in it. From first to last it is
filled with facts and observations drawn, not only from the
stores of an erudition singularly rich with the ancient and
modern science of many countries, but especially from the
experiences of a clinical observer who has had ample oppor¬
tunities of studying the physiology and pathology of
emotional states.
The distinguishing characteristic of all F6r6’s work is—
using the expression in by no means a hostile sense—the
physiological bias . It is this which gives interest to the
suggestive studies in his earlier and well-known book,
6 Sensation et Mouvement.” He seeks to find the key to all
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Reviews.
[April,
morbid states, physical or psychical, in normal physiological
processes. He will not admit that any psychical state can be
examined clinically except by physical methods. Until it is
so examined he will not accept psychology as deserving of
scientific consideration. In reference to Mercier’s remark
that as regards insanity medical men themselves are in the
position of laymen, he observes that this is because the
alienist has been too often content to deal merely with
psychological entities which the ordinary medical man,
trained in physiological methods, rightly refuses to recog¬
nize. This is, one fears, to pay too high a compliment to
the ordinary medical man’s scientific instincts. Still, it
serves to indicate the author’s attitude.
We may gain an idea of his method by glancing at the
way in which he approaches the consideration of hysteria.
He deals with it, we must note, in a chapter on “ Insufficient
or Excessive Physical Exercise,” and points out that the
hysterical resemble normal persons when under the influence
of fatigue, proceeding to indicate various sensory and motor
phenomena which are the same in both conditions. Hysteria
he thus regards as a kind of chronic fatigue by which the
individual is reduced to what Claude Bernard called the
“ vie oscillante ”—a condition of abnormal subjection to the
influences of the environment. Hysteria is a physical condi¬
tion, hence the merely temporary benefits of treatment by
mental suggestion, and the permanent benefits of such a
method as that of Weir Mitchell, which restores the physical
condition. “ From my point of view,” he goes on to remark,
“ to say that hysterical anaesthesia is not an organic malady,
but a mental disease, a psychological disease, is a biological
heresy. All mental diseases and all troubles of sensibility
are dependent on organic troubles.”
The same method characterizes the author’s treatment of
hallucinations, and the chapter dealing with this subject is
entitled “The Physical Signs of Hallucinations.” The
alienist must study the external signs of hallucinations by
the methods of the physiologist—observing attitudes, move¬
ments, and the permanent stigmata which such attitudes
and movements produce on the muscular system. It has
even to be borne in mind that “ movement is the physio¬
logical condition of sensation, and therefore constitutes its
chief physical sign, and that it is this sign which we must
always strive to bring to light. The study of movement,
considered in regard to its energy, rapidity, precision, and
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247
form, constitutes the most solid foundation of our knowledge
of psychology.”
. The book covers a wide field. It begins with the con¬
sideration of the physiological and pathological effects of
physical agents; this leads up to the physiological conditions
of emotions and to their pathological effects, and also their
curative effects. Two chapters are devoted to the very varied
forms of morbid emotivity, and these are followed by a
chapter on the organs of the emotions. The work concludes
with chapters on diagnosis, treatment, prophylaxis, and
legislation. It is a book, taken altogether, which should do
much to further the cause which the author has at heart—
the raising of the study of insanity into a true science.
Traite Clinique et ThSrapeutique de I’Hysterie. Par le Docteur
Gilles de la Tourette. Preface de M. le Dr. Chabcot.
Avec 46 figures. Paris : E. Plon, Nourrit et Cie. 1891.
Pp. 582.
Of recent years hysteria has received little scientific study
in England, although it was an Englishman—Sydenham—
who first placed it on a truly sound and secure basis. It
was nearly two hundred years before Sydenham’s work on
this subject was fully recognized, and then the recognition
came from France. With the exception of Brodie’s notable
contributions—which are fully appreciated in the work
before us—no further advance has come from England.
The school of the Salp6tri&re—Charcot and a very large body
of distinguished pupils—at present holds the field, and it is
difficult to point to any worker not associated with this
school who has lately done anything to advance our
scientific knowledge of hysteria. The work, however, which
has been done by Charcot and his disciples is now very
considerable, and the time had arrived for some authoritar-
tive summary. This has been undertaken by Dr. Gilles de
la Tourette, who has himself made important contributions
to the question, and who possesses many qualifications for
the task he has undertaken. His knowledge is wide, his
tone is always moderate and judicial, and he is entirely free
from that tendency to vague eloquence which has done so
much in the past to render difficult a clear conception of
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hysteria. In this first volume of his work he deals with
u Hysteric Normale” or interparoxysmal hysteria.
The Trench school, as is now fairly well-known, regard
hysteria as u one and indivisible ” disease, and as their
induction has been formed on a wide basis—from individuals
of all nationalities, and from a thorough study of hysteria in
children and in men, as well as in women—the opinion is
entitled to respect. They reject the old conception of
“ hystero-epilepsy 99 as an impossible fusion of two radically
distinct diseases. That epilepsy and many other diseases,
especially of a degenerative character, may co-exist with
hysteria they fully admit. It is, indeed, this occasional
co-existence, they hold, which has, in the past, caused so
much confusion, and which causes Dr. Gilles de la Tourette
to parody a famous saying: “ 0 Hysteria, what crimes have
been committed in thy name ! 99
The chief chapters of the present volume deal with the
history of hysteria, its etiology, the exciting causes,
cutaneous anaesthesia, anaesthesia of the mucous surfaces
and of the sensory organs, hyperaesthesia and hysterogenic
zones, hysterical amblyopia and other troubles of vision,
hysterical affections of the ocular muscles, hysterical con¬
tractions and tremors (including their relation to dis¬
seminated sclerosis), nutrition, and the mental condition of
the hysterical.
The chapter on the mental condition of hysteria is of
much interest and deserves careful study. It is shown
that the chief mental characteristics may be reduced to an
abnormal suggestibility . The suggestions may come from
without or from within; and in the latter case the auto¬
suggestion is sometimes supplied by a dream or vision
during a paroxysm or in ordinary sleep. In this chapter,
and, indeed, throughout the book, the author finds apt and
interesting confirmation in the evidence supplied by the
confessions of witches and hysterical nuns. This is, indeed,
a branch of the subject to which he has himself brought an
important contribution, by editing and publishing the
autobiography of Sceur Jeanne des Anges.
The work may be warmly recommended to those who
desire an authoritative and comprehensive, but, so far as is
possible, concise summary of the recent investigations
regarding hysteria.
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Entartung. By Max Nokdau. Erster Band. Berlin :
Duncker. 1892.
Max Nordau is best known as the author of an attack on
the shams of civilization, which has been translated into
many languages. For the preparation of the present book
he seems to have saturated himself with the methods and
results of modern morbid psychologists from Morel to
Lombroso, and has thus been led to the conclusion that the
literature and art of the present day may be summed up in
the one word which gives the title to his book— degeneration.
Not a single recent artist or writer (not being an alienist) is
alluded to in this book except to be dismissed as a victim of
mental derangement. The works of Millais, Rossetti (who
belongs to the group of imbeciles), Swinburne (Magnan’s
dSgenerS eupSrieur), Verlaine (folie circulaire), Tolstoi, Whit¬
man (moral insanity), Wagner, etc., have all u psychic stig¬
mata ” of degeneration as understood by Morel. At the
outset the author remarks that his results iqay be proved by
physical examination of the writers and artists in question,
and the study of their personal history, but he renounces
this interesting task for the easier one of investigating the
" psychic stigmata.” This is certainly done with remarkable
acuteness, but the author entirely fails to see that the
presence in a work of genius of some mental characteristic
also to be found in persons of weak or perverted intellect by
no means negatives the genius. Max Nordau insists on the
presence of serious punning and the collocation of assonant
words in various modern writers as evidence of feeble mental
power because the same characteristics are found in the
literature of the insane. He is not apparently aware that
such verbal tricks are specially frequent in Shakespeare,
whom he regards as entirely sane.
By way of preface there is a dedicatory letter to the
author’s “ dear master,” Professor Lombroso. He remarks
in this that he desires to do for the artist and man of letters
what Lombroso has done for the criminal and the prostitute.
This is rather unkind to the “ dear master,” who has himself
written a large work (“ The Man of Genius ”) on this very
subject, in which work, moreover, he by no means reaches
the same conclusions as his disciple. He does not hold, for
example, that the element of morbidity in genius is more
frequent to-day than in any previous day, and certainly does
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not believe that such morbidity renders the work of genius
less strong or beautiful. Lombroso, indeed, is not greatly in
love with the whole theory of “ degeneration.”
The author, it will be seen, must not be taken too seriously.
Still, he is very well informed, both as regards the latest
results of psychological research and the latest manifesta¬
tions of art and literature. It is throughout vivacious and
epigrammatic in style. So cleverly, indeed, is the argument
worked out that we are led to speculate concerning the par¬
ticular form of the prevailing degeneration which “ Entar-
tung ” itself illustrates. On the whole such examination of
the author’s “psychic stigmata” as we have been able to
make leads us to believe that he is probably what the “ dear
master ” would call a “ mattoid.” It is certainly some time
since we have seen so well-marked a case of " misoneism.”
A well-known aurist once wrote on a prescription in an
absent-minded moment, “ The ointment to be rubbed round
the world night and morning.” Max Nordau seems to have
received his psychiatry accompanied by similar careless
directions. To the alienist who can here see the formulae
prepared for his own use zealously rubbed round the world
the book may afford considerable amusement.
Psychologic du Peintre. Par Lucien ArriSat. Paris 2 Alcan.
1892. Pp. 267.
The author of this book is well known as a psychologist
of the modern school, more concerned with facts than with
theories. He has collected and summarized most of what
may be gathered as to the special psychology of artists, at
the same time adding fresh material, the fruit of his own
observations. He deals with the anatomical and physio¬
logical characters of artists, with the quality of their vision
and their memory ; with their heredity ; while the conclud¬
ing section is devoted to the pathology of the painter. The
book altogether forms a readable chapter in psychology,
but, as may be anticipated in the first attempt to deal com¬
prehensively with a new subject, the conclusions reached
are not usually very definite.
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Anatomy of the Brain and Spinal Cord . By J. Hyland
Whitaker. Second edition. Edinburgh: Livingstone.
1892.
We had the pleasure of recommending the first edition of
this little book to the readers of the “Journal of Mental
Science,” and we hope in time to see a third edition. We
know that the work has been found a useful text-book for
students in the Edinburgh Medical School, and no doubt also
in other places. Any medical man who wishes to refresh his
knowledge of the spinal cord and brain will find a timely help
in Mr. Whitaker’s clear descriptions and well-planned illustra¬
tions and diagrams. In the present edition the page is larger,
and there are now 178 pages instead of 135. The chapter on
the methods of ascertaining the location of the different sulci
and gyri in relation to the skull and scalp is a useful addition
at present, when surgery is busy with new operations on the
cranial contents. The principal improvement is, however, in
the lithographic plates, of which we have now 40 instead of 22.
They are also more elaborate in outline, and the effect of the
diagrams has been more carefully studied. The labour in
designing these illustrations must have been fully equal to
that of writing the text. Mr. Whitaker does not claim to
teach any new views in his book, but for a clear and concise
description of the nervous centres it has not been surpassed.
Psychopathia Sexualis with special reference to Contrary Sexual
Instinct: A Medico-legal Study . By Dr. R. von
Krafft-Ebing, Authorised translation by Charles
Gilbert Craddoch, M.D. The F. A. Davis Company,
Publishers. 1892.
There are many unsavoury subjects which have to be con¬
sidered in medical practice, especially when that is carried
on among the insane. The lower animal nature in some
patients shows itself often in all its simple beastliness. Yet
we do not think, in England, at least, that it is well that
such subjects should be fully considered in books which may
be bought of any bookseller. Perhaps we are prudish, but
we think that the production of this book by Ebing will not
add to his reputation, nor will it do any possible good to the
medical or the psychological world.
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We understand that already in Germany many editions of
the book have appeared, quite out of proportion to its medical
interest, hence we must infer that a prurient public is
studying it to its own harm. The book under consideration
may be referred to as one considering briefly the psychology
of the sexual relations, and then in detail the forms of
sexual perversion.
In the original certain passages were written in Latin,
and we are glad to say the American translator has left
them in that language.
Various Forms of Hysterical or Functional Paralysis . By
H. Charlton Bastian, M.A., M.D., F.K.S. London:
H. K. Lewis. 1893.
This book is an important contribution to a very difficult
subject. It is carefully and clearly written, and every line
in it gives evidence that the subject-matter has received
deliberate attention. Amidst the much loose writing of the
present day, it is a relief to turn to a piece of close reasoning
so ably set forth.
Dr. Bastian begins by warning us against the diagnosis of
functional paralysis as a positive diagnosis; it is at best a
negative one, and, when arrived at for the most part by a
process of exclusion, it is found to include so much that we
become aware that we are in the midst of Dante’s “ selva
oscura.” For functional paralysis , we are told, includes
hysterical paralysis, since, u hysteria is, after all, only one
of the general conditions under the influence of which
paralyses of a purely functional type may develop them¬
selves,” and the magnitude of a subject of which hysterical
manifestations constitute but a section thus dawns upon us.
The title Dr. Bastian has given to his book does not
quite do justice to his own warnings, for it suggests that
the terms hysterical and functional are convertible, i.e.,
equivalent.
Pursuing his introductory remarks, the author insists that
the diagnosis, hysterical, functional , as here employed, is but
the first approximation to a diagnosis, and that it simply
excludes gross organic changes, and makes it probable the
disease would not reveal its secret even to the microscope;
beyond this negation, “ the problems of a regional and of a
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pathological diagnosis” are alike unsolved. He touches
upon the great difficulties which even the first part of the
diagnosis involves, the exclusion of organic disease, and
instances the protean manifestations to which disseminated
sclerosis gives rise, a subject to which Dr. Buzzard has lately
drawn attention. He points out that it is not sufficient to
discover hysterical symptoms in the case before us, since the
more common of these symptoms “ are associated with those
of actual organic disease of the nervous system;” the
presence of such hysterical symptoms should make us all
the more wary. Further, he warns that the fact of recovery
more or less from a given group of symptoms does not
necessarily suggest a functional origin, since actual experi¬
ment, e.g., the investigations of Mott on hemisection of the
cord, has shown that restitution of function may occur, and
since we are also familiar pathologically with such events as
the resolution or canalization of a thrombus.
But accepting that the diagnosis “functional” has been
arrived at correctly, we have next to attempt to solve the
question, where is the mischief situated (?), and here, on
grounds far less secure than are represented to us by
organic disease, we have, as a preliminary, to settle, is the
lesion cerebral or spinal—is it central or peripheral ? We
are apt, amid the great advances which have been made in
nervous symptomatology, to overlook the great extent of the
unknown, yet, as Dr. Bastian points out, our knowledge of
the brain itself is most meagre. Thus, of the cerebellum we
may be said to know nothing as to its functional diseases,
and of the cerebrum little outside three regions, which he
thus defines:—(a) The Rolandic convolutions; (b) the
posterior third of the hinder segment of the internal capsule;
(c) a region involving some of the outgoing fibres from the
Rolandic convolutions. In this statement he is referring to
the symptomatology of functional defects capable of produc¬
ing paralysis.
Having decided where the mischief may be, we next can
discuss its nature. Are these functional troubles due to
vascular disturbances—say, for instance, a spasm of the
yessels, resulting in an anaraia of the area supplied 9 Of
such a supposition, we not only have no proof, but we lack
the physiological data of the problem, for though Bradford’s
researches led him to believe in the presence of vaso-motor
nerves in the brain, they cannot be said to have been
demonstrated. Beyond this difficulty is another, viz., the
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great duration of the symptoms in many cases of functional
disorder : it is hard to believe in a vascular spasm of equal
duration. Of the existence of prolonged vascular spasm
Dr. Bastian does, however, think there may be some evidence
if we may interpret as such the difficulty in causing bleeding
by even deep needle pricks on the anaesthetic side of the
body. The alternative to vascular disturbance as the cause
of functional troubles is a primary localized failure of
nutrition, but such a statement does not advance matters.
The author then proceeds to discuss cases of functional
paralysis, and first those due to disease in the Bolandic
area. This at once introduces the question of the real
nature of the centres here situated and “ so-called motor/’
Dr. Bastian, as is well-known, combats the view main¬
tained by Ferrier, that they are motor and motor only,
and insists that the centres are sensory, and that in them
are registered the impressions derived from and occasioned
by movements. The arguments in favour of this view are
given more at length in Appendix A. of the present volume,
wherein are embodied portions of the discussion on the
muscular sense which took place at a meeting of the
Neurological Society, in December, 1886. The subject has
more than a mere philosophical aspect, and we may, there¬
fore, touch briefly on the principal points :—
1st. When, like the pious JEneas, we ponder many things
by night and day, it is made clear to us that for the moving
powers to become perfected, as we know they do become,
adjusted to the exigencies of circumstances, there must be
somewhere within the nervous system a locus where the
attempts at movement, successes and failures—in a word,
the motor experiences—are stored up. Without such regis¬
tration successful movement would be the exception, the
result of happy chance; failure would be the rule.
2nd. The experience of a given movement must be the
appreciation of the motor output or muscular effort. This,
however, in one aspect is a peripheral event, and it is
represented by the algebraic sum of the tensions and
counter-tensions, whose resultant is the movement. But for
a movement to be successful, the nervous system must some¬
where be cognizant of the tensions and counter-tensions
already existing at the moment the new movement is con¬
templated, and it must also recall or revive somewhere the
memory of previous attempts at similar movement—on
these data the new movement is initiated. The nervous
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system must thus take note somewhere of the state of its
peripheral mechanism, and must remember past states of
this same mechanism, and the revival of motor experiences
must precede all new voluntary motor attempts.
3rd. Work of this kind must obviously be central, and,
important as it is, seeing that it involves the highest powers
of adaptation, we shall naturally seek for this locus some¬
where among the higher centres of the cortex cerebri or
cerebelli.
4th. But experiment and pathological experience have
alike discovered a region of the cortex cerebri—the Rolandic
area—which is most intimately connected with movements
of the various parts of the body and, in particular, with
volitional movements. This region is evidently that from
which proceed or in which begin the impulses which issue
at the periphery as variously combined movements, and in
this region it may be said the whole motor apparatus is
completely represented.
5th. No other region of the surface of the brain has been
shown to be intimately connected with movements of all
kinds, and since one such region has been postulated by the
a priori reasoner, therefore this Rolandic area must be the
locus or centre where motor experiences are registered and
aroused. To name this region according to this theory the
word kinsesthetic has been coined; it signifies movement-
sense.
The argument thus briefly sketched out is surely logical,
and the annexation of the Rolandic area on these grounds
must be said to be both reasonable and probable, and this is
the position assumed by Dr. Bastian. Against this view.
Dr. Ferrier contends : the Rolandic area, according to him, is
motor only; it issues commands, but does not receive and
register muscular bulletins. Dr. Ferrier was first in the
field of actual exploration in this country, and it must be
regarded as a brilliant piece of strategy on the part of Dr.
Bastian to hold in reserve questionings such as these till the
work of survey had been done fairly completely, and then to
quietly step in and claim as sensory, centres which have been
shown to be motor; one can quite understand that the
annexation has been resented.
However, brilliant as we must admit to be the work of Dr.
Bastian, as an example of the reasoning process, and invalu¬
able as a contribution to cerebral philosophy, the worth of
Dr. Ferrier’s work is not diminished, even though this new
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view should prove, as we think it is likely to prove, the true
one.
Dr. Bastian puts the controversy into a nutshell when he
says that since the revival of past motor experiences must
immediately precede new movements, then, if the Rolandic
area be a purely motor area, there should be, must be,
another region, whose stimulation would as unfailingly
excite movements as stimulation of the Rolandic area itself,
but no such other region has been demonstrated, therefore
the Rolandic area must, pro tern ., be regarded as the region of
motor sense registration and revival.
From another point of vantage the controversy is accessible,
and on this point many of the cases of functional paralysis
which the author records bear evidence. It is, that lesions,
experimental or pathological, of the Rolandic area do not
express themselves merely as motor disturbances, but cause,
at the same time, sensory disturbances. This should be so
according to Dr. Bastian’s theory, and he maintains that in
actual fact it is so, and that, for instance, we shall find in
cases of hemiplegia and of paraplegia that the patient has
frequently a very inadequate appreciation of the state of
tension of his muscles, and, therefore, of the position of his
limbs. This is a point which cannot be investigated on
animals, for we need the statement of the patient himself as
to his subjective feelings. Oddly it is cases of functional
paralysis which help us here more than cases of organic
lesion, and for this reason, that in functional paralysis we
so frequently have conjoined more or less general anaesthesia.
But general sensation is in itself a guide which tells us of
the position of our limbs, and by means of tactile impressions
alone we may be able correctly to report, e.g. 9 as to whether
a limb is flexed or extended. In motor paralysis of organic
cause, general sensation is often scarcely impaired, and we
can hence see why in these the loss of muscular sense should
be less apparent than in the functional cases. In testing
the loss of muscular sense, Dr. Bastian is accustomed to
question the patient, not merely as to the position of a limb
which has been passively moved into a new position, but also
as to his ability to imagine a familiar movement with the
paralyzed limb, and this the patient is frequently unable to
do. Here, again, is a test inapplicable to animals, and in
which we depend on the patient’s subjective feelings as well
as on his bona fides.
On the author’s view of the kinsesthetic functions of the
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centres in the Rolandic area, some explanation is forth¬
coming of those remarkable cases of functional disorder in
which a hemianaesthesia is accompanied by a paralysis of the
anaesthetic limbs with this peculiarity, that the paralysis
may be present only when the eyes are closed; such cases
have been recorded by Duchenne, by Briquet, and by Bazire.
In other cases the paralysis is present whether the eyes are
open or closed.
It is interesting from another point of view to consider
what will be the effect, on the author’s hypothesis, of
destruction, in the one case, of the kinsesthetic centres and,
in the other case, of interference with the inflow of muscular
sense stimuli. In the first, paralysis should ensue, because
it will be impossible to revive or to arouse those motor
imaginings which must precede executed movements, e.g .,
if the centres in which are stored the motor experiences of
the pianist be destroyed there will of necessity be paralysis
of pianoforte execution. But if the muscular sense impres¬
sions of the pianist be at fault whilst the centres are intact,
then, when these latter would play, the execution will be
more or less erratic or insane, since there will be lack of
adaptation between the incoming and efferent stimuli—in
short, the centres will be misinformed. Dr. Bastian com¬
plains of Dr. Ferrier that he has not given due consideration
to this distinction.
Along what paths do muscular sense stimuli travel?
Here is an unsolved question at present, for neither in the
cord, nor in the medulla, pons and cerebral peduncle have
these fibres been traced. Till they have been discovered
and traced home to the Itolandic area, the kinaesthetic
theory may be said to still lack demonstration, or, at least,
to be incomplete.
Do we learn anything new as to the therapeutic indications
in cases of functional paralysis ? It can be said that we do.
Tonics, nervine, blood; careful feeding with such adjuvants
as cod-liver oil, maltine, etc. ; the removal of any special
cause of debility, menstrual or other: by such means we
endeavour to build up the body from the physical side.
Among special treatments the electric takes a hi^h place,
and in particular the treatment by statical electricity, with
the drawing of sparks from the various parts of the body.
Needle baths, saline baths, etc., will belong to the category
of stimulant treatment, and here massage will also find a
place. Concerning all these means of stimulation, the author
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claims that they are such as would be expected to be of value
on the theory of kinsesthesis, since they tend to rouse into
activity centres of muscular sense. Of hypnotic treatment
very little is said; it has been little tried in this country.
Of the Weir-Mitchell treatment a word of caution is added,
to the effect that we must not expect all cases to yield to a five
or six weeks 5 course, and as a case in point Weir-Mitchell is
himself thus quoted on a case: “ Urged and scolded, teased
and bribed, and decoyed along the road to health, 55 and after
a year’s treatment only attaining the stage of walking on
crutches. This case appears not to have been unsuccessful,
but it is a commentary on the patience which may be called
for. Of another case Weir-Mitchell remarks that the cure
of such amounts to nothing less than a “ long and arduous
course of education. 55
In conclusion, we would express our admiration of the
style of work of which this volume gives evidence—it is a
testimony to the value of thinking and thinkers in the
elucidation of the intricacies of nerve physiology and
pathology.
Illustrations of the Mid and Hind Brain . By Alex. Bruce,
M.D., Edinburgh. 1892.
(Second Notice.)
In this work Dr. Bruce embodies the results of his re¬
searches on the pons and medulla, their various nuclei and
tracts of fibres. The method employed was that of Weigert,
or some of its modifications, and was applied to structures
obtained from the human fetus from the fifth month up to
the full time. It is well known that this method has already
yielded most valuable information regarding the origin and
course of many tracts in the cord and other parts of the
nervous system, and in Dr. Bruce’s hands, besides affording
the material on which the illustrations are traced, it has been
the means of his adding still further to our knowledge of
these structures.
Dr. Bruce 5 s book is essentially an atlas, containing, as it
does, thirty-five drawings of sections made at various levels
and in different directions through the pons and medulla.
These have been exceedingly well done, and a comparison of
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them with the original sections at once shows their absolute
correctness. In these drawings one can trace, for example,
all the intricacies of the fillet, or the origin and course of
any individual cranial nerve, except the first and second. In
fact they are the best means we know of for becoming
acquainted with the latest information regarding the minute
anatomy of the mid and hind brain.
Anyone who has worked at the pathological conditions
which are met with in that part of tne nervous system will
readily acknowledge that, to understand these, it is essential
to have a thorough knowledge of the normal structure.
Though this is not by any means an easy thing to acquire,
the difficulties of doing so have been removed, as far as they
could be, by Dr. Bruce in his atlas. The number of drawings
of sections is such that there is no abrupt transition from
one point to another, and thus the tracing of a particular
tract can be followed without much difficulty, and requires
the exercise of only a little imagination. The fifty pages of
letter-press which form the first part of the book give an
excellent account of our present knowledge of the structure
of the pons and medulla. To this Dr. Bruce has himself
added some interesting and not unimportant facts. Among
these may be mentioned his discovery of the independent
medullation of the cochlear and vestibular roots of the eighth
nerve, the connection of Deiter’s nucleus with the inferior
olive, and the various groups of cells in the nuclei of the
third nerves.
Besides giving the results of his examination of the nervous
system of the foetus, Dr. Bruce also draws attention to the
value of pathological specimens obtained from cases in which
some lesion has caused injury and subsequent degeneration
to one or more of the various nerve tracts. This at present
seems to offer a more fruitful field than the older and better
known method, which has hitherto yielded the greater part
of our present knowledge. It is an undoubted fact that, in
asylum practice, one comes across a considerable number of
cases of gross brain lesion, and were all the opportunities
which these cases afford fully taken advantage of, there is no
saying how much valuable information regarding various
nerve tracts might not result from a careful examination.
Some of the numerous asylum pathologists might with ad¬
vantage take up this subject and assist in justifying their
existence to the rest of the medical profession.
In conclusion, we can only once more testify to the excel-
xxxix. 17
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lence of Dr. Bruce’s book, and express the hope that before
long he may add still further to the knowledge of the sub¬
ject which he has already done so much to elucidate.
Recherehe8 Gliniques et ThSrapeutiques sur VSpilepsie , Vhysterie
et I’idiotie. Par M. Boueneyille, M&lecin de Bicfitre
(Publications du “ Progr&s Medical ”). Paris : Vve Bab6
et Cie. Yol. in-8 de 0. 252 p. 1891.
This work is the report of Bicfetre Asylum for 1890, and
produced by Boumeville, with the assistance of his junior
colleagues, Messrs. Camescasse, Isch-Wall, Morax, Raoult,
Seglas, and P. Sollier.
As might be expected from its author, thoroughness is
a characteristic of the book, and a most attractive feature is
the comprehensive account of the life-histories of idiots, which
serve to illustrate the clinical and pathological aspects of
idiocy in its various forms.
It is divided into three parts :—
The first part, which need not detain us in this review, gives
an account of the plan of construction and management of the
idiotic institute at BicStre and its annex the a fondation Vallee,”
and deals with the hygienic and educational treatment of its
inmates.
The second part is devoted to the clinical and pathological
study of various kinds of idiocy, and includes an account of a
few cases of hysteria and hystero-epilepsy in men.
In the third part are included contributions made by
Bourneville to the International Congress of Mental Diseases
in 1889, and a contribution made to the National Congress of
Alienists in 1890.
The clinical and pathological sections will prove the most
interesting to students of idiocy, and the judicious comments
which generally conclude the detailed observations cannot fail
to be appreciated.
Chapters I. to YI. deal with cases of symptomatic idiocy,
including :—(a.) Idiocy associated with general malformation
and traumatism; ( b .) Idiocy with arrest of development of
convolutions and cerebral atrophic sclerosis; (c.) Idiocy due
to simple atrophic sclerosis of convolutions; ( d .) Idiocy asso¬
ciated with cerebellar tumour; (e.) Idiocy with meningo¬
encephalitis ; (f.) Idiocy with epilepsy. These cases have not
been published before.
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Full notes of the family history, previous history of the
patient, actual condition, progress, death, and autopsy are
given, and it is not too much to say that they are models of
their kind. The remarks at the end of each case afford Dr.
Boumeville an opportunity of making careful generalizations,
which are justified by an extensive experience and highly-
trained powers of observation. Of such are the following:—
Eclampsia, occurring during labour, is only exceptionally a
factor in the causation of idiocy in the offspring. There is
often observed in cases of epileptic idiocy a cachexia which
might well be called the “ epileptic cachexia,” progressively
determining a fatal issue, and unexplained by microscopical
investigation. The idiocy symptomatic of atrophic sclerosis of
the brain is susceptible of great improvement when uncom¬
plicated with epilepsy.
The presence of convergent strabismus in meningo¬
encephalitis (Yid. C. Y.) is probably due to a lesion of the
cortex, the result of irritation at the level of the oculo-motor
centres, and is comparable to the temporary convergent
strabismus observed at the onset of an attack of epilepsy or
of hysteria, and carefully described by Parinaud, of the
Salp3tri&re.
The diagnosis of idiocy arising from meningo-encephalitis is
justified in presence of the following signs and symptoms
Absence of intellectual development, appearance of strabismus
without convulsions, grinding of teeth, oscillatory movements
of the head and trunk, knocking of the head, attacks of
violence with shrieks, insomnia and vaso-motor disturbances.
The pathology of meningo-encephalitis, though closely
related to that of general paralysis of the insane, differs from
it in that the lesions of the walls of the cortical vessels are
essentially degenerative, and that the degeneration of nerve-
cells is secondary to that of the vessels, whereas in general
paralysis it is primary.
From the careful analysis of hundreds of cases of idiocy,
Bourneville says he has never observed any attenuation in
the degenerative course of families by a well-selected alliance
or judicious inter-marrying with the healthy; in such cases,
either the children resulting are healthy or they are degenerate,
but rarely less degenerate than their parents, unless the diseased
parent has, before the conception of the child, perceptibly
modified his general condition by suitable treatment.
Chapter VII. is devoted to three observations on hysteria
in men 9 The first is a typical case of hysteria in a man, aged
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27 years, subject to severe hysterical attacks, affected with
incomplete left-sided hemiansesthesia, hysterogenous zones, etc.
Cases two and three are severe cases of hystero-epilepsy, as
may be gathered from the fact that, in one, fracture of the
clavicle took place during one of the attacks, and in the other
a traumatic deformity of the thumb, with severe injury in the
parietal region of the skull. One of the cases improved
notably under bromide of camphor.
In Chapter YIII. Bourneville proposes the following classifi¬
cation of idiocy:—(1.) Hydrocephalic idiocy. (2.) Micro-
cephalic idiocy. (3.) Idiocy symptomatic of an arrest of
development of convolutions. (4.) Idiocy associated with
congenital malformation of the brain (porencephalus, absence
of corpus callosum, etc.). (5.) Idiocy associated with hyper¬
trophic sclerosis. (6.) Idiocy with atrophic sclerosis, (a.)
Sclerosis of one or both hemispheres; (6.) Sclerosis of one
lobe of the brain; (c.) Sclerosis of isolated convolutions; ( d .)
Disseminated sclerosis of the brain. (7.) Idiocy associated
with meningitis or chronic meningo-encephalitis. (8.) Idiocy
associated with myxoedema and related to absence of the
thyroid gland.
Chapter IX. is a contribution to the study of microcephalic
idiocy, and illustrated by five detailed observations. The
important points to which Bourneville draws attention are
that in most cases the antecedents are pathological, either on
the father’s side or on the mother’s side, or on both, and that
convulsions frequently occur in infancy. He disputes the
conclusions of Gratiolet, Ducatte, and others that the patients
are generally undersized and their sexual development markedly
deficient. Microcephalic idiots are susceptible of education,
and often markedly so. The theory that microcephalus arises
from premature ossification of the cranium preventing the
development of the brain, if true in certain cases, is certainly
not the rule (v. obs. iii.). Epilepsy is occasionally associated
with microcephalus. The chances of amelioration in micro¬
cephalic idiots are greater the earlier the treatment is begun.
Chapter X. deals with the subject of porencephalus and
pseudo-porencephalus. Under the name porencephalus are
now included all cases in which there are extensive losses
of substance of the brain. Bourneville is in favour of restrict¬
ing the word true porencephalus to those cases in which the
loss of cerebral substance is due to an arrest of development,
and of grouping under the head of pseudo-porencephalus
those cases in which the loss is consecutive to a destructive
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process (softening, etc.). In true porencephalus (congenital)
the depression in the brain communicates with the lateral
ventricle. It is conceivable that in extensive pseudo-poren-
cephalus such might also be the case. Pseudo-porencephalus
is usually on the left side and involves the Sylvian area, or the
area of distribution of the middle cerebral artery, which is in
favour of attributing its origin to circulatory trouble.
An important difference between true and spurious poren¬
cephalus lies in the arrangement or disposition of the cerebral
convolutions. In the former the convolutions radiate around
the porus, into which they dip ; in the latter they are divided
irregularly by the porus, and the unaffected parts show no
deviation from their normal direction. The shape of the
porus or depression is also quite different in the two varieties.
In true porencephalus there is a kind of funnel, sometimes a
simple slit or an almost circular orifice; in pseudo-porence¬
phalus one finds a large gaping excavation, the walls of which,
instead of being formed by the convolutions, are constituted
by the white substance, covered over by the membrane of the
false cyst, which intimately adheres to it. In spite of pseudo-
porencephalus being relatively a much more extensive disease,
psychical phenomena are often less marked than in true
porencephalus, which is nearly always associated with com¬
plete idiocy.
In the last chapter (Chapter XI.) is a new contribution to
the study of myxoedematous idiocy (also called u idiotie avec
cachexie pachydermique ”) and a record of eight cases, six of
which belong to Dr. E. C. Stirling, of Adelaide (five of these
are members of the same family—a very interesting point).
The symptoms and signs in most cases correspond to those
generally described, stress being laid upon one sign which was
well-marked in all, i.e., a marked tumefaction, with tendency
to hairy growth, in the region of the lower cervical and upper
dorsal vertebrae.
The plates at the end of the book refer mostly to the cases
of microcephalic idiocy described, and are useful additions.
In conclusion, we may say that Dr. Bourneville and his
assistants have published an important and valuable contribu¬
tion to the literature of idiocy, and will earn the best thanks of
those interested in the subject, especially for the very full and
detailed account of their cases.
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The Fort England Mirror: A Magazine to Amuse and
Instruct . Published quarterly. July and October,
1892. Published at Fort England, Grahamstown.
It is with much pleasure that we receive from time to time
evidence of the spirit with which the Grahamstown Asylum
is being administered by Dr. T. D. Greenlees, formerly
assistant medical officer at the City of Loudon Asylum.
We regret that from pressure on our columns we have
hitherto contented ourselves with feeling instead of express¬
ing this pleasure in the pages of the Journal. The above
Magazine is edited by Dr. Greenlees, and no doubt affords
instruction and amusement to the inmates of the asylum.
In the number for October a bird’s-eye view of the
institution is given. What was formerly the mess house of
the military officers is now “The Residency,” that is to say
the residence of the medical superintendent. It is separated
from the male division of the asylum by a cricket ground.
This is bounded by the laundry and clerk’s house. There is
in the distance the location set apart for natives.
We wish success to this Magazine and to the asylum
under Dr. Greenlees’ care. We have no doubt that there is
a great deal of uphill work, and that it is no easy work to
sustain the energy needed for the administration of such an
institution in a climate where we believe the thermometer
is frequently 108° in the shade.
We have before us the Report of the Inspector of Asylums
in the Colony of the Cape of Good Hope, presented to
Parliament by command of his Excellency the Governor in
1892. Dr. Greenlees’ report of the Grahamstown Asylum is
printed, the seventeenth since the opening of the institu¬
tion. Since the asylum was opened 257 patients recovered,
the ratio being 80 per cent, on the admissions; 213 deaths
occurred, the percentage of deaths on the average number
resident being 11.
Great improvements have been carried out, and a new
ward has been opened for quiet patients and those of a
better class in the female European division.
The Inspector observes in his report, “ Dr. Greenlees is
devoting himself assiduously and with great success to the
management of this hospital, which during the last year
admitted as many as 1,990 cases, but his efforts are a good
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deal hampered for the want of a large dining and recreation
hail”
We are glad to see that the statistical tables appended to the
report are those of the Medico-Psychological Association.
Dr. W. J. Dodds presents the report of the Valkenberg
Asylum, the first which has been issued. Dr. Dodds is the
Inspector of Asylums, and he states in his returns that the
total number of lunatic and idiotic persons in the Colony is
1,921, the number in asylums being 645. For the white
population alone the proportion of insane persons uuder
official supervision to the population is one in 1,050, there
being 376,987 white persons, and the number of registered
white insane, January 1st, 1892, being 356. For the
coloured population the proportion is one in 3,796, there
being 1,150,237 coloured persons, and at the above date 303
registered coloured insane. Additional accommodation is
required.
Dr. Impey presents a special report on the Robben Island
Lunatic Asylum. He considers that the island is well
adapted for the safe detention and successful treatment of
lunatics, but by no means perfect. The buildings were built
for barracks, and much requires doing to remove their
prison-like appearance. The accommodation for lunatics,
lepers, and convicts has been very scanty in the past, but
now good buildings are being erected and the old ones trans¬
formed.
The Asclepiad. By Benjamin Ward Richardson, M.D.,
F.R.S. (Vol. ix., No. 35. 3rd Quarter, 1892).
This Journal shows no indication of waning vigour. In
fact the present number contains a large amount of interest¬
ing matter. One note on “ Nervous and Mental Derange¬
ment from Organic Sulphur Compounds ” has reference to
the instances of derangement of mind induced by exposure to
inhalation of sulphuretted hydrogen related by Dr. Andrew
Wilson on the observation of Dr. Wiglesworth. Dr. Richard¬
son recalls his own observations presented to the British
Association in 1870. He introduced the study of the effects
produced by chemical. substances modified by the introduc¬
tion or abstraction of simple elementary parts, and insisted
that it was necessary to commence with a base, and to
follow the modifications of its actions through the varied
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compounds formed upon it. He indicated the peculiar
action of the substance known as mercaptan or sulphwr
alcohol . It was shown that'a person brought under its
action was subjected to strange variations of mind and
body, viz., a desire to sleep, a strange, unhappy, dreamy
sensation as from some actual or impending trouble, suc¬
ceeded by an easy but extreme sense of muscular fatigue, so
that the limbs felt too heavy to be lifted, and with depression
and slowness of pulse for several hours. Sulphur com¬
pounds were also shown by him to be readily constructable
in the animal economy, and a new field of inquiry was
opened as to their presence in the air of a sick room and
in the excretions. When we know how minute a proportion
of sulphur alcohol will produce mental depression bordering
on suicidal propensity, we may infer that the formation of
sulphur compounds within the body would account for many
examples of excessive temporary prostration, for the cause
of which we have as yet no explanation.
In a further research on the same subject Dr. Richardson
says, “ I came to the conclusion that the influence exerted
over nervous matter by the element sulphur, in disintegra¬
tion, was so marked in mental aberration that it was inevit¬
able that melancholia and other nervous affections, attended
with or without paralysis of voluntary muscles, must some
day be accepted as due to the presence of compounds of this
element; that there is sometimes abundant evidence, from
odour alone, of the presence of mercaptan in the excretions
from the lungs, the skin, and the alimentary canal$ and that
by inquiry in this direction we have before us the first steps
towards a rational explanation of insane conditions produced
as deliriums from intoxication by intoxicants developed in
the vital organic chemistry. In respect to deliriums from
sulphur products so many corroborative facts have now
been recorded in addition to these latest by Dr. Wigles-
worth, the view I advanced in the report may be considered
as a demonstration” (“ Asclepiad,'’ p. 254).
Dr. Peterson has drawn attention to the influence of
sulphur compounds in causing attacks of insanity in’the
" Boston Medical and Surgical Journal,” Octobet 6th, 1892.
Three cases of acute mania from inhaling carbon bisulphide
are reported. They occurred in 1887.
In a very careful and thoughtful article on Sir Thomas
Browne and the “ Religio Medici,” Dr. Richardson, in his
earlier headings, arrived at the conclusion that there is a
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1893.]
vein of satire running through this celebrated work. He
shall speak for himself from his later readings of the work
and the times in which it was written:—
“ The majesty of the Catholic Church of Rome had then departed
from the minds of men of the class to which Browne belonged, ex¬
cept in such instances as that of Kenelm JDigby, in whom heredity
carried the majesty almost intact. At the same time the religion
of the Puritan and Presbyterian, the Baptist, the Anabaptist, and
the other sectaries was to this author (Browne) harsh, low, vulgar.
He therefore found refuge in the reformed Church of England,
with sufficient ceremonial in the services of that Church to give
poetry to them and a mixed system of learning as well as worship.
That is not all. He was smitten with science, not deeply, not by
experimental personal labour like Galileo, nor by psychological
labour like Spinoza, but by a kind of secret sympathy which he
dared not fully confess even to himself. In the dilemma he strove
to bring up reason to the bar of faith, and when, in the attempt, he
found reason compatible with faith he was satisfied; whilst, when
he found what he called reason in opposition to faith, he gave
reason its conge , and let faith stand alone.”
Here Dr. Richardson thinks he has found the key to the
mystery. Browne thought it no degradation to believe what
is not only above, but “ contrary to reason and against the
arguments of our proper senses.” We all who have admired
his writings have regretted his superstitions in regard to
witchcraft, practically shown as it was in giving evidence
which helped the convictions of two unhappy victims of this
terrible belief. Dr. Richardson points out that Sir Thomas
Browne would have been guilty of a still worse offence had he
not believed in what he wrote. Dr. Richardson, we are glad
to find, no longer thinks the “ Religio Medici ” a satire, but
that “ it breathes the confession of a struggling scholar, of
a true child of science, a poet striving to read from nature,
understanding some parts, but closing the page as unde¬
cipherable and too fearful to be pursued whenever doubt
proved a traitor.”
We must not enter further upon the fascinating subject so
interestingly handled by Dr. Richardson. We refer the
reader to the “ Asclepiad ” itself, where he cannot fail to find
much to interest him, not only in this essay, but in others.
The “ Asclepiad,” written from beginning to end by Dr.
Richardson, will, if we are not mistaken, retain a permanent
place in our medical literature. We have omitted to state
that the portrait of Sir Thomas Browne is, like all those
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268 Reviews. [April,
which have appeared in this publication, an admirable pro¬
duction.
Since writing the above we have received the “ Medical
Magazine” for January, containing an article by Dr. A. C.
Farquharson on “ Organic Sulphur Compounds in Nervous
and Mental Diseases.” He regards the observations of both
Dr. Eichardson and Dr. Wiglesworth as “ undoubtedly of
interest and importance in their relations to the subject of
toxaemia from the fact that the common element, sulphur,
forms part of the intoxicant compounds. Hut the charac¬
teristic features differ so much in the two groups of observa¬
tions that they appear best considered apart. In fact, the only
feature which they possess in common is this one of the
presence of sulphur in the intoxicant for each case.” Dr.
Eichardson would argue that the symptoms arising from
sulphuretted hydrogen must be different from those caused
by mercaptan, because in one instance the sulphur is com¬
bined only with one element—hydrogen—in the other with
two—carbon and hydrogen—and because one is a volatile,
the other a fixed compound. This common tie is, Dr.
Farquharson considers, “ considerably weakened when it is
remembered that it rests upon a presumption, viz., that
sulphuretted hydrogen was the inhaled poison in Dr.
Wiglesworth’s cases.” His conclusion is that “the in¬
sanity of mercaptan differs greatly from that of sul¬
phuretted hydrogen, and while differences so great may, for
speculative purposes, be grouped together under the compre¬
hensive phrase of ‘ mental derangements/ they are still so
wide apart as to suggest setiological factors beyond sulphur
compounds, and to justify the contention that one cannot be
taken as corroborative of the other.” (“ Med. Mag.,” p. 642.)
Der Rapport in der Hypnose . Untersuchungen iiber den Thie -
rischen Magnetismus. Yon Dr. Albert Moll. Leipzig,
1892.
Dr. Moll’s latest book, “ Der Eapport in der Hypnose,” is
published under the auspices of the German Society for
Psychological Eesearch. This Society, we might add, was
formed in November, 1890, by the amalgamation of the
“ Psychological Society ” of Munich, and the “ Society for
Experimental Psychology 99 of Berlin, and corresponds, in a
more sceptical sense, to the “Society for Psychical Ee-
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search ” in this country. A knowledge of the above fact
explains at once the standpoint from which the question is ap¬
proached. It is well known that the purpose of the societies
mentioned is to investigate impartially all kinds of phenomena
brought under their notice, and not a 'priori to reject such
phenomena as impossible. In the same way Dr. Moll has
taken in hand the assertion of the so-called mesmerists , that in
the hypnotic rapport there is at work some kind of unknown
influence, which cannot be appreciated by our generally
recognized senses, and which they call animal magnetism;
and he has considered it worth the trouble of making a
great number of experiments in order to test the influence
of animal magnetism in and on the hypnotic condition,
especially in producing the so-called rapport. The last
number of this Journal contained a review of an article by
Professor Wundt on hypnotism, in which the question of
animal magnetism, telepathy, etc., is rejected without
experimental investigation as a scientific impossibility. To
this article Dr. Moll refers at the end of his book, saying
that Professor Wundt was not quite correct in stating that
only those give their time to experiments of the kind
mentioned, who thoroughly believe in the phenomena they
are going to investigate, for it is almost needless to say that
Dr. Moll comes from his experiments to the same conclusions
at which Professor Wundt arrives without experiments,
through scientific reasoning. Professor Wundt's standpoint
is very good for the limited number of those who are so well-
informed in science as is the Leipzig Professor himself, and
able absolutely to follow the course of his logic, but the
standpoint adopted by the societies mentioned, and also by
Dr. Moll, is certainly the more suitable and practical one
for convincing the greater number of people of the erroneous¬
ness of the assertion that there is such an invisible and
powerful factor at work in hypnotic suggestion as “ animal
magnetism." The latter standpoint also avoids the objection
of unfairness from the opposite side. It is almost super¬
fluous to say that the number and variation of the experi¬
ments which Dr. Moll performed and describes is as
complete and thorough as we have become accustomed to
expect from Dr. Moll's former work. His knowledge Of the
subject and of the related branches is very wide, and to us it
was especially interesting to read his remarks on the taming
of wild beasts, and the conclusions he draws from the
analogy of the influence of the dompteur on his animals and
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270 Reviews . [April,
of the hypnotizer on the person with whom he is en rapport .
We doubt whether Dr. Moll's latest book will find so wide
a circle of readers as his book on “ Hypnotism '' has found.
Hypnotism in itself is so interesting that such an excellent
book as the one mentioned could not fail to find a large
circulation. It is, however, not everybody's liking to read
about experiments which all prove to be failures, i.e., to find
a record of negative results only. The greater number of
people—and this is certainly true in the case of a large
number of those who are interested.in hypnotism, and to this
latter class alone the remark of Professor Wundt applies—
in performing or witnessing experiments, expect and want to
see positive results, and are unable to appreciate that the
failure of an experiment is quite as valuable from a scientific
point of view as a successful experiment. Dr. Moll's
“ Rapport in der Hypnose" is a collection of negative
results with regard to the proof of the existence of animal
magnetism, and therefore of great scientific value, although
not to medical hypnotizers, who knew them already.
Lemons sur les Maladies de la MoeUe. Par le Dr. Pierre
Marie. PariR: G. Masson. 1892.
The lectures of which this book is composed were delivered
at the Paris “ Faculte de M&lecine" in 1891, and deal with
some of the most important diseases of the spinal cord,
especially with the chronic scleroses.
After giving a full and lucid account of the anatomy
(physiological and pathological) of the spinal cord, com¬
prising seven lectures, and embodying the most recent
researches on the subject, the author begins with the
description of spasmodic tabes dorsalis.
Lectures X. to XIY. deal with disseminated sclerosis, of
which Marie distinguishes three forms:—
a. The spasmodic.
#. The cerebellar.
7 . The cerebello-spasmodic.
Among other interesting points we note that the most
constant oculo-motor symptom is paralysis of the associated
movements of the eyeballs, and that the psychical disturbance
generally present consists in slight dementia, apathy, or
melancholia, with the frequent presence of attacks of un-
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271
controllable laughter. The importance of infectious diseases
in the etiology of this affection, a subject which Marie has
investigated thoroughly, is dwelt upon, and he inclines to
the belief that the inflammatory process—an interstitial one
—which characterizes the pathology of the disease is due to
a microbe.
A very large portion of the book (sixteen lectures) is
devoted to the subject of locomotor ataxy, or “ tabes
dorsualis,” as Marie prefers to call it, and we have here an
admirable and exhaustive account of that most interesting
disease. The occasional association of Graves’s disease with
locomotor ataxy is dwelt upon, and the chapters on etiology
and pathology are most thoughtful. Erb’s recent statistics
of 369 cases, of which 89 per cent, were due to syphilis,
accord with Marie’s opinion that this is perhaps the only
real cause of the affection, while heredity and age hold a
small share in the etiology. As regards treatment, while we
should, as a rule, try the effect of anti-syphilitic remedies, we
are reduced to combating symptoms—ergot for urinary
troubles, the suspension treatment for inco-ordination and
genital symptoms, and analgesics for pains.
After discussing the various hypotheses to account for the
changes in the cord, Marie believes that the lesions in tabes
are not due to a primary systematized sclerosis of the
posterior columns, but to a degeneration originating in the
posterior root-fibres, which itself is due to an alteration in
the spinal ganglia and in the peripheral ganglion-cells.
Lectures thirty and thirty-one deal with Friedreich’s
disease, and the last lectures with infantile paralysis and
amyotrophic lateral sclerosis.
One’s feeling after reading this work is the desire that
the author should complete the task which he has so well
begun by including other diseases of the spinal cord in a
second volume.
The book carries with it throughout the impress of
thoroughness, and of an extensive practical experience with
the diseases treated therein. While recording the work of
other observers in the field of nervous pathology, the author,
whose reputation is great, has freely embodied the results of
his own observations, and this adds considerably to its value.
Of the easy, graceful style of the author, and of the good
illustrations scattered throughout the work, one can but
speak in terms of high praise.
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272
[April,
Clinique dee Maladies du Systeme Nerveux. Par M. le Prof.
Charcot. Paris : Veuye Bab6 et C le . 1892.
This is a welcome contribution to the diseases of the
nervous system from the prolific pen of Prof. Charcot, and a
worthy addition to his already numerous volumes on the
subject. It is for the most part a record of clinical lectures
delivered, and of cases observed, at the Salpetri&re between
1889 and 1891, and reported by M. Georges Guinon, chef de
clinique, and other of Prof. Charcot's assistants.
The twenty-three chapters into which the book is divided
teem with interesting observations ; the details of the cases
are most copious, their salient features, diagnosis, treatment,
etc., are discussed in that fluent, incisive, and attractive
style of which Charcot is a master.
Three chapters deal with Morvan's disease and syringo¬
myelia, which the late researches of Joffiroy and others seem
to show are identical, and typical cases are described in full.
Hysteria, as we might expect, has many pages devoted to
it. Thus in Chapter III. we find a most interesting account
of hysterical trembling in its various forms, simulating
either the tremors of paralysis agitans, or of Graves's disease,
or of disseminated sclerosis. In Chapter Y. an uncommon
complication, which Charcot calls “blue oedema," is discussed,
and the fact mentioned that it may be artificially induced
in hysterical cases by hypnotic suggestion. Further on, after
commenting upon the prevalence of hysteria in men (espe¬
cially manual labourers) as evinced by late records, Charcot
gives the notes of a curious case of hysterical facial paralysis
in an alcoholic subject with an unsound family history.
Illustrating the difficulty which may arise in differentiating
hysteria from organic brain-disease, is a case of hemiplegia
with crossed .ptosis due to spasm of the orbicularis palpe¬
brarum, and Charcot draws attention to the lowering of the
eyebrow on the affected Side as distinguishing ptosis due to
spasm from paralytic ptosis; moreover, in hysterical ptosis
there is corneal anaesthesia. Finally, the last chapter of the
book is given to the subject of hysterical yawning, a most
graphic account of this symptom being supplemented by.
useful tracings of the respiration.
In Chapter IV. we find an account of ophthalmoplegia com¬
plicating megrim, of which only about twenty cases have
been published, and for the treatment of which Charcot con¬
siders large doses of potassium bromide efficacious.
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Chapter VII. treats of those uncommon cases of sciatica com¬
plicated with muscular atrophy in the region of the external
popliteal nerve, which are independent of traumatism or of
any lesion in the pelvic cavity affecting the sciatic nerve in
its course, and the pathology of which seems to be obscure.
The chapter devoted to cases of ophthalmoplegia externa
complicated with general muscular atrophy is excellent, and
a tribute to the clinical acumen of the author.
Diabetic paraplegia is the subject of Chapter XIII., which
in most of its symptoms resembles alcoholic paraplegia.
Other chapters deal with cerebral syphilis and atypical
forms of disseminated sclerosis.
We have said enough to show the varied interests of these
clinical records, and the perusal of this volume cannot but be
most pleasurable to the student of neuropathology.
Les Phenomenes Psychiques et la Temperature du Cerveau,
Par le Prof. A. Mosso. Turin: Hermann Loescher. 1892.
This is a reprint of the Croonian Lecture (March 24th,
1892), published in “ The Phil. Trans. R.S.,” t. clxxxiii., p.
2 ".
By means of very sensitive mercury thermometers,
especially constructed by Baudin, of Paris, Prof. Mosso is
able to record minute differences of temperatures—even
t o ' V o’C.— and by careful tracings the temperature of the
blood in the brain, the carotids, the uterus, etc., are com¬
pared and contrasted at any given moment.
By successive experiments performed upon dogs under the
influence of laudanum, or chloroform, or chloral, Prof.
Mosso draws important conclusions respecting the production
of heat in the brain by psychical phenomena, and the effect
of certain agents and drugs on the metabolism of brain-cells.
In a partially narcotized dog, for instance, a psychical
stimulus (a noise) produces an appreciably, though very
slight, elevation in the temperature of the brain, but the
effect of the induced current is much more marked.
Consciousness, even in the absence of definite or objective
mental work, involves in itself an active metabolism in the
brain-cells, and the development of heat in the brain during
the conscious state is, according to Prof. Mosso, consider¬
able, and greater than that generated by the muscles during
rest.
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Reviem.
[April,
Opium and other narcotics markedly check metabolism in
the brain-cells ; cocaine and strychnine, on the other hand,
favour metabolism and cause increase of temperature,
without necessarily producing evident physical activity.
Mosso concludes that sleep is not due to mere alteration in
the circulation of the blood, as is widely believed, but with
psychical processes it is dependent on chemical metabolism
in the brain-cells.
Prof. Mosso’s experiments and results are most interest¬
ing, and we can but look to their extension with hopeful
pleasure.
The Life of William Cowper. By Thomas Wright, Principal
of Cowper School, Olney. T. Fisher Unwin, London.
1892.
We are obliged, in consequence of the press of matter, to
postpone to the next number our review of this work, which
we commend to readers interested in the insanity of the
poet. The subject is one which has long engaged our
attention, and we intend entering at some length upon the
study of Cowper’s mental affection.
PART III.-PSYCHOLOGICAL RETROSPECT.
1. Asylum Reports for 1891-92.
(Continued from p. 128.)
Leicester and Rutland .—The rate of mortality was high—14 per
cent, on the average number resident. There was an epidemic of
diarrhoea, which caused four deaths. Forty cases of influenza
occurred, and several deaths were due to the sequelae. The cause
of the outbreak of diarrhoea was not discovered, though Dr.
Higgins was assisted in his examination by the Medical Officer of
Health and a hospital physician. Such outbreaks are too common
in asylums, and unfortunately efforts to discover their origin are
frequently unsuccessful.
Leicester (Borough ).—The drainage has been completely over¬
hauled, and it is believed that all defects have been remedied, so
far as it is possible to do so. The weekly services by Nonconfor¬
mist ministers are continued, and are much appreciated by the
patients.
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Asylum Reports .
275
During the last four years the death-rate has been remarkably
low. Last year it was only 4 3 per cent, on the average number
resident.
It was resolved by the Visitors to adopt the following scale of
wages for attendants and nurses:—
Attendants commence at £32 per annum and rise by £2 per
year to £48 per annum; charges continuing to £52. Nurses
commence at £18 per annum, and rise by £1 per year to £32 per
annum; charges continuing to £35.
Limerick .—A large observation dormitory for male patients
has been completed. It is evidently, from the description given
by Dr. O’Neill, a handsome room, and much attention has been
paid to its heating and ventilation. The work was done by the
staff, assisted by patients, and under his direction and supervision.
The report by the Inspector is very satisfactory and complimen¬
tary. Only one grave fault is pointed out—the absence of an
assistant medical officer. The necessity for appointing one is
strongly urged.
Lincolnshire. —During the year several outbreaks of dysenteric
diarrhoea occurred, due to the impurity of the water. There were
also a few cases of mild typhoid due to the same cause. All water
intended to be drunk requires to be boiled and filtered.
It has not yet been decided how to provide the required accom¬
modation, whether to build an annexe to the present asylum, or
a new asylum in another part of the county. A second assistant
medical officer is much required. The Commissioners recommend
his appointment, and it appears as if their wishes are to be
carried out.
Lincoln. “ The Lawn. 11 —We congratulate Dr. Russell on the
presentation of a satisfactory Report of this hospital.
Various structural improvements are in progress, and others
are contemplated.
A specially good feature in the hospital is the strength of the
staff of attendants and nurses.
County of London. —By the authority of the Council the Asylums
Committee have advertised for a site of from one to two hundred
acres for an asylum to contain not more than 1,000 patients. The
offers received are still under consideration.
With a view to maintaining the supply of provisions, stores,
etc., up to the standard samples, frequent analyses have been made
by the Council’s chemist, and it has been agreed to pay the sum
of £100 a year to the Council for these services.
The water from the wells at each of the asylums has also been
periodically examined both chemically and microscopically. By
these means a faulty main at Hanwell was discovered and replaced
by a new one, and the cause of certain impurities in the well water
at Colney Hatch was detected and stopped.
London , County of. Banstead Asylum. —It has been decided tg
xxxix. 18
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276
Psychological Retrospect.
[April,
improve the infirmary accommodation by the addition of spur
blocks, one for each sex, at an estimated cost, including furnish¬
ing, of £14,000.
The following paragraph occurs in Dr. Clay Shaw’s report:—
We hear very little now from the patients on the subject of beer. They have
quietly aoquiesoed in its withdrawal. It is difficult to gauge the effect on the
physical condition of the abstinence movement, but my impression is that it has
been favourable, partly by causing more solid food to be taken, and partly by a
greater degree of induced mental quietude, owing to the withdrawal of what was
undoubtedly at times a source of quarrelling and excitement. On the other
hand, some patients have been unable to take the ordinary diet without a little
stimulant in some form, and here we have been compelled either to give the
required stimulant, or to change the ordinary diet into some palatable “ extra.”
It cannot, I think, be said that the innovation has been on the economical side,
but its great service, in my opinion, is the strong inducement given to persons
admitted from insanity due to alcoholic abuse to abstain in future from what
they have been made to see was the cause of their downfall. In the readiness
with which patients have borne the withdrawal of all kinds of stimulants I see
an argument in favour of the theory that insanity is caused by drink, and that
only comparatively rarely is drinking the result of the insanity; not denying,
as of course clinical experience does at times show, that the converse may occur.
I do not recall one case during the last two years* experience in which the
drink-craving has given any trouble.
London, County of. Cane Hill Asylum. —The large additions are
now occupied, and the asylum contains nearly 2,000 patients.
Plans and estimates have been prepared for an extra nurses’
block, attendants’ cottages, cow-houses, new farmyards and
piggeries, assistant medical officers’ office and additional quarters,
additions to workshops, etc.
The transfer of 190 patients from Lancaster was effected at one
time, in a special train of eleven saloon carriages. Dr. Moody
believes this to be the largest removal at one time yet attempted.
It appears that he questions any happy results from the recent
extension of holidays to the younger nurses.
London , County of. Claybury Asylum. —This is not yet ready for
occupation.
A contract has been entered into for converting the old Mansion
into an asylum for fifty paying patients.
London , County of. Colney Hatch Asylum .—The following occurs
in the Commissioners’ report: —
A glance at these figures, a survey of this vast building, and a review of the
patients in its large wards would, we think, convince most thoughtful persons
that the task of supervision, thorough supervision , must be beyond the powers of
any individual, and yet dual superintendence was even worse. The mischief
which that dual superintendence, inter alia , created (and which is, we fear,
irreparable) in defeating the Commissioners* objections to bringing together so
many patients, unhappily survives. The difficulties now existing and inherited,
should be a lesson to keep down the number of patients in any asylum within
reasonable limits. We have no hesitation in saying that we afready see happy
results from the appointment of a single superintendent to the charge of the
whole asylum. ... We press for the employment of clinical clerks in the wards,
and especially for the appointment of a pathologist of experience, whose resi-
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277
1893 .] Asylum Reports.
dence in the asylum is not necessary, and who, indeed, would he more useful if
not withdrawn from his fellow scientists.
Dr. Seward reports :—
Towards the end of December there commenced a much more serious outbreak
of influenza, the disease being of a very malignant type, and in a very large
number of cases |it was complicated by pleuro-pneumonia and pericarditis;
inflammation of the middle ear was also very frequent, and in some cases there
was meningitis. In the course of the epidemic, which lasted about three
months, 71 male and 334 female patients were attacked, the deaths numbering
five and 41 respectively, and the average age of those who died being 64. It
will be noticed that the disease was much more prevalent and much more fatal
among the women than the men. Of the staff, in addition to many cases among
the officers, 25 attendants and 42 nurses were attacked; two cases among the
former unfortunately ended fatally. That our staff was severely tried will be
readily understood from the fact that in the last two weeks of January there
were 53 deaths from all causes, and 75 during that month. The highest praise
is due to all, and particularly to the nurses in the female infirmaries for their
unremitting attendance upon the sick.
An advanced course of lectures on nursing has been given to
those nurses who have already passed the first aid examination of
St. John Ambulance Association.
London , County of. Hanwell Asylum .—The Visitors report that
the most noticeable events of the year were the resignation, owing
to failing health, of Mr. J. Peeke Richards, the medical superin¬
tendent of the female division of the asylum, and the appointment
of Dr. Alexander as sole medical superintendent. They record
their appreciation of the services rendered by Mr. Richards during
his long tenure of office, and acknowledge their indebtedness to
his knowledge and experience, which were so freely placed at their
disposal.
The members of the medical staff instruct the attendants by
means of lectures. It is hoped that arrangements may be shortly
made to provide a pathological laboratory and museum, as well as
a billiard room for the medical officers.
Five cases of typhoid fever occurred ; two ended fatally. The
well water, after chemical and microscopical analysis, was pro¬
nounced free from injurious matter, and of satisfactory quality,
but suspicion was thrown upon the water mains. A new one has
therefore been put in.
Concerning general paralysis Dr. Alexander remarks :—
We have year by year, with monotonous regularity, to deplore the prominence
of general paralysis as a form of mental disorder in the male admissions. It
may be of interest to note the numbers of both male and female general paralytics
admitted during each year of the first sub-committee’s tenure of office:—
In 1889 there were 31 men (16 p.c.) and 8 women (3 p.o.)
In 1890 „ 76 „ (25 p.o.) and 17 „ (5 p.c.)
In 1891 „ 63 „ (26 p.c.) and 13 „ (6 p.c.)
One sees from this a great increase in both male and female general paralytics,
also the disparity in the incidence of the disease in the two sexes, a disparity
rather greater than usually obtains.
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278 Psychological Retrospect . [April,
The continuous supervision of suicidal patients at night is now
in operation.
Dr. Alexander states that concurrently with the outbreak of
typhoid fever there was an epidemic skin disease of a most peculiar
character, and following closely on the outbreak was an epidemic
of diarrhoea and sickness, as if from the operation of some irritant
poison. The actual causes of these disturbances of health could
not, however, be determined. Both of those epidemics affected a
considerable number of patients of both sexes, but no deaths ensued
therefrom.
London. St. Luke's Hospital .—Several improvements were
effected during the year. A new padded-room, of the most ap¬
proved modern construction, has been fitted up. Modern bedsteads
have replaced old and objectionable ones.
The Committee have still under active consideration the estab¬
lishment of a Convalescent Home. During the year numerous
instances arose to demonstrate the great need for this valuable
auxiliary to the hospital. It has been decided to carry the balance
of revenue over expenditure for the year to an account for the
establishment of a Convalescent Home, instead of following the
usual precedent of carrying the same to the capital account for
investment in support of the charity.
An assistant medical officer has been appointed. This addition
to the staff has been found most beneficial.
London. City of —The report of the Visitors is largely occupied
by the enumeration of the many structural improvements effected
during the year.
It has been decided to receive private patients at a uniform
charge of a guinea per week, the patients to wear their own
clothes.
The following scale of annual leave of attendants and nurses
has been adopted :—
Male Attendants ...
Charge ...
... 12 days.
Ditto
... ...
Second ...
... 10 „
Ditto
...
Ordinary...
... 8 „
Nurses
...
Charge ...
... 14 „
Ditto
... ...
Second ...
... 12 „
Ditto
... ...
Ordinary...
... 10 „
Dr. White continues to instruct the attendants and nurses pre¬
paratory for the examination for the certificate of the Medico-
Psychological Association. Twelve passed the examination—all
that presented themselves. Dr. White says that he cannot speak
too highly of the theoretical and practical training in asylums.
He attributes the non-occurrence of a bedsore for several years to
the fact that the attendants and nurses have been told that it is a
preventable disease, and have been shown how to prevent it.
Middlesex. Wandsworth .—Gratuities from the Queen Adelaide
Benevolent Fund were given to 36 patients on leaving the asylum
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1893.]
279
Asylum Reports.
cured. They amounted to £40 7s. 6d. Twenty-nine patients
received an allowance of 10s. 6d. per week during discharge on
probation.
The Committee have adopted a scale of “ holi4ay money ” for
the whole of the attendants and nurses, in lieu of rations, as
follows:—
s. d.
For one to six years* service ... ... 10 0 per week.
For six to ten years’ service .15 0 „
Above ten years’service... . 20 0 „
Plans have been prepared for the erection of a building for the
accommodation of idiots. Dr. Gardiner expects good results
from the separation of these persons from the ordinary lunatic
patients. He says :—
The permanent good results that have been achieved by existing establish¬
ments in the education of idiots, although considerable, are not encouraging
enough for me to recommend that a very costly and elaborate system be
attempted with the object of obtaining! a high standard of education, and
with the hope that the idiots may be made sufficiently self-reliant as to be able
on their own resources to earn their living, but I do consider that buildings and
an adequate staff, such as you propose, ought to be provided to give them an
elementary education, to teach them to attend to their daily wants and to
employ themselves usefully, so that they may have pleasure ih feeling they have
some share in the common objects of life.
Montrose .—The number of patients resident continues to increase.
It has been necessary to notify to the parishes in Orkney that no
more pauper patients can be received.
The new hospital has been fully occupied for about twelve
months, with results entirely satisfactory in all respects. The
chief male sick ward is under the care of a trained female nurse,
and there is also a trained nurse in the wards for the women. The
new matron is also a trained nurse. Two serious epidemics of
influenza occurred. Erysipelas affected one man and 16 women.
The cases were generally of a mild type, and none ended fatally,
though several women had relapses or fresh attacks.
Newcastle. —After much consideration the Committee have
resolved to enlarge the asylum, as the already existing accom¬
modation is too limited. They have solicited plans from architects
practising in Newcastle for a new building for 350 additional
patients.
Norfolk. —The sanitary condition of this asylum is being
gradually improved, but it is not yet beyond reproach. During
the year several cases of dysenteric diarrhoea, erysipelas, and
typhoid occurred.
Concerning treatment Dr. Thomson says:—
Nothing very novel in the way of treatment has been introduced during the
past year. Asylum physicians, like their confreres in general practice, are
aware that cure of an attack of insanity or any other disease is not to be looked for
in the prescription of a particular drug; excitement, it is true, can be allayed
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280 Psychological Retrospect. [April,
. /
by hyoscine, or sleep induced by chloral, etc., but those drugs merely modify
a symptom, and do not prevent the malady running its course any more than
an expectorant mixture will cure pneumonia or ice cure meningitis; rather is
it aimed at nowadays to place the patient in the best possible circumstances to
wrestle with the illness, hence the improved nursing in asylums, the liberal
supply of extra diet, including good stimulants. In this connection your
expenditure on spring mattresses for the hospital wards and some other wards
was most advisable, and has added greatly to the comfort of the patients. I was
induced to try a vegetarian diet for epileptics for a period of three months, and,
without going into details or referring to the elaborate notes that this experi¬
ment involved, I may say that, speaking generally, the frequency or severity of
the fits was not diminished by abstinence from butcher’s meat.
Under this head I may refer to the fact that with the increasing and vexatious
clerking duties thrown upon medical superintendents by the recent Lunacy Acts
and Lunacy Commissioners’ regulations, the treatment of patients, which I
understand to be their primary functions, cannot help being in a greater
measure delegated to their less experienced colleagues, the assistant medical
officers; a more ill-advised and uncalled-for piece of legislation, not to speak of
the almost unintelligible English in which the section is worded, than the
annual, biennial, triennial, and quinquennial recertification of chronic cases it
would be difficult to find; for example, A. B. has the delusion that his inside is
made of brass. I know that he has this delusion, and that he will never lose it.
I see him nearly every day, sometimes half-a-dozen times a day; a member of
the Committee sees him once a week; his case has already been fully described in
various statutory books. I have no interest in his detention, on the contrary, I
want to have a high recovery rate and discharge as many patients as possible,
and yet once a year he has to be brought to my office, half-an-hour has to be
wasted over useless formalities, and a report sent up to Whitehall, and so on,
with the seven or eight hundred cases.
While a party of working patients were unloading bricks from
a wherry at the river staithe, a patient jumped into the river with
suicidal intent. Attendant William Thompson, who was in charge
of the party, at once jumped into 11 feet of water, and succeeded,
with some assistance, in saving the patient’s life. For this gallant
action the Committee awarded him a gratuity of £5, and recom¬
mended him to the Royal Humane Society, who award him their
parchment certificate.
Northampton. St. Andrew's Hospital .—A house adjoining the
hospital grounds has been purchased, and will be used for the
accommodation of male patients.
The Commissioners report that as many as 81 male patients are
induced te employ themselves, and of these 61 help on the farm
or in the garden. It is Mr. Bayley’s intention to extend this form
of exercise to many more gentlemen, as he is strongly convinced
of the great value of outdoor employment as a method of treat¬
ment.
Concerning restraint Mr. Bayley says :—
One female patient was restrained on two occasions for a total period of two
hours. The means of restraint used were the hands fastened behind the back
with a padded strap, and the object for employing restraint was the prevention
of constant bad and indecent habits, which prevented improvement in the
mental and physical condition of the patient herself, and were a constant source
of annoyance and disgust to all about her.
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281
1893.] Asylum Reports .
The patient, a young girl, has since recovered and returned to her home. I
have always been, and still am, strongly opposed to mechanical restraint in the
treatment of mental excitement, and I would never permit it until every other
means of treatment had been fairly tried, but the result in this case proves that
there are times when such restraint, properly used, under strictly medical
supervision may be most useful.
I should state that the patient was brought from private care after having
attempted to commit suicide, and that she had been in the hospital about 2$
years before restraint was tried,[every other plan of treatment having utterly
failed.
Northumberland .—The Committee have had under consideration
the gradual improvement of the entire asylum as regards ventila¬
tion, warming, and sanitary requirements.
Concerning alcoholic cases Dr. McDowall says:—
By reference to Table X. it will be seen that no fewer than 31 patients were
admitted in whom the cause of the attack was attributed to drunkenness, and
there is every reason to believe that the same cause operated in several other
cases. As a rule a very considerable proportion of these alcoholic cases recover,
return to their homes, and, it is to be feared, too frequently to their former
habits. It has been my practice for several years earnestly to warn them of the
danger of their ways, and many have made solemn promises of amendment; but
what proportion adhered to their good intentions it is impossible to ascertain.
That some were unable to struggle against inclination and prevent temptation is
proved by their return to the asylum. To diminish this evil as much as possible
I have of late endeavoured to bring such cases under a kind and benevolent
supervision on discharge, and have written to the clergyman of the Communion
to which the patient happened to belong, stating the facts, and recommending
him to his care and attention. It is gratifying to find that the clergy of all
denominations have readily co-operated in this work, and have at once taken an
active interest in any patient brought under their notice, and there is every
reason to hope that the efforts made to benefit these people will be successful in
more directions than one.
The following paragraph refers to another subject:—
A number of months ago I forwarded to each member of the committee a
copy of a report of a Committee of the Medico-Psychological Association, dnd
perhaps you will permit me to refer briefly to it. As you are aware, the ques¬
tion of the care and treatment of the insane has of late engaged much attention,
and on some points there is some diversity of opinion, as might be expected.
Still, in the great majority there is practically an agreement, and in these it
appeared to the Association, which is composed of medical men specially
interested in the care of the insane, that the public should know the principles
which shoifld be attended to in providing and governing asylums, in regulating
their size, in appointing their officers, etc. The report appears to me of much
public importance, and deserving of wide circulation and careful study. In
order that it may obtain these I propose to append it to this report, and thus to
bring it under the notice of the county generally. An asylum involves a large
expenditure, and for buildings and structural improvements there is a con¬
tinuous demand. In the administration there is, and must be, a constant struggle
to keep up with modern requirements; and in the medical treatment the same
efforts are demanded, so that if possible the proportion of recoveries may be
increased. During your official visits, and at other times, these subjects have
been brought under your notice, and I must express my deep sense of obligation
for the careful consideration you have bestowed on them. It is now three
years since the administration passed into your hands, and my testimony is not
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282 Psychological Retrospect. [April
required to prove the enlightened liberality which has marked your term of
office, but it would be ungrateful if I failed to acknowledge your readiness to
consider all questions affecting the welfare of the asylum and its inmates.
Northampton .—The deaths include three from enteritis and one
from typhoid fever. The occurrence of these diseases has not
been satisfactorily explained. The report of Mr. Bohn, the sanitary
expert consulted, states :—
I do not think that any building in the kingdom has more perfect sanitary
arrangements. All large buildings containing a great number of persons of the
poorer classes are likely to have occasional outbreaks of diarrhoea, enteric fever,
dysentery, etc.; and with the insane these diseases are probably personal to
begin with. The fact that only a small percentage was attacked would seem to
prove that the drainage was not at fault. Bad drainage is known to carry or
propagate these diseases, and it may therefore fairly be presumed that the
disease was not in this case attributable to any defect in the sanitary arrange*
meats of the asylum.
I am informed that the water supply has frequently been analyzed and found
free from contamination, but as my late investigations render it more than
probable that some of the rain which falls at Berry Wood finds its way even¬
tually into the water-bearing stratum from which the asylum is supplied, I
strongly urge the prudence, as a matter of precaution, of diverting the sewage
of the detached hospital, which is at present discharged into an open ditch, and
thence into a watercourse.
Norwich .—The following short extract from the report of this
Committee brings home to one the costliness of pauper lunacy :—
The total cost per head, including all outlay by the Committee on the build¬
ings and estate, together with the additions, alterations, and improvements
made during the year, has been 13s. lOd. If the interest on the outstanding
loans is taken into account, the cost per head has been 15s. 6d.
Dr. Harris reports that the ambulance lectures were commenced,
but did not prove a success. He has found it better to give in¬
structions at opportune occasions in the wards, and the results, he
states, have been more advantageous to all concerned.
Nottingham. County .—The following extract from the Commis¬
sioners’ report will interest many:—
We hear that the auditors object to any change ever being made in the
regular dietary of the patients, and therefore the monotony of giving a specified
dinner on each day of the week is considered by Dr. Aplin to be imposed upon
him. We hope Dr. Aplin is mistaken in his opinion of the auditors’ ideas, but
if he be not we hope the County Council will appeal to the Local Government
Board on the matter. It must not be forgotten that the real object of an asylum
is a hospital for the cure of mental disorders, and the medical officer in charge
should have the same power of altering the patient’s diet as he has of changing
the patient’s medicine.
The wages of the attendants have been increased by allowing
the annual increase to continue to the seventeenth year of service
instead of to the eleventh. The maximum is now £50 per annum.
The annual holiday has been lengthened, and is now ten days
instead of seven.
Nottingham . Borough. —Dr. Powell reports that in cases of
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283
1893.] Asylum Reports.
insanity following influenza the prevailing type of this disease
was melancholia of a very acute form. It usually ran a favour¬
able course, and terminated in recovery. One case, however, did
not survive more than three days, but died of acute pneumonia,
from which she was suffering on admission.
Nottingham. Lunatic Hospital .—The Commissioners point out
that it is to be regretted that magistrates should sign orders for
detention without first seeing the person for whose detention they
are the authority, as when a patient is fairly intelligent he claims
his right to be seen by a judicial authority, and the patient has to
be taken to see some magistrate very shortly after his admission
to the hospital, which is the time when it is of great importance
that he should be as little disturbed as possible, his early recovery
being very likely retarded by the excitement thus needlessly
occasioned.
Oxford. —It can scarcely be contended that the Committee
of Visitors erred on the side of liberality when, after careful
inquiry, they increased the salary of the medical superintendent by
£24 a year.
Perth. James Murray s Royal Asylum. —The following are
extracts from Dr. Urquhart’s interesting report:—
The home treatment of insanity gains favour year by year. Not of the «
ancient type—the unintelligent imprisonment of a lunatic in the least desirable
room of the house—hut the rational adoption of means that have been approved
in the best hospital experience. Even in those huge aggregations of the pauper
insane in densely populated districts efforts are being made to separate and
differentiate the wards—to sink the institution in the home in so far as is prac¬
ticable. Much more so in hospitals of this class, where the idea of a central
hospital with succursal houses, constantly promulgated for many years by Dr.
Lauder Lindsay, is almost universally carried into effect. Our experience has
been all in favour of this principle of management. The houses complemental
to the main asylum have now been in occupation for a considerable period, with
benefit to patients and staff, and with satisfactory financial results. There can
be no doubt that the margin of cure and contentment is thus enlarged, and that
any further accommodation required by this institution should be obtained by
extension on these lines.
There have been ten actively suicidal and four dangerously homicidal patients
under care during the. year. These difficult cases present serious problems of
management, and their treatment is embarrassed by their destructive attempts.
The constant vigilance required, the perennial trial of patience and endurance,
the demands on tact and temper, which are all in the day’s work of an asylum
attendant, are very inadequately recognized by the world at large. But it is
even easier to bear with the abuse of an actively insane patient than to keep
up constant warfare with the destroying angel of dementia. Nothing can be
more detrimental to the insane than apathetic and selfish management in nursing.
A great deal has been done of late to improve the position of attendants, and
this institution has not been behind in promoting their educative, social, and
recreative interests; but it is undoubted that further advances must be made in
this direction if the asylums of this country are to maintain their place in the
vanguard of progress.
Roxburgh , Berwick , and Selkirk. —The water supply has always
given trouble in this asylum. The quantity has all along been
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284 Psychological Retrospect. [April, .
insufficient, and the quality of some of the sources.is distinctly
objectionable. Steps are being taken to rectify these serious
defects.
Dr. Johnstone reports that significant indications continue
to be afforded (by the occurrence of various cases of illness of an
“ insanitary ” type) that the institution is not in a satisfactory
hygienic condition. It is gratifying to believe that this state of
affairs will not exist much longer. As the result of their inspec¬
tion of the asylum the Edinburgh Sanitary Protection Associa¬
tion have reported that extensive changes are called for in
its sanitary arrangements. The recommendations of the Associa¬
tion have, with some exceptions, received the sanction of the
District Board, and the necessary works will, it is expected, shortly
be commenced,
Salop and Montgomery. —A new supply of water has been obtained
by sinking a well. The report of the analysts was of a most satis¬
factory character. During the year three cases of typhoid fever
occurred, but they all recovered.
Somerset and Bath. —This asylum, in spite of the ninety patients
boarded elsewhere, continues to be overcrowded. Another asylum
is to be erected. The plans have been prepared, and working
drawings have been ordered to be got ready as speedily as pos¬
sible. Among the additions and alterations may be mentioned the
new stores and offices, which are nearly ready.
Staffordshire. Lichfield. —The erection of a third asylum for
this county is under discussion, at any rate, is being talked of. In
connection therewith Dr. Spence says :—
As the provision of suitable accommodation for the care and treatment of
idiot and imbecile children is a burning question at present in many counties,
perhaps it is not out of place to suggest that advantage might be taken of the
contemplated erection of a third asylum for this county to consider whether it
would not be well to build in connection therewith a detached block specially
adapted to the requirements of the class of patients referred to. This would
supply a long-felt want, would satisfy a very distinctly-expressed public demand,
and would be of much benefit to the inmates themselves, though probably not to
the extent that is generally supposed to be the result of the training of such
cases.
Staffordshire . Stafford. —In his report Dr. Christie says:—
The question of wages and hours of duty of the attendants was also con¬
sidered by the Committee, and a scale of pay adopted which is a distinct im¬
provement on the old; at the same time increase of leave has been granted, and
besides the annual fourteen days, each attendant and nurse has half a day in
the week. Of course, to carry this out a considerable increase had to be made
to the staff, but the object for which it was done is so deserving and well-
merited that surely the necessary increase of expenditure which it entails is
justified. The time is yet too short for me to express an opinion as to the
probable effect these inducements will have in attracting and retaining suitable
and trustworthy people in the asylum service—it is to be hoped it will be bene¬
ficial—but at the same time one cannot shut one’s eyes to the fact that the
duties are so peculiar and so trying that changes, more frequent than one
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285
1893.] Asylum Reports.
would desire, are sure to take place, however good the wages and emoluments
may be.
Sussex .—This asylam is still insufficient for the accommodation
of the insane belonging to the county. In his report Dr. Saunders
says:—
It is a question whether the wording of the Justices’ order in the Lunacy
Act, 1890, describing the patient either as “ a pauper, or in such circumstances
as to require relief for his proper care and maintenance,” may not have opened
still wider the door for persons well able to pay a moderate sum for treatment
in a non-pauper asylum. There is no doubt that persons on whose behalf ap¬
plication has been made by the relatives for admission as paying patients, and
who have had to be refused as such, have subsequently been admitted as
paupers, showing that the words “ requiring relief ” have a very elastic inter¬
pretation. Such patients do not become chargeable to the rates, because the
Guardians recover the cost of their maintenance, but they help to fill the
already overcrowded asylum.
Warwick .—The extensive alterations in the sanitary arrange¬
ments are nearly completed, and it is reported that already a
marked improvement has occurred in the health of the establish¬
ment. The following are extracts from Dr. Miller’s report:—
I cannot report any great advancement in the medical treatment of the
patients. New drugs are tried, and too frequently found wanting. Sedatives
and hypnotics, the use of which can very easily become an abuse, are the drugs
to which I allude more especially, as they are no doubt a very necessary adjunct
to our treatment, and in acute cases are very useful; but when they are used
in chronic cases to control, or more properly to stupefy the noisy and trouble¬
some, I think it is there that the abuse may come in, and, as regards restraint,
I fail to see any real difference in controlling the violent patient mechanically,
and in submitting him to a course of drugs which in many cases materially
affect the constitution.
The best means of treatment I consider consists in providing bright and
cheerful wards, well warmed and ventilated, steady and well-trained attendants,
as liberal and varied a dietary as lays in our power, and every opportunity that
can be afforded for work and healthy recreation.
Personally I am strongly averse to very large asylums, and this opinion is
held by many senior men in my profession, whose long experience must
necessarily bear considerable weight. In order to satisfactorily carry out the
meaning of the recent Lunacy Act it appears that the patients must be looked
upon and studied as individuals requiring careful treatment. Medical super¬
intendents must necessarily bring themselves into closer contact with their
patients than was previously thought sufficient, and I am led to believe that
the capabilities and energy of a man of ordinary calibre will be sorely strained
when he is asked to administer to the requirements of a population exceeding
1,000. The co-operation of hard-working, intelligent assistants will not meet
the case, however willing and zealous they may be. It is all important that
the superintendent should be acquainted with all his patients and some of their
history, and the special points of each individual case.
In a former report I pointed out that there would be a tendency all over the
kingdom to improve the condition of the pauper insane, and that the weekly
cost would probably be higher. Last year the average weekly cost for county
asylums was 8s. 7|d., and I expect that next year we may see a still further
increase. For my own part I am glad to see it, as it shows that the day for
“ cutting down ” asylum maintenance to below what it should be is fast dying
out, and I think so much the better for the ratepayers, and the greater the
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286 Psychological Retrospect . [April,
difference between asylums and workhouses (the former being made as much
like hospitals as possible) the greater the ultimate saving effected, as it must be
utterly wrong to imagine that people who are physically and mentally in¬
capacitated can be expected to recover from their malady if they are not fed
and cared for to a greater extent than if they were in a healthy state.
Wilts .—Among other important structural additions and im¬
provements, the ventilation, drainage, and water supply systems,
and the disposal of sewage are being thoroughly brought up to
modern requirements, at great cost, under the charge of Mr.
Rogers Field. It is proposed to build a new chapel, and to use
the old building as mess and recreation rooms for the attendants.
Concerning pensions the Committee report:—
The question of granting superannuation allowances to operatives and
labourers employed at the asylum has given rise to a good deal of discussion.
The Committee consider that the work of the officials and attendants employed
in the asylum, who are much in contact with the insane, entitles them to look
forward to a pension, on the conditions laid down by the Act, and they are glad
to find that the Commissioners in Lunacy in their last report (p. 99), after
fully considering the question, have come to the conclusion that the system of
moderate salaries with superannuation allowances has had a fair trial in the
past, and with satisfactory results, and they deprecate any departure from it.
But the Committee do not consider that those employed as labourers, operatives,
or artisans can at all be considered as entitled to such allowances. They all
receive the full current rate of wages, they are only partially brought into
contact with the insane, and with such of them only as can be safely trusted
out of doors, and their duties and responsibilities do not require the exercise of
the qualities of intelligence, tact, patience, and self-control which are looked for
in the attendants. Applications for pensions made during the past year by a
plasterer and a carter have been refused.
Wonford House. —Dr. Deas reports :—
By a rare coincidence three cases—all ladies—have been under care, to
whom I did not hesitate to apply “ mechanical restraint ” as the best and most
humane treatment. The object was to limit the use and movement of the
hands or arms, or both, and the means used were soft padded gloves, the
sleeves of the dress closed at the end, or the sleeves attached to the side of the
dress. In two of the cases the object was to check flesh-picking or rubbing, a
habit for which I believe restraining the hands is the only effectual remedy.
In one of these the restraint was necessary for about six weeks. The patient
has now been free from the habit for ten months, and is mentally considered
improved. The second case was more inveterate. Restraint was employed
during three months; there was then great improvement during five or six
months; then for a month it was necessary again. The patient has now been
free from the habit for five months, and is greatly improved. The third case
was of a different character. It was characterized by constant struggling and
violence, and attempts to injure herself and others, and was one of the very
worst cases that has ever come within my experience. The great value of
restraint in this case was as a conservative agent, saving the patient from the
exhaustion of constant struggling, allowing her to have exercise regularly, and
to be managed with much less risk of injury. In this case restraint was
employed during two months; then for three months there was considerable
improvement; then a relapse, and restraint was employed during three months.
Dinring this last attack the patient was for some time in a most precarious state,
and yet would struggle; then improvement began, and has continued steadily
for three months. She is now strong and active, and mentally apparently con-
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valescent. I firmly believe that this patient’s life, and probably her reason, have
been saved by “ mechanical restraint.” I need hardly say that this restraint in
these cases was not continuous, usually employed only for a portion of a day,
and dispensed with from time to time, as a trial, according to circumstances.
No bad effect whatever seemed produced on the patient’s mind by the re¬
straint, and only one of the cases seemed to feel it irksome, and this became a
useful moral agency in checking the morbid habit. The third case never com¬
plained about it, and it was remarkable how much the excitement and tendency
to struggle ceased as soon as her arms were not free, nor since the great
improvement in her condition does she allude to the matter, or show any sign
of its having produced a painful effect on her mind.
I have alluded rather fully to these cases, because there is still a tendency in
some quarters to blame anyone who honestly uses “ mechanical restraint ” as
treatment, and a remedy where other means are inadequate or fail. To refrain
from its use in such cases as I have described is certainly a policy of masterly
inactivity; but it might also be called a policy of fear.
Worcester .—Buildings for the accommodation of 140 male
patients are in process of erection. Three pairs of cottages for
married attendants are nearly ready for occupation. The water
supply is still unsatisfactory, but the Committee have agreed to
postpone the consideration of this very important matter. The
amount of leave of attendants and nurses has been increased, and
a new scale of wages came into force on the 1st April.
An important legal question has been raised by the Auditor
upon the construction of sub-section ix. of the 269th section of the
Lunacy Act, 1890. The sub-section referred to provides :—
That where a reception contract has been made by a Visiting Committee the
Local Authority for whom the Visiting Committee acts shall, while the
contract subsists, defray out of the County or Borough Fund so much of the
weekly charge agreed upon for each pauper lunatic as in the opinion of the
Visiting Committee represents the sum due for the accommodation, not exceed¬
ing one-fourth of the entire weekly charge, in exoneration to that extent of the
Union to which the maintenance of any such pauper lunatic is chargeable.
The Committee report on this subject:—
In Mr. Boberts’ (the auditor’s) opinion so much of the weekly sum paid for
the maintenance of a pauper patient under a reoeption contract as is in excess
of the sum received, under the sub-section of the Lunacy Act above quoted,
from the Local Authorities for whom your Committee act, should be charged
to the Union to which the maintenance of each pauper patient boarded out at
another asylum is chargeable. It has been the practice in this asylum, as at
others in the kingdom, to charge the extra amount not covered by the sum
received from the Local Authorities generally to maintenance account, thus
spreading it over the whole of the Unions within the county and city, though
at some asylums it is understood it is charged to repairs account.
Your Committee have submitted this question to the Local Government
Board, who concur in the view expressed by their auditor. It appears to your
Committee that where particular patients, whose cases permit of their being
more conveniently sent to, and being boarded out at, another asylum, and have
thus relieved the other patients in the asylum from the dangers and risk of
overcrowding, a step which, up to the present time, has relieved the contri¬
buting authorities from the cost of extra buildings for the accommodation of
from 30 to 50 patients, who could not be provided for within our own asylum,
the Legislature would hardly have intended that the Unions from which such
patients may be selected to be sent to another asylum should be called upon to
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288
Psychological Retrospect.
[April,
pay the extra charge incurred thereby. This matter will receive the very
earliest consideration of your Committee, and they propose to communicate
with other asylums with a view to taking such combined action to remedy what
appears to be a very anomalous state of the law in the above respect.
Tl^e following interesting case is recorded by Dr. Cooke:—
A female patient was admitted who stated, both before she left home and soon
after she came here, that she had thrust a darning needle into her stomach in
the hope of committing suicide. Successive examinations failed to discover the
presence of a needle, although, from time to time, the patient had serious ab¬
dominal symptoms of obscure origin. After several months she improved
somewhat, but in the early part of 1892 phthisis set in, of which she died about
a year after admission. A post-mortem examination was made, and, partly
embedded in the liver and partly lying between that organ and the angle of the
ribs, a large darning needle was discovered. Though not directly, the needle
was undoubtedly indirectly the cause of death, for the irritation and suppura¬
tion which it set up caused disease of the abdominal glands which ultimately
resulted in phthisis.
Yorkshire. North Biding .—A new asylum is to be erected by the
Borough of Middlesbrough for the accommodation of its lunatics.
This will afford relief to the over-crowding experienced at
Clifton.
Tenders for the erection of a new detached laundry for the sum
of £7,368, exclusive of machinery and fittings, were accepted.
The machinery will cost £1,369, and a new boiler £285. The
works are well advanced.
York. The Retreat (1891-2).—The Committee have to report
a deficit of nearly £900.
In bidding farewell, after eighteen years’ service, Dr. Baker
says:—
I cannot conclude this, the eighteenth and last report of my superintendence
of the Retreat, without a throb of deep emotion. Indeed, I should be less than
human if I could do so. Believe me, I am profoundly grateful to all those
many friends who have governed this hospital, who have extended to me in¬
numerable deeds of kindness all through the lengthened period of my imperfect
ministry. It is no formal expression of words that it is my earnest desire that
under the new regime this hospital may continue to prosper, and that its
influence may ever continue to be exercised in attempting to minister, in the
highest sense of the word, to the many necessities of the insane.
The reference to the interesting celebration of the Centenary is
somewhat curt, having regard to those who a century hence will
refer to this Report for information.
Yorkshire , West Biding. Menston .—The male mortality was
unusually heavy. This was chiefly due to a severe attack of
dysenteric diarrhoea. Forty-two patients were more or less
affected, and exactly half of them died. It is believed that the
disease was imported, and that it spread by infection ; all the
cases occurred in one block.
This asylum is nearly full, and plans for large chronic blocks
have been prepared. Much continues to be done to bring this
new asylum into good working order.
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Asylum Reports.
289
A pathological laboratory and a photographic studio have been
completed, and a good beginning has been made towards obtaining
the necessary instruments.
All the candidates, 16 in number, for the nursing certificate of
the Medico-Psychological Association succeeded in passing the
examination.
Yorkshire , West Riding. Wadsley .—Most successful efforts
continue to be made to maintain this asylum in the highest state
of efficiency.
A qualified dispenser has been appointed. The lectures and
instruction given by the medical officers to the attendants and
nurses, with the object of training and rendering them more
efficient in the discharge of their duties, have been continued.
Already good practical results are seen in the better nursing of
the recent sick and feeble cases. The medical staff has been
increased by the appointment of another assistant medical officer.
By the necessary structural alterations a great improvement has
been effected in the arrangements for the recent sick and acute
cases on the male side.
The pathological laboratory and photographic room have been
completed, and now afford to the medical staff the necessary
means and facilities for acquiring useful and scientific know¬
ledge.
Yorkshire , West Riding. Wakefield .—This great asylum also
continues to be directed with conspicuous enterprise and success.
It is reported that the out-patients’ department continues in
active operation, and has been supplemented by a scheme of
private nursing on a small scale. Among the structural improve¬
ments effected or in progress is a nurses’ residence.
The following paragraph is from Dr. Bevau Lewis’s report:—
The visitation of a preventable disease, such as small-pox, whose incidence
upon a community so lowered in vital resistance (such as an asylum population)
would he fraught with such serious results, calls for restrictions of the most
rigid character. When the necessary commerce between the asylum and out¬
lying districts is considered—the difficulties encountered from a non-resident
staff of attendants—the unavoidable contact at times of parochial officers with
infected subjects, delegated for the common duty of dealing with fever cases,
and the removal of lunatics to asylums—the caution and reserve with which
even medical certificates of freedom from infectious disease in recent admissions
must be taken—it must be emphasised that the duties are sufficiently onerous
and harassing without the introduction of any further difficulty. I would very
clearly state my conviction here that the interests of union and asylum
authorities upon the question of removal of such fever-infected cases (suffering
from mental disease) to asylums is a common interest , best served by a rigid
exclusion of such cases, and that any suggestion that cases of insanity suffering
from fevers, such as small-pox, should be received into our asylums and properly
provided for by isolation hospitals is, I consider, open, to the gravest objections.
To the uniform and continued support I have received from my Committee in
the exercise of these somewhat invidious duties I can alone attribute our success¬
ful isolation from this malady.
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290 Psychological Retrospect . [April,
Concerning the instruction of attendants and nurses Dr. Lewis
writes:—
A class for nursing and ambulance lectures was commenced here early in the
spring for the female attendants, under the supervision of my colleagues, Drs.
Goodall and Dunn; and subsequently a similar course of training and lectures
was given through the winter months by Dr. Bullen to the staff of male
attendants. Considerable interest was maintained in these lectures—a very fair
attendance secured—and at the examination in November last eleven nurses
secured the certificate of the Medico-Psychological Association. The Com¬
mittee provided class books and such other requirements as were demanded for
this very desirable movement, which is now being adopted very generally in
English Asylums. This attempt at training the nursing staff towards securing
an intelligent interest in their work is, I think, a very hopeful sign of the times,
and cannot but issue in the best results; a community of sympathy—far more
substantial than a mere sentiment—is established betwixt nurse and patient;
the former is encouraged to develop her best interests—to look forward to higher
spheres of duty—whilst her systematic training develops habits of oare,
vigilance, thoughtfulness, and self-control, which it is impossible to overrate
as desirable qualities in a mental nurse. Moreover, I am much mistaken if this
movement does not indicate the approach of that general wave of change which
has long been anticipated as likely to transform our asylums into veritable
hospitals for the insane, awakening those latent potentialities which are un¬
doubtedly available for the future welfare of English lunacy.
Reports Subsequently Received :—
Birmingham City Asylum , Winson Green. —The report of Dr.
Whitcombe for the year 1892 contains a notice of two deaths
which call for special remark.
A patient (J. A.) was admitted at mid-day, and having no history of dan¬
gerous proclivities, nor exhibiting any, was put to sleep at night in a dormitory
with four other patients, where he would be visited every half-hour. Suddenly
he jumps out of bed, pulls one patient out of bed, and jumps upon him, then
strikes another with a chamber utensil, and pulls him out of bed, and is arrested
by a night attendant just in time to save a third patient from his violence.
Such an event could not possibly have been foreseen, and, in
fact, it would be difficult, if not impossible, to parallel it in asylum
experience. It is one of the risks which must be run in the manage¬
ment of the insane. Had there not been a night attendant, another
life at least would have been sacrificed to the sudden fury of the
newly-admitted patient. In fact, a large staff of nurses is the only
practical means of rendering fatal assaults infrequent. Although
not a particle of blame can possibly attach to the Medical Super¬
intendent, the sympathy of all engaged in the treatment of the
insane is, we are sure, felt for Dr. Whitcombe under the worry
caused by the painful circumstances which have occurred.
Psychologically the case is of great practical interest, on account
of the suddenness of the assault, and the determination to kill
persons who, being complete strangers, can have hardly been
associated with any delusions in the patient’s mind. Dr. Whit¬
combe writes:—
The aot was one of sudden homioidal impulse, arising in a patient who had
previously shown no signs of being dangerous, but, on the contrary, exhibited
symptoms of exaltation, and was in a benevolent frame of mind.
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Asylum Reports .
291
It would be interesting to know all particulars in regard to the
past history of J. A., and in the future to be informed what course
the mental malady has taken.
Broadmoor. —Dr. Nicolson reports that in 1890 the Council of
Supervision brought the inadequacy of the accommodation on the
female wing to the notice of the Secretary of State, and the
result was that the Treasury sanction was received to carry out an
extension of this division of the asylum at an estimated total cost
of £8,855. The work was commenced in 1891, and one portion of
the extension, together with certain alterations, has already been
constructed. It consists of an addition to the south front of
block 2, 90ft. in length, and includes 12 single rooms, sculleries,
and staircase.
A Departmental Committee of Inquiry into the pay and position
of prison warders and of the subordinate staff at Broadmoor Asylum
sat during the year, under the presidency of Lord de Ramsay. The
recommendations of the Committee resulted in sanction being given
by the Treasury to an increase in the scales of pay for the various
grades of male and female attendants and others ranking with
them.
Dorset .—Dr. Macdonald directs attention to the evils of sending
recent cases to workhouses. He says :—
Notwithstanding that the admissions generally were of a more favourable
class, the numbers admitted at an early stage of the disease were fewer. There
would seem to be an increasing tendency in the direction of sending acute cases
to the workhouse, which system cannot be too strongly condemned. Apart from
the injury done to the patient by loss of time, it is hard to explain the rationale
of keeping a case in the workhouse, where there is no proper staff, and where
the treatment at best can be but tentative. It is the invariable custom in
certain unions to send all reported cases to the workhouse, where they are
detained for weeks, nay, for months. Sooner or later they are sent to the
asylum, and for one or both of the following reasons: First, because no im¬
provement has taken place; or, second, on account of the case being too trouble¬
some. Unfortunately many of these cases are far from hopeful by the time they
reach us, and it does seem hard that even the poor should be deprived of asylum
treatment at the most favourable stage of the disease, because of some lingering
parsimonious object. Reflection on this retrograde system reminds us of the
old saying, “ Neglect a cold and in walks the doctor, to be followed by his bill.’*
How often does it occur to those who fail to obtain the best possible treatment
for the mentally afflicted at the commencement of the disease, that to neglect
the early symptoms of mental disease means insanity.
Dr. Macdonald is fortunate enough to be able to record the
recovery of three chronic male cases.
We are often told there is no chance of a patient being discharged recovered
after having been in the asylum for a few years, but that this is happily not the
case we shall be able to prove. During the past year three male patients were
discharged as recovered after a residence of many years, and, from repeated
inquiries, all are doing well, and have regular employment. These men had
been patients here for 10, 11, and 12 years respectively, and it was not till
within twelve months of their discharge that any actual improvement was
noticed. For years two of the cases were troublesome in every sense of the
xxxix. 19
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292
Psychological Retrospect.
[April,
word, having—among other episodes—made several attempts to escape. It was
an indescribable pleasure to witness the change in the conduct and character of
these men when the mind began to regain its normal standard. No more
grumbling, no more deceitful ways and methods, no more abuse of the
authorities; they became sociable, agreeable, obedient, and willing, and when
they left the asylum were full of thanks and kind words. In neither case were
we accused of not discharging the patient when recovered, because the friends
were reasonable people, and would it were so more frequently.
Glamorgan .—Plans hare been prepared for extensive and much-
needed enlargements, but money cannot be obtained, as the con¬
tributing bodies cannot agree.
The following paragraphs are from Dr. Pringle’s report:—
In this, as in former years, I have had to deplore the admission of epileptics,
who have been so from childhood, and yet had married and become parents.
One woman lately told me she had got married because “ everybody ” told her
if she did so the fits would leave her. I have seldom an opportunity of testing
the mental capacity of the partners of such people, as I generally find, on
inquiry, that they have gone to America or some other distant place as far away
as possible from their unhappy mates, and have left their miserable offspring to
be maintained by others; and I do not wonder much, since to be tied for life to
one of these unhappy creatures is more than can be expeeted from any average
mortal. The deplorable ignorance and recklessness displayed by such marriages,
and the grave consequences to the children born of them, and the ratepayers, to
whom many of them become permanent burdens, make me often think that the
schoolmaster is abroad to little purpose, and that it ought to be made a criminal
offence to enter into such marriages, or for anyone to celebrate or register
them.
I have lately been endeavouring to make the surroundings of the attendants
at both asylums more agreeable by improving their sitting and bedrooms, and
have been most kindly supported by the House Committee in so doing. I can¬
not say that as yet much success dias attended those efforts, so far as making
them more settled is concerned, as the changes of the year have been numerous
and vexatious. Prosperous times outside our institutions always result in many
changes, as the men leave for higher wages in the ironworks and collieries, and
more marriages occur amongst the nurses. I am confident, however, that our
efforts are in the right direction, and will gradually tend to induce a better
educated and more refined class to enter the service. On the whole the general
conduct of the attendants and nurses has been good, and if a black sheep does
now and again get into our fold, it is not much to be surprised at amongst so
many.
Ipswich .—The reports by the Committee of Visitors and the
Medical Superintendent are chiefly noticeable for their extreme
brevity.
Lancashire. Lancaster .—The following is a quotation from Dr.
Cassidy’s report:—
In former periods of our history a spirit of emulation was encouraged, and
there was every possible freedom of development, with the result that English
asylums have taken the first place among the asylums of the world. It seems
now to be considered that we require the restraining influence of an autocratic
official (the auditor appointed by the Local Government Board), who holds up
before himself and before us that grand ideal—Uniformity. I am not myself
inclined to fall down and worship it, nor do I care for the Government-office,
the diet of parchment and red-tape. This central audit of asylum accounts is
an expensive mistake, entirely unsuited to asylum needs, and must, I think.
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1893.]
Asylum Reports ,
293
have slipped into the Looal Government Act by some mistake. Surely it will
be promptly ended or mended as soon as this is recognized. That the Lanca¬
shire Asylums Board or a Visiting Committee should not be able to give a
gratuity under many circumstances which may arise seems to me to be monstrous.
If it really is so in law, which I do not believe, the sooner the law is altered the
better. A minor objectionable matter is the difficulty and delay which seems
to exist in obtaining the sanction of the Local Government Board to loans.
Thus, our fire protection works were regarded by the Committee as urgent, but
after the plans and proposed expenditure had been sanctioned by the Committee,
by the Central Committee, by the County Council, by the Commissioners in
Lunacy, and by the Home Secretary, we had to wait for several months for an
inspector to come down and hold an inquiry before we were allowed to obtain a
penny to pay for them.
Lancashire . ’Prestwick .—We are accustomed to talk of certain
lunatics as harmless, but every now and again events occur which
tend to make us use that phrase with extreme caution. Dr. Ley
mentions a case which refers to this subject.
The other suicide was in the case of a man who injured himself so severely in
the head that he died from the effects some weeks afterwards. This also occurred
in a patient not suspected of harbouring suicidal tendencies; in fact, the man
had so much improved mentally that he was recommended for discharge at the
approaching meeting of the Committee. He had been employed at his trade of
brick-setter for some months previously. One day, when at work, he suddenly
took an axe from a joiner’s bag and struck himself several severe blows on the
forehead, penetrating the bone. The injuries to the head progressed favourably,
but symptoms of brain mischief developed themselves a few weeks after the
occurrence, and rapidly proved fatal. The patient admitted that his only motive
for committing the act was annoyance at not having been visited by his friends
on the previous day. These cases emphasize the fact that a lunatic, however
quiet, docile, and apparently harmless he may be, will often upon the slightest
provocation, and sometimes upon no provocation at all, become the prey of
sudden impulses, which render him dangerous to himself or to others. How far
a suicidal or homicidal taint underlies the mental disorder it is impossible to say
—some authorities assert that it is present in all cases, though it may be less
developed in some than in others. There is much in the records of this asylum
to bear out this theory, and it is a curious fact that all the accidents which from
time to time have occurred here during the last twenty years have, with one
exception, taken place among patients whose previous histories, conduct, and
behaviour afforded no warrant for suspecting them of harbouring any dangerous
propensities.
Lancashire. Bainhill .—Several cases of typhoid fever occurred
during the year. One patient and two attendants died. A patho¬
logist has been added to the staff.
The following paragraph occurs in Dr. Wiglesworth’s report:—
Two of the male patients admitted during the year were discharged as not
insane, their insanity having been assumed for the purpose of obtaining admis¬
sion into the asylum. They both have been in this institution before, and one
of them, at least, in numerous other asylums throughout the country. They
are both also thoroughly familiar with the inside of prisons. Although there
was no question about their insanity having been assumed, previous experience
having convinced them of the superior comforts of asylum life as compared with
that in prisons, and though they were, hence, not insane in the ordinary accepta¬
tion of the term, there can be no doubt that they both possessed erratic, unstable
mental natures, which brought them into rather close proximity to the border¬
land of insanity. They were, indeed, but types of many more in the great
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294 Psychological Retrospect . [April,
criminal class from whence they were drawn, in whom it is often a matter of no
small difficulty to determine the dividing line which separates badness from
madness. Although we are still far from the idea that all crime is insanity, and
should be treated as such, nevertheless evidence is continually accumulating
which tends more and more to show that no small number of our criminal classes
are, as regards the social side of their nature, nothing but moral idiots and
imbeciles, who, by virtue of the defective brain constitution with which they are
born, are alike without the moral feelings which are supposed to be innate in the
race, and who are more or less incapable of acquiring them. Upon individuals
such as these kindness and sternness, reward and punishment, are alike thrown
away, or are operative only within narrow limits. For persons so constituted
the discipline of prison life has too much of a punitive ring about it, whilst at
the same time the constitution of existing asylums is not adapted for their recep¬
tion. An intermediate institution, which might combine the restraint of the
one with the moral training of the other, would perhaps more nearly fulfil the
requirements, and thus society may some day find it more profitable to endeavour
to train its moral imbeciles than simply to seclude them and turn them loose at
stated intervals to demonstrate anew their anti-social natures.
Lancashire. Whittingham .—The following are Dr. Wallis’s
ideas relative to the treatment of habitual drunkards:—
Intemperance in drink seems to figure, as in 1890, rather more prominently
than usual, accounting for 22 per cent, of the admissions, and perhaps for more
if the histories of the unknown cases were cleared up. This is certainly one
reason why the recovery rate is higher than usual, for the insanity due to drink
is certainly favourable in character as to prospect of recovery when the habit
has only been recently acquired, and the patient is kept for a time absolutely
free from the poison. On looking through the discharge-book, intemperance in
drink is certainly seen as the cause of the illness far too often, and it is not un¬
usual to see the same person figuring twice in the same year. Promises of
amendment are easily made, but I have no faith in them, unless total abstinence
is resolved upon and adhered to, when a permanent recovery may be relied upon.
It seems to me, in these days, when social legislation is, happily, in everybody’s
mind, that some steps should be taken to save the drunkard from himself, for
his own sake, and, even more urgently, for the sake of his family. Persons of
means have their inebriate hospitals and homes to go to, and their families are
not, as a rule, reduced to want and misery on this account. For the intemperate
among the wage-earning classes no provision has as yet been made, and it is in
these classes that the want of some suitable provision is felt most acutely.
Habitual drunkenness is a crime against society, and requires punishment.
The drunken parent robs his family of food, clothing, and comfort to indulge in
his debasing habit, and offers his children a lamentable example, which they, in
their turn, but too frequently follow. Nothing short of compulsory detention
of the habitual drunkard for a considerable period is likely to do any permanent
good. Under these conditions he should be compelled to work, and be made not
only self-supporting, but to contribute to the support of his wife and family as
far as possible. As it is a drunken man is allowed to go on until his health is
destroyed, his children neglected, half-starved, and stunted in growth and con¬
stitution, some of them flighty and unstable in mind, or perhaps actually idiotic
or epileptic. When he has worked all this mischief he is sent to the asylum,
first, perhaps, for a short visit, again for a longer visit, and finally for the rest of
his life, a burden to himself and the ratepayers. Temperance methods do not
reach the great majority of victims to intemperance, and public institutions for
the treatment of the habitual drunkard should be provided.
Midlothian and Peebles .—The rate of admissions continues high.
Dr. Mitchell considers that the causes of the high admission-rate
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Asylum Reports.
in recent years are obscure and complex, but he has no doubt
that the low rate of board for pauper patients accounts for the
increase in this class to some extent, but not altogether.
Suffolk .—Many structural defects still exist here, but something
is being done, though very slowly, to improve matters. The
building is overcrowded, and does not provide the accommodation
required. The sanitary condition is still very unsatisfactory. A
new water supply is in process of being “ laid on,” but unfortunate
delays have occurred in obtaining the necessary machinery. The
manner in which necessary work at the asylum is delayed is men¬
tioned by Dr. Eager:—
Though the plans for the new infirmaries which it was decided to erect as the
best means of securing further accommodation were laid before the Committee
on the 28th of April (1891), and were forwarded to the Commissioners in
Lunacy on the 9th May, it was not until the beginning of September (1891)
that they received the sanction of the Home Office. They were then forwarded
to the Local Government Board, where they were detained until January of the
present year, when the sanction to the raising of the loan was given.
Notwithstanding, however, that on February 6th of the present year a tender
was accepted for the erection of these buildings, which are so urgently needed,
we are, owing to the indisposition of the Councils to borrow under the terms of
the new Act, no nearer securing the accommodation they would provide than
we were two years ago, when their erection was first decided on.
Besides one case of erysipelas and another of diphtheria, there
were 74 cases of infectious disease. Four patients died from dysen¬
teric diarrhoea, five from typhoid fever, and one from diphtheria.
The amount of leave granted to attendants and nurses has been
increased, and Dr. Eager reports that the result is satisfactory.
Surrey .—Plans have been prepared for the enlargement of the
infirmary for female patients. The following interesting case is
recorded by Dr. Barton :—
One of the recoveries, that of a married woman, aged 39, who was discharged
after a period of probation, deserves special mention as being a case of great
interest. This patient was admitted in October, 1890, with well-marked
symptoms of general paralysis. She suffered from persistent headache, and
there was a history of a blow on the head some months previously. The disease
was steadily progressive, and as the pain was localized about the right parietal
region, which was also the seat of the injury, the case was regarded as an excep¬
tionally good one for operative interference. The consent of the husband having
been obtained, Dr. Gayton, in February, trephined the right parietal bone, just
behind the coronal suture, and evacuated a quantity of serous fluid. The patient
made a good recovery.. The result of the operation was decidedly satisfactory.
Permanent relief from headache was obtained, the mental symptoms gradually
disappeared, and the disease became apparently arrested. The patient left the
asylum in July, and when last heard of was going on well, with no return of
symptoms.
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Psychological Ritrospect.
[April,
2. Pathological Retrospect .
By Edwin Goodall, M.D.Lond., B.S., M.R.C.P., West Riding
Asylum, Wakefield.
The following notes may, perhaps, be of service to those engaged
in pathological work, including the preparation of museum speci¬
mens, in asylums:—
Sections of Fresh Cord .—From time to time attempts have been
made to obtain sections from the fresh spinal cord, and, as far
as I know, satisfactory sections have not hitherto been secured.
The procedure introduced by Bevan Lewis for the fresh brain is
not applicable to the cord; the requisite fixation of the medullated
nerve-tubes in the white columns cannot thereby be obtained. I
find that pyridin has the necessary fixing power. De Souza* and
Vassalef have used pyridin as a hardening reagent for brain land
cord. The methodj of use now referred to is, however, quite
different. Briefly it is as follows :—Sections are made from the
ether-frozen fresh cord, and floated on to water. They must not
be allowed to dip at any part beneath the surface, for if they do
wrinkling occurs; if water lies over the whole upper surface of
the knife-blade they will not sink when floated off. They are
taken up from the water as soon as possible with a perforated
lifter, and floated on to pure pyridin (Merck) contained in a dish
at hand. Here the sections stiffen. When fairly stiff push them
beneath the surface of the pyridin. They lie in this 12-24 hours
(possibly less time would suffice). I have usually left them 24
hours. Passed thereafter into water, it is observed that the
sections keep unwrinkled, though they become again flexible ; the
elements of the white matter are fixed. Wash thoroughly in
water (2-4 hours, changing occasionally), stain, wash again, and
pass the sections into weak pyridin (diluted with water), thence
into stronger, and thence into pure pyridin. In this the section
becomes dehydrated and cleared in a few seconds. Mount in
balsam dissolved in pyridin. I have now sections prepared by
this method six months old, and they are perfectly preserved.
For staining various anilin dyes are suitable. Most are dissolved
out pretty quickly by the pyridin, and therefore the sections
should be over-stained. Kernschwarz, diluted to one-fourth its
original strength, stains in a few minutes. It does not come out
in pyridin. It sometimes produces a black ppt. on the specimen
in course of time, which is unfortunate, as it is otherwise an
excellent stain for these sections. Ten minutes in kernschwarz
* “ Zeitschr. f. wiss. Mikroskopie,” Bd. v.. Heft. i.
t “ Bivista Sperimentale di Freniatria,” Vol. xvii., Fasc. iv.
t A preliminary note of this appeared in the “ Med. Chronicle,” January.
181)3.
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Pathological Retrospect.
297
’ 1893.J
may be followed by hour in picrocarmine, or a day or more in
purpurin. Another combination is anilin bine-black per cent,
aqn. sol.), 20 min., and picrocarmine, half-hour. By this method
the spinal cord can be removed, cut, and sections stained and
mounted within the day. Hitherto my experience has been chiefly
with cords of the lower animals, cut within an hour of death; in
two cases the human cord has been cut. In each of the latter the
autopsy took place 24 hours after death, and in each the elements
were seen to have their proper shape, and to be fixed. The nerve-
tubes, when this method is used, are found tightly packed together,
without the intervening spaces seen in chrome-hardened prepara¬
tions, and in immense numbers. Between the larger tubes lie
collections of small ones; these are obscured if the staining has
been overdone. The great difficulty presented by this process is
this—rwhen the sections, passed from water into pyridin, have
been a few moments in the latter, the cornua become mapped out,
in many instances, by minute air-bubbles. These it is often
impossible to get rid of by agitation; if allowed to remain any
time circular area corresponding to the bubbles in size are left
indelibly stamped upon the grey matter. Very frequently, but
not always, I have avoided this formation of bubbles by cutting
the sections into water which had been thoroughly boiled in a
flask, and rapidly cooled before use, the flask being well closed
after boiling by india-rubber cork and paraffin. If then air bubbles
collected on the cornua they were mostly got rid of by agitating the
section in the pyridin. It is to be hoped this difficulty may be
thoroughly surmounted, as I believe the process promises to be of
practical service.
Museum Preparations . Glycerin-Jelly as a Mounting Medium.—
My object here is to draw attention to glycerin-jelly as a mount¬
ing medium for healthy or diseased sections and pieces of nerve-
tissue in the fresh state, and for portions of diseased cerebral
meninges and blood-vessels. The preparations in our collection
include pieces and sections (the latter either of microscopic thin¬
ness or 1-2 m.m. in thickness) from various cerebral regions,
complete brains of rodents (rat, rabbit), sections of the whole
brain of cat and rabbit, and various specimens of diseased lepto-
meninges. Sections of fresh pons, medulla, or cord could probably
be equally well preserved. On this point I have no experience,
but as the method, after a year’s trial, proves satisfactory, it is
proposed to try it on a large scale. I believe that most tissues
mounted in jelly have been previously hardened. In the museum
of the Yorkshire College, Dr. Jacob, of Leeds, recently showed me
a number of jelly preparations, amongst which were a few speci¬
mens of fresh liver and lung; so that our preparations, if novel,
are only so in that they have to do with cerebral structures.
Their age varies between six months and one year; the tissues are
perfectly preserved. It must, however, be acknowledged that the
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[April,
Psychological Retrospect .
blood-tint has in a measure faded.* Quite exceptionally moulds
have developed to a slight extent upon the surface of the jelly,
but no damage to the specimen itself has resulted ; though the
moulds gain a footing, it appears that the soil is unfavourable to
their further development. In these rare instances the specimens
were transferred to fresh jelly, and this has remained sterile. The
following is the formula for the jelly: Best French gelatine,
8-10 gram., glycerin 25 c.c., sat. sol. boracic acid 75 c.c. Dissolve
the gelatin—cut up—in the boracic solution by heat, add the
white of an egg, and apply heat until the albumen has separated
out thoroughly; add the glycerin. If the fluids are contained in
a flask floating in water, to which the heat is applied, but little
loss by evaporation occurs. Filter through a hot-water filter.
The jelly should be quite clear. It will have a slight yellow
tinge. If this is thought undesirable less gelatin must be
employed; the proportion stated above is that employed for
gelatin culture-media, w T hich remain solid in this climate through¬
out the year, and show no shrinkage for a very considerable
period. The preparations are put up in glass vessels; Soyka’s,
Petri’s, or Esmarch’s dishes are convenient. Pour a little of the
melted jelly into the vessel, let it rest, arrange the preparation on
its surface, and cover with more jelly. If a fresh section of brain
is to be mounted direct from the freezing microtome, it may be
floated on to saturated boracic acid solution; the glass vessel, half-
filled with set gelatin, is passed into the fluid beneath the section,
and the latter arranged with a camel-hair brush on the jelly.
The vessel with its section is then withdrawn, excess of fluid
allowed to run off, and melted jelly (not too hot) is poured in up
to the brim, care being taken to prevent floating of the section. It
appears to me best not to seal down the lid of a vessel containing
glycerin-jelly preparations; fresh jelly can then be added from
time to time as necessary. None has yet been added in the case
of our one-year-old preparations, as no appreciable shrinkage has
occurred. A very good background to these preparations of fresh
brain is obtained by painting the back and sides of the glass
vessel employed with black bicycle varnish.
Plaster Casts of Brain .—These may be made as follows : Place
the brain in a suitable position in a basin, pour over the surface
melted paraffin (hard quality), sufficiently warm to ensure pene¬
tration into the sulci; it must not be allowed to approach too
closely the setting point; on the other hand, too, great heat must,
of course, be avoided. The pouring is done deliberately. Finally
the brain is completely hidden by solid paraffin, which also fills in
the space between it and the basin-wall. This procedure occupies
from four to five minutes. As soon as the paraffin is well set, cut
* Thoma’s fluid (" Centralbl. f. Allgem. Pathol.,” 1891, p. 401) is said to
preserve the blood-tint better than any medium hitherto recommended.
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Pathological Retrospect .
299
through the portion surrounding the brain down to the bottom of
the basin, in a complete ring round the organ. Place the basin
and contents into cold water; the paraffin sets hard. Now remove
from the water, and turn out the brain, covered by its paraffin cap,
using a strong scapel for the purpose. By a little shaking the
cap can be separated from the brain; from its inner aspect
numerous ridges and processes are seen projecting; these corre¬
spond to sulci. By this means a mould of the brain is obtained.
Fill this mould with good plaster of Paris, made up to the usual
consistence of a cast with water. When the plaster is thoroughly
set place the whole in water in a saucepan, and heat. The
paraffin melts away, leaving a cast of the brain. The convolutions
and sulci are ^ell mapped out; the under surface is quite flat.
Any little holes—sometimes such are seen, 1-2 mm. in diameter—
may be filled up with plaster. Expose the cast to a gentle heat
to dry it. Subsequently it may be painted of the same tint as a
Giacomini preparation. Abnormal disposition of gyri, difference
in size of hemispheres, local atrophy and depressions, gaping
sulci, and other lesions may be represented by this method with
accuracy. Good fresh sections may be obtained from brains
which have been subjected to this process provided they were not
notably softened beforehand.
(To be continued.)
3. German Retrospect .
By W. W. Ireland, M.D.
On the Influence of Diseases of the Ear upon the Development and
Course of Insanity.
The following is taken from a resume of Dr. Bjeljakow in the
“Wjestnik Psych.” (viii. Jahrgang, Heft 2), as given in the
“ Allgemeine Zeitschrift fur Psychatrie ” (xviii. Band, 1 Heft).
Dr. Bjeljakow, who has studied the subject in a hospital of St.
Petersburg, has confined his observations to cases where there was
distinct inflammation of the middle ear. Out of 135 post-mortem
examinations which he made during four years 17*12 per cent,
suffered from internal otitis. Of these one of the patients had
melancholia, one paranoia hallucinatoria acuta, eight paranoia
hallucinatoria chronica, two secondary dementia, three epileptic
insanity, four general paralysis, one acute delirium, one senile
dementia, and three hebephrenia. The author, at the end of his
paper, gives the following conclusions :—
1. An inflammatory process of the. internal ear is frequently the
cause of mental derangement, especially of insanity accompanied
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300 Psychological Retrospect . [April,
by hallucinations. If the local inflammatory process take an
unfavourable course the insanity often passes into secondary
dementia, which, otherwise, this form of insanity is not so liable
to do.
2. One-sided hallucinations of hearing are very frequently the
result of a heightened excitability of the cortical centres, the
result of the transmission of the irritation from the auditory
nerves.
3. Hallucinations of hearing on both sides, which support the
hypothesis of the independent function of each hemisphere, may
be caused through disease of the auditory apparatus.
4. Irritation of the organ of hearing frequently does not stop
at exciting hallucinations of hearing, but as a result of the
influence of this sense upon the others, it also excites other
hallucinations, especially those of taste, smell, and general sensi¬
bility. The character of the delusions of the senses is tinged by
the personality of the patient.
5. In many of these patients, who suffered from ear disease,
there was found a hyperesthesia of hearing, which, as a sequel to
noises or musical sounds in the ear, becomes changed into a
diseased sensation. At the same time the sensibility to hearing
outward sounds is not increased, but, for the most part, diminished.
6. The overflow of saliva, which often accompanies suppuration
of the middle ear, is caused by irritation of the chord and the
nerves of the tympanic plexus. The hypochondriac depression
and pain about the prsecardium, which from time to time trouble
these patients; may be explained through irritation of the nervi
vagi of the auricular branch, and the propagation of this irrita¬
tion to the auditory brain centres.
7. The connection of disease of the ear with insanity accom¬
panied by hallucinations is only observed in cases where mental
activity and apprehension are not yet much diminished.
8. Epilepsy seems sometimes to depend upon disease of the
labyrinth. The irritation, coming from inflammation of the
middle ear, may assume the form of a false general paralysis.
9. Hallucinations of hearing, though rare in general paralysis,
may, when they appear, be the result of otitis on one side. In
this case the hallucination is generally confined to the same side
of the brain.
Unilateral Hallucinations.
Professor Pick, of Prague, records a case (“Neurologisches
Centralblatt,” No. 11, 1892), which closely resembles one already
published by Sir Henry Holland in his “ Medical Notes and
Reflections.’' An epileptic had an attack of paresis of the right
extremity, and aphasia with lateral homonymous hemiopia.
Cutaneous sensibility was much diminished. On recovery from
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German Retrospect.
301
1893.]
some disturbance of consciousness it was ascertained that not only
was there motor aphasia, but also word deafness. On the third
day these symptoms had considerably abated. The patient became
restless, struck the bolster, and said that someone from below
cried into his ear, “ Senat, Senat.” The man, whose speech was
Bohemian, did not know the meaning of this word. A little after
he heard incessantly the word “ Prosto, prosto.” This also had
no meaning to him. In a few hours these hallucinations ceased,
but the patient remained unquiet. Nearly two months after this
the patient again had a paralytic attack implicating the right arm
and right side of the face accompanied with loss of sensibility.
He again became affected with sensory and ataxic aphasia with
right hemiopia. In three days this disorder of speech had, in a
great measure, abated, when there were hallucinations of hearing.
He said that there had been a row since the morning, and that a
dog had been howling. These visions seemed to come from the
right. After three days they passed away along with the remain¬
ing traces of the disorder of speech. It is here to be noted that
the hallucinations were on the right side, although the paralysis
of the limbs indicated disease of the left hemisphere. A month
after the patient had an attack in which this succession of
symptoms was repeated, but the increasing weakness of the
patient prevented the case being carefully studied.
The next case described by Professor Pick was a woman of 58
years of age subject to delusions with intercurrent attacks of
epilepsy. She heard voices in the right ear which conveyed
threats or remarks about what she did. If the ear was stuffed
with wadding only an indistinct murmur was heard; but when¬
ever the wadding was removed the voices returned. No voices
were heard in the left ear, in which the sense of hearing was dull.
On examination the left auditory meatus was found to be full of
hardened wax, and on this being removed the voices were heard
in the left ear also.
In this last casQ described by Dr. Pick auditory hallucinations
confined to the left ear were found to cease when the ear was
stopped.
On the Theory of Hallucinations .
Dr. Tigges begins a thoughtful paper on this subject in the
“ Allgemeine Zeitschrift fur Psychiatrie ” (xlviii. Band, 4 Heft)
by observing that the fundamental condition in hallucinations is
an increased excitability of the sensory centres in the cortex.
These centres are roused by a stimulus which, in ordinary cir¬
cumstances, is inadequate. Most authors now place the seat of
hallucinations in the cortex, but some, as Hagen, Kahlbaum, and
Schule, still place them in the lower cerebral ganglia, a view also
upheld by Meynert.
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302 Psychological Retrospect. [April,
Petersen has described the case of a young man who suffered
from delusions of persecution. He heard voices only in the right
ear, and had hallucinations of sight, visions of men and skeletons
upon the right half of the visual areas of both eyes. These never
passed across the vertical line of separation, and when the patient
turned his head towards the light the hallucinations followed him.
Petersen regards this as undoubtedly a central hallucination caused
by lesion of the occipital and temporal lobe, nevertheless it followed
the movement of the eyes. Dr. Tigges adds an instance where a
voice heard on the left side ceased when the ear was stopped.
He asks the question whether there can be a centrifugal excite¬
ment or stimulation where the lesion lies in the cortex ? Dr.
Tigges cites Jolly’s observations, who found, on applying the
constant current to the auditory nerve, that in four or five persons
subject to hallucinations of hearing there was an increased irrit¬
ability of the nerve with paradoxical reaction, that is, the opposite
ear was affected instead of the ear to which the electric current was
applied. Dr. Tigges found a similar result, but only in cases where
there was organic affection of hearing.
Insanity following Multiple Neuritis.
Doctors Korsakoff and Serbski (Gesammelte Abhandlungen,
Moscow, 1890, quoted in the “ Allgeraeine Zeitschrift fur Psy¬
chiatric,” xlviii. Band, 3 Heft) have described a case of this form
of insanity. The patient was a woman twenty-seven years old.
She had an extra-uterine pregnancy for which laparotomy was
performed, and a putrefying foetus was removed. A week after
this operation the mental derangement appeared. There was
great excitement, weakness of memory and clouded consciousness,
associated with general weakness of the extremity, loss of the
patellar reflex, and pain on pressure on the nerve trunks and
muscles. There was fever with small pulse. The disease
lasted two months and ended with death. The mental derange¬
ment showed all the characteristic symptoms which Karsakow
had already assigned as symptoms of the polyneuritic psychosis.
On examination after death there was found a widely diffused
degenerative neuritis implicating the nerves of the extremities as
well as the vagi and phrenic, and, in part, the cranial nerves.
There was an alteration in the size and form of the spinal canal
which was thought to be congenital and not connected with the
insanity. In the columns of Goll the neuroglia was found to be
increased, no alteration was noticed in the brain cortex. There
was colloid degeneration of the thyroid gland.
This case goes against the view of Tilling, who holds that the
polyneuritic psychosis is only found after alcoholic neuritis,
whereas Korsakoff has observed it to follow every species of toxic
polyneuritis.
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1893.] German Retrospect . 303
Another Case of Psychosis Polyneuritica.
At a meeting of the Psychiatrischer Verein of the Rhine
Provinces, held at Bonn (“ Allgemeine Zeitschrift fiir Psy¬
chiatric, M xlviii. Band, 1 Heft), Dr. Brie described at length
another case of this new form of insanity. He began by observing
that some impairment of the intellect, and especially of the
memory, had been long noticed in drunkards suffering from
multiple neuritis, but it is to Dr. Korsakoff that the merit is due
of having directed attention to a type of insanity which is
characterized by a peculiar disorder of the memory combined
with multiple neuritis, afterwards passing into stormy mental
excitation. This has been styled psychosis polyneuritica or cerebro -
pathia toxcemica psychica. Korsakoff considered this mental
affection is caused by various toxic agents as well as by alcohol.
In the case described by Dr. Brie the characteristic mental
symptoms appeared without any abuse of alcohol. The patient
was a man of thirty-four years of age, free from hereditary
disease, and who had previously enjoyed good health. About
eight years before he set up a grocer’s shop in Bonn. After the
death of his wife, who assisted him in his business, he turned
hard and suspicious. At the Whitsuntide of 1889 he became ill
with persistent vomiting and diarrhoea, by which he was much
prostrated. He was troubled with double vision, and in July of
the same year his memory began to fail. He soon got so weak in
the legs that he could scarcely stand, and on the 7th of October
was received into the asylum at Bonn. He was found to have
paralysis of the abducens of the right eye with nystagmus; the
fundus of the eye was normal. He could not turn himself in bed
without great exertion, was quite unable to walk, and very
helpless. The legs were kept bent at the knee. The patellar
reflex was wanting, and there was pain on pressure over the
muscles. There was weakness of the arms on pressure; cutaneous
sensibility and excitability to the electric current were found to
be diminished. The pulse was 120 in the minute ; the appetite
very poor. There was much loss of memory. He told silly fables
about himself, which varied from day to day. He could not
remember what had happened to him a few days before, was
surprised on being told where he was, and then forgot it again.
He called the physicians and attendants by strange names.
Towards the end of October the patient was seized with distress¬
ing symptoms which indicated an affection of the vagus and
phrenic nerves. He felt faint, was restless in his bed, had a
great difficulty in breathing, and had a cyanotic appearance.
These symptoms got worse and better till the end of December,
when his mental condition improved, his memory began to be
stronger, and his judgment more correct. During the six months
which had elapsed before Dr. Brie read his papers there had been
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Psychological Retrospect.
[April,
considerable improvement in the patient’s mental condition. The
memory had gained strength, ana he described himself as having
passed through a dream. But the legs were contracted, he walked
with difficulty, and only with the assistance of his hands; sen¬
sibility was still deficient; the patellar reflexes had not returned,
and there was pain on pressure being applied to the muscles.
Dr. Brie observes that in this case there was no known con¬
stitutional disease, nor poisoning with alcohol, lead, or arsenic.
He is disposed to think the toxic agent was connected with the
continued intestinal disorder.
Peripheral Neuritis in the Course of General Paralysis.
Dr. A. Pick (“ Berliner Klinische Wochensehrift,” No. 47,
1890) describes the case of a man whose mother was insane, and
who was imbecile from birth. At the age of twenty-two years he
was visited with the characteristic symptoms of general paralysis,
delusions of grandeur, stuttering in his speech, twitching of the
tongue and muscles of the face, and sluggish action of the pupils
to light. During the course of his illness, after he had become
confined to bed, there was paralysis of the peronei muscles which
disappeared after several months, and was succeeded by spastic
rigidity. Professor Pick regards this as an undoubted peripheral
paralysis of the nerves occurring in the course of the general
paralysis. After death the usual lesions were found in the
membranes, with atrophy of the brain substance, and widening of
the lateral ventricles.
Dr. Pick adds another case of the kind in a woman 38 years of
age, who suffered from headaches and paralytic attacks which
ended in mania with delusions of grandeur. There were char¬
acteristic motor disturbances with progressive diminution of
intelligence, the ideas of grandeur still persisting. In this case
also there was a sudden paralysis of the peronei muscles. Dr.
Pick believes this complication also to be the result of peripheral
neuritis.
PART IV.—NOTES AND NEWS.
MEDICO-PSYCHOLOGICAL ASSOCIATION.—QUARTERLY MEETING
AT LIVERPOOL.
The Quarterly Meeting of the Medico-Psychological Association of Great
Britain and Ireland was held on Thursday, 9th March, 1893, at the Medical
Institution, Mount Pleasant, Liverpool. Dr. Baker, of York, President of the
Association, occupied the chair, and amongst those present were Drs. Clouston,
Hayes Newington, Richards, Bonville Fox, Savage, Conolly Norman, Bnllen,
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1893.]
Notes and News .
305
Shuttleworth, Stanley Gill, Hack Tuke, Yellowlees, Campbell, Monld, Ley,
Wiglesworth, Bower, Turnbull, Menzies, Urquhart, Fletcher Beach (Hon.
General Secretary), etc., etc.
The President —The first business is the election of candidates.
The Secret art read the names of the candidates for election as fol¬
lows :—
Thomas Philips Cowen, M.B., B.S.Lond., Assistant Medical Offioer, County
Asylum, Prestwich, Manchester.
Arthur Allen Fennings, M.B., B.S.Durh., Junior Assistant Medical Officer,
Camberwell House, Camberwell, London, S.E.
Finlay Murchison, M .A., M.B., C.M.Edin., Resident Proprietor, Wyke House,
Isleworth, Middlesex.
James William Aitken Murdoch, M.B., C.M.Glasg., Medical Superintendent,
Berks County Asylum, Wallingford.
The candidates having been submitted to the ballot,
The President announced that all the candidates had been elected. He then
called upon Dr. Wiglesworth to read a paper on “ General Paralysis occurring
about the Period of Puberty.”
Dr Wiglesworth then read his paper, which will appear in the July number
of the Journal.
The President—I now invite discussion upon this very interesting
paper.
Dr. Clouston —I express the feeling of everyone present when I say we are
very much indebted to Dr. Wiglesworth for his highly instructive and unique
paper. It is one of those concrete and well-balanced papers that seem
to give us all necessary information, because it is founded on definite
clinical facts. As regards the occurrence of general paralysis at this period of
life of which Dr. Wiglesworth speaks, I admit I was extremely sceptical of
the first case. One’s whole ideas of general paralysis were contrary to its
occurrence taking place at this early period of life. I, along with Dr. Maudsley
had attached very great importance to sexual excess in the causation of
general paralysis; and here we had cases where undoubtedly there had been
nothing of the kind in any shape or form. Then it seemed extraordinary
that every other possible cause of general paralysis was absent in these
particular cases. On the whole it had the effect on my mind of almost
revolutionizing my ideas of general paralysis. To begin with there were
great doubts expressed as to whether they were cases of general paralysis or
not; but I think the evidence is so striking, and in Dr. Wiglesworth’s paper it
is of so conclusive a nature that such cases will not be questioned in the future.
Thinking that perhaps Dr. Wiglesworth was going to show microscopic speci¬
mens, I brought specimens from two cases with me, one of which died, and the
diagnosis was absolutely confirmed by the naked eye and by the microscopic
examination of the brain. I have at the present time a fourth case—a patient
of 18 years of age, who has been ill from three to five years—and the general
characteristics of the case are the same as those I reported before. She is a
girl of country parentage, and she is better developed than in the cases yet
reported. She is stouter, and her mammas are larger than usual, but she
has not menstruated, and the sense of sexual reproductive development
is absent, and as she has lived in the country she would probably have been
very much more developed had she not become insane. The mental and bodily
symptoms are absolutely characteristic. In regard to the common absence of
grandiose delusions, I would remark that all my cases have had a peculiar, happy
“ facility.** It was not merely dementia. You may have a demented patient
who has not that peculiar, happy sort of facility, and is pleased with every¬
thing. This condition is, as we know, more common in general paralysis than
even grandiose delusions. With regard to the ages at which general paralysis
occurs, I am beginning to be more impressed with the fact, that we may have
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306 Note8 and News . [April,
it occurring not only at puberty, but that we may have general paralysis be¬
tween 60 and 70 years of age.
Dr. Savage —My experience of these unusual cases of general paralysis has
brought me into contact only with boys. I have not bad any experience of a
girl suffering in this way. The cases I have seen, as were Dr. Wiglesworth’s,
have gone into dementia, in one case certainly with “ facility,” and in three
others with marked emotional disorder. In the next place, in one case at all
events—and I believe in some others that have hitherto not been recognized
—they have been looked upon by general and neuropathic physicians as ordinary
cases of neurosis. Those cases seem really deserving to be called cases of general
paralysis in which there was progressive degeneration with dementia ending in
death, and in which the symptoms were confirmed by post-mortem examination.
They were cases characteristic of general paralysis of the insane. There was
one other case which struck me, in which there was an alcoholic history, and one
in a boy who had been a huge meat eater and whose earlier symptoms were
associated with the most violent urticaria I have ever seen, so that he was
supposed to be suffering from scarlet fever. I should like to hear the ex¬
perience of others as to whether they had met with any cases occurring after
influenza. I met with some such belonging to a neurotic stock, who had a high
temperature, with influenzal symptoms, the result being that within a very short
time all the symptoms of progressive paralysis of the insane developed them¬
selves. In another case there was a distinct history of general paralysis occur¬
ring in the father; the boy died of progressive dementia, and there was pachy¬
meningitis. My experience agrees with that of Dr. Wiglesworth, that senile
neurosis is a factor to be considered, and there are several cases of quite
young people in which one has seen evidence of hereditary syphilis, so that I
agree with Dr. Wiglesworth that we may have marked cases of youthful general
paralysis. I think that when our ideas have become clearer we shall have many
more cases than we expected.
Dr. Shuttleworth—I should like just to refer to three or four oases
which the reader of the paper was good enough to bring before us to-day. I
may say, as the superintendent of an idiot asylum, that my own knowledge of
general paralysis has been comparatively limited. My cases which have been
quoted and alluded to by Dr. Wiglesworth were collected, I think, at the request
of Dr. Savage, to illustrate a paper which he brought before the Congress in
America in reference to the relation of syphilis to insanity. I was able then to
find four cases under my care out of some 500 cases in the institution to which
I belong. There were the symptoms which I now perfectly recognize as agreeing
with those distinguished by Dr. Clouston, and in fact I did so after seeing some
of his cases in Edinburgh, and reading a paper on the subject there. Those
cases were of a syphilitic history. That is the peculiarity, perhaps, and I do not
remember any similar cases, presenting similar symptoms, in which there was
no syphilitic history. I do not mean that they themselves always dis¬
played syphilis, but I think the majority of them had certain symptoms—either
symptoms which were ascertained from the parents, or were detected by the
medical men attending the children in their infancy—which really did point to
a syphilitio affection of the children. In all these cases there were some specific
skin affections in their infancy, followed by a period of comparative health and
intelligence in earlier childhood. They had gone to school, and most of them
had passed two or three standards, and then at the age of ten—always at the
age of 10,11, or 12—there was a breakdown, and it was strongly insisted in the
majority of cases by the parents that what followed was the consequence of a
fall. Well, we can discount this as being partially the case, or the consequence
of the condition induced. But one found always when one had further insight
into the history of the cases that there had been symptoms showing clearly that
there was an inherited syphilis in the child. I got, for instance, a very exact
history from the father of one of the children. He was a man of great respecta¬
bility, as far as I knew. He told me that the child had gone to school, and had
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Notes and Nems.
307
fallen down in a fit and hurt his head, but the medical attendant—a practitioner
well known in this city—ascertained that it was a very clear form of syphilitic
affection ; and not only the father himself, but the majority of the children in
the family suffered from it, so that I have no doubt that if one had the same
opportunity one would have been able to trace the syphilis in the others in
like manner, and that this theory of a fall was merely a symptom. In two
cases out of four there were eye affections, and in the other two marked
inequality of the pupils, and I got to think that the developmental period had
set the thing going, or probably the period of second dentition had occurred. It
was hardly the age of puberty when the first symptoms of breaking down
showed themselves. I put it down rather to a certain amount of excitement in
the period of second dentition. Then there were four cases which, in 1888, I
looked up in that way. Three died, and one of them still remains, with
unquestionable symptoms of syphilis. But yet she is not going down the
hill very fast. She is not improving at all, but she, at any rate, gets no more
paralytic, and I do not know how long she is going on in that state. I have had
her under my care for six or seven years, and she does not really get rapidly
worse. However, there were three cases in which death resulted, but they were
taken home by the friends without any opportunity for post-mortem examina¬
tions. In the third case we did get a post-mortem examination, but un¬
fortunately I was away at the time, and this is merely the hemisphere which has
been preserved (holding up a specimen). That was a boy. He had a head nearly
22 inches in circumference, but this specimen shows pretty well the shrivelled,
atrophied condition of the brain. In none of these cases did I witness any
symptoms of grandiose feeling or emotional feeling, which are so characteristic
in general paralysis. I have now a boy of ten years old, who, without having
any paralytic symptoms, certainly has these grandiose symptoms very markedly
exhibited. He says to me, “ Come here, doctor. What shall I give you at
Christmas? I will give you ahorse, 1 will give you a carriage and pair/* and
all that sort of thing, and I am looking with interest to see what will be the
subsequent history of that case.
Dr. Conolly Norman— It is said, sir, that general paralysis is rare in the
country in which I practise, and possibly on that account I have only seen one
case which bears upon Dr. Wiglesworth’s paper. Somewhat more than three
years ago I was consulted about a female child, who was then of the age of 13
years. Some ten months before, her relatives noticed that she was becoming
dull in mind. During the course of the case she had several falls and hurt her¬
self, but her relatives distinctly noted that she was dull before the occurrence of
these falls. She was the fifth child of her parents. The four previous children
were still alive, and they had been always healthy. Subsequently to the patient’s
birth two pregnancies ended respectively in a still birth and a miscarriage.
When I saw the child she was 13 years old, and she presented typical symptoms
of general paralysis as far as physical signs are concerned. She was quite un¬
conscious of being ill. She professed always to be very well and happy, and she
was quite in the demented and happy condition which Dr. Clouston has referred
to. I was very much struck by the child’s state, and formed a very positive
diagnosis. I could not see my way to come to any other conclusion than that
it was a case of general paralysis. I may add that the father of the child died
within about a year of paralytic symptoms, which his physician, who bad no
connection with me whatever, attributed to syphilis, and the mother died of very
similar symptoms about a year later. The child has died since, the paralysis
having progressed very much, as far as I can learn, in the usual course that
general paralysis takes in our experience. I have, unfortunately, had no
opportunity of verifying the diagnosis by post-mortem examination.
Mr. Richakds —It has struck me that we as specialists have been too apt
to restrict the age at which general paralysis can occur in a human being. We
have usually understood it to be on the basis of middle age, but I have often
thought that it was really a mistake, for if we take th6 trouble to look more
zxxix. 20
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[April,
closely into the matter we shall find such cases as those mentioned by Dr.
Wiglesworth, and even in younger children; and there is no doubt, as Dr.
Clouston remarked, that we shall find it in more advanced ages, and, indeed, as
time progresses we shall find it in any period of life. The time has almost now
come when we should take general paralysis out of the domain of psychology
and put it more into the regions of neuro-pathology, and this we shall find to
be the case as we come to be more intimately acquainted with the form of the
disease.
Dr. Fletcher Beach— I may just mention that I remember now a case
which I formerly looked upon as one of chronio meningitis, but which I now
think was a case of general paralysis. It was the case of a boy, aged 16. He
had no grandiose symptoms. The case was under observation at a London
Hospital—the Hospital for Children—and was also in an asylum for three
years. The case had been carefully watched at the London Hospital and the
Hospital for Children before it came before me at the Darenth Asylum. I had
the history ol the case for two years before he came to me, and although he had
no grandiose symptoms there was a period of excitability and depression. One
does not expect to get grandiose delusions in children. The case progressed
from bad to worse, and death took place from exhaustion. We found a very
small brain, presenting very similar appearances to the brain shown to-day by
Dr. Shuttleworth. The membrane was about one-eighth of an inch thick,
extending over the whole convex surface of the brain and passing downwards
into the fossae of the skull. There was also a history of syphilis in that case.
Dr. J. A. Campbell —I only wish to ask Dr. Wiglesworth whether he has had
his attention ever called to the case reported by Dr. Donnett Stone, of a boy of
14, who suffered from general paralysis 22 years ago. It is reported in Dr.
Braithwaite’s Retrospect. I think it is the first case of general paralysis in
the young distinctly described.
Dr. Wiglesworth —I am much obliged to Dr. Campbell for calling my
attention to this case, which I shall not fail to look up. I have not much to
reply to, because there has been a general unanimity of opinion that general
paralysis occurs at the early age which I have mentioned. I may just mention
in regard to Dr. Shuttleworth’s remarks, that his evidence strongly supports the
theory of syphilis being a powerful factor in producing juvenile general
paralysis.
THE OUT-PATIENT SYSTEM IN CONNECTION WITH ASYLUMS.
Dr. F. St. John Bullen read the next paper, entitled (t The Out-Patient
System in connection with Asylums, and its Further Development.” (This paper
will appear in the Journal.)
Dr. Hack. Tuke —I should like to make this remark, that in a case in which
theoretical objections to outdoor treatment are so very considerable, one would
like to have some practical results of success, which would show that these
objections are not so great in practice as they seem to be in theory. It has
always seemed to me that there is one very strong objection, and that is that in
so large a number of cases of real mental disease you wish to remove the patient
entirely from home and his surroundings, and that you certainly do not do
under these circumstances. There are other objections to this mode of treat¬
ment, and I repeat that if one could have had any definite fact adduced on the
whole favourable to it, I for one should think differently of it to what I am inclined
to do at present. Perhaps Dr. Bullen would kindly mention whether at Wake¬
field the treatment of out-patients has been fairly successful. I think Dr.
Bullen’s paper a very good one, and feel heartily indebted to him for bringing
this important subject forward.
Dr. Bullen —With regard to the question Dr. Tuke asks as to the practical
results, and whether they justify the establishment of the system, I consider
that, at the present time, really the system is so much hampered by the mode
in which it is carried on that it is very difficult to say aye or no. As at present
Conducted, I am inclined o think myself that the results are not likely to be
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Notes and News.
809
very good. So many of the patients are in very poor circumstances, and so
wholly unable to get away from those conditions that perhaps caused their in¬
sanity, that it is not very likely any ordinary system of treatment can be bene¬
ficial. (Hear, hear.) The scheme ought to be very much modified, but bow
this modification is to be brought about I really cannot say. The results up to
the present time have been good, considering all things. We have had 16 cases
out of 116 in which the condition has been alleviated, and 12 in which recovery
has occurred, and some are under treatment now. The percentage of those who
have recovered is, however, it must be admitted, very small.
Mr. Richards —As most of the large lunatic asylums are in close proximity to
some of the large towns, of course the difficulty Dr. Bullen has put forward now,
that the patients have to come sach long distances, is reduced to a nullity almost.
Then I should like to ask if the patients who come to the asylum — which, I pre¬
sume, would be the proper place, if it is one that is near some large town— f,
when the patients go there, do the medical officers there prescribe for them,
because I presume they would be mostly poor persons, requiring drugs without
any expense; and I should like to know how he would get over the difficulty in
county asylums of supplying drugs outside. For you must be well aware that
when the account came to be reported by the Auditor of the Looal Government
Board, and it came to his knowledge that drugs were supplied to those outside,
there would be a great outcry ; and perhaps the doctor would tell us how he
would get over the difficulty.
A Member —Having been for many years in general practice, and having
been at Morningside Asylum, and then for several years the Assistant Physician
in another asylum, I have had some experience in insanity cases before I went
into general practice, and therefore any patient that came under my care came
into the hands of one not totally ignorant of the subject. I am sorry to say that
my experience of the treatment of patients at home has been very unfavourable.
(Hear, hear.)
Dr. Stanley Gill —It seems to me that the only benefit from this treatment
would be so far as medical students are concerned. The great difficulty in
treating oat-patients at asylums is the great distances they are from large towns.
I cannot see how you could expect the patients mostly affected to go a long
distance to be treated outside an asylum, whioh treatment could not really be
beneficial unless they had a class of students sufficiently large to warrant the
patients being brought that distance. A few years ago I wrote a paper on this
question, upon the examination of lunatics, and I certainly did advocate that
more use might be made of the out-patient department of the infirmary. The
hospital, and even the Union infirmary, were places where those cases could be
seen, and classes could be held for medical students, instead of taking the
medical students such long distances as they probably have to go to visit the
various asylums. Besides, people object to take their friends to an asylum, and
the patients object also.
Dr. Savage —This question has been considered by a London Hospital, as
to whether they shall establish an out-patient department for mental disorders.
My own opinion is that the advantage is very limited. (Hear, hear.; In con¬
nection with Queen’s Square Hospital, or any Hospital for Nervous Diseases
and Paralysis, it seems to me that it would be well to have consulting
physicians, and it would not be a bad idea if at the Queen’s Square
Hospital once or twice a week an alienist physician attended to see any
cases referred to him by the general neurologists. My experience of
hospital life has been this, that I used to encourage as much as possible
patients to come as out-patients. There were very few who came, however,
and this confirms one in the idea that the patients who do come are not those
who can be greatly benefited. We know there is one class of patients who are
always sure to come, namely, the brain hypochondriacs. (Laughter.) This
individual has already worn out the patience of nearly every doctor who has
seen him, and he will not fail to come and worry the medical man in attendance
at the hospital. Besides that, there is the general paralytic, who believes there
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Notes and News.
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is nothing wrong with him, and he is quite willing to go there as well. But as
for treating patients on the out-door system, I think that except from the general
medical students’ point of view, or from the point of view of diagnosis, this
system is rather over*done. One is inclined to think that if the doctor, instead
of writing a prescription for white mixture or black mixture, or quinine,
or the like, if lie could only put his finger upon a beef steak, or some port wine,
or a mutton chop, he would cure his patients much more readily than by the
ordinary medical prescriptions. (Laughter.) The great advantage, if there be
one, in the outdoor system would be that patients would be sooner under definite
care and treatment than they are at present; but as for the treatment, I do not
think much of what would follow. Supplementing what I have said in regard
to the Queen's Square Hospital, it has often struck me as strange that they
should not have an alienist physician, because they are not particularly expen¬
sive. (Laughter.) We know they have a larynologist, and if they acknowledge
the principle in one direction I do not see why they should not have an alienist
physician, with very great advantage to the institution.
Mr. Mould— The hospital movement for many years has done a good deal of
out-patient work under this system. I have three or four cases in Manchester.
Many of the patients are of the poorer class of life, and they are often sent to
me by general practitioners in order that I may suggest a place for them to go
to elsewhere than their own homes; and I am glad to say that it is not an un¬
common thing for a Lancashire manufacturer, if you prescribe that these
patients should go to the seaside for a few weeks, to bear the expense of their
removal and maintenance there. I consider this is a very good way of treating
patients. I often send cases to a nurse at the seaside who understands them,
and patients not very seriously affected do very well indeed. I have at least 30
such cases under my supervision. They are from young medical men, or medical
men in the neighbourhood in which they go to reside, and I do think that the
plan might be followed out much more than it is, as many a patient might be
saved from going into an asylum if he were treated in that way. As we know,
in the higher class of life they never think of sending patients to an asylum at
all, but they carry out this non-asylum treatment which I have indicated, or
which I have had on the brain for the last ten years. (Laughter.) It is very
often against the law, but I am glad to say it has resulted in marked benefit to
my patients, and in some little credit to myself. (Renewed laughter.) I would
emphasize the encouragements to patients to come to you. They will not come
to the asylums. Every physician should have—and Dr. Clouston has—rooms
in the town nearest to which they reside, where such patients could come with¬
out such feelings of discomfort that they would have if they had to go to an
asylum. We do not tread for one moment on the general practitioner's practice,
but adopt the means and management to carry out a course of treatment that
is essential to the benefit of such patients, and which, as a rule, can only be
carried on outside an asylum. You only have to run a certain amount of risk
(laughter); but I think every man ought to face risk for the benefit of
humanity. I feel it would not put me about at all to do it, and I should try
again. Although I do not say with Dr. Bullen that it can be carried out in
county asylums, I am quite sure it can be carried out in hospitals.
Dr. Clouston —The physicians of the Edinburgh Royal Infirmary are in the
constant habit of sending me out-patients. They want some advice as to their
mental condition, and I am bound to say that in many cases ther^ is a very great
benefit to be derived from giving such advice. We may do these patients a very
great deal of service in that way. Of course, there are inevitable risks in certain
cases that we must be prepared to take. With regard to giving advice at dis¬
pensaries, my friend Dr. Batty Tuke is connected with one of the dispensaries
in Edinburgh, and he goes there once a week, and gives advice as to the mental
cases that come to him. The practice must be successful, because I think he
still continues it after the experience of a great many years. It is quite true
what Mr. Mould says, that there is no essential difference between the treat¬
ment of the rich patients and the poor patients. If the rich come to us, we pre-
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Notes and News.
311
scribe for them. Why should we refuse the poor ? There are very few cases
so poor but what they have some amount of money to get for themselves a few
days* or weeks* change by going to the seaside. I am in the habit of laying
it down to my students that we are bound to cure a patient, poor or rich,
out of an asylum if we can; and I think poor or rich should have a right to
such advice as is suitable to their condition outside an asylum before an asylum
is tried. I agree that patients often do not like to go to asylums, and there
is no doubt that we ought to organize it, so that the asylum physician and his
assistants should go to the dispensary and there give advice ; and if that
could be done a great deal of service would accrue. This subject ought to have
been discussed by us long ago, and we are very much obliged to Dr. Bullen
for having brought it forward. (Applause.)
Dr. Urquhart — I concur with Mr. Mould and Dr. Clouston in what they
have said, for I think it is our duty as physicians to treat every possible case,
whether rich or poor. In this experiment it really comes to be a question of
money, and surely we can educate the public, and educate the County Councils
into spending money in keeping people out of asylums, and, if possible, curing
them outside the asylums. I have very much pleasure in supporting the views
expressed by Dr. Bullen.
The President— We are nearly all of us in practice, and have seen that
almost daily the people who come to consult us come regularly, and are not
likely to go to an asylum. The difficulty seems to be at most a financial one.
The poor do not like to come and take up our time and not be able to give
us a money fee. Of course most of us try to do some charitable work, but the
amount we do in that direction is limited.
Mr. Mould —It is a very common thing for medical practitioners to send poor
patients to consult me with the view that I might give my advice as to whether
a course of treatment might be carried out. I have rarely found an employer
or a tradesman or a friend of a patient appealed to unsuccessfully by a doctor
to pay the expenses of granting to the patient a few weeks* rest and change,
which often stays the more moderate cases of bodily and mental mischief, and
effects an entire cure.
Dr. Conolly Norman —I am one of those who had heard about the experi.
ments of the West Riding Asylum with reference to the out-treatment of patients,
and I was very much interested to hear whether they had succeeded. I think it
would be a very great pity if we let our poorer people think that there was
no way of treating them except by sending them to the asylum, because if you
do not give them some opportunity of out-treatment that is what it means.
From my experience, I should like to see an out-patient department in connec¬
tion with every large public asylum, for my experience, as far as it goes, does
not coincide with that of Dr. Savage. A week scarcely passes that someone
belonging to the class from which my asylum is recruited does not come to con¬
sult me about mental symptoms. I have no opportunities of seeing patients of
the class I refer to except at the asylum, and they come there for advice with
remarkable freedom. I admit that I have had wonderful luck, for I have never
had a hypochondriac visit me voluntarily yet. (Laughter.)
Dr. Mould —I did not quite catch what you said just now.
Dr. Conolly Norman— I say that perhaps hypochondriacs may be rare in
the class among whom I practice (laughter), and that I have never had one
come to me voluntarily yet. When I heard Dr. Savage just now I ran over in
my own mind the cases which I could recollect. There are five of
melancholia, two of epileptio insanity, two of folie du doute , and I believe
one of tormenting hallucinations. It would, I think, be a very good thing
to introduce the out-patient treatment, even if not very largely successful,
because it would bring us better into line with other medical specialists and
associate us more closely with general medical work and less exclusively with
the official and routine life of asylums. (Hear, hear.)
Dr. Yellowlees said he admitted that the question was one of very great
importance. Of course, it is true that what we do for the one class of
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[April,
patients we ought to do for the other class. The difficulty very often is a
financial one. You feel how futile it is to give advice which you know cannot
be fully carried out. We know that manufacturers and employers are ready at
all times to put their hands in their pockets and do the liberal thing in this
county of Lancashire. (Laughter.) I agree with Dr. Savage that the right
place to treat patients of the poorer class for mental conditions would be
in the out-patient department of a general hospital. That would have two
great advantages. It would lessen the sense of reluctance which the patients
have to come to the asylum at all, not to speak of the inconvenience of coming
so far, and it would bring the asylum physician into much closer contact than
he is at present with the staff of the hospital and with the practice of general
medicine. (Hear, hear.) I know that many of us are often asked by the
physicians of general hospitals to see patients in this or that ward who have
developed mental symptoms; I think the same thing should be practised in
the out-patient department, and there ought to be an asylum physician in
attendance on stated days ready to give counsel in such cases. That, I think,
would be the best thing for the patients, certainly it would be the best thing
for us as asylum physicians, and probably the best thing for the other physicians
also. This system was one of the alternatives which the reader of the paper
very properly suggested, and in my opinion it is a wise and a right one.
Dr. Bullin —Allow me to express my thanks for the kind consideration
which this paper has received. It was only read for the purpose of provoking
discussion, and not because I posed as an advocate of the system. It is very
satisfactory to me to find that so many good and valuable opinions have been
expressed. There is only one question which, I think, I have to reply to, and
that is Mr. Richards' remark with regard to the supplying of drugs at Wake¬
field. I may say we supply drugs to the patients at cost price.
The President—I have to announce that Dr. Goodall is unable to give his
lantern demonstration on subjects connected with insanity, which is the next
item on the agenda. We will, therefore, pass on to Dr. Mackenzie’s paper.
DISEASES or THE CELTIC HIGHLANDER.
Dr. J. Cumming Mackenzie was down to read “ Notes on General Paralysis,
Alcoholic Insanity, and Allied Neuroses in the Celtio Highlander." He said:
—Rather than read you my paper, which is scarcely yet ripe for publication, I
will briefly indicate to you types of psychoses in the Celtic Highlander as they
appeared to me on assuming duty in the Inverness District Asylum about three
months ago. I was struck very much with the number of patients who
laboured from impaired locomotion. Rows of them sat fixedly round the day-
room just as we may see rows of advanced paralytics in some of your Saxon
asylums. Much of this wreckage has an alcoholic history, which is undoubtedly
responsible, as far as I have been able to ascertain, for some of it. The
diminution and decadence of muscular vigour, the lustreless eye, the hazy
lens, and restricted vision, are some of the features that strike one. The
remarkable number with grey hair—the exception is to see an alcoholic without
grey hair—and the number that are of untidy habits were also conspicuous
features in the institution. Suicidal or homicidal impulse in the Celtic chronic
alcoholic is the exception rather than the rule; certainly in many cases a
drunken Highlander is a fighting one, and his every intoxication may demon¬
strate the mania a potu. He is not a soaker, however, and, therefore, he
cannot boast of that immunity which is the impress of probably a higher
civilization. In the Celtic woman drunkenness and tippling are a reproach and
very exceptional. In the population of Inverness District Asylum only two
females smoke. In the chronic alcoholic when the alcohol is withdrawn the
decadence stops, but when the damage is done there is no recovery., Dr. B.
Lewis observes that excitement predominates as the type in cases with an
insane heredity, the proportion .still increasing in cases of ancestral intem¬
perance, a form of history that you might not be unprepared to find in the Celt.
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Notes and News.
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The type of psychosis in him, however, is depression, a type also perhaps por-
portionately more frequent in the female and thus conforming to the usual rule.
General paralysis .—In the Inverness District Asylum the admission of a case is
a rare event, says Dr. Clouston, while Drs. Blandford and Savage favour the
view that the Highlander at home in his native glen enjoys an immunity from
paralysis that forsakes him when he goes abroad. What is the explanation ?
In the Highlands of Scotland general paralysis is hardly ever seen, says
Maudsley, “ where,” he observes, “ there is no deficiency either of women or
whisky.” There are strong indications, says Mickle, that the Celt is
less liable to general paralysis than the Saxon. Id fact, the North of Scotland,
where the Celtic element predominates, appears to be comparatively free
from general paralysis. “ Dementia,” he adds, “ is the marked groundwork
of general paralysis.” He believes that three-fourths or more of general
paralytics have hallucinations or illusions'of one or more of the special senses
at one time or other, and half of them marked hallucinations or illusions,
or perversions of internal or common sensibility. The Celtio insane could
easily fit in here, for the insanity of the imaginative and romantio Highlander
is one of delusions. Ours is an extraordinary institution for delusions, for nearly
all the cases have delusions. General paralysis in the female is generally be¬
lieved to run a longer and more protracted course. General paralysis in the Celt
at home is also protracted, and probably for the same reason may be relegated
to a chronic group. Protracted cases are not unusual. They are recorded by
Savage, Clouston, Mickle, and others, and it would appear as if the chronic
protracted group enlarged with our knowledge of the disease. Psychic signs,
from all I can gather, are the first to appear. It would not be always accurate,
however, to diagnose general paralysis in the Highlander from psychic signs
alone. The dawn of somatic signs is often so insidious that it is apt to be
overlooked. In this asylum senility and chronio alcoholic dementia are the con¬
ditions most likely to be confounded with general paralysis. I have here an
example of alcoholic polyneuritis, spastic paraplegia, and tabic general paralysis
in females, and notes of a ‘male case with post-mortem record, and several
alcoholic types, but I think that perhaps you would rather not hear me just
now upon them.
The President invited discussion.
Dr. Hack Tuke —Will Dr. Mackenzie tell us the proportion of paralytics ?
Dr. Mackenzie—I have just taken types of these various neuroses. I have
one case that died in a few days and I have also the post-mortem record. I
.should think I have got two female paralytics, probably more. As for males,
I would not like to say. I have not oounted the number. But I have one with
a syphilitic history, ana I have got three or four, I should think, with a very
strong alcoholic history. But as to proportion, I am not prepared to say. My
object is more to show that the Celt can acquire general paralysis, or something
very closely allied to it, without going very far abroad.
Dr. Yellowlees —What number of patients have you in the asylnra?
Dr. Mackenzie —The usual number is 600 or 520.
Dr. Yellowlees —Have you half-a-dozen general paralytics altogether P
Dr., Mackenzie —I should think there are about half-a-dozen. There are
records of people who have died undoubtedly of general paralysis. In refer¬
ence to the remark of Dr. Savage as to general paralysis following influenza, I
note a case at the present moment where this has exactly occurred. It was a
case of general paralysis. The man nearly ruined himself by signing cheques
and by other ridiculous conduct. That was immediately following an attack
of influenza. He got a little better and was discharged. Bat he is going
bad again.
Dr. Clouston —It seems quite clear that the lower we go in civilization the
less liability there is to general paralysis, because it is extremely infrequent in
the negro and unknown amongst the still lower races. At the same time, I do
not say for a moment that the infrequency of general paralysis among the High-
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[April
landers and the Irish is owing to their having a low type of brain. It is
owing, perhaps, to the quiet lives they lead. They probably obey the laws of
nature in their lives more than the operatives of Lancashire towns, or than
the miners of Durham or of Glamorganshire. I am surprised to hear that
the Inverness Asylum now boasts of six general paralytics. There used to
be only one or none at all. It is certainly a strange fact that the Celt, in his
native country, is free from this disease. It seems as though he may have
drunk whisky, but that whisky, on acconnt of its being good, had not affected
his brain in tie way alcoholic liquors very frequently do. As regards the
general type of insanity among the Celts, we do see a certain difference be¬
tween the type of mental disease in the Celt and in the Saxon. It would take
rather too long to analyze it. But there is no doubt about this, that, on the
whole, they are much more decorative. There is no question that when the
Celt becomes insane he has a strong craving for colour. The Celt is anxious
to put on all sorts of gaudy things. The Celt insane is a much more
demonstrative lunatic than the Saxon. He is not nearly so dangerous, but he
makes twice or thrice as much noise, and his wife makes still more. ^Laughter.)
That is accounted for by excessive excitability, just as there is ten times as
much noise in the female wards as there is in the males.
Dr. Cox—Mr. President, I have listened with very great interest to the paper
read by Dr. Mackenzie and to the remarks made by Dr. Clouston. It has
occurred to me that, with regard to the Welsh nation, in whom I am consider¬
ably interested, there are exceedingly few general paralytics admitted to the
asylum in which I am engaged—that is, the North Wales Asylum at Denbigh.
We have now not more than three or four general paralytics in a population of
about 550, in round numbers, and it has occurred to me as a very odd circum¬
stance that we do not receive more of them. I have been listening to Dr.
Clouston’s remarks with regard to the peculiar temperament of the insane class
of patients in Scotch asylums. It occurs to me that they very much corre¬
spond in many features with the Welsh temperament. They are excitable
and noisy. But I am not able to give you any positive reason why the general
paralytics are so few in number.
Dr. Fellowlees —In reference to what has been said about the character
of the patients in the Welsh asylnms, I may say that in Glamorganshire—in
the asylum for that part of South Wales—the proportion of general paralytics
is extremely large. It is second only to Durham, and perhaps is explained
by the fact that the mining and dock population of Glamorganshire is entirely
different from the agricultural population round Denbigh.
Dr. CONOLLY Norman —I must say that I think, sir, the difference in occu¬
pation among populations in different parts of the country has a great deal
more to do with the prevalence of general paralysis than any racial distinction.
I was an assistant in the asylum in Monaghan for about seven years. My
chief was a man who had been trained in Hanwell, so that he was not likely
to mistake a case of general paralysis. We had a population of 450, and the
largest number of general paralytics we had in the asylum at that time was
five. Occasionally we sank as low as one. The population in that district
was chiefly Celtic blood and so forth. But it was quite a rural population,
with few manufactures or anything of that kind. There was little industry
in the district. Some years later, after I had studied general paralysis for
some months at Bethlem Hospital, I became superintendent at the asylum for
the county of Mayo, and during the time I was there, which extended over
three years, there was only one general paralytic. The great majority of the
population was Celtic, but they were mountaineers, and entirely agricultural
and pastoral in their habits. There were no towns, scarcely even villages.
In the asylum where I am now, belonging to the metropolitan district of
Ireland, we have just as many general paralytics as there are anywhere else.
The great bulk of my people are Celtic—that is to say, out of 1,500 patients
fully 1,300 are Celtic by blood.
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1893.]
Notes and News.
315
Dr. Mackenzie — I am quite aware that the diagnosis of general paralysis
is a very difficult question. Even Dr. Clouston says that sometimes the differ¬
ence between general paralysis and alcoholic insanity is only cleared up by
time. And there are various forms of psychoses that are very difficult to
diagnose. But if the ordinary idea of general paralysis is to be accepted in
connection with the mental symptoms, then these cases are certainly paralytics
in the Celt. As to the general type of psychoses in Inverness, it is distinctly
depression. Let the Highlander be as decorative as Dr. Clouston says he is,
there is still a certain amount of gloom about him, after all, and even the most
lively of my Celtic patients suffer from an element of depression.
The President —Before we separate I beg to propose that the best thanks
of this Association be tendered to the President and Committee of the Liverpool
Medical Institution for their kindness in allowing us the use of this hall for our
meeting.
Dr. Yellowlees seconded the resolution, which was carried with applause,
and the proceedings of the Conference terminated.
In the evening the members and several visitors, including the Mayor of
Liverpool, Mr. Suape, M.P., Mr. Barrett, Chairman of the Rainhill Asylum
Committee, and the Rev. J. M. Lund, dined together at the Adelphi Hotel.
IRISH QUARTERLY MEETING.
An Irish meeting of the Medico-Psychological Association of Great Britain
and Ireland was held at the Mullingar District Asylum on October 27, 1892.
There were present: Drs. Garner (Clonmel), Woods (Cork), Patton (Farnham
House), Petit (Sligo), O’Neill (Limerick), West (Omagh), J. Nelson Eustace
(Highfield), Nolan (Richmond, Dublin), Nash (Richmond, Dublin), Finnegan
(Mullingar), Gordon (Mullingar), and Conolly Norman, Hon. Sec.; also, as a
guest of the Association, Dr. Middleton, of Mullingar.
Dr. Garner having beeu moved to the chair, the minutes of the preceding
Irish meeting were read, confirmed, and signed.
The following gentlemen were elected members of the Association :—
Dr. George W. Hatched, Medical Superintendent, District Asylum, Castlebar.
Dr. George Robert Lawless, Assistant Medical Officer, District Asylum, Sligo.
Dr. Vincent J. Ruttledge, Assistant Medical Officer, District Asylum, London¬
derry.
Dr. L. T. Griffin, Medical Superintendent, District Asylum, Killarney.
Dr. William C. Sullivan, Clinical Assistant, Richmond Asylum, Dublin.
Dr. J. O’C. Donelan, Clinical Assistant, Richmond Asylum, Dublin.
Dr. P. J. Ward, Assistant Medical Officer, District Asylum, Ballinasloe.
Dr. Francis O’Mara, Assistant Medical Officer, District Asylum, Limerick.
Dr. Geo. W. O’Flaherty, Assistant Medical Officer, District Asylum, Down¬
patrick.
Dr. Joseph Hatchell, Medical Superintendent, District Asylum, Castlebar; and
Dr. W. H. Middleton, Visiting Physician, District Asylum, Mullingar.
The Secretary mentioned that the Association now numbered twelve more
members in Ireland than in the beginning of the year. One member had resigned,
a member had come from England to Ireland, and twelve members had joined
the Association. Before the business on the notice paper was taken up, he
understood Dr. Woods had a communication of urgency to lay before the
meeting.
The consent of the meeting having been given,
Dr. Oscar Woods said that, without having any direct resolution to move,
and while he was not prepared to inaugurate a discussion, he spoke because he
had a strong feeling that the present occasion, the first on which a quarterly
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316
Notes and News.
[April,
meeting had been held in an Irish provincial asylum, was a suitable one for the
assembled asylum officers to take into consideration and discuss matters affect¬
ing themselves and their own interests. He thought that the Irish superin¬
tendents hardly made themselves sufficiently heard in such matters, and seldom
attempted to take that collective action which might be of service. Dr. Woods
referred to the unsatisfactory state of the law as to pensions for the servants
and officers of asylums, whereby pension was still left entirely uncertain. He
said that in view of the fact that a Local Government Bill of some kind was
certain soon to be adopted for Ireland, and that such a Bill would no doubt con¬
tain provisions dealing with asylums and asylum staffs, he was strongly of
opinion that the Association should consider how the interests of its members
might be affected. He did not know whether it would be premature just now
to enter into any discussion of details.
The Chairman said that in his opinion the time had scarcely come for dis¬
cussing the subjects referred to in the latter portion of Dr. Woods’ remarks, but
he was anxious to hear the feeling of other members on this point. He quite
thought that when the time came the Association should make itself heard.
Dr. O’Neill expressed his approval of Dr. Woods’ views, and thought that
the meeting should discuss the question at large, with the object of endeavour¬
ing to prevent such mistakes as had been made in some recent Lunacy Acts.
Dr. Eustace deprecated any public discussion of a Bill, the existence of
which they only knew by inference. He thought they should appoint a Vigi¬
lance Committee to look into the matter, and to watch clause after clause any
Bill proposed in the next session of Parliament that might in any way affect
their interests.
The Secretary said that he was glad the question had arisen. He had
long felt that the machinery for dealing with Irish'affairs was defective. The
quarterly meetings of the Council of the Association were too far apart and the
difficulty of Irish members attending was too great to render them of much
service to us. The work that was to be done in this way had hitherto virtually
fallen upon the Secretary. Personally, the speaker desired aid; and, besides,
he did not consider it a healthy thing for the Association that such work should
be left altogether to one man. He thought it would be serviceable if it were an
instruction to the Secretary from time to time to communicate with members
residing in Ireland on subjects of general interest, and having ascertained their
views to transmit an abstract of all to each member, with a view to facilitate
early and collective action. A more practicable course, perhaps, would be the
appointment of a small committee, whose function it would be to direct and
instruct the Secretary from time to time as to the action to be taken in matters
such as those referred to.
The Chairman said—I understand that our Secretary has made a definite
proposal that a committee be appointed from among the Irish members to confer
with the Secretary and look after the Irish interests and affairs of the Associa¬
tion. Is the proposal seconded ?
Dr. Finnegan seconded the motion.
Dr. Nolan inquired whether such a committee would deal with the interests
of the assistant medical officers ?
The Chairman —Decidedly, sir; it is not our intention that they should be
neglected.
The SECRETARY said that questions generally affecting the officers of asylums
would,be dealt with by this committee. It would be always open to assistant
medical officers individually to bring under the notice of such committee any
points they might wish to be dealt with. He hoped dll the members would
understand that he would always be anxious to receive suggestions for the
common good from any member of the Association, whether belonging to this
committee or not.
The proposal was then put to the meeting as a resolution, and unanimously
adopted.
After some further discussion the following gentlemen were elected members
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Notes and News.
317
1893.]
of the committee: Drs. Gamer, Woods, Finnegan, Graham, O’Neil], Nolan, and
Gordon.
Dr. Woods then introduced a discngsion on the training of attendants in the
Irish asylums. He pointed out the importance of the subject, advocated
systematic teaching by lecture and otherwise, and regretted the fact that so little
had been done in the way of training attendants in this country.
The Chairman pointed out that the very unsatisfactory disciplinary regula¬
tions as to the appointment, etc., of attendants in many asylums would tie the
hands of superintendents.
Dr. Finnegan referred to various other difficulties, the small pay of Irish
attendants, the probability that a certified Irish attendant would immediately
try and better himself by going to England or Scotland, the smallness of the
medical staff in most Irish asylums, and the great amount of work already
cast on them which would render teaching very difficult, etc. [Nevertheless, it
appears that Dr. Finnegan, with his usual energy, has already inaugurated
classes for his attendants, has placed the Association Handbook in their hands,
and is preparing them for examination.]
Dr. Eustace and others having spoken,
The Secretary mentioned that a Committee of the Association was at pre¬
sent at work revising the Handbook for Attendants, which was now out of print.
When the new edition is issued, it is hoped that all superintendents will intro¬
duce it to their staffs.
Dr. Finnegan read a paper on “ Systematic Dress Fitting for tho Female
Inmates of Asylums.” (See Original Articles).
The Chairman spoke of the value of Dr. Finnegan’s excellent and practical
paper. He elicited from Dr. Finnegan a number of interesting details as to
the various processes necessary in the work of “ scientific dressmaking.” The
latter stated that he had at present no less than eleven dressmakers, taught in
the institution, all competent to cut out at least ten dresses in a day. Several
girls who had been admitted as patients, without any trade, had learned
dressmaking in the asylum. In one instance a patient was able, on discharge,
to take charge of the dressmaking department of a large business house.
Dr. Petit having visited the female wards of the asylum, was struck by the
excellent appearance of the patients in their well-fitted dresses. To this con¬
dition of things, and the employment it afforded, he attributed the remarkable
appearance of happiness and contentment observable in the wards.
Dr. Conolly Norman regretted that Dr. Drapes, of Enniscorthy Asylum,
who had also adopted this system, was unavoidably prevented from being pre¬
sent on this occasion. The speaker, like many other superintendents, was in¬
debted to Dr. Finnegan not only for introducing the system to his notice, but
also for most kindly lending him a nurse skilled in the work to start it at the
Dublin Asylum. Dr. Finnegan might take as his motto the words of the great
Norwich physician, “It is an honourable object to see the reasons of other
men wear our liveries, and their borrowed understandings do homage unto the
bounty of ours.” It was a sign of the times that such a subject was brought
forward at one of our meetings, for hitherto the distinguishing note of our
asylum costumes in this country had been their utter tastelessness. They
looked a3 if they were designed to make the patients hateful to themselves
and others. The hideous friezes, corduroys, and Scotch caps of the men were
more than matched by the squalid druggets of the women. The speaker was in
a position to say that a very few years ago certain wearing materials long obso¬
lete, and not endurable elsewhere, were still manufactured in England for the
sole purpose of consumption in Irish asylums.
The Chairman introduced a discussion on the heating of asylums.
As a superintendent of many years’ experience, Dr. Garner was disposed to
think that modern opinions had perhaps drifted a little too far in the direction
of the more artificial modes of heating, particularly as to bedrooms. He was
inclined to think that the heating of bedrooms by hot water increased the
mortality of patients, and to this cause he was disposed to attribute the high
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318
Rote8 and Nerts.
[April,
mortality in many modern English asylums constructed on principles now in
vogue. Sudden and great alterations of temperature would always occur from
time to time in bedrooms heated by hot water, and were, no doubt, followed by
disastrous effects. Persons in fair general health also did not seem to him to
need to have their bedrooms heated, and to do so only made them unduly sus¬
ceptible to cold.
Dr. Finnegan expressed concurrence with the Chairman, and said that his
experience of heating corridor day rooms with hot water pipes at the Castlebar
Asylum had not been favourable. At the same time he thought that if an
asylum was damp, as the Castlebar Asylum was exceedingly, other heating
than by fire places may be necessary to secure dryness of the walls. Again, in
asylums where ventilation is imperfect, heating apparatuses are very undesir¬
able. In one asylum in a neighbouring country, where the hot-water system
of heating was employed, the mortality at one time ran up to such enormous
proportions as to cause serious alarm. On inquiry, it was found that the venti¬
lation was in the highest degree imperfect. When this was rectified the death-
rate rapidly went down.
The Chairman —It is almost impossible to ventilate the rooms properly
where the hot-water system of heating is used. There is a new system
of heating, which I think would be a commendable one for superinten¬
dents (Blackman’s). The method consists in forcing a current of air, heated by
a large furnace, through pipes, in which an apparatus revolves, which carries
the air through the pipes. Ventilation is combined with heating. I have seen *
one of these working during the past week ; it was used for the purpose of
drying in a laundry, and it appeared to me to be an admirable arrangement
for the heating as well. It was rather expensive, and it required about a ton of
coke weekly. I am somewhat surprised to hear it said that the mere heating of
wards predisposed to an increase in the mortality. I think the increase in the
mortality is not due to the heating of the wards, but to allowing the tempera¬
ture of the rooms to fall from time to time. I think we ought to have the day-
rooms of our asylums far warmer at the present time. In mid-winter there
should be a temperature of 60°, provided there is plenty of ventilation.
Dr. Woods disapproved of the hot-water system, and recommended the vane
process, where a current of air was made to pass over heated pipes by means
of a revolving fan.
Dr. Conolly Norman said, in considering the heating of a place, a great
deal depended upon the construction of the bui ding. He thought sufficient
attention had not been paid in the past to the building material of which
our asylums were constructed. Many of our institutions were built with a
strongly hygrometric limestone, which required a great amount of heat on
account ot its moisture-condensing properties. He thought the better
course would be to have the asylums built with such material as brick, or
to have the walls brick-lined. Regarding the second question—ventilation—
it was acknowledged that an important factor in the production of phthisis
was the breathing of impure air. But he was of opinion that healthy
patients required very little heating in their bedrooms, that is provided the
walls be dry. At the same time, the single rooms for the sick required a
better system of heating than was prevalent in this country, and he thought
that dry warm air was better than the hot-water process.
Dr. West read a paper describing a “ New Farm at the Omagh Asylum.” (See
Original Articles.)
The Chairman, while approving of the extension of asylum farms, thought
that much more ought to be done in the way of making patients work at trades.
Because a man did not know a trade on coming into an asylum there was no
reason that he should not learn at least the simpler varieties of mechanical work.
The speaker taught his tailor and shoemaker and other workmen that it was the
most important part of their business to pick out helpers from among the
patients, and to teach them to be useful in the shops.
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1893.]
Notes and News.
319
Dr. Conolly Norman said that Dr. West’s paper marked, if it did not make,
an epoch. The old prejudice against the insane, the notion that they ought to
be locked up like dangerous wild beasts, must have been the real basis for the
very singular opposition that had till recently been offered by asylum authorities
to the acquisition of sufficient land either to give the patients breathing space or
employment. In no district in Ireland were the bulk of the male patients
accustomed before admission to anything except agricultural labour, and yet, as
has been often remarked, in no country were asylum farms so small in recent
years. A strange spectacle of how hard these cruel prejudices die had been
afforded to the public when an entire Board of Governors of an important Irish
county asylum had resigned en masse in consequence of a dispute with the Board
of Control of Lunatic Asylums over the acquisition of land. This cataclysm or
storm in a tea-cup had occurred because in an agricultural country some 27
acres had been added to an asylum property which originally consisted of less
than 30 acres 1 The speaker hoped that Dr. West’s paper might be taken as
showing that better feelings and more enlightened views were already beginning
to prevail. In connection with the question of the employment of patients at
farm labour, there was, Dr. Norman said, a matter to which he wished to draw
the special attention of the meeting, as it affected their kind host. Dr. Finnegan
had been in the habit for some years back ol sending out gangs of his male
patients to work on farms belonging to farmers in the neighbourhood of the
asylum. The advantages to be expected from so progressive a step were, the
speaker thought, enormous. Dr. Finnegan was, he believed, the first to adopt
this plan in Ireland, but he thought Dr. Bucknill had done something of the kind
years ago in Devon. Dr. Norman quoted passages from the life of the late Dr.
Snell, of Hildesheim, showing that that distinguished physician almost thirty
years ago (1863) was in the habit of sending out gangs of 20-24 male patients
to work lor farmers close to Hildesheim. Dr. Snell has recorded that “ the
interest in the work itself, the pleasant change of occupation and surroundings,
and the enjoyment of fresh air operated together most beneficially towards the
improvement of the patients’ bodily strength and the calming and curing of
their minds.” The conservative tendencies that prevailed in Ireland had led to
Dr. Finnegan’s action in this matter being very severely criticised in the district.
It might perhaps help him if the meeting expressed their opinion on the sub¬
ject. The speaker had no doubt of what their opinion would be, judging from
the trend of their discussions that day, which had been strongly in the direction
of progress, improvement, and increased freedom. He therefore proposed the
following resolution for the acceptance of the meeting :—“ That this Association
has learned with great satisfaction that the Governors of the Mullingar Asylum
have permitted patients to be sent out to agricultural work in neighbouring
farms.”
A long and interesting discussion followed.
The Chairman pointed out that Dr. Norman was in error in supposing that
this was a new departure in Ireland. Some years ago it had been done in a
northern asylum. An ill-feeling had arisen in the neighbourhood, and questions
were even asked about the matter in the House of Commons. [This also
occurred with reference to the Mullingar Asylum.]
Dr. Petit stated that for ten years he had been in the habit of sendiug out
patients from the Sligo asylum to work for the neighbouring farmers. He had
seen no bad results. On the contrary, he was satisfied that many patients had
benefited very materially. The system also had the advantage that it helped to
break down the old prejudice against and tear of lunatics among the public out
of doors.
Drs. Patton, Nelson Eustace, O’Neill, Gordon, and others also spoke.
Dr. Middleton, being connected with the Mullingar Asylum as Visiting
Physician, and being also one of those to whose farm Dr. Finnegan had sent
patients, was glad to bear most emphatic testimony to the advantage that had
resulted to the patients and to the perfect safety of the experiment.
Dr. Finnegan pointed to the results as being the best justification for his
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320
Notes and News.
[April,
action. The opposition offered to what he had done was, he was satisfied, qnite
fictitious. Nobody’s interests were really injured by his sending out a few male
patients to work on neighbouring farms. At all events he looked on the matter
solely from a medical point of view, and regarded only the undoubted benefit to
his patients. In the discharge of his duties he considered no one else.
Dr. Woods having inquired carefully into the practical working of the sub¬
ject, expressed himself satisfied that no exception ought to be taken to the
employment on the score of injury to the interests of sane workers. He there¬
fore seconded the resolution, which was then unanimously adopted.
A paper by Dr. Vincent J. Ruttledge was read on “ A Case of Bilateral
Atrophy of Certain Groups of Muscles in the Neck/* and discussed by Drs.
« Patton, Nash, Middleton, and Norman. (We hope to have this paper for an
early number of the Journal.)
Dr. Nash read a paper on “ Alcoholic Neuritis with Mental Disease,” con¬
tinuing his observations communicated at the last Irish meeting with further
cases.
Dr. Norman spoke.
A paper by Dr. W. C. Sullivan was read on “ A Case of Sexual Perversion
recurring in Acute Mania.** (See Clinical Notes and Cases.)
Dr. Nash described a case occurring in a female patient at the Richmond
Asylum, in which double pyosalpinx existed.
Drs. Patton, Gordon, and Middleton spoke.
Time running short, a paper by Dr. Nolan “ On Syphilis and General
Paralysis ** was unavoidably taken as read.
Dr. Patton having been moved to the second chair, a vote of thanks was
passed to Dr. Garner for his conduct as Chairman, and a most agreeable and
successful meeting terminated in a warm vote of thanks to Dr. Finnegan for
having invited the members to meet at the Mullingar Asylum, and for having
provided most hospitably for their needs, mental and physical.
MYXCEDEMA AND SPORADIC CRETINISM.
Arrangements were made to deliver a series of lectures and demonstrations
on myxoedema before the Edinburgh Medico-Chirurgical Society on the 15th
and 16th February. Never, probably, had so many cases of this rare disease
been collected together, and the information given might be said to be complete
up to date. Though the proceedings occupied two sittings, there was no spare
time for discussion. Lecturing and not debating is the forte of the Medico-
Chirurgical Society, as most of the speakers are attached to the Edinburgh
Medical School. Towards the end the audience began to be somewhat weary of
notes of cases which only repeated the same general history. The subject was
introduced by Dr. Byrom Bramwell, who described with great clearness and
precision the symptoms of myxoedema, which he contrasted with those of
exophthalmic goitre and acromegaly. Dr. Bramwell also described cretinoid
idiocy or sporadic cretinism, which he regarded as a congenital or infantile
form of myxoedema. After explaining the nature of the affection of the thyroid
gland in myxoedema, cretinism, and exophthalmic goitre, and the supposed
deficiency of the pituitary body in acromegaly (megalakria would be a better
word), Dr. Bramwell gave illustrations of the success of the treatment of feeding
with portions of the raw thyroid of the sheep or pig. The interest of Dr.
Bramweirs observations was enhanced by the introduction of several clinical
cases of these diseases, and the exhibition of some very realistic coloured
drawings.
Professor Greenfield explained the pathological character of the myxoedema,
dwelling principally upon the atrophy of the glandular.tissue of the thyroid, and
the general increase of connective tissue in the body. Of 17 patients with
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Notes and News.
321
1893 .]
myxoedema whom he had seen two were insane. In one cage he had carefully
examined the brain, bnt could detect no change, though he found traces of
neuritis in the peripheral nerves, which perhaps might be accounted for by the
changes in the integument. Dr. Greenfield’s paper was illustrated by a large
number of preparations under the microscope, and some views of patients
thrown from the magic lantern. Dr. R. A. Lundie then dealt with the treat¬
ment by injection of thyroid juice. He found that the raw thyroid, or thyroid
extract, was a safer and equally efficacious method of treatment, and exhibited
some cases in which improvement amounting to an absolute cure had followed
his treatment. Dr. John Thomson showed two cases of sporadio cretinism—one
a child aged four, the other a dwarf said to be eighteen—in which there was
great improvement from thyroid feeding, both in the physical symptoms and in ♦
the intelligence. Other cases were exhibited by Drs. Affleck, W. Russell, A.
Bruce, Dunlop, Church, Dr. A. T. Davies, of London, and Dr. Stalker, of Dundee.
On the second day Dr. Murray, of Newcastle, appeared. He explained the pro¬
cess of reasoning and observation by which he had been induced to commence
this new method of treatment, and cautioned his audience against the danger
of large doses, whether in the form of injection of the juice or thyroid extract.
Dr. Foulis gave a warning of the same kind. He had a patient who died within
twenty-four hours after taking a quarter of a sheep’s thyroid—that is, of the
whole thyroid, for in the sheep it appears as two glands loosely held together
by connective tissue. A safe dose seems to be to commence with one-eighth of
a whole gland taken in rice paper. The fact that undoubted improvement has
taken place from transplantation of the gland, and the use of thyroid juice in
one form or another, cannot fail to excite reflection amongst those who have to
treat insanity. The conclusion seems to be that the thyroid gland secretes and
sends into the circulating fluid something useful to the function of the brain,
and that the blood is not only a repairing, but a vivifying fluid, without whose
stimulus the functions of the nervous system would cease.
THE FREEMANTLE ASYLUM FOR WESTERN AUSTRALIA.
The reports of the Superintendent and of a Select Committee of the Legisla¬
tive Assembly on this Asylum afford an interesting view of the needs of the
insane in this colony.
The Asylum contains 125 patients, of whom 26 are of the old Imperial con¬
vict class, Chinese and Malays forming a large proportion of the residue, many
other nationalities being represented. These are under the care of six male and
five female attendants, and appear to be crowded together without any possibility
of separating the violent, obscene, and filthy from the decent, orderly, and con¬
valescent. The mixture of nationalities must render this state of things doubly
injurious and obnoxious.
The great predominance of the Malay and Chinese insane, it is suggested, is
due to their being imported, there being no supervision of immigrants in this
respect.
The Asylum has 13£ acres of ground, and already appears to be nearly
surrounded by the rapidly growing city of Freeman tie. Regret must, there¬
fore, be expressed that the necessity which exists for the enlargement of the
Asylum is not taken advantage of by transferring the institution to a more
rural district, where a much larger area of ground could be obtained and
segregation carried out on the plan of Alt Scherbitz and other insane farm
colonies.
A reception house could be retained on the present site on the plan advocated
by Dr. Norton Manning.
The Superintendent, Dr. Burnett, is to be congratulated on the manly and
temperate expression of the great difficulties against which he has had to con¬
tend, in spite of an altogether inadequate pecuniary recognition of his services.
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322
Notes and News.
[April,
THE AMERICAN JOURNAL OF INSANITY.
We note with interest that the January number of this well-conducted
Journal is printed and bound in the Utica Stale Hospital for the Insane. The
reason for this is a very commendable one—that of giving occupation to the
patients and of maintaining the Journal typographically on a footing of inde¬
pendence. We cordially wish success to our contemporary under the able
editorship of Dr. Alder Blumer. In this connection we may observe that the
above Hospital completed its semi-centenary on January 16th, 1893.
ST. JOHN AMBULANCE EXAMINATION.
FIRST AID CERTIFICATE.
At the St. John Ambulance Examination recently held at the Derby County
Asylum, Mickleover, on 13th February, the result of which was made known on
6th March, 58 members of the staff went in for examination, of whom 55
successfully passed, including the two head attendants and all the attendants
and nurses who were candidates.
Three candidates were rejected on account of having failed to satisfy the
Examiner, Dr. J. W. Martin, Sheffield.
Lectures on General and Mental Nursing are to follow preparatory to
examination for the nursing certificate of the Medico-Psychological Association.
AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION.
We are requested to call attention to the annual meeting of the above Asso¬
ciation, so that the alienists of Great Britain and Ireland who are likely to attend
the World’s Fair at Chicago may have the further inducement to cross the
Atlantic in order to be present. The date is June 6th continuing three days.
On the 12th the Sessions of the International Congress will begin.
The Secretary of the American Medico-Psychological Association is Dr.
Henry M. Hurd, Johns Hopkins University, Baltimore.
THE WORLD’S CONGRESS AUXILIARY.
The International Congress of Charities, Correction, and Philanthropy will
be held June 12-18, 1893, at Chicago. Section 4 deals with “ The Commitment,
Detention, Care, and Treatment of the Insane.” The Chairman is Dr. Alder
Blumer, the Superintendent of the State Hospital for the Insane, Utica, and the
Secretary Dr. A. B. Richardson, Superintendent of the Asylum, Columbus. It
is hoped that it will be a truly international gathering for conference on the
subjects allotted to this section. All who are interested in them are cordially
invited to be present and to take part in the discussions. Those who are
desirous of reading papers are requested to communicate with the Secretary.
“ THE BLOT ON THE BRAIN.”
We are glad to see that a new edition of this valuable work will be issued
before long. This is all the more satisfactory when it is notorious that publica¬
tions bearing upon mental disease meet with little encouragement. On the
covers of most of them might be inscribed “ Much toil and little gain.” Dr.
Ireland’s writings are calculated to enlighten the reading public in regard to
the true nature of many of the striking events which have been performed upon
the stage of the world’s history, being based upon psychological knowledge and
a keen scientific insight into character, and merit success.
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1893.]
Notes and News.
323
M.P.C. EXAMINATION.
December, 1892.
The following Candidates for the M. P. C. in Scotland passed the Examina¬
tion :—
Dr. A*. W. Anderson.
Dr. J. T. West.
Dr. J. W. S. Attegalle.
We mnch regret that by an oversight the name of Dr. Fennings was omitted
from the List of Candidates who passed the Examination for the M.P.C. in
England in December last.
M.C.P. EXAMINATION (IRELAND).
John Neilson Eustace, M.B., B.Ch.Univ.Dubl., and John O’Conor Donelan,
L.R.C.P.I., L.R.C.S.I., obtained the Certificate at the examination held in
Ireland in December, 1892.
Obituary .
PROFESSOR BALL.
The health of this distinguished alienist had been failing for a considerable
time from January 17th, 1892, when he delivered his last lecture at the Asile
de Ste. Anne, and he had been unable to engage in his professional work. He
had an attack of paralysis and became aphasic, but it is understood that his
mind was clear.
Dr. Benjamin Ball was born on the 30tli of April, 1834, at Naples. His father
was English, and his mother (nie Audrat) was Swiss. In 1849 he was natura¬
lized as a Frenchman. His medical career, which commenced in 1863, was a
very brilliant one. In 1855 he was Externe des Hopitaux, and in 1856 was
Interne. He became M.D. in 1862, agrtge & la Faculte 1866, and Hospita
Physician in 1870. He was the first Professor of Mental Diseases in the
University of Paris. This was-in 1877. He became a Member of the Academy
five years later.
Dr. Klein, of Paris, writes :—“ You yourself have known the man, and you
know how various and wide was his knowledge, not only in medicine, general
and psychological, but in all branches of science, as history, philology,
geography, and philosophy. You also know, in common with all who have
approached him, how kind, how good-hearted, and charming he was in everyday
life, how broad-minded and tolerant of other people’s opinions, and how willing
and ready to help anyone, especially the English people. There is no doubt
about his having been one of the most, if not the most eloquent professor of
the Faculty of Paris. The Theatre of the St. Anne Asylum, where he used to
deliver his lectures, was always overcrowded with students and others, attracted
by the eloquence and sympathy of the master. His speech was so clear, the
mode of marshalling facts so striking and vivid, that it used to impress the mind
deeply. For myself, I may say that I was so strongly impressed by the first
lecture I heard from him that I could have repeated it phrase by phrase, word
by word, the day after it was delivered. The more I think about it, the more I
realize how much I have lost by the death of this dear friend and master, in
whose intimacy I lived for the last eight years.”
Dr. Ball attended many medical meetings in England, and took a lively part
in the discussions of the papers that were read.
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324
Notes and News.
He was a voluminous writer. A few only of his articles and works can be
enumerated here:—“ Lemons sur les Maladies Mentales ; ” “ De la Morphino-
manie; ” “ De la FolieErotiqne; ” “La Claustrophobic ; 99 “ IschemiaC6rdbrale
Functionnelle;” “Les Impulsions Intellectuelles “ La Torpeur Cdrdbrale; ”
“ L f Insanitd dans la Paralysie Agitante ; '* “ Les Frontidres de la Folie ; ” “ La
Folie G&nellaire ; n “ Folie Consecutive au Cholera,” etc. To Dr. Tuke’s “ Dic¬
tionary of Psychological Medicine 99 he contributed the articles on “ Insanity
of Doubt ” and “ Insanity in Twins/’
Dr. Ball died on Sunday, February 23rd. He was buried on the 26th. A
service was performed by M. Monod, the Protestant Pastor, at his residence in
Paris, and the remains were laid in a vault in the Montmartre Cemetery. MM.
Charcot, Brouardel, and many other distinguished physicians and professors
attended the funeral. By his own special request, no orations were delivered
at the grave.
THE MAY QUARTERLY MEETING.
This meeting of the Association will be held in London on Thursday, May
18th, 1893.
Fletcher Beach,
Hon. Secretary.
The Elms, Chislehurst Road,
Sidcup, Kent.
Appointments.
Campbell, Colin MaCIvkr, M.A., M.D., has been appointed Hon. Consulting
Physician to the Perth District Asylum.
Donelan, J. O'C., L R.C.S.I., L.M., and L.K.Q.C.P.I., appointed Assistant
Medical Officer to the Richmond District Lunatic Asylum, Dublin.
Francis, Lloyd, M.A., M.D.Oxon., has been appointed Medical Superinten¬
dent to the Earlswood Asylum.
Jones, R., M.D.Lond., B.S., F.R.C.S., has been appointed Medical Superin¬
tendent of the new London County Asylum, Clavbury.
Mair, L. W. Darra, M.D.Lond., D.P.H., has been appointed Acting Medical
Superintendent, Grove Hall Asylum, Bow.
Nobbs, Athelstane. M.B., C.M.Edin., appointed Assistant Medical Officer
to the Northumberland County Asylum, Morpeth.
Robertson, G. M., M.B., C.M.. M.P.C.. has been appointed Medical Superin¬
tendent, Perth District Asylum, Murthley. '
Stanspield, T. E. K., 51 ,B., C.M.Edin., has been appointed Senior Assistant
Medical Officer to the London County Council’s new Asylum, Claybury,
Woodford, Essex.
Walmsley, F. H., M.D., has been appointed Medical Superintendent to the
Metropolitan Idiot Asylum, Darenth.
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THE JOURNAL OB MENTAL SCIENCE
[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland .]
No. 166. "Vm”- JULY, 1893. Vol. XXXIX.
PART 1.—ORIGINAL ARTICLES.
The Amok of the Malays. By W. Gilmore Ellis, M.D.,
M.R.C.S., Medical Superintendent, Government Asylum,
Singapore.
We are all of us familiar with the expression “to run
amuck,” but perhaps comparatively few of us are familiar
with the significance of the term in the Eastern Archipelago.
Amuck, or, as it is properly spelt Amok 9 is a Malay word, and
means a furious assault, its derivatives, Mengamok and Pen-
gamok respectively, meaning to commit a furious assault and
the person who runs Amok.
A Malay who runs Amok is always in a state of furious
homicidal passion, and runs armed through the most crowded
street or village stabbing right and left at man, woman, or
child, relation, friend, or stranger.
For the convenience of this paper I shall call the man who
runs Amok an “ Amoker,” and the crime “ Amoking.”
It is necessary to state at once that I do not in any way
intend to discuss the point as to whether the judicial execution
of men Amoking is right or wrong, or as to whether execution
of all Amokers would tend to lessen the frequency of the
crime. I believe Penang has claimed that the Chief Justice’s
(Sir Wm. Norris) sentence, which reads like one of those of
the middle ages, and which I will give in detail later on,
passed upon an Amoker, and carried out within eight days of
the Amok in 1846, was the means of stamping out Amok
entirely for years, but I can obtain no reliable information in
proof of this. I intend trying to give a brief sketch of
Amok and its causes, some notes on recent cases, and to point
out a possible field in which its pathology may eventually be
determined.
xxxix. 21
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326
The Amok of the Malays , [July*
• From 60 to 100 years ago in all Malay states and islands
long poles with prongs at their ends, shaped like pitchforks,
were kept in the villages, and at the then fairly frequent cry
of “ Amok ! Amok ” were used by the inhabitants to pin the
unfortunate Amoker to the ground if caught up from behind,
or, if approaching, to ward off his attack and keep him from
coming near enough to use his weapon, which was generally a
short spear, a Malay-curved knife (kris), or a chopper
(parang). These prongs are to be seen in the more uncivi¬
lized parts of Malaya to this day. If caught whilst running
Amok the man was almost invariably treated as a mad dog,
and killed on the spot in any way and by any means; but if
he got successfully away and claimed the protection of his own
or any neighbouring Rajah, he was at times taken by the
Rajah as his slave, and allowed to marry none but a slave, any
children subsequently bora to him also becoming slaves. If
the Amoker were an influential man, and the friends of his
victims were willing to accept compensation, which was forth¬
coming, the Rajah also getting his share, he was frequently
pardoned and taken back into his village. On the other hand,
some Rajahs had all Amokers sentenced to death, and they
were then immediately executed in the Malayan manner, which
is as follows:—The victim is made to kneel down, the execu¬
tioner approaches from behind, places a piece of teazed-out
cotton in the right supraclavicular fossa to prevent the escape
of much blood, and pushes a kris through the cotton diagonally
across the thorax into the heart. At the present time in the
English States, and in all European protected native States and
islands, an Amoker is arrested, if possible, and tried , in the
law courts for his crime, but in a few of the less civilized
States in the north of the Malay peninsula, and upon many of
the islands of the Archipelago away from Dutch influences, the
before-mentioned customs are still retained. The Bugis, natives
of the Island of Celebes, are of all the Malay races by far the
most addicted to Amok; in fact, nearly all Amoks occurring
in Singapore within recent times have been run by men of this
tribe. The inhabitants of the Island of Bali, situated at the
south-east extremity of Java, are also said frequently to Amok,
but few of these men ever come to Singapore. A better
control over their impulses is undoubtedly being evolved among
the more civilized Malays, for Amok is far less frequent now
than it was formerly.
It may be interesting here to give an account of the Amok
which occurred in Penang in 1846, and to which I have before
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1893.]
by W. Gilmobe Ellis, M.D.
327
alluded. On the 8th July of that year a respectable Malay
house-builder, named Sunam, ran Amok in Chuliah Street and
Penang Road, and before he was arrested had succeeded in
killing an old Hindoo woman, a Kling man, a Chinese boy, a
Kling girl, about eight years old, who was in the arms of her
father, and in wounding two Hindoos, three Klings, and two
Chinese, of which seven persons only two ultimately survived.
On his trial it appeared that the prisoner had been greatly
upset by the recent death of his wife and child, which had
preyed upon his mind and quite altered his appearance. A
person, with whom he had lived up to the 15th June, said as
follows :— u He used to bring his child to his work, and since
its death he has worked for me. He often said he could not
work, as he was afflicted by the loss of his child. I think he
was out of his mind. He did not smoke or drink.” On the
morning of the Amok this witness met the prisoner and asked
him to work at his boat. He replied that he could not, as he
was very much afflicted. He had his hands concealed under
a cloth, and frequently exclaimed, “ Allah ! Allah! ” At the
trial Sunam declared that he did not know what he was about
or what he had done, and persisted in this at the place of
execution, adding, “ As the gentlemen say I have committed so
many murders, I suppose it must be so.” The Amok took
place on the 8th, the trial on the 13th, and the execution on
the 15th July* all within eight days.
Sir Wm. Norris (the Chief Justice) passed sentence on the
prisoner in these words :—
Sunam, you stand convicted on the clearest evidence of the
wilful murder of Pakir Sah on Wednesday last, and it appears that
on the same occasion you stabbed no less than ten other unfortunate
persons, only two of whom are at present surviving. It now be¬
comes my duty to pass upon you the last sentence of the law. I
can scarcely call it a painful duty, for the blood of your innocent
victims cries aloud for vengeance, and both justice and humanity
would be shocked were you permitted to escape the infamy of a
public execution. God Almighty alone, the great searcher of
hearts, can tell precisely what passed in that wretched heart of
yours before and at the time when you committed these atrocious
deeds, nor is it necessary for the ends of justice that we should
perfectly comprehend the morbid views and turbulent passions by
which you must have been actuated. It is enough for us to know
that you, like all other murderers, had not the fear of God before
your eyes, and that you acted of malice aforethought and by the
instigation of the devil himself, who was a murderer from the
beginning. —^Jdm^atrocities you have committed are of a
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328
The Amok of the Malays
[July,
peculiar character, and such as are never per
Hindoos, Chinese, or any other class than Mahomedans, especially
Malays, among whom they are frightfully common, and may, there¬
fore, be justly branded, by way of infamous distinction, as
Mahomedan murders. I think it right, therefore, seeing so great
a concourse of Mahomedans in and about the Court, to take this
opportunity of endeavouring to disabuse their minds and your own
of any false notions of courage, heroism, or self-devotion which
Mahomedans possibly, but Mahomedans alone of all mankind, can
ever attach to such base, cowardly, and brutal murders; notions
which none but the devil himself, the father of lies, could ever
have inspired. But if such false, execrable, and dangerous
delusions really are entertained by any man, or body of men what¬
ever, it may be as well to show from the gloomy workings of your
mind, so far as circumstances have revealed them, that not a
particle of manly courage or heroism could have animated you, or
can ever animate any man who lifts his cowardly hand against
helpless women and children. You had lately, it seems, been
greatly afflicted by the sudden deaths of your wife and only child,
and Gt)d forbid that I should needlessly harrow up your feelings
by reverting to the subject. I do so merely because it seems in
some degree to explain the dreadful tragedy for which you are now
about to answer with your life. Unable or unwilling to submit
with patience to the affliction with which it had pleased God to
visit you, you abandoned yourself to discontent and despair, until
shortly before the bloody transaction, when you went to the mosque
to pray. To pray to whom or to what ? Not to senseless idols of
wood and stone, which Christians and Mahomedans equally abomi¬
nate, but to the one omniscient, Almighty, and all merciful
God in whom alone Christians and Mahomedans profess to believe.
But in what spirit did you pray, if you prayed at all ? Did you
pray for resignation or ability to humble yourself under the
mighty hand of God ? Impossible. You may have gone to curse
in your heart and gnash with your teeth, but certainly not to pray,
whatever unmeaning sentences of the Koran may have issued
from your lips. Doubtless you entered the mosque with a heart
full of haughty pride, anger, and rebellion against your Maker,
and no wonder that you sallied forth again overflowing with
hatred and malice against your innocent fellow creatures; no
wonder that, when thus abandoned to the devil, you stabbed with
equal cruelty, cowardice, and ferocity unarmed and helpless men,
women, and children, who had never injured, never known, pro¬
bably never seen you before. Such are the murders which
Mahomedans alone have been found capable of committing. Not
that I mean to brand Mahomedans in general as worse than all
other men, far from it; I believe there are many good men
among them, as good as men can be who are ignorant of the only
true religion* I merely state the facts^J^t-^^ atrocities dis-
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1893.] by W. Gilmobe Ellis, M.D. 329
grace no other creed, let the Mahomedans account for the fact as
they may. But whatever may be the true explanation, whether
these fiendish excesses are the result of fanaticism, superstition,
overweening pride, or, which is probable, of all combined, public
justice demands that the perpetrators should be visited with the
severest and most disgraceful punishment which the law can
inflict. The sentence of the Court, therefore, is that you,
Sunam, be remanded to the place from whence you came, and
that on the morning of Wednesday next you be drawn from
thence on a hurdle to the place of execution, and there be hanged
by the neck until you are dead. Your body will then be handed
over to the surgeons for dissection, and your mangled limbs,
instead of being restored to your friends for decent interment,
will be cast into the sea-, thrown into a ditch, or scattered on the
earth at the discretion of the Sheriff, and may God Almighty have
mercy on your miserable soul!
The case just described suggests many reflections pointing
in different ways, and the sentence at the time appears to
have been severely criticized, it being asked if justice should
so closely imitate revenge as almost to kill the criminal red-
handed. Had the trial not followed so rapidly on the crime it
is possible that a different view might have been taken of the
condition of mind under which the criminal acted. I am
unable to discover that any medical man examined Sunam as
to his mental condition; under the circumstances a strange
omission. Sir Wm. Norris seems to have been under the
impression that Amok has something to do with Mahome-
danism, that the murder of infidels ( i.e ., non-Mahomedans) is
advocated, or at least spoken well of in the Koran, and that to
be killed while running Amok is a sure road to heaven. To
this day this is frequently put forward by some European
residents as the real reason for committing Amok. Never was
there a greater error; Amok is a peculiarity of the Malay race,
and the fact of their all being Mahomedans has really nothing
to do with it. As to the Koran, I have studiously searched
through it for anything bearing on the point, and can find
nothing, and questioning educated Malays has given the same
result; besides, did the Koran commend such an action Amok
would be of daily occurrence among such bigoted Mahomedans
as many of the Malays are. Let me quote here two sentences
from the Koran —" And fight for the religion of God against
those who fight against you, but transgress not by attacking
them first, for God loveth not the transgressors; 39 and, again:
“Let there be no violence in religion.” Moreover, a Malay is
no respecter of persons when Amoking, and he stabs members
330
The Amok of the Malays, [July*
of his own race and religion, sliould he come across them, with
the same indifference with which he wonld stab others, an
action he would certainly not commit were the Koran or his
religion in any way the cause of the outbreak. Concerning
such a crime the Koran says : “ But whoso killeth a believer
designedly his reward shall be hell, he shall remain therein
for ever, and God shall be angry with him, and shall curse him,
and shall prepare for him a great punishment.”
I have been told by educated Malays, supposed to know
something of the ancient history of their country, that Amok
was prevalent before their conversion to the Mahomedan
religion, but as this event occurred several hundreds of years
ago, and there are but few Malay records even one hundred
years old, the statement must be received as most unreliable.
Dr. Oxley, in a medical report written on Singapore about
the year 1845, says :—
Amoks result from an idiosyncrasy or peculiar temperament
common amongst Malays, a temperament which all who have had
intercourse with them must have observed, although they cannot
account for or thoroughly understand it. It consists in a proneness
to chronic disease of feeling, resulting from a want of moral elas¬
ticity, which leaves the mind a prey to the pain of grief, until it
is filled with a malignant gloom and despair, and the whole horizon
of existence is overcast with blackness. . . . These cases require
discrimination on the part of the medical jurist to prevent irre¬
sponsible persons suffering the penalty of the injured law. For
instance, a man sitting quietly amongst his friends and relations
will, without provocation, suddenly start up, weapon in hand, and
slay all within his reach. I have known as many as eight killed
and wounded by a very feeble individual in this manner. Next
day, when interrogated whether he was not sorry for the act he
had committed, no one could be more contrite. When asked
“ Why, then, did you do it ? ” the answer has invariably been,
a The devil entered into me ; my eyes were darkened ; I did not
know what I was about.” I have received this same reply on at
least twenty different occasions. Those about these monomaniacs
have generally told me that they appeared moping and melancholy
a few days before the outbreak.
Infidelity of wife, grief (especially that due to the death of a
near relation), sight of blood (especially the person’s own),
brooding over real or imaginary wrongs, loss of money by
gambling, loss of hope of living (as in a foundering ship),
shame and disgrace (such as being considered a coward or
being imprisoned), and last, though by no means least, malarial
1893.]
331
by W. Gilmore Ellis, M.D.
fever, have all been noted as exciting causes to Amok. Should
a man kill his wife and her paramour, and then sit quietly down,
he is not considered to have run Amok, and, according to Malay
laws, his action would be justifiable, but there are few instances
recorded of such an action, for the mere fact of killing the two
culprits would, in nearly all cases, excite the unfortunate husband
to Amok and slay other and innocent beings. Many Malays
have told me that they consider Amok a kind of suicide; a
man, from some cause or other, considers life not worth living,
and wishes to die—suicide is a most heinous sin according to
the ethics of the Mahomedan religion, therefore he Amoks, in
the hope of being killed. Concerning the crime of suicide,
the Koran says—“ Neither slay yourselves, for God is merciful
towards you, and whoever does this maliciously and wickedly
he will surely cast him to be broiled in hell fire; and this is
easy with God.” I cannot discover that any Malay has ever
been known either to commit or to attempt to commit suicide
after having run Amok. Suicide is extremely rare amongst
Malays, and only one attempt has ever been brought to my
notice. This was the case of an English-speaking Malay, bom
in Ceylon, who cut his throat rather severely whilst suffering
from acute melancholia; he refused all food, and was fed by the
pump for weeks, and did not recover for more than a year.
I will now give in detail two typical cases of Amok, both of
which occurred in Singapore :—
On November 5th, 1887, there were sleeping in one room
Mamoot (boy, set. 16), Ahamat (the owner of the house), a Malay
girl, Hadji Ibrahim (a Bugis trader), and his brother Aboo. At
about 11.30 p.m., Hadji Ibrahim suddenly got up and attacked
Ahamat with a long cutting and pointed knife, inflicting an incised
wound down to the bone of the left temple, a long deep incised
Wound on the left shoulder, a deep incised wound in the middle of
the back, an incised wound of the front of the left side of the
thorax, penetrating through the ribs to the lung, a stab on the left
side of the abdomen, wounding the intestines, and there were deep
gashes on the hands and forearms. During this attack Mamoot,
Aboo, and the girl ran away into the street; they were all asleep
when the attack commenced. Hadji Ibrahim must now have
jumped out of a window into the back court of an adjoining
house, which he found open. He entered this house, and went
upstairs into a room, where he found Mariam and Umborasih (two
Malay women) sewing, and a man named Syed asleep. He imme¬
diately rushed across the room and stabbed Mariam several times
in the back, and Syed in five places. Mariam and Umborasih ran
downstairs, and Hadji Ibrahim left Syed and followed them,
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The Amoh of the Malays , [July,
stabbing Mariam again and Umborasih to the heart.
None of Mariam’s wounds were very serious, but Syed had
several severe cuts and stabs. Continuing the Amok, Hadji
Ibrahim ran out of the house into the street, meeting Mariam’s
husband at the door; making two ineffectual stabs at him as he
passed, he ran on up the street. Neither Mariam, Syed,
Umborasih, or Mariam’s husband knew Hadji Ibrahim. In the
street the first man he met was a Kling, and him he stabbed in
the chest and twice in the right forearm. Further on he met two
Chinamen; one ran safely away, but the other was stabbed in the
abdomen, the knife passing through liver, intestines, and stomach.
The next to be met was a Malay named Bakar, whom he stabbed
in the forearm as he ran by to attack a Malay named Sed. Sed
grasped the knife with his hands and a struggle ensued, in which
Hadji Ibrahim lost his weapon and Sed obtained two slight
wounds. The Amoker now ran off unarmed, and was chased, by
Sed and other people who had come up, into the arms of a native
constable, by whom he was arrested. Ahamat, Umborasih, and
the Chinaman were picked up dead; the five wounded persons
recovered. The prisoner, when arrested, had an excited, hunted
expression, was sullen, and refused to answer questions bearing on
his crime, but I can glean no further information as to his
condition. At the assizes he was found too insane to plead. He
first came under my notice rather more than a year after the
crime, and there is little to be said about him. He was a tall,
spare man, about 40 years old, pitted with small-pox marks, with
a quick, irregular heart’s action, and a wild stare in his eyes. He
rarely spoke unless addressed, but was perfectly rational aqd
coherent in his answers. He was cleanly and industrious, and
slept and ate well. When spoken to about his Amok, he always
became somewhat confused, and persisted in saying that he
remembered absolutely nothing about it. At the present time he
is fairly cheerful, quite rational and coherent, memory very fair,
in good physical health, but his heart is slightly hypertrophied,
pulse hard, and heart’s action somewhat irregular. Although he
knows that any confession can now make no difference to his
future, he still denies any recollection of the Amok, and says, “ As
you state I committed these murders and murderous assaults, I
suppose I did, but I remember nothing of it.”
The second case was that of a man named Nyan.
Nyan came to Singapore on January 4th, 1890, four days before
Amoking, with a party of traders from Brunei and Borneo, and all
went to a lodging-house. On the evening of January 7th he went
for a walk in a part of the town three miles from the lodging-
house, and there met a man named Noor, whom he had never seen
before, and after having a chat with him, asked to be allowed to
sleep in his house that night, and this request was granted. On
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1893.] by W. Gilmore Ellis, M.D.
the morning of the 8th, Nyan returned to the lodging-house, Noor
accompanying him; they went into an empty upstair room, and
Noor was given a cigar and left by himself, Nyan entering an
adjoining room, where were Awang and Mahomet, Bornean
Malays, and members of his party. Awang was ill in bed, and
Sleyman, his father, entering shortly afterwards, they all con¬
versed amicably together. Nyan remained but a short time,
leaving the room and going downstairs. He is supposed to have
gone to an outhouse, where was his box, and obtained from it a
kris and a parang. In the meantime, Mahomet also went down¬
stairs, entered the eating-room and commenced to eat some fruit,
and whilst he was sitting there, Nyan came in, and, without saying
a word, cut at him, wounding him on the face and on the left fore¬
arm. Mahomet then fled upstairs, closely chased by Nyan, who
succeeded in wounding him in the back as he jumped down a
second staircase and got away. The Amoker now entered the
room in which was Noor, attacked him, cut off his left hand at the
wrist, and wounded him on the head and ear as the poor old
fellow jumped out of the window into the street. Continuing the
Amok, Nyan entered the room in which were Sleyman and his
sick son, Awany. Sleyman promptly jumped out of the window,
dislocating his ankle as he fell, and the body of Awang was after¬
wards found with the following wounds :—Right hand cut off with
the exception of a small portion of the skin, a cut at the back of
the head going into the brain, a cut five inches long at the back of
the right shoulder wounding the scapula, two stabs in the back,
one penetrating the lung, along cut on the left of the front of the
chest going through the ribs into the pleural cavity, and a stab
between the fourth and fifth ribs completely piercing the heart. After
this ferocious attack, Nyan got out of a window on to the roof of some
outhouses, and tried to enter the adjoining house through a window,
that he found open, but was prevented by a man inside with an
old unloaded gun. He then got off the roof and out into the
street, which he crossed. He then entered the sea, and was
shortly afterwards arrested by a policeman in a boat, after first
throwing both his kris and parang at his captor. None of his
friends forming the party knew of any cause for the outbreak, and
he had not quarrelled with any of them. Sleyman had known
him for ten years as a quiet and industrious man. The ferocious
attack on Awang could certainly be only the action of a madman,
quiet and rational as Nyan was when I examined him but a short
time after the occurrence. Nyan’s story was that he overheard
his friends say that he was not fit to live, and ought to die, so,
getting frightened, he ran away and was kindly put up for the
night by Noor. Coming back the following morning he again
heard them speaking of him, and getting still more frightened he
went for his weapons to protect himself, and then everything
became red before his eyes and he can remember nothing more.
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The Amok of the Malays, [July,
This man also has a quick, easily excited heart's action, and a
peculiar stare in his eyes, which show much sclerotic, otherwise,
although under observation for the last two years, I can discover
nothing abnormal about him; certainly he does not appear to ever
suffer from either visual or oral hallucinations. He is averse to
being questioned as to the Amok, has a malignant expression, and
his respirations become short, if so spoken to. He persists in the
statement that after seeing everything red he remembers nothing
until he found himself in the hands of the police. At his trial he
was acquitted on the ground of insanity, and sentenced to be
detained during her Majesty’s pleasure.
I may mention here a.case of doubtful Amok that occurred
in the lunatic asylum early in the year 1889, and which varies
from the other cases in that the Amoker had an undoubted
attack of mania a month prior to his outbreak.
Mounselin, a male Javanese, about 32 years of age, admitted
December 10 th, 1888. Was then incoherent and rambling in his
speech; could give no connected account of himself; said that his
countrymen had a spite against him; had a vacant expression of
face, and was dirty in his habits. He had been arrested as a
wandering lunatic by the police, and we were unable to obtain
any history of him prior to his arrest. The day after admission
he refused food, and would not speak, slept but little, and was
very dirty, and so he remained for three days. On the 18th
December he was much better, fed himself, spoke rationally, and
was anxious to work with the gardeners—his own occupation. I
have a note in my case-book dated 5th January, 1889. Is now
quite well, sleeps and eats well, converses rationally, works
industriously with the gardeners. On the 15th January he
suddenly clutched the scythe of one of the gardeners, and took it
from him, wounding his fingers, and running with it to a part of
the asylum where were a few chronic dements out for an airing.
He attacked and seriously injured an old Chinaman before he was
knocked down and disarmed by the attendants. I examined
Mounselin immediately after this unfortunate event; he was
sullen, squatting down taking little notice of anything; he had a
mixed expression of fear and malignancy, and showed an enormous
amount of sclerotic; his respirations were short and hurried, and
his cardiac action irregular and quick. If pressed he answered
my questions rationally on all manner of subjects, but when asked
about the assault he would only say “I don’t know; I can’t
remember.” For months afterwards he remained quiet and
industrious, but was somewhat sullen at times, especially if
questioned about the Amok. On August 28th a piece of sharpened
iron was taken from him, a second piece which he had commenced
to sharpen being found concealed in his cap. A few days after
this he was found to have tied a piece of string tightly round his
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1893.] by W. Gilmore Ellis, M.D.
scrotum, which had commenced to slough. At this time he would
neither speak nor take food; his heart’s action was most irregular,
and he was slightly anaemic. He became very weak, and remained
in a feeble condition, requiring at times to be fed by the stomach-
pump, until May, 1890. Then he again became quite rational and
industrious, and said he remembered nothing of what had passed ;
but he was always looked upon with suspicion, both on account of
his shifty expression and the abnormal action of his heart. The
following month he was attacked with beri-beri, and he died in
August. Unfortunately I was away when he died, and did not
see the post-mortem. From our register I gather that his pia
mater was thickened and opaque, his cerebral blood vessels,
especially those of the base, atheromatous, his heart large and
flabby, the pericardium containing eight ounces of clear fluid (due
to the beri-beri), and the aortic valves being atheromatous; his
abdominal viscera were congested, and his kidneys small.
Are these Amokers insane and unable to refrain from obey¬
ing their homicidal impulses ? I think so. In fact, considering
how they mutilate some of their victims—victims they have
never seen before, and whom they can have no reason to slay
—I fail to see how anyone can doubt it. Dr. Savage writes,
in an article called “ The Plea of Insanity,” published in the
u Journal of Mental Science” for April, 1891 : a And in my
experience prisoners are safest when they deny all memory of
acts, and if they can be persistent in their denials they will
baffle the most acute, for a time at least.” It is this denial of
all knowledge of their offence that persons who have Amoked
invariably persist in that makes it most difficult to deal with
their case, and which causes a large proportion of the Straits
Settlements public to believe them feigning insanity to avoid
punishment for their crimes. Personally, I believe all Malays
consider imprisonment for life a greater punishment than
execution by hanging. If malingering would they one and
all deny their insanity, would they months after the crime and
trial, with no fear of further punishment hanging over them,
still persist that they remembered nothing of their criminal
acts, and with such an air of telling the truth ? They remember
that they were depressed, that they were upset, that they suf¬
fered from grief, in fact, that their affective nature was at
fault. ' Many of them speak of having seen everything red, of
having been giddy, or of their eyes having been turned in¬
wards, but then comes the blank. In from a few hours to a
few days after the Amok these afflicted individuals go back to
their normal state, passing through a stage of sullenness and
apathy, into which they are liable to relapse for months after-
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The Amok of the Malays , [July,
wards, if much questioned as to their outburst. It was but a
few weeks ago that I examined a man about 48 hours after
running Amok and killing one person. He was then depressed,
would not raise his head, and would only speak in a whisper.
His respirations were short and hurried, and his cardiac action
quick and regular. He spoke coherently, telling me that he
had been greatly upset of late by the elopement of his wife,
and that he had brooded over this; he remembered seeing
everything like blood, and then he remembered nothing more
until he found himself in confinement, accused of murder. He
could or would tell me nothing further about his crime. This
man a few days later brightened up considerably. At his trial
he was acquitted on the plea of insanity, and ordered to be
detained during her Majesty’s pleasure.
There is a peculiar condition of mind the Malay is liable to,
to a greater or lesser extent, in which he sits down and broods
over his wrongs, or supposed wrongs, with revengeful feelings,
to which the name of “ sakit-hati,” literally heart-sickness, is
given. Persons suffering from “ sakit-hati ” have been sent
to this asylum. They do not appear to be really insane, and
as a rule quickly recover. They remain in the condition for
periods varying from a few hours to a few weeks, but rarely
longer than four or five days. Their state is very similar to
that of a bad-tempered child sulking and having occasional
outbreaks of wrath. At these times their activity, especially
of brain, is low, for it has frequently struck me that they have
shown some slight impairment of memory when questioned
afterwards as to what had occurred. Heredity, I think, has
nothing to do with the condition, otherwise than the heredity
of the whole race, for all Malays are subject to these attacks.
Many have told me that the man who has run Amok always
suffers from “ sakit-hati ” prior to his Amok, and I am of
opinion that careful examination of the Amoker shortly before
his outbreak, were it possible, would invariably show diver¬
gencies from the man’s usual habits, and in some cases marked
peculiarities. An instance of this occurred last month in
Province Wellesley, where one Mat Saman reported at the
police-station that his friend Salim had suddenly commenced
behaving in a strange way. The police went to Salim’s house,
but he had gone, and all search proved of no avail. On the
following morning Salim entered a shop some distance away,
and instantly attacked the shop-keeper with a knife, then run¬
ning out and up the village he stabbed^ second man before
he was knocked down and captured. The shop-keeper was
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1898.] by W. Gilmobe Ellis, M.D.
fatally injured. Salim was examined by the Colonial Surgeon
a few hours after his capture, and I am told he was then
excited and nervous, with a tumultuous heart's action, and
that he answered questions wide from the subject. The next
day he was morose, sullen, and apparently brooding over some¬
thing, but by the fourth day he seemed quite well. His
friends have communicated that for several days before the
Amok he gave up all work, avoided intercourse with others,
and was evidently brooding over something, but they could
not discover what.
Bevan Lewis, in his text-book, writing on the fulminating
psychoses, says :—" In the genuine impulsive forms of insanity
consciousness is never so far impaired as to issue in forgetful¬
ness of the details of the homicidal act. When such is the
case—when any marked obscuration of memory is apparent—
we may presume the impulse to have been of epileptic origin,
or to be the outcome of alcoholic delirium.”
The aversion of the whole Malay race to alcohol in any form
places the last-mentioned disease out of the field in seeking
for the pathology of Amok. Dr. Maudsley, writing about
masked epilepsy, states ‘'that many cases of so-called transitory
mania are really cases of this kind—cases of mental epilepsy.
Instead of the morbid action affecting the motor centres and
issuing in a paroxysm of convulsions, it fixes upon the mind
centres, and issues in a paroxysm of mania, so to speak, an
epilepsy of mind.” Ordinary epilepsy is comparatively rare
among Malays; out of over one hundred insane of this race I
have only seen one epileptic, a youth of about 20 years of age,
who has from one to two fits a month, and is quite demented.
As in epilepsy strong emotions sometimes bring on a convul¬
sive seizure, caused by disturbances in the motor centres, so I
believe that in some Malays strong, emotions bring on sudden
paroxysms of acute homicidal mania, due to disturbances in
the sensory centres, i.e., masked epilepsy. But, whether this
be so or not, I contend that the man who runs Amok, such as
I have described, undoubtedly suffers from some form of im¬
pulsive insanity, generally of a most transient character. It
may be that the Amoker in some few instances wilfully allows
his emotions full play when he might control them, desiring to
die, and knowing that the culminating point will be Amok; on
the other hand, in the majority of instances the impulse to
Amok is sudden and uncontrollable. Those who wilfully work
themselves into, or allow themselves to drift into, a blind rage,
and then Amok, although I believe quite unconscious as to their
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338
The Amok of the Malays. [July,
actions whilst running Amok, should, to a certain extent at
least, be held responsible for their actions, for they must
thoroughly understand what is likely to be the result of that
first wilful action. As a man who of his own free will makes
himself drunk, and in blind drunken rage, more or less uncon¬
scious of his actions, commits a crime, is responsible, so are
they.
Insanity in Greece. The Hospital of Athens. By F. B.
Sanborn, Esq., late Inspector, Massachusetts State Board
of Health, Lunacy and Charity.
Little has been written, and comparatively little is known
with precision, concerning the insane of Greece—whether we
speak of the little kingdom alone, with its present population
of nearly 2,500,000, or of the Greeks in general, who live in
Macedonia, in Asia Minor, in Egypt, or elsewhere outside of
the present limits of Greece. This whole community, diverse
in origin and residence, but united by a common language and
a common religion, considers itself as one, and sends to the
two asylums in Greece—the old Phrenokomeion of Corfu
(founded in 1838), and the comparatively new Dromokditeion
in Athens—insane persons from all the countries in which
Greeks reside. Thus, during the year 1892 the Athenian
Asylum (which takes its special name from a Greek family
named Dromokaites, whose wealth has endowed it) received 70
admissions; and of these 13, or nearly one-fifth, came from
places outside of Greece. A smaller proportion among the
175 (more or less) who now reside in the Corfu Asylum are
from outside of Greece, and it is probable that this proportion
is constantly diminishing there. But Athens, from its central
position, its rank as a capital, and the affection with which
most Greeks regard it, is likely to draw to itself more and
more the persons attacked with insanity outside of Greece.
This fact will increase a little the visible insanity of the king¬
dom ; but so many are the causes tending to conceal the extent
of this malady there that the circumstance of * these outside
accessions need hardly be taken into account. There is no
census of the Greek insane, even professing to be exact, and I
have been forced to rely, in my tours and inquiry during two
visits to Greece (in 1890 and 1893), on the estimates of careful
persons and my own observation.
Insanity in Greece is not so common, I am convinced, as in
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1893.]
Insanity in Greece .
339
the northern countries of Europe or the older parts of the
United States, with which, in this respect, I am quite familiar.
Massachusetts (U.S.A.), where I have long resided, and
where, for 30 years, I have studied the condition of the insane,
has a population almost exactly the same as that of the Greek
kingdom—let us say 2,500,000. But there are at present in
Massachusetts not less than 7,000 insane persons, and probably
7,500; while Dr. Chirigotes, the chief expert of Greece, does
not estimate the Greek insane at much above 2,000, which
would agree with my own observation. If the number in the
two States who are receiving asylum treatment is compared,
the disproportion between Massachusetts and Greece appears
still more striking. For in Greece there are no more than 300
insane persons in asylums—116 at Athens and less than 190
at Corfu—while in Massachusetts more than 4,500 are in
asylums of the same general character as those mentioned;
that is to say, the proportion of cases under treatment in
Massachusetts is 15 to 1, as compared with Greece, while, by
estimate, the proportion of all the insane in the two States is
less than 4 to 1. But why should this different ratio exist in
two communities of the same population ? There are various
reasons, one of which is the far less prevalence of alcoholic
insanity in Greece, as compared with England, France, and
New England; another is the lack of a dense population,
which everywhere promotes insanity by its complications of
disease and vice; a third, undoubtedly, is the difference of
race.
The Greeks as a nation are prone to crime, at least to crimes
of violence, which are shockingly numerous among them; but
they are not so much addicted to vice as are their neighbours,
East, West, or North. Now vice is a very frequent cause of
insanity, which is also promoted, no doubt, by that greater*
freedom from traditional habits and modes of thought which
high civilization produces. That fatal form of insanity, so
distressingly prevalent in Western Europe and the densely
peopled parts of America—general paralysis—is much less
common in Greece; and this is a malady which almost always
proceeds from vice, and generally from debauch. For this
reason it is less common among women than men, and among
Greek women far less common—as statistics seem to show—
than among women in France, Germany, or the northern
United States.
The present Director of the Athenian Phrenokomeion (Dro¬
me k ait eion), Dr. Chirigotes, was in 1877 at the head of the
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340
Insanity in Greece , [July,
Corfu Asylum ; and his report for that year gives much infor¬
mation respecting the early history thereof. It was founded
by Sir Howard Douglas in 1838, 25 years before the English
ceased to govern the Ionian islands; it was at first very
small, but in 1867 it treated 130 patients (93 men and 37
women); in 1873 (20 years ago) there were 150 (112 men,
38 women); but at the beginning of 1878 there remained only
104 patients (84 men and 20 women). Thus in forty years it
had only reached this small number of resident patients. But
the Athenian Asylum, which only opened in October, 1887,
had 44 patients, January 1, 1888, and 116, January 1, 1893,
showing a much greater rate of growth.
At my last visit, April 28th, 1893, the number of patients
was a little less than this—114—but when the new building is
completed, which Dr. Chirigotes is erecting for 40 patients of
the poorer class, it will soon be filled, the capacity of the asylum
being thus far the only limit to its number of patients. When
I first visited it, in March, 1890, there were less than 70
patients; whoever shall go there in 1894 will probably find
140, for it will have doubled its number in four years. Its pro¬
posed building limit at present is for 250 patients, and it may
be five years before detached buildings of that capacity will be
completed; but when that is done it will not be long before
they will be filled with the insane, since Greece is no exception
to the rule of constant increase.
Dr. Chirigotes has practically planned and built his asylum,
and it differs somewhat from any which I have yet seen. The
situation is fine—three miles to the north-west of Athens, on
the road to Eleusis,upon high ground, overlooking the beautiful
Attic olive grove between Mount JEgaleos and the Acropolis,
and commanding also a noble view of the sea and the moun-
* tains which give to Athens so great and peculiar a charm.
The estate is not very large—less than 100 acres—and the
water supply for purposes of irrigation is r ather inadequate, so
that the grounds do not yet present that aspect of fertility and
shade winch is so attractive in asylums of more northern
climates. But time and cultivation will change this, while
nothing can deprive the Dromokditeion of its noble position in
front of Athens, and in view of Hymettus, Pentelicus, and
Parnes—the ranges which shut in the Attic plain.
The buildings are all detached, and none of them are large,
nor is it proposed that they shall be. They are built with high
storeys, because heat is more dreaded than cold in Attica, and
they have abundance of light, air, and space* The groups are
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341
1893.] by F. B. Sanborn, Esq.
twofold—one for tlie paying patients, some of whom pay as
much as 4,000 drachmae a year, which is about £115,
a little more than two guineas a week—and the other for poor
patients, who reside in larger day-rooms and dormitories, in¬
stead of haying one or two rooms to each patient, as in the
most costly class. The lowest sum paid by families for an
insane member is 1,200 dr. a year—say £35—but there are 30
or 40 of the 116 patients who pay nothing, but are supported
from the funds of the asylum. These funds are drawn upon
to their full extent, and therefore there can be no accumulation
of them except by further donations, the Government paying
little or nothing towards the expenses of the asylum. This
has its advantages, inasmuch as it keeps the establishment free
from political influences, and allows it to be managed without
serious interference by official persons not acquainted with its
needs. The whole expenses in 1892 were 230,341 drachmae,
about £6,580, for an average of 110 patients, about £60 each.
The whole property of the asylum is now rated at 1,104,094
drachmae, nearly £31,600, not a very large sum, and one that
requires to be well husbanded. Its financial management is
excellent; and its course of treatment for patients is in many
respects exemplary. They do not seem to have sufficient em¬
ployment, but this is a defect of most establishments for the
insane in which wealthy patients are received. The number of
attendants is larger than in most asylums, even for the wealthy,
and it would not seem difficult to organize occupation, both of
employment and amusement, for the patients. The climate of
Attica admits of outdoor pursuits more days in the year than
most climates; even in winter there are few days in which the
cultivation or ornamentation of the estate could not be carried
on; and although in the hot summers, from June 1 to Septem¬
ber 15, there are many hours when labour and exposure to the
sun are oppressive, and even dangerous, yet there are morning
and evening hours when it is not so. The buildings are well
arranged to diminish the annoyance of heat, and there must
usually be a breeze, either from the sea or the mountains,
where the Dromokaiteion stands, on its high slope of hills.
I ought to bear testimony to the devotion, experience,
scientific knowledge, and other high qualities of Dr. Chirigotes,
the director for ten years of the asylum at Corfu (1877-1887),
and now for about six years at the head of this interesting
Athenian Asylum. All the more ought this to be done because
he labours in a field apart, and is but little known, perhaps, to
his professional brethren of W estern Europe. He is a Greek,
xxxix. 22
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342
Insanity in Greece , [July,
and writes his reports in Greek, a language not yet widely
known in its modern form, outside of the Greek-speaking
communities of the Levant. This prevents his ingenious,
sensible, and often profound observations on his life-specialty
from being much known where Greek is not read; and even
here, though he is highly valued, I fancy he finds but few
persons who enter into his plans and wishes for the better
treatment of the insane in these interesting countries. There
is hardly any situation in life which appeals more forcibly to
men of generosity than that of an accomplished person devot¬
ing himself religiously, and with the true bias, both of a man
of science and a philanthropist, to the improvement of a
class so helpless and forlorn as the insane; especially if he
works in solitude, and finds few to echo or even to understand
the voice which he raises in their behalf. Such a man I
esteem Dr. Chirigotes to be, and I do not speak without
frequent observation of his methods, his isolation, and the
instructive character of his yearly reports. He is also a man
of much practical talent, and both the asylums with which he
has been connected are remarkable for the frugality of their
management and the important results obtained with a small
outlay of money. Thus in the Corfu Asylum in 1877 he cared
for an average of 105 patients at the annual cost of 44,914
drachmae (about £1,500), say £14 6s. for each patient, or five
shillings and fourpence a week. The Athenian Asylum, intended
for a wealthy class of patients, with many poor persons included
however, cost last year, as I have said, 230,341 drachmae for
its current expenses, with an average of 110 persons, about
£60 for each, or £1 3s. a week. In England I fancy such
care would have cost £2 or £3 a week, and in New England,
I am sure, it would cost at least £2 10s. The whole funded
property of the Dromokaiteion is valued at 1,104,094 drachmae,
about £31,600; and it is upon the income from this, mainly,
that reliance is placed for the maintenance of the poor persons
who find treatment there. I hardly know an establishment
where such good results are obtained with such frugal outlay;
but then frugality is the rule in Greece.
What then are the results of treatment by Dr. Chirigotes ?
I have not the full reports of his work in Corfu, but in the
eight years before he took charge there, together with his
first year, 1877, there were 350 discharges, of which about 50
were recoveries, 141 were deaths, and about 158 were dis¬
charged without recovery. This shows the usual result in a
chronic asylum, to which few new cases are admitted. In the
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1893.] by F. B. Sanborn, Esq.
Athenian Asylum, although many chronic cases were admitted
in the first six months, from October, 1887, to April, 1888, yet
the results have been widely different from those in Corfu. The
whole number of admissions from October, 1887, to January,
1893, was 361, covering, I suppose, about 350 different persons.
Of these 361 there had been discharged up to January 1st,
1893, 245, of whom 66 had recovered and 57 had died,
leaving 116 then under treatment. This shows a preponder¬
ance of recoveries over deaths, which would have been con¬
siderably greater but for the number of deaths from general
paralysis; these have been about 15 in the five years, I believe.
Of the comparative prevalence of this fatal malady in Corfu
and at Athens, Dr. Chirigotes said in his first report (up to
January 1st, 1889) that there were not so many cases of
general paralysis among his 400 patients in Corfu, during the
ten years 1877-1886, as among the 88 cases received at the
Athenian Asylum in its first 15 months.
With these imperfect observations, which may, perhaps, lead
others more competent to write on the interesting subject of
insanity in Greece, I submit the matter to the readers of the
" Journal of Mental Science.”
The Treatment of Myzcedema and Cretinism , being a Review of
the Treatment of these Diseases with the Thyroid Gland ,
with a Table of 100 Published Cases.* By Cecil F.
Beadles, M.R.C.S., L.R.C.P., Assistant Medical Officer,
Colney Hatch Asylum.
Introductory.
I propose in the following paper to review briefly the treat¬
ment that has recently been made use of in myxoedema, and
compare the several ways in which it has been carried out,
after a few preliminary remarks on the pre-thyroid methods.
First let me note that myxoedema, although not common, is
now known not to be so rare a disease as was supposed only a
few years back. During the past five years, that is to say
from the year 1888, when the profession was more generally
* The most important discussions that have yet taken place are those at Not¬
tingham in July, 1892 (in the early days of the new thyroid treatment), and
Edinburgh, February 15th and 16th, 1893. To the reports of these I would direct
your attention. I understand that at the annual meeting of the British Medical
Association, at Newcastle, in August next, Prof. Horsley has promised to open
a discussion on “ The Thyroid.”
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The Treatment of Myxoedema and Cretinism , [July,
awakened to the existence of this disease by the Clinical
Society’s report, up to the present time a careful search reveals
just 200 distinct cases* * * § referred to in the various medical
journals of this country. But the vast majority of cases go
unrecorded, for until within the last eighteen months cases
were seldom reported unless there was something of particular
interest in the symptoms of the case, or some point in the
pathology of the disease that was thought worthy of notice.
The Older or pre-Thyroid Methods of Treatment .
From the time Sir William Gullf iu 1873 first called atten¬
tion to the disease now known under the name of myxoedema, J
up to July, 1891, when Dr. George Murray read his paper in
the Section of Therapeutics of the British Medical Association,
at Bournemouth, entitled tc Note on the Treatment of Myx-
cedema by Hypodermic Injections of an Extract of the Thyroid
Gland of a Sheep,” no treatment was known that could be
said to have anything but the slightest influence on this slowly
progressive disease, much less cure it. Since Dr. Murray’s
valuable suggestion, however, I think we may say that we now
have in our possession a substance which can produce a greater
change in persons suffering from myxoedema than is the case
with any single drug or any other known disease.
During the time above-mentioned most of the preparations
in the pharmacopoeia, as well as others not contained therein,
had been tried with a singularly unfavourable result. There
was only one drug known that appeared to exercise any notable
influence for the better. This was jaborandi.
Of the 65 out of the 109 cases of myxoedema reported on
by the Committee of the Clinical Society§ in which the form of
treatment adopted was specified, this was the only drug men¬
tioned that seemed to be followed by a slight improvement.
It was made use of in eighteen of the cases. This result was
the same as that which has since been observed, and the result
was similar in a patient I had under my care in Colney Hatch
Asylum || in the early part of 1892, where she had been an
* These include 40 cases referred to at the Edinburgh Med.-Chir. Soc. on
February 16th and 16th, 1893, but not the 60 cases which were then mentioned
as known to exist about the neighbourhoods of Edinburgh and Dundee.
f “ On a Cretinoid State supervening in Adult Life in Women,” Clin. Soc. of
London, 1873.
X “ Ord. Medico-Chir. Trans.,” Vol. lxi., p. 67, 1877.
§ “ Report of a Committee of the Clinical Society of London to investigate
the subject of Myxoedema,” 1888.
Case reported in “ The Journal of Path, and Bact.,” No. 2, 1892.
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1893.] by Cecil F. Beadles, M.R.C.S.
inmate over seven years. Although, a slight improvement at
times appeared to follow the administration of jaborandi, it
was only very transitory, with but a slight noticeable change
either in the bodily or mental symptoms, and the patient
rapidly relapsed into her former condition.
Myxoedema is naturally a very chronic disease, in which
periods of abatement are wont to occur, and, as is well known,
myxoedematous patients under no special treatment vary
greatly from time to time, but especially so with change of
temperature and the season of the year; but although they
feel in better health and are more active when the weather is
warm, they never lose the characteristic facial aspect, although
it may to a slight degree diminish. I have never heard of a
patient who has so far recovered that it has been impossible
to diagnose the case as one of myxcedema. They are always
worse in the winter months, and it is then that death almost
invariably takes place. Some of the improvement that has
been said to occur after the use of jaborandi may therefore
depend on the patient’s surroundings, and it should be stated
in which months this has taken place—a point which has not *
always been noted, and has, therefore, tended to somewhat mis¬
lead as to the benefit derived from this medicine.
Dr William Ord* at one time went so far as to state that in
a few cases “ under the prolonged use of jaborandi the signs
of myxcedema have almost disappeared.” But even this is by
no means the rule, and only the other day Dr. Ord remarked
at the Clinical Societyt that “ two years ago the disease was
regarded as incurable.”
The Committee appointed by the Clinical Society in their
classical work on myxcedema already referred to, in their
general summary of treatment, say :— u The use of tonics, par¬
ticularly of iron, quinine, and hypophosphites (meeting the
obvious debility belonging to the disease) has been adopted
with a certain amount of temporary success. Having regard
to the defective action of the skin, Jaborandi and pilocarpin
have in many cases been administered, and, when administered
over long periods, have appeared to exercise much beneficial
influence. Nitro-glycerine has been used in a very limited
number of cases with fairly good results. An important
element in the treatment is the maintenance of warmth in the
surrounding atmosphere, and the regular removal of patients
during the winter to southern climates has appeared to mitigate
• Quain’s “ Dictionary of Medicine,” 1883, p. 1016.
t “ Brit. Med. Journ.,” February 4th, 1893, p. 262.
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346 The Treatment of Myxcedema and Cretinism , [July,
their sufferings and to prolong their tenure of life/’* On
another pagef they enter more fully into the results reported
of individual drugs.
Other drugs appear to be of even less value, and the same
remarks apply as those just made with regard to jaborandi.
Of the drugs which have had special attention called to them
and been stated at various times to have been used beneficially
may be mentioned nux vomica, strychnia, arsenic and iron, and
nitro-glycerine, by the use of which drugs, when combined with
careful diet, baths, and massage, Sir Andrew Clark “ regards
the disease as fairly curable/’f This is a vague term, and few
would hold that there is even a “ temporary cure ” by these
means.§ There are few illustrations on record. Dr. McCall
Anderson, of Glasgow, has lately published a case || of a female,
20 years of age, with myxcedema of one year duration. The
treatment consisted of taking arsenic and strychnine internally
with a shampoo daily for half-an-hour, and an occasional vapour
bath, in addition to which every now and then she had a subcu¬
taneous injection of pilocarpine, gr. £, and a hot electric bath
for half-an-hour at a time. A change for the better commenced
after ten days, and in three months 5 time u great improvement
was manifest.” This, of course was an early case; the mind
was not impaired. In another case, of longer duration, which
he publishes at the same time, similar treatment produced no
result after continuation for two months; it was then combined
with the administration of thyroid juice, and was followed by
marked improvement. I shall, however, refer to this case
again.
Dr. A. Morison, at a meeting of the Pathological Society on
October 18, said “ he had seen a great benefit follow systematic
* “ Myxoedema Beport,” p. 34.
t This is as follows :— “ Jaborandi in 12 and pilocarpin in six. Of these 18,
11 improved. In three improvement was great, and in one of these hot-air
baths were also used. In five no improvement; in two results not stated.
Nitro-glycerine in three. Marked temporary improvement in one, slight im¬
provement in one, no effect in one. Iron, quinine, and sulphur baths caused
almost entire disappearance of oedema in one. Iodide of potassium in large
doses temporarily relieved occipital headache in one. Induced current in two.
Improvement in one. Galvanism to the spine probably of use in one. Iron
beneficial in four, but in a much larger proportion no good resulted. Strychnia
or nux vomica in 10. Improvement in two. Quinine, hydrobromic acid,
phosphorus, cod-liver oil, cold baths, milk diet, and * tonics * apparently useless.”
The above are extracted from 65 answers received. See page 22 of report.
t Quain’s “ Dictionary of Medicine,” 1883.
5 Dr. Affleck (“ Edin. Med. Jour.,” May, 1893, p. 1060) has, however, known
great improvement to follow this treatment.
II “ The Practitioner,” January, 1893.
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847
1893.] by Cecil F. Beadles, M.R.C.S.
massage; the patient improved for a time, but ultimately the
massage lost its apparent effect and a fatal result ensued.*
Other observers have noted precisely the same fact.
Dr. William Dyson, in recording a case of myxoedema in a
male who was under his care at the Sheffield General Infirmary,t
writes, “ On the whole the drug treatment did not appear to do
much good; I was inclined to attribute this general improve¬
ment to the warmth, excellent nursing, and good wholesome
food which he received.” A photograph reproduced, which
was taken when he was at his best, shows, however, an
undoubted well-marked case of myxoedema. With this remark
of Dr. Dyson many will agree.
Dr. Hector Mackenzie, lately in a lecture on the recent
advances in the treatment of myxoedema, when speaking of a
certain case that he has since treated by thyroid extract, said:
“ During the two years and a half we had been watching the
pat ient the disease had been slowly, but steadily, progressing.
Whether our treatment by jaborandi, tonics, rest in bed,
massage, and the other means we had employed had prevented
a more rapid progress we cannot say. Certainly, she had
been temporarily benefited a little by her two admissions, and
she herself had some faith in the efficacy of the medicines
prescribed for her.”J
Dr. Hermon Gordinier read a paper last year before the
Medical Society of New York, in which he said of a female
with myxoedema of two years’ duration, “ The patient has been
under my care for over a year, and I can see but little improve¬
ment in her condition. She thought at one time that pilocar¬
pine did her good.Ӥ
The uselessness of a “tonic treatment” has been shown
again and again. Dr. Benson || records a case of eight years’
duration in which this treatment was persisted in for five
months “ without any effects.” The thyroid extract was given
by the mouth, and in less than a month she became a *' new
creature.”
We must conclude, therefore, that by such treatment little
could be hoped for beyond producing a very temporary benefit
by improving the appetite and increasing the action of the
skin.
* “Lancet,” October 22, 1892.
t “ Sheffield Medical Journal,” No. 1, October, 1892.
I “ Lancet,” January 21, 1893,
§ “ Medical Reprints,* September 15,1892. “ Report of Two Cases of Myxoe-
dema with one Autopsy.”
|| “ Brit. Med. Journ.,” April 15,1893, p. 795.
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The Treatment of Myxcedema and Cretinism , [July,
The Treatment of Myxcedema by Thyroid Grafting .
So much for the older methods of treatment. I now pass on
to the more modern form, viz., the treatment of myxcedema
by means of the thyroid gland.
First, I will deal with the subject in its primary or surgical
aspect, viz., thyroid grafting, and afterwards with the
modifications and improvements that have since been intro¬
duced, by which the treatment has been simplified, rendered
more efficient, and at the same time taken out of the hands of
the surgeon and given into those of a larger class of men—the
physicians and general practitioners.
It was in February, 1890, that Prof. Victor Horsley suggested
the transplantation of the thyroid of a healthy sheep into persons
affected with myxcedema, with the view to arresting the pro¬
gress of the disease, basing his arguments on the experiments
of Pchiff, Eiselsberg, and his own.* These experiments went
to prove that, when the myxcedematous process (cachexia
strumipriva) developed in an animal deprived of its thyroid
gland, the animal could be kept alive and in good health by
the transplantation of the same gland from another healthy
animal.
Cases are often recorded in the medical journals immediately
after an operation or at the commencement of a new form of
treatment, and we hear no more about them. Some of these
are exceedingly interesting, and we should like to know how
the case progressed and what was the final result of the treat¬
ment recommended. A case in point is that of thyroid grafting
for myxcedema. Now that the subject of myxcedema is attract¬
ing so much attention, it would be interesting to know what
has become of those patients who have been treated by this
method, whether they show any permanent improvement, and
how this mode of treatment compares with that of the sub¬
cutaneous injection and ingestion of the thyroid extract in this
disease.
With this object I have collected together all the cases of
which I know, and, where possible, have obtained further infor¬
mation concerning them. Let us see what have been the
results so far.
M. Lannelongue, of Paris,+ appears to have been the first
* “ Note on a Possible Means of Arresting the Progress of Myxcedema,
Caohexia Strumipriva, and Allied Diseases.** “ Brit. Med. Journ.,** Peb. 8,
1890 p. 287.
t “Lancet,” March 22,1890, p. 665.
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349
1893.] by Cecil F. Beadles, M.R.C.S.
to carry out the operation. He reported his case to the
Biological Society on March 7th, 1890, immediately after the
patient had recovered from the operation and before any
change in the patient’s condition had occurred. No further in¬
formation concerning this patient has been reported in the
English journals, and we do not know if any improvement
followed the operation. On September 3rd, 1890, M. Walther*
performed a similar operation on a woman, 40 years of age,
and reported the case to the Medical Society of Paris, the
following November: slight improvement with less character¬
istic appearance of myxoedema was noted. Here again we are
left in ignorance as to a later result. In the meantime Drs.
Battencourt and Serrano, of Lisbon, reported on the subject of
thyroid grafting for myxoedema.f Their case is briefly as
follows :—A female, set. 36, had myxoedema for several years
with apparent absence of the thyroid. These observers intro¬
duced into the subcutaneous tissue of the inframammary region
on each side the half of a thyroid gland of a sheep. An
immediate amelioration was produced, which was first marked
by an elevation of the temperature. The red blood corpuscles
rapidly increased in one month from 2,442,000 to 4,447,000.
The patient’s movements became more easy, her speech less
affected, and perspiration returned. The oedema went down,
and her weight diminished from 239 lbs. to 227f lbs. Men¬
struation now lasted only four days, whereas, previously, it
was many weeks. It is to be noted that Battencourt and
Serrano state, “ The fact that amelioration commenced so soon
seems to indicate to us that the thyroid tissue was absorbed.” J
This account, which appears to have been written about a
month after the operation, is the latest to hand.
Mr. Hurry Fenwick§ first performed the operation in this
country. It was on a woman, and was carried out at the
request of Dr. Sansom. No improvement followed, for “ the
disease was too advanced to admit of any satisfactory inference
being drawn as to the efficacy of the method.” The case was
fatal on the fifth day.
On April 2, 1891, Dr. W. J. Collins transplanted the thyroid
gland of a sheep into a patient at the Temperance Hospital
at the suggestion of Dr. Ridge. || The patient was a woman
* “ Lancet,” Nov. 29,1890, p. 1192.
f “La Semaine Medicale,” Aug. 13, 1890.
X For the translation notes of this case, and from which the above is taken, I
am indebted to my friend Dr. Boyce.
§ “ Lancet,” May 2,1891, p. 1003; also “ Brit. Med. Joum.,” Oct. 10,1891.
|| “ The Medical Pioneer,” Oct,, 1892, and “Lancet,” May 2,1891, p. 1003, j
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The Treatment of Myxoedema and Cretinism, [July,
aged 34. The symptoms, which commenced two years back,
do not appear to have been advanced. Dr. Collins 1 latest
remark on the case was in September, 1892. He says: “ She
pronounces herself in good health, is cheerful. Those who
watched the patient most closely insist upon mental improve¬
ment having taken place, and there are not wanting more
material points in which involuntary misconception is less
probable.”
Of the two remaining cases of thyroid grafting, that of Dr.
Thomas Harris and Mr G. A. Wright was reported fully in the
“ Lancet.”* The patient, a woman aged 48, who had shown
signs of the disease for nine years, had, on April 4th, 1891, at
the Manchester Royal Infirmary, part of the thyroid of a
young monkey inserted beneath the breast. The operation
was quickly followed by improvement in some respects, but in
a few weeks the patient appears to have relapsed completely
into her former state. She improved slightly again on return¬
ing to the Infirmary, a fact which the authors attribute to
hospital diet and surroundings. Her speech remained quite
unaffected. In reply to an inquiry as to the condition of the
patient more recently, Mr. Wright, on October 18th, 1892,
writes as follows: “ The myxoedema case has not turned up
lately, but when I saw her last she was much the same as be¬
fore, though she thought herself better. Nothing further has
been done so far as I know. My impression was that the stay
in hospital improved her a good deal more than the thyroid
grafting.”
On the 2nd March, 1892, Dr. John Macphersonf showed a
patient at a meeting of the Edinburgh Medico-Chirurgical
Society on whom he had performed this operation on the 22nd
October previously. The patient, who was an inmate of the
Stirling District Asylum, was a woman, 39 years of age, with
myxoedema of three years 1 standing. A remarkable mental
and physical change followed rapidly on the operation, and
appears to have continued for a time. On October 11th, 1892,
Dr. Macpherson was good enough to write me: “ My patient
has quite recently been readmitted into this asylum. When
formerly under my care she was melancholic, stuporose, and
otherwise manifested the usual mental concomitants of
myxoedema. On this occasion she is mildly maniacal, and she
presents none of the mental or physical symptoms of
myxoedema.”
. * “Lancet,” April 9,1892, p. 798.
t “ Edin. Med. Journ.,” May, 1892, and “ Lancet, 9 May 12,1892, p. 609.
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351
1893.] by Cecil F. Beadles, M.R.C.S.
Writing again under date of May 11th, 1893 (just seven
months later), he says: a The case is still under my care in
this asylum. She is subject to slight recurring attacks of
mania and melancholia, the latter, when it occurs, being
characterized by mild stupor. Occasionally there appears on
her cheeks the characteristic pink flush of myxoedema—the
only symptom, if one accepts the mental disturbance as doubt¬
ful, of myxoedema. I am quite prepared to observe a relapse
in her condition at any time. It suggests to my mind the
possibility that there is just sufficient thyroid secretion being
produced to prevent pathological symptoms, and that occa¬
sionally when the production falls below the necessary re¬
quirement of the system the mental symptoms make their
appearance.”
In this case, in which the myxoedema seems to have been
more or less cured,, there is raised the question as to the cause
of the insanity, and this case would appear to make it the
more difficult to explain the reason for the insanity that
follows on myxoedema.
In addition to these cases, at a recent meeting of the
Clinical Society of London, Dr. Ord said he had tried im¬
plantation of the thyroid gland with only temporary success.*
Note. —The operation of thyroid grafting for cretinism is
commented on elsewhere. The results of Bircher (“ Sammlung
klinischen Yortrage,” No. 357, 1890) and Kocher, obtained
by thyroid grafting on the subjects of cachexia strumapriva,
are not here referred to, as they form a slightly different class
of cases.
From the above references it will be seen that regarding
the ultimate effect of the treatment in the earliest cases, those
operated on abroad, we are ignorant, and it is to be hoped that
an endeavour will be made to trace them. Excluding Mr.
Fenwick's case, there remain four cases of which we know
something. Of these, two appear to have been followed by a
more or less prolonged period of improvement, the others only
very temporary. Of Dr. Macpherson's and Dr. Collins , cases
there are points worth noting. In the first the insanity
returned within a few months, and concerning the second one
can read in Dr. Collins' words that signs of the disease are
still present although the disease was never advanced.
On the whole, I think we may conclude, therefore, that at
present there appear to be no advantages to be gained by the
severer operation of grafting over the minor one of subou-
• " Lancet,” Feb. 4,1893, p. 24a
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852
The Treatment of Myxoedema and Cretinism , [July,
taneous injection, or the simple injection of the thyroid prin¬
ciple ; moreover, we cannot at present point to a collection of
cases such as we now have with the latter where the treatment
has been followed by such uniform results.
Historical Sketch of Recent Modifications in the Treatment of
Myxoedema by Subcutaneous Injection and Ingestion of an
Extract , etc., of the Thyroid Gland .
. We now come to the more recent suggestion of Dr. George
Murray, a pupil of Prof. Victor Horsley. Dr. Murray being
struck with the rapid action that was recorded as following the
operation of thyroid grafting concluded that this was due to
the absorption of the thyroid juice that was still present in the
piece of thyroid tissue at the time of implanting, as the interval
was too short for the formation of either fresh secretion or
new thyroid tissue. Working on this hypothesis, he prepared
an extract of the fresh thyroid gland of a sheep by mincing
the gland and extracting the principle with glycerine, and
injecting this subcutaneously into a patient the subject of
well-marked myxoedema. The result was astonishing, and he
communicated it to the profession, as already stated, at
Bournemouth, in July, 1891.
On the Continent, about the same time, Brown-Sequard and
d’Arsonval are said* to have suggested, from the experimental
results obtained oh animals by Vassale and Gley, the probable
utility of thyroid juice in myxoedematous persons if injected
hypodermically. But they do not appear to have carried it
into practical effect. Bouchard,t later, came to similar conclu¬
sions from his own experience.
Murray’s paper appeared in the u British Medical Journal,
and the treatment there proposed, of the subcutaneous injec¬
tion of a glycerine extract of the thyroid gland of some animal,
has since been carried out in a large number of cases, and the
results obtained have been almost invariably as satisfactory and
wonderful as those first recorded, in many cases even more so.
Up to the present time (May 18th), so far as I have been
able to discover, there have been 100 cases published in which
this treatment, or some modification of it, has been tried.
About 40 of these were actually treated by the subcutaneous
* “ Lancet ” Jan. 21, 1893, p. 124.
f “Brit. Med. Journ.” (Epitome), Nov. 12, 1892,and “ Arch.G6n.deM6d.,”
Oct., 1892.
J “ Note on the Treatment of Myxoedema by Hypodermio Injections of an
Extract of the Thyroid Gland of a Sheep.” “Brit. Med, Journ.,” Qet. 10,-
1891,
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353
1893.J by Cecil F. Beadles, M.R.C.S.
injection of an extract in all respects similar to that used by
Murray.*
A large number of the cases appeared originally in “ The
British Medical Journal,” and the majority of those elsewhere
reported, may be found referred to in that journal.f With
the exception of two cases they have all been followed by a
remarkable improvement in the condition of the patients.
The two exceptions were those referred to by Dr. Michell
Clarke, at the meeting of the British Medical Association at
Nottingham.^ No details are given, but it is said that “ no
change resulted from the injections,” a fact exceedingly strange
when we consider that every other observer who has carried out
this treatment has obtained so marked an alteration in the ap¬
pearance of the patients when the subject of myxcedema. One,
therefore, cannot help thinking that some discrepancy must
have occurred in the diagnoses or mode of treatment adopted
by Dr. Clarke.
Murray’s method was a much simpler one than that of
implantation, and the risks of a large operation were done
away with; at the same time the immediate results were more
satisfactory, and the remote were equally good or better.
The next real advance made in the treatment was that
proposed by Dr. Hector Mackenzie.§ On July 27th, 1892,
being unable at the time to obtain the extract for injection, he
commenced to feed a patient at the Boyal Free Hospital on
fresh thyroid glands. As an equally good result followed this
mode of treatment it was continued, and in less than three
months the disease was scarcely recognizable. Dr. Mackenzie
claims for this method that it has advantages over the sub¬
cutaneous mode in that it is more readily obtainable, can be
more easily carried out, and is free from many of the risks and «
other disadvantages attendant on the injection of the fluid
extract. The thyroids in this case were pounded and given in
a little brandy. He showed that it was sufficient to let the
patient eat the thyroid or swallow an extract made with
glycerine.
* I have been informed that some time back Messrs. Brady and Martin alone
were supplying the extract for the use of 100 cases, so there are probably now
considerably beyond that number of cases undergoing the treatment.
t The earlier cases have also been tabulated by Dr. Robert A. Lundie on
much the same lines as that now presented, and appear with his paper, “ The
Treatment of Myxcedema,” which he read before the Edin. Med. Chir. Soc.,
and are printed in “ The Edin. Med. Journ.,” May, 1893.
X “ Brit. Med. Journ.,” August 27th, 1892.
§ “ A Case of Myxcedema Treated with Great Benefit by Feeding with Fresh
Thyroid Glands.” “ Brit. Med. Journ.,” October 29th, 1892.
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The Treatment of Myxoedema and Cretinism , [July,
At the same time as Dr. Mackenzie reports his case, Dr. E.
L. Fox, of Plymouth, reports another case of myxcedema,*
whom he had treated at first by the injection of a glycerine
thyroid extract, and afterwards by lightly fried and minced
glands taken in currant jelly. This was followed by a similar
result. The treatment was begun on June 2nd, 1892.
Professor Howitz, of Copenhagen,t however, had already
carried out this principle, for on March 22nd, 1892, he com¬
menced feeding a patient with the thyroid gland of calves, and
he made known his results on July 6th. He, too, adopted this
method on the principle that it was more accessible in daily
practice, and was a safer form of administering the remedy.
At a meeting of the Clinical Society of London on January
27, 1893, Dr. Arthur Davies showed a case X in the treatment
of whom he had employed a further difference in detail. This
was the administration by the mouth of a powdered extract
obtained by extracting the active principle with glycerine and
reducing the resulting extract to a powder by heat. It was
Dr. Mackenzie who first suggested its preparation, which was
carried out by Mr. Edmund , White, pharmaceutist to St.
Thomas's Hospital.
These various methods, which differ only in detail, have all
been since tried on a number of cases, and they differ little in
their result. There is invariably the same remarkable improve¬
ment and cure recorded. The extract has been given in a
variety of vehicles, such as brandy, beef-tea, water, milk,
jelly, with pepper and salt, etc., and the gland has been first
subjected to a variable amount of cooking, with the object of
rendering it more palatable.
It remains for me to mention one more modification that
has been introduced by Vermehren, of Copenhagen.§ He
records a case of sporadic cretinism whom he treated with
success by the administration of “ thyroidin.” This sub¬
stance is obtained by the precipitation with alcohol from a
glycerine extract of the finely minced gland, and takes the
form of a greyish powder. This substance is, of course, equally
applicable to cases of myxoedema, and probably differs little,
if at all, from the powder used by Davies.
* “A Case of Myxoedema Treated by taking Extract of Thyroid by the
Mouth.” “Brit. Med. Journ.” October 29th, 1892.
f “ Brit. Med. Journ.,” February 4th, 1893, p. 266, and “ Semaine Med.,”
8th F6v., 1893.
X “Brit. Med. Journ.” and “Lancet,” Feb. 4, 1893.
§ “Brit. Med. Journ.” (Epitome), April 15, 1893. (“Deut. Med. Woch.,”
March 16, 1893).
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355
1893.] by Cecil F. Beadles, M.R.C.S.
With all these various minor modifications there still
remains the one disappointing fact that as soon as the treat¬
ment is discontinued the patient relapses, so that in a few
weeks the patient gradually passes back into the condition of
myxcedema from which he has only too lately been resuscitated.
So long as the drug is in use, whether it be by hypodermic
injection or the ingestion of the gland or a preparation there¬
from, so long the improvement continues; but let it be dropped
for a time, then without fail do we see only too soon the
reappearance of the disease. But it has now been proved that
only a small dose is needed to maintain the condition, and that
not at very frequent intervals, and the taking of an occasional
dose is surely a hardship not hard to bear even were it neces¬
sary for the remainder of the patient’s life. Although at
present there are wanting real indications of a permanent
cure, it would seem that after a considerable period the dose
may be reduced to a mere trifle, and who knows but that it
may finally be dispensed with altogether !*
(To be continued .)
General Paralysis Occurring about the Period of Puberty .
By J. Wiglesworth, M.D.Lond., M.R.C.P., Lecturer on
Mental Diseases, University College, Liverpool, and
Examiner in Mental Diseases, Victoria University.
We are in the habit of regarding general paralysis as in
the main a disease of the prime of life—of a time when the
fresh vigour of youth has subsided, but before the first touch
of decay has laid its hand upon the organism; when the
mental faculties are strained to the utmost in the pursuit of
wealth or pleasure, or social distinction, or in the keen
struggle for existence entailed upon so many of our race.
We are not indeed unaccustomed to meet with cases of this
disease occurring both before and after this epoch of life, but
the association of general paralysis with the period of child¬
hood and puberty has hitherto been a very unfamiliar idea.
Nevertheless, scattered cases have from time to time been
published which tend to show that the period of life which
appears to offer most exemption from all the ordinary causes
of the disease may still claim its victims, and that at, or
* Such, too, are the views of Dr. Robert Lundie, as contained in an interest¬
ing and popular article, “A New Departure in Medical Treatment,” which he
has lately contributed to “ Chambers’s Journal,” May 0, 1893.
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356 General Paralysis about the Period of Puberty , [July,
about, the period of puberty cases may occur which, both
clinically and pathologically, appear incapable of separation
from the ordinary forms of the disease with which we are so
familiar.
So far back as 1877 Dr. Clouston published a case of
general paralysis occurring in a boy aged 16; and in 1881
Dr. Turnbull recorded another one, also in a boy, which
started at the still earlier age of 12 ; whilst in 1883 I myself
reported a case in a girl commencing at the age of 15. Re¬
ferences to a few other juvenile cases reported by R6gis and
others will be found in Dr. Mickle’s invaluable work on
general paralysis.
Attention has, however, more particularly of late been
directed to this subject by the publication of Dr. Clouston’s
work on the “ Neuroses of Development,” in which two
fresh cases are fully recorded under the title of “ Develop¬
mental General Paralysis,” both in girls, the disease in each
case commencing about the age of 15. Previous, however,
to the appearance of Dr. Clouston’s work I had had two more
cases of this description under my care, and in March, 1891,
I had the pleasure of calling Dr. Clifford Allbutt’s attention
to one of them in the wards of Rainhill Asylum, and Dr. All¬
butt has alluded to these cases in his article on “ Insanity in
Children ” in Dr. Hack Tuke’s “ Dictionary of Psychological
Medicine.” Recently another case has been reported by
Charcot and Dutil in a boy, which commenced at the age
of 14.
I may also in this connection allude to a paper by Dr.
Shuttleworth “On Idiocy and Imbecility due to Inherited
Syphilis.” It is true that Dr. Shuttleworth does not class
any of his cases as general paralytics, nor, indeed, allude to
this subject in connection with his paper, inclining to the
belief, expressed by Heubner, that the “ progressive patho¬
logical change ” observed in his cases was to be referred to
affections of the cerebral arteries, the calibre of which, having
become narrowed by endo-arteritis, more or less cerebral
atrophy was produced. But Dr. Shuttleworth, in a com¬
munication on the subject with which he has been good
enough to favour me, tells me that cases I., III., and IV., de¬
scribed in his paper, were very like Dr. Clouston’s cases
which he saw at Momingside; so that the possibility of some
of Dr. Shuttle worth’s cases being really examples of juvenile
general paralysis appears open to discussion.
I will now give a short account of the two cases already
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357
1893.] by J. Wiglesworth, M.D.
alluded to which I have recently had under my own care, and
will then briefly summarize the leading features of these and
of the other published cases referred to.
Case I.—M. E. M., girl, aged 15, was admitted into Rainhill
Asylum on September 19th, 1888. Her parents were living,
healthy, and temperate, the father being fifty years of age and the
mother forty-two, and they had been married eighteen years.
Patient was the second child in the family, and she was one of
three survivors out of a total of thirteen pregnancies, eight of which
were females and five males ; of the eight female pregnancies
patient was the only survivor; two of the others were miscarriages
at five months, two were stillborn, one (an eight months child)
died two weeks after birth, and the other two died aged three and
a half years and seven years respectively of scarlatina. Of t-he
five male pregnancies, one died aged five weeks in a fit, one aged
two years of some cause unknown, and another, aged two and a
half years, of scarlatina; the other two were living. Thus out of
the total number of 13 pregnancies no less than six were either
miscarriages, still-births, or died within a few weeks of birth—a
history certainly suggestive of syphilis, though no other evidence
of this disease was forthcoming. There was no history of nervous
disease in the family, nor indeed anything worthy of special note.
Patient herself was said to have been a bright child until eleven
years of age, and had passed the third standard at school. At this
time she was running one day in the street when she slipped and
fell, striking her head violently on the kerbstone ; she was uncon¬
scious for two hours, and was several days in bed with headache.
Some months after this she appears to have developed some weak¬
ness of the limbs, for which she was treated in the Liverpool Royal
Infirmary. About a year from the accident, patient being then
twelve years of age, it was noticed that she was getting dull and
losing her memory, and from that time her mind appears to have
gradually faded away, though the downward progress had been
more rapid during the few months preceding admission. During
the three or four years previous to admission she had had several
falls apparently as the result of paresis of her limbs, and on one
occasion fell down a whole flight of steps and had convulsions all
night afterwards. Possibly some of these falls were really
examples of paralytic “ seizures.”
Tbe facts certified on admission were:—
Her intelligence is very defective. She answers “ I don’t know ”
to all questions. Her powers of attention and understanding are de¬
ficient. She is quite unable to look after herself. She is inattentive
to the calls of nature, and occasionally noisy.
When admitted, though fifteen years of age, she was described as
a well-developed child , and the signs of puberty appear to have been
xxxix. 23
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358 General Paralysis about the Period of Puberty , [July,
but slightly marked, though her mammae were partially developed.
She had never menstruated. Her pupils were slightly dilated and
of normal reaction. Her viscera were sound. Mentally her con¬
dition was one of considerable dementia. She was quiet and
tractable for the most part, and sat quietly most of the day taking
no interest in her surroundings; when touched, however, she
cried and seemed frightened. She had much loss of memory,
could give scarcely any account of herself, and could only be got
to answer correctly the most simple questions. She was wet and
dirty in her habits. She remained much in this condition for
about three months, when, at the urgent request of her mother,
she was sent out to her care. Five months later, viz., in May,
1889, she was readmitted, and in the interval the disease had
made rapid progress. She was now a complete wreck, both
mentally and physically. She was thin and haggard, and so feeble
that she could not stand unsupported. Her mind was a blank ;
she could give no particulars about herself and could not even
tell her own name ; she seemed, indeed, to understand nothing of
what was said to her. She continually moved to and fro in her
chair, uttering a crowing, meaningless laugh, and when touched
she cried loudly and continuously. Her tongue was tremulous, as
also were her lips, and her speech was hesitating and ejaculatory.
She was wet and dirty.
From this time her course was rapidly downward. She became
so paralyzed that she was shortly confined to her bed, where she
remained until her death, and her limbs soon became strongly
contracted in flexion. She screamed a good deal at times, but
showed no sign of intelligence. All her evacuations were passed
under her. She became excessively emaciated, literally being
mere skin and bone, and bedsores developed on all points exposed
to pressure. She finally died on August 31st, 1889, being at that
time 16 years of age. No convulsions were noted at any time
during the period she was under observation.
The patient having died during my absence from home, I
unfortunately did not see the autopsy, but the following is
the record of it (19 hours after death) :—
Body extremely emaciated, lower limbs rigidly contracted in
flexion. Sores on both elbows, trochanters, sacrum, and heels,
inside of thighs, backs of hands, shoulders, and dorsum of feet.
Cranium .—Skull cap thin and very dense, not adherent to dura.
Superior longitudinal sinus empty. Great excess of subdural
fluid, about 450 c.c. Encephalon, 885 grammes. Right hemis¬
phere, 348 grammes. Left hemisphere, 290 grammes (both un¬
stripped). Cerebellum, 102. Pons, 13. Medulla, 5£.
Great and general opacity of arachnoid, the white lining along the
course of the vessels being a prominent feature. Vessels prominent,
but no general congestion. Large excess of subarachnoid fluid,
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Google
359
1893.] by J. Wiglesworth, M.D.
Pia mater and arachnoid stripped readily over the whole of the left
hemisphere, except along the superior temporo sphenoidal convolu¬
tion and the angular gyrus; here extensive decortication occurred,
though the adhesion was very slight, the cortex being extremely
soft. Great and general wasting of gyri. Ventricles enormously
dilated, the cornua especially so. Slight roughening of floor of
fourth ventricle. Great wasting of cortex, the grey matter being
reduced in thickness to about J normal. Striation for the most
part completely absent. White matter very pale, almost no
puncta cruenta. Basal ganglia dark-coloured and softish. Brain
as a whole firm, though surface layers very soft. Cerebellum
rather pale and firm. No macroscopic lesion of pons or medulla,
which were fairly firm.
Thorax .—Right lung, 6oz.; left, 4J oz. Both dry and partially
collapsed. Heart , 3oz., soft and flabby, but otherwise normal.
Pleura and pericardium quite normal.
Abdomen. —Liver, 23£oz., normal. Right kidney, 2oz.; left,
lfoz., both normal. Spleen , lfoz., soft, dark, and diffluent.
Bladder empty.
I will now proceed to describe the next case.
Case II.— C. K., girl, aged 15, admitted November 17th, 1888.
Her friends neglected her and did not visit her, and the history
was only obtained with considerable difficulty upwards of two
years after her admission.
Father living, aged 50; he was a heavy drinker, but no further
information could be obtained about him; her mother died at 39
years of age, of phthisis; she was 18 years of age at the time of
her marriage. There were seven children born as the result of
the marriage.
1. Girl, aged 24 (who gave these particulars of the history);
she had been married three years, and had had one child stillborn
at seven months.
2, 3, and 4. All died in infancy of convulsions and teething, etc.
5. Patient.
6. Boy, living, aged 14.
7. Boy, living, aged 12.
The sister stated that patient was a bright child, and was in the
fourth standard at school when between 10 and 11 years of age.
Four years before admission, viz., in 1884, she one day fell down
stairs and hurt her head and leg, for which injury she was treated
in the Northern Hospital, Liverpool, for two months, the entry in
the books of the hospital stating that she suffered from “ osteitis
of tibia.” Her mother then died, and her father being a great
drunkard she was much neglected, and depended on neighbours
for chance meals. She became thin and weak, and it was thought
she was going into a consumption. Six months before admission
she was noticed by her sister to be “queer” at times, and she
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360 General Paralysis about the Period of Puberty , [July,
became subject to “ faints,” from which she soon recovered. The
medical certificate upon which she was admitted stated that “ she
sits in one position all day, takes no interest in her surroundings or
future prospects, answers questions very unwillingly and stupidly.
Her intellectual powers and memory are deficient. She is unable
to look after herself; does not go to her food unless fed.”
When admitted she was noted to be a girl of fair physical
development, but her mammas were small, and she did not display
any signs of puberty. She had never menstruated. Viscera sound.
Pupils normal. No noticeable paralysis, but appeared awkward
on her feet, and tripped over any irregularities on the floor. Knee
jerks very brisk. Plantar reflexes normal. Mentally she was in
a dull, listless state, with a tinge of depression, taking no interest
in her surroundings, although she appeared to understand some¬
thing of what was going on around her, and when roused could be
got to answer a few simple questions, giving her age correctly,
for instance; very few particulars about her family could, how¬
ever, be elicited from her, and her memory was evidently at that
time considerably impaired. She was clean in habits. She re¬
mained in this sort of semi-stuporose condition for many months,
capable of being roused to answer questions, or at times to laugh
at trifles, but sinking back again at once into her usual state.
Then, rather more than a year after admission, she had several
well-marked epileptiform convulsions, and soon after this, viz., in
March, 1890, she was noted to be steadily growing worse, her
mental condition being one of slowly progressive dementia. She
was also at that time becoming unsteady on her legs, and dragged
her feet when walking. Sensation appeared normal, but her mind
was too dull for reliable data of this kind to be ascertained. She
was already beginning to lose flesh. A few months after this,
owing to the advance of the paralysis, she was confined to her bed,
and her condition assumed the characteristics which persisted for
nearly two years—up to the time of her death—with very little
change. She was completely paralyzed, and lay huddled up in
bed with all her limbs rigidly contracted in flexion, nor could
these be straightened by any reasonable force; knee jerks un¬
attainable owing to the rigid contracture. The excitability of the
muscles was found about equally diminished to all forms of elec¬
trical stimulation. She was wet and dirty. She gradually
developed small bedsores over points of pressure—elbows, hips,
etc.—but these did not enlarge to any size, and showed a tendency
to heal as time went on. Reflex closure of the eyelids when the
hand was brought near the face was very marked. At the com¬
mencement of her bedridden period she frequently repeated words
and syllables spoken in her hearing in an automatic manner, but
latterly she was very silent, scarcely uttering a sound, except to
cry when disturbed. She was quite fatuous, displaying no sign of
intelligence. She ground her teeth for hours together after the
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361
1893.] by J. Wiglebworth, M.D.
fashion of the most typical general paralytic. For some time
before her death she had not sufficient intelligence to protrude
her tongue, but at an early period this was markedly tremulous as
a whole when protruded, and the tremor spread to the muscles of
the lips and face; her speech also was distinctly quavering. She
was greatly emaciated. Pupils much dilated; right 7 m.m., left
7*5 ; sluggish, but contracted to strong light. Optic discs normal.
As she lay in bed, with her small wasted limbs and features, she
had all the appearance of a child of nine or ten years of age,
instead of being, as she then was, in her 19th year. There were
no signs of menstruation all the time she was in the asylum. She
died on March 3rd, 1892.
Autopsy * (seven hours after death).—Body much emaciated.
Great contracture of all the limbs.
Cranium .—Skull cap : thickness and density slightly increased.
Slight adhesion of dura to bone. Sinuses moderately full. Inner
surface of dura mater coated with an old laminated membrane,
which covered both hemispheres, extending down on each side as
far as the 1st temporal gyrus, backwards to the tip of the occipital
lobe, and forwards to the tip of the frontal lobes; it was evidently
of old date, and was adherent to the dura, though it could readily
be detached from it. Near its margin it was transparent, of a
straw colour, and extremely thin, but towards the vertex of the
skull it rapidly increased in thickness, and measured here from
1‘5 m.m. to 2 m.m. thick. It appeared quite free from haemorrhage,
bat was plentifully sapplied with blood vessels. In its thicker
parts it was very distinctly laminated, opaque, and of a brownish
colour. Inner surface of dura smooth and shining when the
membrane was removed. Great excess of almost clear colourless
serum in subdural space, appearing not only to distend the dura
mater, but to float up the brain, as when the fluid was drained off
the brain sank to the bottom of the cranial cavity, and it became
evident that it did not fill more than | to § of the cranial space.
The encephalon as a whole only weighed 720 grammes. Arachnoid
thickened, and showing widespread opacity. Marked adhesion
between frontal lobes and across Sylvian fissures, the adhesions
showing themselves as thick bands of membrane bridging across
the fissures. Slight general thickening, and marked general
hypereemia of pia mater. No decortication on stripping, but the
arachnoid showed a tendency to separate from the pia, leaving
portions of this behind on the cortex. Great excess of serum in
subarachnoid space. Convolutions of cerebrum immensely wasted,
the sulci widely gaping, these conditions being particularly
marked on the inner aspect of the right hemisphere; the wasting
was less marked in the occipital lobes than elsewhere. Surface
of convolutions red in colour.
* Pathological notes by Dr. Wynne.
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362 General Paralysis about the Period of Puberty , [July,
Bight hemisphere (unstripped) weighed 287 grammes;
(stripped), 265. Left hemisphere (anstripped), 290 grammes.
Cerebellum , 91 grammes. Pons , 11. Medulla oblongata , 7.
Cortex purplish red in all parts, of firm consistence and
increased vascularity; depth much diminished, and striation very
indistinct. White matter slightly yellowish in colour. Ventricles
much dilated, containing clear fluid.
Ependyma not granular. Corpora striata, optic thalami, corpus
callosum and fornix all unusually small and rather too firm.
Cerebellum; cortex small, but not out of proportion to size of
organ. Pons small.
Medulla oblongata. —Fourth ventricle slightly dilated ; ependyma
a little granular at calamus scriptorius.
Spinal Cord. — Smaller and firmer than usual. Membranes
hypersemic but not thickened.
Spinal Nerves. —Brachial plexus, great sciatic, and anterior
tibials small, but not out of proportion to muscular development;
appeared normal.
Microscopical Examination. —Sections from superior frontal and
from parietal and occipital lobes (fresh condition) all showed a
fine spider-cell formation, which passed deep into the cortex; the
nerve cells were much degenerated and distorted, apparently by
contraction of the connective tissue elements. Vessels thickened
and showed proliferation of the nuclei. The spinal cord showed
small patches of sclerosis in the posterior columns in both cervical
and dorsal regions. There was marked sclerosis of the posterior
part of the right lateral column throughout the cord, and in the
cervical region of the left lateral column also; there was also a
small patch of sclerosis of this left lateral tract in the dorsal
region, but none at all in the lumbar.
The peripheral nerves above noted were examined fresh and
after hardening in osmic acid, and staining with picrocarmine.
No segmentation of the myelin and no nuclear proliferation were
detected; the nerve fibres appeared quite healthy, and in teasing
out no undue roughness or increase of connective tissue was
observed.
Thorax. —Right pleura; local empyema at base. Right Lung,
lloz.; upper lobe in a condition of complete pneumonic consolida¬
tion. heft Lung, 6oz. At apex scars of old tubercle. Small
bronchi dilated.
Heart. —Weight 5oz., normal.
Abdomen. — Liver, 23oz., congested; capsule not thickened; no
sears.
Spleen. —2oz., pale and firm.
Kidneys. —Right, 3oz. Left, 3oz.; healthy.
Other organs healthy.
No evidence of syphilis.
Digitized by ^ooQie
1893.]
by J. Wiglesworth, M.D.
363
If now we add to the above two cases the six others
referred to at the outset of this paper, we get a total of eight
cases in which the disease commenced at or about the period
of puberty, which may be briefly subjected to analysis.
These cases include three reported by Clouston, one by
Turnbull, one by Charcot and Dutil, and three by myself.*
I have only seen an abstract of the case published by
Charcot and Dutil. It may be premised that of the eight
cases two were living at the time the cases were reported;
in the remaining six the disease had proved fatal, and the
diagnosis had been confirmed by post-mortem examination.
1. The age of the youngest patient at the time the disease
commenced was 12 years, that of the oldest 16, the average
of the whole being 14. It is, of course, impossible to state
with precise exactitude the time at which the disease made
its first appearance, and probably, if anything, the patients
were a little younger than the above figures indicate.
2. The duration of the disease shows a tendency to be
prolonged. Of the six completed cases the duration of the
shortest case was three years, of the longest six, the
average of the whole being 4£ years, which is certainly
rather a longer average duration than that of ordinary adult
general paralysis. Here, again, these figures probably
understate the actual duration.
3. The high proportion of females is a noteworthy feature,
five of the cases having been girls and only three boys. Of
course from such a small number of cases one must be care¬
ful about drawing general conclusions, but it is unlikely
that the above proportion is altogether accidental. Having
regard to the large preponderance of adult male general
paralytics over female, it would appear that in these juvenile
cases the disparity between the sexes tends to disappear, the
incidence of the disease being more equally divided between
them.
4. The mental state is of interest, as indicating an
immense preponderance of the demented type of general
paralysis. In only one case (one of Clouston’s) were any
grandiose ideas present, and these only in a slight degree;
in all the otter cases the condition appears to have been one
of dementia, from first to last; this was very marked in my
own cases, a gradual, almost imperceptible failure of mental
* I have not been able to include in this summary all the oases referred toby
Mickle, as details of the eases are not given by him, and I have been unable to
consult the original papers.
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364 General Paralysis about the Period of Puberty , [July,
power having been noticed from the first. The cases, indeed,
seem to have partaken more of the degenerative than the
sthenic type of general paralysis.
5. It seems to be the rule either that the signs of puberty
do not appear at all, or if they have commenced that they
are arrested, and tend to disappear as the disease progresses,
menstruation in the females being absent. And pari passu
with the above, and, indeed, as a part of it goes, arrest of
the bodily development generally. This has been especially
remarked upon by Clouston, and in my own cases the child¬
like appearance of the patients when the disease was well
advanced was a very striking feature, although the last two
patients at the time of death were aged 16 and 18 years
respectively.
6. The excessive emaciation exhibited by both of my cases
was a very striking feature.
7. The extreme atrophy presented by the brains was also
very noteworthy. In the case of M. E. M. the brain, with
membranes adherent, immediately after removal from the
cranial cavity weighed 885 grammes, whilst in the case of
C. K. the brain in similar condition weighed only 720
grammes; this, it must be remembered, was from a person
then in her 19th year, who was not microcephalic (her head
circumference was 20 inches).
8. On the question of aetiology hereditary tendency was
distinctly traced in four of the cases, and in the fifth it pro¬
bably existed (in Turnbull's case the father of the patient
was himself a general paralytic), whilst in two others there
was marked alcoholism in one or both parents, so that we
may fairly consider that there was a neuropathic taint in £
of the cases—an immensely higher proportion than obtains
in ordinary adult general paralysis.
Next, perhaps, to heredity, syphilis appears to be a cause.
In both of Clouston’s last two cases the syphilitic history
was well marked, and both patients exhibited in their persons
evidence of congenital syphilis. In one of my cases
(M. E. M.) a syphilitic taint was suggested by the history,
though the evidence was not conclusive. I have already
referred to the possibility of some of Dr. Shuttleworth’s
syphilitic imbeciles being examples of juvenile general
paralysis.
The only other factor which seems to stand out at all
prominently is traumatism. Both of my latter two cases
had had severe falls on the head, and the disease was said to
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1893.]
365
by J. Wiglesworth, M.D.
have dated from about the period of the accident. It is, of
course, necessary to be cautious in accepting this as an
©tiological factor, for apart from the tendency of parents to
assign an injury as the exciting cause of mental disease,
there is the further fallacy that the fall may have been
occasioned by a paralytic seizure, which may itself have
been the first symptom of the disease. In both my cases,
however, the falls appear to have been of a severe character,
and I am disposed to regard the injury as a factor in the
production of the disease. I may also mention parental
neglect as a contributing factor, which appears to have been
operative in several of the cases.
I remarked at the outset that these juvenile cases of
general paralysis occurred at a time of life which appeared
to offer most exemption from all the ordinary causes of the
disease. But here we are reminded that the above causes
which appear to have been operative in the cases analyzed are
also causes generally recognized as operative in adult general
paralysis. Heredity, syphilis, traumatism are all regarded as
causes of general paralysis, although the relative importance
assigned to each by different authorities varies greatly.
It might be inferred, indeed, that these causes were more
potent when acting in early life, but in the immense number
of mental and nervous disorders owning a neuropathic
heredity how seldom do we meet with these juvenile cases
of general paralysis; and whilst the congenitally syphilitic
are fairly common, it seems very rare to meet with general
paralysis amongst them, though possibly cases are more
frequent than published records would seem to indicate.
Dr. Clouston suggests that in these cases the strains of
development at puberty may have the same effect as strains
and undue outputs of energy in after life have in other
cases in causing the disease. And possibly when an indi¬
vidual is strongly predisposed to nerve degeneration by
reason of neuropathic heredity, or inherited syphilis, or
other cause, there may not be sufficient energy left in the
organism to enable it to respond to the great calls upon the
nervous system which the onset of puberty entails, and
hence a deadly decay may take the place of that develop¬
ment and higher life which is the normal outcome of this
epoch.
But the period of adolescence is also by no means free
from attacks of general paralysis. I give here in very brief
outline the notes of two cases which have been under my
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366 General Paralysis about the Period of Puberty, [July,
care, in each of which the disease commenced at the age of
18 and proved fatal at 20, which cases I have not included
in the above analysis, since they do not in strictness come
within the scope of the title of this paper.
John McC., aged 19. Admitted August 21,1890. Both parents
very intemperate. Patient was said to have been naturally weak-
minded, but had been to school, and was in the 4th standard when
he left. Fifteen months before admission he had a fall on the
back of his head, and lay unconscious for four days in convul¬
sions ; was said never to have fully recovered his mind after this.
When admitted he was in a condition of advanced dementia.
He could not be got to answer a single question rationally, and
did not appear to understand anything that was said to him; he
was also excited and noisy, shouting and chattering, and mutter¬
ing an incoherent jargon. Was wet and dirty. He died on
February 27, 1891, and at the autopsy the brain was found to
have typical general paralytic characters. It weighed 1,185
grammes. The arachnoid formed a dense white opaque watery
membrane over nearly the whole of both hemispheres, and there
was great congestion of the vessels of the pia mater. Great and
pretty general decortication occurred on stripping the membranes.
There was great wasting of the convolutions, atrophy and darken¬
ing of the cortex, and the ventricular floors were very granular.
Alice S., aged 20. Single. Admitted April 8th, 1889. Was
formerly a barmaid, ahd had been deserted by her paramour, and
since then had been on the streets. Was confined of a child in
the workhouse two years before admission, after which she had an
attack of mania, which was clearly the starting-point of general
paralysis. When admitted she was in the last stage of the disease,
quite fatuous, wet and dirty, could understand nothing, but cried
out at intervals. Could not walk or stand. Tongue could not be
fully protruded. Died two months after admission, viz., on Jane
8th, 1889. The brain was typical of general paralysis. There
was considerable opacity of arachnoid and injection of pia
mater, and the latter membrane was so adherent that it could
not be stripped anywhere without decortication. Great wasting
of gyri. Ventricular floor granular. Weight of brain, 1,070
grammes.
Between 20 and 30 years of age, as we know, the disease
is fairly common, and we all could quote several examples
of it.
It is thought by some that general paralysis is becoming
more frequent now than formerly, and certainly, with the
constant straining effort entailed by modern civilization, we
are not likely to see a diminution in the victims of this
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367
1893.] by J. Wiglesworth, M.D.
disease ; and, along with this, it may be thpt the disease is
tending to appear in the individual at an earlier age than
formerly. Be this as it may, I submit that the above cases
prove that the disease may be met with at a far earlier age
than has until lately been thought possible, and that the
period of puberty, and even childhood, can no longer be
regarded as exempt from its attacks.*
Since the above paper was written I have had another
case of juvenile general paralysis under my care, in a boy,
which proved fatal at 16 years of age. The case bore a close
resemblance to those above described—the progressive
paralysis, with complete fatuity and great emaciation, to¬
gether with contractures, being prominent features. The
brain, which weighed 912 grammes, was very typical of
general paralysis, there being great opacity and thickening
of membranes, extensive adhesion and decortication, and
immense wasting, etc. The duration of the disease could
not be ascertained, but he was in a very demented state a
year before his death. His father was English and his
mother Italian. Both parents were very intemperate, and
parental neglect and a condition of semi-starvation were
prominent features in the case.
REFERENCES.
Clous ton.—A Case of General Paralysis at the Age of Sixteen. Journ.
Mental Science, Oct., 1877, p. 419.
Turnbull.—Notes of a Case of General Paralysis at the Age of Twelve.
Journ. Mental Science, Oct., 1881, p. 391.
Wiglesworth.—Case of General Paralysis in a Young Woman, Commencing
at the Age of Fifteen. Journ. Mental Science, July, 1883, p. 241.
Mickle.—General Paralysis of the Insane. 2nd Edition, 1886, p. 249.
Shuttleworth.—Idiocy and Imbecility due to Inherited Syphilis. American
Journal of Insanity, January, 1888.
Clouston.—The Neuroses of Development. 1891, p. 74 et seq.
Charcot and Dutil.—General Paralysis of the Insane in a Boy. Archives
de Neurologic, March, 1892 (abstracted in British Medical Journal, May 28,
1892).
• Dr. Percy Smith has kindly sent me notes of a case of a youth of 16, seen
at Bethlem Hospital as an out-patient in 1890, with symptoms closely resem¬
bling those of general paralysis. He was admitted for a short time into St.
Thomas’s Hospital, but the symptoms remaining stationary he was taken away,
and the case has been lost sight of. As Dr. Peroy Smith did not see the case
again, he is unable to speak decidedly as to the diagnosis.
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368
[July,
The Formation of Subdural Membrane s, or Pachymeningitis
Hcemorrhagica* By George M. Robertson, M.B.,
F.R.C.P.Edin., Medical Superintendent, Perth District
Asylum, Murthly, late Senior Assistant Physician,
Royal Asylum, Morningside, Edinburgh.
(Concluded from page 12).
Part II.
Physical and General Conditions of Membrane Formation .
At the commencement of our description of subdural
membrane formation, we deferred consideration of the
sudden lessening of intracranial pressure, which we regard
as the most important cause of its production. This is a
point we shall take up now, along with some other general
questions connected with subdural membrane formation.
Lessened pressure may be divided into two important
varieties. There is that which is due to a slowly acting
cause, like cerebral atrophy, and there is that due to a
suddenly acting cause, like a vascular spasm. The maximum
effect is of course produced when both causes act together,
and this combination is not uncommon. The occurrence of
cerebral atrophy in most cases of membrane formation is
fully recognized, and the loss of support thus produced is
given by many as the principal cause of the engorgement
and rupture of the vessels. That it has a tendency to do so
must be conceded, when we consider its effect on such a
resisting substance as the cranium. Paget has stated that
the skull is thickened in cerebral atrophy, and it has become
customary to speak of such thickenings of the cranial vault
so often found in chronic insanity as “ Compensatory hyper¬
trophy 99 on that account. Another remarkable observation
has also been made by Dr. Yellowlees of a patient of whose
head a cast had been made on admission, and another after
seventeen years, when he died. On comparing these two
casts it was found that the latter had shrunk in all direc¬
tions “ by an amount equal to at least twelve cubic inches.”+
Accompanying the shrinkage there was cerebral atrophy,
the cerebrum only weighing 35^ oz. If thickening of bone
* Essay awarded the Bronze Medal of the Association,
t “ Ed. Med. Journal,” Yol. viii., 1863.
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369
1893.] The Formation of Subdural Membranes.
and shrinking of the skull can be assumed to be due to the
loss of support produced by atrophy of the brain, the effects
of this cause on the blood vessels of the dura cannot be
overlooked. It is our belief also that this action is
intensified by the greatly diminished quantity of blood which
the comparatively functionless and inert brain requires.
Although it is generally conceded that atrophy of the
brain tends to produce diminution of intracranial pressure,
with loss of support to the vessels, yet it may be legitimately
advanced that this loss of support is greatly neutralized by
the increased effusion of cerebro-spinal fluid of a compensa¬
tory nature. The amount of this fluid in cases of atrophy
is very greatly increased, as was known to Magendie, and we
will need to describe this process of compensation before
passing on to the sudden diminution of pressure produced
by vascular spasm.
The brain is an organ inclosed in an air-tight case with
rigid walls. All other organs have a tough elastic capsule
to protect them from injury, and which permits the expan¬
sion and shrinking consequent upon functional activity and
rest, but the protective covering of the brain is the cranium,
and it is inelastic. The brain therefore needs special
arrangements to permit of its expansion and shrinking, and
these must be of a very perfect kind, for, on account of the
enormous blood supply of the brain and its semifluid con¬
sistence, it may properly be considered an erectile organ.
These results have been obtained by means of the cerebro¬
spinal fluid.
It is commonly stated that the brain may be considered to
be suspended in fluid, but this is a very erroneous view, for
the brain with its pia-arachnoid covering is in a serous
cavity—the subdural space—in which normally little or no
fluid exists.* All the cerebro-spinal fluid exists normally in
the meshes of the pia-arachnoid, where it is bound down
and mainly confined to reservoirs, the so-called water-
cisterns, and in the ventricles, and it probably does not
exceed four ounces in amount, in a state of health. The
sources of this fluid are the choroid plexuses of the lateral
and fourth ventricles, which consist of innumerable villi or
tufts of capillaries, covered with cubical epithelium. These
tufts secrete the fluid, which passes from the lateral
ventricles by the foramen of Munro to the third ventricle,
and by the iter to the fourth ventricle, where it receives an
* Foster’s “ Physiology,” p. 1126 .
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370
The Formation of Subdural Membranes , [July,
addition from the choroid plexus there. It next passes by
the foramen of Magendie to the inferior cerebellar lake, and
round the cerebellum and crura cerebri to the superior
cerebellar lake. This communicates along the peri peduncular
and basilar canals with the great central lake, at the base of
the brain. From the sides of the central lake there arise
the two Sylvian lakes, which are extended into the Sylvian
and Eolandic rivers. From these rivers tributaries extend
along the minor sulci, and by these means, though somewhat
circuitous, cerebro-spinal fluid is carried to every part of the
surface of the brain.* Much of the usefulness of cerebro¬
spinal fluid for purposes of compensation will depend upon
the rapidity with which it can be secreted and absorbed.
In the dog fluid has been seen to be secreted at the rate of
from one ounce to 7£ ounces in the 24 hours.f This fluid is
absorbed by the Pacchionian glands and secreted into the
veins and sinuses, for Quincke found that cinnabar injected
under the spinal arachnoid found its way into these glands. J
The rate of absorption is very much more rapid than the
rate of secretion, as Duret found, and appears to depend on
the pressure the fluid is subjected to.
The cerebro-spinal fluid plays a very passive part in the
regulation of intra-cranial pressure, and the blood is the
active agent. In this respect the cranial contents may be
conveniently divided into three agents; there is firstly the
more solid parts of the brain substance, which may be
described as neutral . Though these do effect changes in
course of time, as in atrophy and in tumour formation, yet
in sudden alterations they act a neutral part. There is
secondly the blood, which is, par excellence , the active agent.
If the arteries dilate or contract, or if there be retardation
to the venous outflow, there are sudden alterations in pres¬
sure. Of sudden alterations there are several which are
physiological; there are the pulse waves, the respiratory
waves, the vascular waves (2-6 a minute), the diurnal wave
of functional activity and sleep, and finally innumerable
accidental waves due to cerebral activity, as in intellectual
and emotional states.
The third agent is the cerebro-spinal fluid, which is the
passive agent, and whose quantity usually depends upon that
of the blood. As the cranium is a closed box, and its con-
• Duret, “ Traumatismes Cerebraux,” 1878.
t Poster, “ Physiology,” p. 1129.
t Meynerfe’s “ Psychiatry,” p. 229.
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371
1893.] by George M. Robertson, M.B.
tents always completely fill it, when the active agent, the
blood, increases or diminishes in amount, the passive agent,
the cerebro-spinal fluid, must alter in amount inversely, the
brain substance being regarded as neutral. Now, we believe
that those who are liable to suffer from false membranes of
the dura are especially prone to have great vascular disturb¬
ances in the brain. Both the general paralytic and the
senile * are subject to sudden congestive or apoplectiform
attacks, which must disturb the intracranial pressure, and
put a great strain on the regulating mechanism. The exact
vascular condition during these attacks is not definitely
known, but if there be a paralytic distension and engorge¬
ment of the vessels at one stage, it is most probable that
at another stage there is constriction.
We had a case which strongly supported this belief, for,
during a so-called “ congestive attack” in a general
paralytic, the left temporal artery was dilated to nearly the
thickness of a lead pencil on one day, and on the next it
could not be felt with the finger. Since then we have seen
several analogous cases.
Let us now picture to ourselves the exact physical pheno¬
mena in such a case. In the first place, we have an
atrophied brain, containing a diminished quantity of blood,
and an abnormally large quantity of cerebro-spinal fluid.
The brain now becomes congested by a vaso-motor paralysis,
probably of the anterior and middle cerebral arteries, and
the swollen brain causes an absorption of most of the
cerebro-spinal fluid. Then a third stage of vaso-motor
spasm occurs, with anaemia and a morbidly great shrinkage
of the just swollen brain. The demand for cerebro-spinal
fluid will be sudden and great, and it comes at a time when
the supply has been much diminished to regulate the
previous over-pressure. The result will be that, in many
cases, the lessened pressure cannot be met by the secretion
and conveyance of fluid for a considerable time. A vacuum
will tend to be produced, allied to dry-cupping, and the
vessels of the dura will become engorged and will rupture
as we have indicated. The effused blood may be regarded
as being compensatory in its nature.f «
We have observed a fact which lends great support to the
above view of diminished pressure. The dura mater—of
which we have a dried specimen—was intensely engorged
* Charcot, “ Syd. Soc. Trans.”
t Wiglesworth, “ Joura. of Ment. Sci.,” 1888.
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372
The Formation of Subdural Membranes , [July,
with blood, and a dense meshwork of capillaries covered its
surface. It was observed, however, that there was a sinu¬
ous line, about one-eighth of an inch broad and about two
inches long, which was pale and uninjected. The area of
capillary engorgement stopped short suddenly at this line,
and this made the contrast between the pale line and the
reddened surroundings very striking. The sinuosities and
position of this line exactly corresponded with those of the
largest frontal vein. We believe to account for this that
there must have been a sudden diminution of intra-cranial
pressure, and that the superficial capillaries of the dura
became engorged owing to this dry-cupping action. The
same cause would produce engorgement of the most super¬
ficial veins of the brain, and these being distended would
project above the surface of the pia-arachnoid. This slight
projection would to some extent neutralize and compensate
for the shrinkage of the brain, and would give support to
the capillaries of the dura lying in contact with the pia-
arachnoid along the course of the vessel.
We may mention that this peculiar marking occurred on
both sides of the brain, and we have several times seen it
since, in a less marked degree. It can only occur when
there is a certain limited degree of brain shrinkage,
which corresponds exactly with the distensibility of the
vein, and its projection above the surface of the pia-
arachnoid.
The site of the false membranes also supports the above
view, and the extreme frequency of its occurrence over
the convexity of the hemispheres is a most remarkable
feature, which has never been satisfactorily accounted for.
The distribution of the membrane is almost invariably as
follows. It extends in breadth from near the falx to the
outer wall of the middle fossa, where it gradually thins
away ; and in length from the middle of the frontal region
to the beginning of the occipital region, being more in
front than behind the middle line. This localization is
acknowledged by all parties, and, whereas Huguenin
merely states that it corresponds with the parietal bone
without giving reasons, Virchow states that it is con¬
tained within the area of distribution of the middle
• meningeal artery, but why this area should be specially
prone to inflammation he does not explain. We, on our
part, believe that several different and apparently satis¬
factory reasons can be given for the selection of this site
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1893.] by Geobge M. IIobebtson, M3. 373
by the false membranes, which are in keeping with and
support our theory of diminished intracranial pressure.
In this relation the views of Dr. Luys* on the exact position
of the brain in the cranial cavity are most interesting. He
believes that the attitude makes a difference to the position
of the brain—that in the erect attitude the brain tends to
fall away from the cranial vault, and that in the recumbent
attitude it tends to fall away from the frontal bones. In
the dead body a movement of from 5 to 7 m.m. is found to
take place. In the living body the cerebro-spinal fluid
would facilitate these movements, and, of course, would
compensate for any vacuum that would tend to occur.
That the weight of the brain must tend to cause such
movements is obvious when the old and erroneous view of
an organ suspended in fluid is given up. This tendency is
demonstrated to us by the fact observed long ago by
Magendie,t that the weight of the brain has imprinted the
shape of the convolutions on the orbital plate, and on the
floor and side of the middle fossa, while oven the vertex and
parietal eminences no marked depressions have been left by
the convolutions. Now, it so happens that the regions
which are not marked correspond very accurately with the
site of the false membrane formations, in which area we
believe there is diminished pressure. Of the diminished
pressure in this area we have another confirmation—the
apparent converse of the above—in a specimen of so-called
“ compensatory hypertrophy 33 of bone in an imbecile. The
cancellated tissue is enormously increased in amount—no
doubt because the cause operated during development—so
that the parietal bone is nearly half-an-inch in thickness.
This compensatory thickening is limited inferiorly to the
parietal bones, and stops short on the outer side of the middle
fossa, just where the imprint of the convolutions begins as a
rule, and we have found similar examples in senile skulls.
Let us now study what movements take place when
sudden shrinkage of the brain occurs. Were the brain
lying free in the middle of a spherical space and unaffected
by gravitation, when shrinkage occurred it would leave the
walls of the space equally in all directions; but, apart from
gravitation, the brain does not lie free in the cranial cavity;
it is stacked superiorly to the middle line of the cranial
vault, and it is firmly bound down to the floor of the cranial
* “ I/Encephale/’ Yol. iv., 1884.
t “ 1*90118 sur le systfeme nerveux.”
xxxix. 24
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374 the formation of Subdural Membranes, [July,
cavity. The adhesions near the middle line superiorly are
by veins entering the longitudinal sinus, and by prolonga¬
tions of the pia-arachnoid into the pacchionian bodies.
These adhesions, as may be tested, allow a considerable play,
being elastic. The adhesions of the base, on the other
hand, are of a much stronger and more rigid description.
They include the crura cerebri, the carotid arteries, and the
optic nerves, and these bind the organ firmly down. When
shrinkage, therefore, takes place, instead of leaving the
dura equally, the brain must contract towards the base, and
this increases the tendency to the production of a vacuum
over the upper surface of the brain much more than at the
base, and it is, therefore, at the former site that false
membranes are more likely to be formed.
In connection with shrinkage, the arterial supply of the
brain is an important consideration. There are three
cerebral arteries—the anterior, middle, and posterior—and
of these the anterior and middle are from the same source
—the internal jcarotid^—whereas the posterior cerebral arises
from the basilar, produced by the union of the two
vertebrals. Whatever may be the explanation, whether it
be the different origin or not, the area of distribution of the
posterior cerebral is less affected by disease, especially
general paralysis, than that of the two vessels arising from
the internal carotids. Their common origin may predispose
to their being diseased together, as may be seen in the area
of atrophy and adhesions in general paralysis. When a
vaso-motor spasm occurs, especially in this disease, it is
exceedingly probable that these two vessels will be involved
together, and that the brain will shrink most markedly in
the area of their distribution. This area, on the outer
surface of the brain, corresponds remarkably accurately with
the usual site of false membranes, which extends more
anteriorly than posteriorly, and which passes down to the
side of the middle fossa. The middle cerebral artery
supplies the whole of the superior and part of the middle
temporo-sphenoidal convolution, and these form the inferior
boundary of its area of distribution. By examining Fraser’s
plates,* or the convolutional depressions on the bone, it will
be seen that this inferior boundary also corresponds almost
exactly with the lower border of the parietal bone.
We have thus discovered an extraordinary series of coin¬
cidences which must be of more than an accidental nature.
• *< Atlas of Cranial Surgery . 14
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375
1893.] by George M. Robertson, M.3.
There is, firstly, the absence of convolutional marking,
limited inferiorly by the parietal bone; secondly, the
occurrence of compensatory hypertrophy limited inferiorly
to the parietal bone; and, thirdly, there is the occurrence
of subdural membranes with the same limitation. All
these three conditions we believe to be brought about
by the same cause—diminished intra-cranial pressure—
and, as regards the production of subdural membranes,
there is the additional coincidence that the middle cerebral
artery—the most liable to disease of the three cerebral
arteries—has also the same limitation. This last fact we
consider of supreme importance, for we believe the patho¬
logical lesion of subdural membranes is almost invariably
associated with and is the result of cerebral disease, and
the coincidence of its usual site with the area of distribu¬
tion of the middle cerebral artery gives our theory ex¬
ceptional support. If subdural membrane be a purely local
disease of the dura, such as inflammation, then these
coincidences, however extraordinary, are accidental, but we
do not consider this to be the case, as our study of the
shrinkage of the brain towards the base, and our theory of
diminished intra-cranial pressure connect them together.
No other explanation of the site has ever been offered,
excepting Virchow’s statement that it usually corresponds
with the middle meningeal artery, but as this artery supplies
almost all the dura mater surrounding the cerebrum, this
fact is not very remarkable.
As a positive demonstration of the tendency to the forma¬
tion of a vacuum over the convexity of the brain, we have
the well-known fact that comparatively large effusions of
blood may remain there, in opposition to the force of gravita¬
tion ;* and Heschl has made use of this argument,
erroneously we believe, to prove that a retaining membrane
must, therefore, previously have existed. Professor Green¬
field has informed us of an instructive case of his in point,
in which fracture of the skull was followed by effusion of
blood in the subdural space. This was traced to its source,
and, instead of gravitating to the base, it was found to have
flowed upwards over the convexity. This fact is interesting
in conjunction with the observation of Duret,t that, after
concussion, there is intense arterial constriction of the
• In cases of profuse haemorrhage, where the, l?lood is not compensatory, it
obeys the law of gravitation.
t “ Traum&tUmes Certobraux,” 1878.
Digitized by t^ooQle
S76 The Formation oj Subdural Membranes,
cerebral vessels, in one experiment so complete that no blood
flowed from the jugular veins. The occurrence of such a
constriction, with great shrinkage of the brain towards the
base, would fully account for the phenomena of Professor
Greenfield’s case, according to the views we have advanced.
We have seen two cases of undoubted primary haemorrhage
of which the sources were traced, and both of which occupied
the convexity. One was a case of phosphorus poisoning, in
which a fatty vein had burst near the longitudinal sinus.
The other was a rupture of a large Rolandic branch of the
middle cerebral artery, through the pia-arachnoid, during an
attack of influenza. These cases have convinced us, along
with results of the experiments of injecting blood, that sub¬
dural membranes may develop directly from effused blood in
this manner, without the previous formation of a fibrinous
film, such as we have described in the first part. This we
did so fully in order to meet all the objections of those who
hold the Inflammatory Theory, and to account for their
observations.
.Regarding some of the general conditions which pre¬
dispose to the occurrence of subdural membranes, we would
agree with Huguenin* that all “diseases which impair
seriously the constitution and nutrition M do so on account
of the anaemia and shrinkage of the brain they produce.
We would mention specially phthisis, which is sometimes
accompanied by very great emaciation, and in which the
coughing tends to produce venous engorgement. Of 41
cases reported by Dr. Wiglesworth,f 22 were general
paralytics, and of the remaining 19 nearly one-half (eight)
were apparently cases of consumption.
These exhausting diseases also tend to develop fatty
degeneration of the walls of the intra-cranial and other
blood vessels, and, therefore, they rupture more readily than
in health. This is, without doubt, in many cases a pre¬
disposing cause.
A very interesting cause, given by Schneider,J is trau¬
matism, which occurred in 17 out of 74 cases, and Dr. H.
Sutherland § also believed it to be a frequent cause. Direct
rupture of the vessels in all these cases is doubted by
Huguenin, and we suggest that Duret’s arterial spasm,
♦ Ziemssen’s “ Cyclopaedia of the Practice of Medicine, 5 * 1877.
t “ Jour. Mental Scienoe, 55 1888.
t “ Inaug. Diss. Zurich,” 1874.
§ #< West Riding Asylum Reports, 55 Yol. i.
Digitized by ^ooQie
377
1893.] by George M. Robertson, M.B.
following concussion, may be the immediate cause. All
cerebral diseases accompanied by wasting, such as dementia,
predispose to it, but we believe that coarse cerebral lesions,
which are so often accompanied by periodic vascular storms,
also favour its occurrence. Of all diseases general paralysis
is by far the most frequent cause of subdural membranes.
It is accompanied by the greatest amount of atrophy and is
peculiarly liable to the occurrence of vascular storms. The
same may be said, in a lesser degree, of senility, and the
following table from Huguenin demonstrates the frequency
of its occurrence in the aged:—
Under 1 year. 2*7 per cent, of all cases.
From 1 to 10 years ... 2*7 „ „
»» 10 ,, 20 ,, ...... 1*5 ,, ,,
«, 20 „ 30 „ 5*5 „ „
„ 30 „ 40 „ . 12*5 „ ,,
»> 40 ,, 50 ,, 17*6 „ „
»> ,, 60 ,, •••••• 13*5 „ ,,
» 60 „ 70 ,, 19*0 ,, „
» ^0 >» 60 „ ...... 22*0 ,, ft
The high percentage between 40 and 50 years is due to
the greater frequency of general paralysis in that decade;
otherwise there is a steady increase with advancing years.
This last fact we believe to be one which tells most severely
against the inflammatory theory, for inflammation is an
affection much more liable to occur in the earlier periods of
life. We may also mention here that in two recent cases in
which there was found a lately-formed membrane, we were
told by the patients, on the day of their death, that they
suffered from no pain in the head, though direct inquiries
were made, as the presence of membranes was suspected by
us on theoretic grounds. The dura is well supplied with
nerves, and is very sensitive in health, and, therefore, it is
inconceivable that recent inflammation could have occurred
in it without giving rise to some pain.
In conclusion, we again state that not in an active
inflammatory hypersemia of the dura mater is the explana¬
tion of “ pachymeningitis hsemorrhagica ” to be found, but
in the passive engorgement of a compensatory nature, caused
by a process analogous to dry-cupping. This is brought
about by a shrinkage of the brain, which, owing to its
suddenness, and to a deficiency of cerebro-spinal fluid, has
not been compensated for. A negative fact of value is the
statement by so experienced a pathologist as Dr. Sevan
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378
The Formation of Subdural Membranes . [July,
Lewi8,* that he has never seen a subdural membrane form
round the cerebellum. Our explanation of this fact is that
shrinkage of the cerebellum, from its small size, can never be
great in amount, and as the organ is not only exceptionally
well supplied with water-cushions, with a ventricle and a
choroid, plexus of its own, but contains the orifice from
which all the cerebro-spinal fluid gushes out, the necessary
physical conditions analogous to dry-cupping can scarcely
ever occur under these circumstances. In addition, the
cerebellum is not encased in a rigid box, as it has a mem¬
branous lid. We wonder what explanation the Inflammatory
School would give of this negative fact of importance;
possibly, that the dura here is not supplied by the middle
meningeal artery. We may add that we have seen subdural
membrane in the cerebellar fossa, but it had obviously
developed from blood which had trickled into it by gravita¬
tion.
A Chronicle of Infant Development and Characteristics.
By Sir Walter G. Simpson, Bart.
The following notes have been made from time to time in
the hope of contributing materials which will serve to
elucidate the important subject of the gradual unfolding of
mental capacity in childhood.
Child James, born 5th September, 1882. Jottings begun
30th May, 1883.
Summary of first eight months. —Kicking, eating, sleeping,
crying when wishing to eat or sleep, crying when unsatisfied
began first hour, and were all he did for some time.
At the age of three months one could judge by direction of
eyes that ear directed to actual person speaking. For three
weeks previously desire to know whence sound came shown
by eyes wandering at sound of voice, but unable to determine
whence it came.
Infant began to coo with satisfaction. After fourth month
James learned to coo to people for things, and used “ coo ”
as a sign of approval on entrance of anyone he was well
accustomed to. At this stage, being scolded (when ill and
unable to sleep for hot going to sleep), he replied by cooing in
evident imitation of the scolding. At four months took notice
* “A Text-Book of.Mental Diseases/ 1
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1893.] Infant Development and Characteristics.
of a bright-papered room, and continued to show a particular
exclusive interest in said paper for weeks.
Till six months old he showed no objection to persons, even
strangers. At this age exhibited a dislike to a lady whom he
was accustomed to see often. At seven months ceased to object,
she putting out end of tongue to him, and making a noise, a
motion he at once imitated, though he had never seen it before.
During the first eight months the following powers were
noticed as developed:—(1) Distinction of persons and
difference of manners to them, e.gr., readiness to go to his
father, who only came in to see him for minutes at a
time, and was never demonstrative; a pretence of turning
away from mother when she came in, knowing she would fuss;
and an expression of triumph and a look to nurse or mother,
asking approval. (2) At this time a new nurse, whom he
liked at once. Former one had taught him by scolding to lie
in bed for long periods playing with things. Found by crying
that he could make new one take him up; refused to lie.
(3) About seven months decidedly learned to smile and to use it
as a sign of recognition and pleasure, and almost suddenly,
and for some weeks indulged in this sign of approval inordi¬
nately. (4) Delighted and smiled when made to clap hands;
very doubtful whether or not attempts were made (at ei^ht
months) to do it himself, but remained with hands touching
each other in position when encouraged to do so. (5) When
laid on back could roll on to face. (6) When lying on floor
could recover any object within reach. If out of reach and
given, say, a ruler, hit at things he wished for which were out
of reach, and took them if they came within reach. Evidently
throws it out of reach again and tries to recover it. But
there is no knowledge of how to bring it within reach. He
merely sweeps at it, but knows enough not to strike from
above. I say knows , because, for instance, if given a spoon
and dish cover he strikes cover from above in order to make
sound.
(2) Takes pleasure in throwing pieces of bread to dog.
Always shown interest in dog since first saw anybody, i.e.,
looked at them. Dog showed repugnance to him, would not
look at him, whimpered with jealousy when master took child.
Since child has been able to sprawl on floor (six months) dog
licks his face—shows, in short, that it recognizes his humanity.
(3) Voice. Crying. After three months cooing has done
more and more as language. At five months ug-gug came into
use as another word meamng the same. Since he has learnt to
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380 Infant Development and Characteristics, [July,
smile, cooing and ug-gug given up, and crowing combined
with smiles used instead. Crying has two tones, one expres¬
sive of pain or desire for sleep, the other of impatience. Seem
to be more tears with the cry of impatience than with the
other. In addition to crowing he expresses himself by a kind
of groaning grunt when he wishes food and sees it being pre-
? ared. This grunt has various tones, more and more impatient.
n short crowing has its analogy in the articulate sounds made
by deaf-mutes.
Nine months old showed modified jealousy. Mother kissing
before him another child, crowed, laughed, tried to get to her,
and finally impatient. Learned to feed dog with biscuits given
him, and enjoyed the fact of its eating them.
Noted when nine-and-a-half months old .—After absence from
home in London taken to look at birds in aviary; was interested
and followed their motions with eyes. Before (absent three
weeks) had not seemed to see birds, but was only vaguely
astonished at their song, not recognizing whence it came.
Noted when ten months old .—Taken to the country. Distinctly
began to look at objects not within reach, and even at general
landscape. Previously no appreciation of objects not within
reach or interest in anything not verifiable by touch (except
startling and bright pieces of colour, such as painted glass as
already mentioned). Has as yet no understanding of scolding.
Prevented throwing off his hat; does not see there is a conflict
of wills, but throws it down again and smiles at scolding. Being
restrained from doing anything, has nothing but the instinct
to resist the restraint. No sense of conflict of wills. Desire
of approval well developed. Having achieved (with difficulty)
to stand leaning against a chair, looks round for approval, i.e.,
understands applause, but does not understand the meaning of
blame. My wife kissing me when I had him in my arms, he
was evidently interested, and after some time imitated her by
putting out his tongue and touching my cheek . The operation
often repeated with same result. No sign of jealousy as in
the case of the other child.
It is noteworthy that dog now recognizes his humanity;
does not lick him like a puppy; is not jealous when he is made
much of, yet does not treat him like a grown-up person in
this. If child has a biscuit, takes it if child offers indeed,
but never asks by tail-wagging; merely waits till child's
attention is distracted, and then steals it out of his hand. Boy
persists in habit of pretending not to notice persons who
pretend not to notice him. If he make advances to come to
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1893.] by Sib Walter G. Simpson, Babt.
me when I enter the room, and if I pretend to take no notice,
I have found that even during three minutes, though brought
near me, he will not look till I make the first advances.
Noted when thirteen months old .—Met him in the street in
his perambulator far from home. The day before when I called
from my window (second storey) to him, he (being accustomed
to notice me from there) chuckled and showed a disposition to
go to me. When I came upon him far from home it evideutly
caused him to reflect. There was no demonstration, reflection
evidently absorbing him. He gazed, and after gazing held out
his hand and smiled, and then holding my finger continued
evidently thoughtfully to gaze. When I left him he gazed after
me, leaning over the perambulator to see where I was going,
but without crying to be lifted, his habit when he meets me
in a familiar place.
Thirteen months old .—Suddenly developed an interest in pic¬
tures. Seems suddenly to have noticed them. Since this kind
of observation has dawned, whenever brought into a room
with pictures he points to them and utters sounds which either
mean pleasure or a desire to draw attention. I have tested
this picture mania. A coloured photo of my father is his
favourite, though others are near it. In another room an oil—
“ a jester”—is his selection. A portrait of myself (the same
size and frame) does not arrest him, probably because in a bad
light. It is not brightness of colouring which attracts him,
because—1st, he turns away from some bright landscapes near
his favourites; 2nd, if put near enough he puts a finger on my
father’s and the jester’s face; 3rd, a framed photograph of
myself and others is a favourite. When brought near this
photo, however, he does not recognize me. It is another face
(which is the largest white patch in the group) that he lays a
finger on when brought near the photo. He babbles to his
favourite pictures when held before them, as if he were con¬
versing.
Thirteen months .—Having been away from home for nine
days, he accepted my reappearance with indifference, so great
that his mother said he did not know me. Just as she said so
he stretched out his arms to come to me, and instantly went for
a whistle attached to my watch chain, which before I left he
had been fond of spitting down in attempting to blow. It
was some days before he showed the same amount of predilec¬
tion for me that he had exhibited before I left. I have no
doubt that a longer absence would have obliterated me from
his memory. I do not mean by this that merely seeing people
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382
Infant Development and Characteristics, [July,
endears them to him. On the contrary, my impression is that
he more readily takes to near relatives than to strangers, e.g. 9
servants, whom he sees as much of.
Noted when fifteen months old. —Walked quite suddenly.
Till the day he succeeded, a tendency to fall back, which
deterred him from trying. The day he did it his hands happened
to be out in front of him. For some time after his success
he could only walk with them in this position.
Noted when eighteen months old. —Observation of things at a
normal distance and in unaccustomed places has gradually
developed. If at a window, and I in the street, he recognizes
me, but not unless signs are made. Whilst out with his nurse
I attracted his attention from across the street by waving my
hands. There is no word he seems to have specialized and
limited in meaning yet except “ dad.” “ Dis,” “ dat 99 are his
only other English words. Rapidly learning conditions of life
by imitation, e.g. 9 opening and shutting boxes, putting things
in and taking them out. Except crying and sucking I have
recognised no actions purely instinctive. Of course distinctive
character is developing, apparently from inborn qualities, e.g, 9
hemmed into a corner by a box, he squeaked like a guinea pig
(his call for aid). I taught him to crawl over it. Having
hemmed him into the same corner with a broomstick several
times he will not cross it, though less formidable than the box,
as I purposely abstain from teaching him to do so. The lid of
an open box in which he was delving, having fallen on him, he
squeaked till I answered, then waited till released (I kept him
waiting some time), though it seemed easy to withdraw his
head and shoulder. There is memory, e.g. 9 a week ago he was
much amused on Sunday evening (the only evening he comes
down) with a game with a bearskin rug. This Sunday evening
he drew me to the rug and made me understand that he
wished the game repeated. I had forgotten it till he explained.
He, the rug, and I have been in the room every day since, but
not after dinner .
Case of Reasoning .—Having hurt his mouth by licking the
pepper pot, he won’t let it near his mouth, but whenever he
gets it tries to put it into my mouth.
H is mother having been away two weeks he refused to go
to her the evening of her return, cried when taken, and
struggled to me or his nurse. Next morning he would have
nothing to say to anyone else, i.e ., showed a strong preference
for her to any one else. Comparing this with my absence at
thirteen months, it is observable that the first reception in both
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1893.] by Sir Walter G. Simpson, Bart.
cases seems to show resentment at the absence. At thirteen
months nine days had diminished his recollection of me as
shown by my only becoming as much to him as before I left
in the course of days. At fifteen months his mother had not
begun after two weeks 5 absence to fade out of his life.
When I say I have seen nothing inborn as regards conduct,
perhaps this is an exception. Behind the house at the foot of
the back garden, which is bounded by a railing, there is a
precipice. The child likes to walk up this garden, or green,
with me, but recoils when within sight of the precipice, and
screams if made to walk nearer to it. No one else has taken
him to the spot. When carried right to the railing as an
infant, say twelve months, he evinced no interest. This is
curious, when contrasted with the desire to touch fire, and
his complete want of fear in a dark room.
Some days later .—Has quite overcome fear of precipice.
Wishes to walk up to the railings at the foot of garden, which
directly overhang it. This not allowed, because they are wide
enough for him to fall through.
Noted 18 th February , 1884.—At this date I, having for five
days had an attack of lumbago, could not take him about.
Though his chief favourite to this date, on this account he
showed, 1st, anger; 2nd, a proportionate coldness. Three
days ago I took him downstairs to breakfast (though unfit),
on account of his distress at not being taken. I had to let
him down on the landing and finally to fall down myself with
a spasm of rheumatism. He roared. Since, he Will not come
to me, and is only recovering confidence as I recover. To¬
day, being somewhat reconciled to me, I pretended to be
stiller in rising from my chair than I really was. This he
watched, and although he had been playing round me till then,
he fled roaring when I touched him, and has refused to come
to me, although yesterday he was doing so, with the caution
of a scout, but still coming.
Noted July 20 th> 1884.—During five months most of his time
occupied in acquiring knowledge of things by touch. Great
insistence in getting into hands anything never seen before.
If there is nothing more to be done with the thing, it soon
ceases to interest. Anything mastered is given up, e g., rolling
a ball on floor, but things not perfectly acquired are persevered
with, e.g., carrying coals to the fire, opening and shutting
boxes. No original departures. Combinations of material,
things made, and things employed in certain ways only when
he has seen them so used and applied. Each time a thing is
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Infant Development and Characteristics , [July,
seen done which he desires to do, it is perseveringly attempted
till the imitation is nearly complete; after that it is never done
except when necessary, never experimentally. Now being easy
he will only do it if I refuse to lift him up or bring it him.
On the other hand perseveres in putting a pipe in his mouth
when he sees it done, because (only having seen an empty one)
he can’t produce smoke. A lighted match held to his pipe
pleases. Smoke not coming, disappoints. Feeding himself
with a spoon persisted in, also lifting his tumbler himself,
although (or because ?) very clumsy at both.
A new thing if within ability at once attempted if manual,
e.g., sweeping crumbs up with brush and shovel; giving money
to cabmen, porters, interests but does not excite imitation,
though coins are recognized playthings.
Original thought compared with imitative power very slight.
Have not seen him attempt to put anything but coals and fire-
irons into fire, except once his pipe after long thought. Into
water everything is thrown, but this likely because his toys
were thrown into his bath to keep him quiet. Could not go
downstairs till last week, when he saw a child slip from step
to step sitting. This he learned without trouble, practised
perseveringly for an hour, and has since only done when
required, preferring to be carried.
Smell seems little developed. He sniffs at flowers when
his elders do, but snuffs too hard to smell, and as often with
the flowers held to open mouth as not. Refuses intoxicants,
but from colour, not smell. Raw, colourless whisky he puts
to his lips if offered instead of water.
Sight has gradually developed from seeing only objects that
were touchable to full development. Travelling last week,
some things never before seen caused exclamations. These
were woods, lakes, and rivers. Sheep and cows seen from the
train excited him, but only if within about a hundred yards
(these animals he knows at home). Smoke of steamer and
steam engines caused fear. When passing through barren
grand mountainous country he came from window.
Last week I saw first symptoms of indecision. He could
not decide between going with me a walk and playing
indoors with a child. He stood motionless half-way for some
time, deciding finally for the child. The decision once made,
he appeared not even to hear when I stood for a while (at some
yards distance) persuading him. Hesitation probably caused
by the novelty of refusing to go anywhere with me.
Noted November , 1884.— Speech .—Passed through parrot
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385
1893.] by Sir Walter G. Simpson, Bart.
stage of reluctantly repeating a word simply to get a reward, a
period during which continually talking to self inarticulately.
This suddenly given up, and words willingly attempted with the
view of learning them for use. At this date will only attempt
sentences for reward. Does not use them, but uses isolated
words to express himself (along with gesture), and in answer,
e.g., will say who gave him a thing truly though the person not
present. Knowledge of things said much more developed
than apprehension of the use of words, in fact, understands
language pretty fully, e.g., being asked to do so he tried to reach
and ring the bell; it being too high he brought, placed, and
got on a chair as instructed, and then rang entirely from verbal
orders without understanding the reason for the actions till the
bell pull was in his hand.
Habit .—This is noticeably developing. Given the same
place and circumstance he wishes to repeat the same actions,
e.g ., next morning the whole process towards ringing the bell
was gone through. Just before going to bed, if his father
comes in, he is pointed to a chair, each pocket examined in
the same order—pocket-book, watch, pipe, etc., etc. Rebels
if not allowed to go through the whole routine; goes to bed
if allowed to complete it. Also, three days’ refusal will break
a habit acquired, e.g., having got a piece of apple at his
father’s breakfast regularly, after third day’s refusal seemed
to forget.
Deduction. —Being told to throw away a nut which no one
would break for him he threw it in the fire. Since then all
nuts he can find are thrown in the fire, and off his own bat he
lifted his doll’s clothes and placed it on the chamber.
Artistic. —Being taken down a wooded valley he had never
seen in his father’s arms he seized him by the ear, crying,
“ See! ” and (father purposely looking in different direction) was
not satisfied till my head was turned so as to see the most
striking aspect of the scene.
Lying .—Even if caught red-handed in mischief, if scolded,
unhesitatingly names someone else as the culprit, not always a
person in the room.
Noted 8th July , 1885.—During the last nine months he has,
of course, been acquiring greater accuracy and skill in every
department in which he had made a start. It is noticeable
that handling a new thing is not so much the chief way of
acquainting himself with it. Shown a new thing he will now
look at it very closely and be content (if it is not a thing he
wishes to take away), finally merely to touch it. In no case,
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386 Infant Development and Characteristics , [July,
however, is ocular examination alone sufficient. Looking at
the works of my watch, I found from the first time he saw
them that there was no desire to do anything but look for
about 30 seconds, but invariably after that time, although he
has never been allowed to do so, his hand rises for the pur¬
pose of touching. Distant objects of which he has no actual
experience ho does not seem to see, e.g., clouds or a distant
hill. But he recognizes a sailing boat at sea, and having
come to the country in a steamer within the last week he
yesterday recognized one at sea, and in pointing it out to me
his excited manner evidently expressed delight in his own
perspicacity and pride at identifying it. A proof how much
touch has to do with knowledge is that till within the last few
days I have apparently failed to get him even to see so common
an object as a sparrow. When he did get his eye on what I
was pointing at it roused no interest. I told him to catch the
sparrow. This he rushed to do eagerly, but gave up at once
when it flew away. He now points to a sparrow when he is
with me, but evidently only to call my attention to a thing
which (unaccountably) seems to interest me. Canaries in an
aviary at home interest him. If allowed he tries to catch
them. He calls them “birdie.” When I explained that
sparrow was birdie, he answered decidedly, “ No, not birdie.”
Within the last six months the necessity for restraining and
even punishing has been forced upon seniors. Up till then,
except in the matter of withholding things unwholesome,
there was no feeling that the child ever did anything wrong.
The wish to punish on the one hand and to play on the other
seem to grow side to side. Up to about two and a half years
he did not play. Up till then things were manipulated for the
direct purpose of learning their nature and acquiring skill in
using them, and they were thrown aside as soon as all the
uses the child supposed they could be put to were mastered.
Life was in earnest. There seems to be a pause in the desire
to acquire knowledge in proportion to the new developing
wish to get fun out of what he knows. For instance, till
within the last few months mixing bread and water in a cup,
or chopping up egg with salt would occupy him during my
breakfast, and any spilling and messing arose accidentally, not
by design. Now he tries from mere wantonness to upset the
cream, he steals any food and runs away with it, etc., etc.
A short time ago he was allowed a pair of blunt-pointed scissors.
For days he clipped pieces of paper given to him, until he had
mastered the art of clipping. After that the scissors had to
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1893.] by Sib Walter G. Simpson, Babt.
be hidden away, as he would no longer cut waste paper or
anything given him to cut, bat tried to exercise his art upon
clothes. Having got a piece of string I said he must not cut
it, and designedly pretended not to notice whilst he persever-
ingly minced it into small pieces. Next day he sat down
to a similar task with another string, but at once gave it up
when I expressed approval of what he was doing. Of course
the playful spirit is not designedly mischievous. Doing
wrong is an accidental concomitant, not its object. At an
earlier stage, having mastered the nature of a doll he gave it
up. He tired of one I used to make from a handkerchief; he
has returned to it, he now talks to it, rolls it on the floor,
quarrels with it, etc.
Each period of childhood seems to devote itself very indus¬
triously and principally to one branch of knowledge. He is
always at work on language. Every day he learns one or two
new phrases or terms. A new one which he catches in con¬
versation he repeats with apparently a conscious effort to
remember. A very large proportion of them—indeed, nearly
all—are forgotten again. Nor is it certain that they will be
adopted into his vocabulary even if noticed and echoed several
times. When they do appear they crop up without effort,
and appear as natural as the simplest child word. Such
phrases as “I really must,” “Certainly,” etc., have so
appeared. Of course, each phrase is a single word to his
mind. They are always, if used at all, used in their proper
sense. Some phrases are wrong, but these have been taught,
e.g. y “To-morrow day,” the history of which I know. He
learnt it when I was trying to explain what to-morrow was,
and it remained with him because everyone in speaking of
to-morrow to him so calls it, knowing it to be intelligible to
him. Proper names are not all picked up by this process, e.g .,
there is a rake in the garden which I have taken out of the
toolhouse every morning for him, and which I purposely hid
away during the day. For three days its name had to be
repeated, on the fourth he knew it. I let a day elapse without
producing it. On the sixth day its name was forgotten. For
several days he had it every morning. Two were allowed to
elapse. After this interval he seemed to know it without an
effort, as there was after the first twenty-four hours of recollec¬
tion.
Smell completely developed. Refused to taste kummel,
although the colour of water, disliking the smell.
Discovered some facts of comparative anatomy lately with
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§88 Infant Development and Characteristics , [July,
great delight, e.g ., my feet, his feet, my hands, his. Not
quite definite about homology of respective fingers.
Satisfied with very coarse resemblances, preferring a
coarsely-made wooden horse with straight stick legs to a more
artistically made one. When pointed out that his favourite
had no feet, no knees, he pointed to the place where feet and
knees would be, and said, “ Not footy, no kneey,” but did not
seem to consider the absence of them a disadvantage.
He began to walk about two months ago. Before that,
pace always a trot. Although still very seldom walks, the use
of that pace is becoming more frequent.
Counts only up to two. Three conveys no idea to him.
Repeats “ three ” when said to him, but not as a word he
wishes to learn or understands the use of. If wishes more
(e.g. 9 strawberries) put on his plate along with first two, says,
“ Another one two.” Beyond that he says, “That enough,”
“not enough,” or “a lot,” according to quantity. If a lot
are counted over one by one he does not attend and try to
catch up the words three, four, etc.
Coming into new room last week (in house taken for summer)
all things within reach attracted attention. Brass coal-scuttle
“ very pretty.” Took no notice of pictures which at home he
likes. Happening to climb on a chair some days later, a small
water-colour of Merlin being level with his eye, he examined,
and said, pointing to his red stockings, “ Man pretty; tocky,
dada, keechie tocky ” (I wearing knickerbockers). Having
seen a dancing-bear lately he detected one in “ Coming of Age
in the Olden Time,” though there on a very small scale in the
background.
Colowr .—Has tastes. Objects to my wearing dark clothes
if accustomed to see me with light. Objects when I take off
a very gay house-coat. Picks it out from a heap of coats if
asked to choose me a pretty coat. Attention being called to
one picture on the wall when put down wished to be lifted to
another, decidedly the gayest in the room. Being lifted up to
it was disappointed and no longer interested, it being very
sketchy, without definite forms in it from near. I have been
teaching him the names and differences of colour, with little
success. With one telling he learnt and remembered next
day that my slippers were blue. This is the only colour he
seems to comprehend at all. Thinking that blue slippers
might be merely a name for that pair I showed him another pair,
and asked if they were blue. He said at once, “ Dada shoes
not blue.” Still, shown a flower in the garden of nearly the
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1893.]
389
by Sir Walter G. Simpson, Bart.
same shade as the slippers said, “ Not blue.” After several
lessons in flowers, although he will repeat red, yellow, white,
when shown flowers of these colours he cannot name the
colour, saying red, white, blue, yellow by guess. There is one
exception. He is decided that the bush of bluish flowers are
not blue, and equally decided that a bush of light pink and
white flowers are. Thus, in general, bright colours please his
eye. In particular, blue is the only one he has an idea of, and
that not a definite one.
(To be continued.)
CLINICAL NOTES AND CASES.
Acute Mania following Rupture of the Rectum by Enema
Thirteen Days after Ovariotomy. Recovery. By A. C.
Butler-Smythe, F.R.C.S.Ed., Surgeon to Out-patients,
Samaritan Free Hospital for Women and Children,
Surgeon to the Grosvenor Hospital for Women and
Children, Westminster.
Mrs. W., set. 43, was sent to me in September, 1886, suffering
from a large abdominal swelling. She gave the following
history:—Married 20 years, but had never become pregnant.
Health good up to two years ago, when she first noticed a swelling
in her left side, and had difficulty in passing water. She also
complained of back-ache and pain in the lower part of the
abdomen, and was troubled with an offensive brown-coloured dis¬
charge from the vagina. Menstruation became irregular and
painful, the flow varying in quantity. The swelling increased
rapidly, extending from left to right, and filling up the whole
“ abdomen.” Some weeks before her visit to me she had an attaok
of inflammation in the abdomen, which seemed to fix the swelling
and greatly impeded her breathing.
When I first saw her it was evident that she was suffering
greatly and in a dangerous condition. Her face was drawn, lips
blue, nostrils dilated, conjunctivas suffused, and the respirations
40 to the minute. Pulse, 120; temperature, 100. Skin dry,
tongue foul, bowels costive, and the urine scanty, high-coloured,
and loaded with lithates. Sp. Gr. 1028. No albumen or sugar.
The abdomen was greatly distended, the circumference at the
umbilicus measuring 50 inches. There was dulness over the
whole surface, except far back in the right flank, and immediately
below the ensiform cartilage. No distinct fluctuation could be
made out.
xxxix. 25
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Clinical Notes and Cases.
[July,
Bimanual examination revealed tlie uterus in front of tlie
tumour, drawn high up on the right side, the body and fundus
being easily distinguished through the abdominal wall. Per
vaginam, the cervix uteri could be felt behind the pubes, and the
sound passed into the uterine cavity to the extent of three inches
with a forward curve. The lower part of the tumour was firmly
wedged in the pelvis, and pulsation could be detected through the
vaginal wall.
On September 16^, 1886, ether was administered, and the
abdomen opened. The tumour was found to be universally
adherent to the parietal peritoneum, omentum, and intestine, and
much time was spent in separating adhesions and securing
bleeding points. The pelvic portion of the tumour was enucleated
and the capsule fastened to the lower end of the abdominal
incision. The peritoneal cavity was then thoroughly sponged out
and a drainage-tube placed in the sac formed by the capsule. The
wound was closed with silk sutures and dressed with carbolic
gauze, and the patient was then removed to bed after an operation
lasting 3£ hours. Much blood had been lost, and the patient was
extremely collapsed, but she rallied well and had no sickness. The
tumour removed was a cystic papilloma of the left ovary, burrowing
deep into the left broad ligament. The contents were dark and
gelatinous, and the cyst wall was, in parts, half-an-inch thick with
masses of papilloma spread over it. The first urine drawn off was
dark with carbolic acid, and this condition lasted for three days,
after which the urine was quite clear. Flatus did not pass
voluntarily till 48 hours after the operation. Metrostaxis occurred
on the third day, and continued for a week, during which time the
pulse averaged 120, and the temperature ranged between 104 6
and 101*8.
At the end of the first week the abdominal wound had healed,
but the drainage-tube was left in situ , as a couple of drachms of
sour sanious fluid were drawn off through it night and morning.
On September 24 th, the eighth day after the operation, an
enema of ten ounces of olive oil was ordered. By an unfortunate
mistake a pint and a half of soap and water was given after the
oil, and there being no immediate action of the bowel, this was
followed by another injection of soap and water, the result being
that the rectum burst and the fluid came through the drainage-
tube, saturating the dressings. The patient afterwards declared
“ that whilst the enema was being administered she felt a sudden
pain as though something had given way in her inside, and
almost immediately the bandages became soaked through.” About
four hours after the accident I was informed of the occurrence,
and on examining the patient found fluid still welling out of the
drainage-tube. As much faeculent fluid as could be got out of the
tube was drawn off by the syringe, and an enema-tube passed into
the rectum to assist in draining the intestine. A large pad of
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1893.]
Clinical Notes and Cases .
391
absorbent iodoform dressing was placed over the abdominal wound,
and the patient put into another bed. Pulse, 120; temperature,
101*6. Within the next 48 hours the temperature rose to 102*2;
but there was no pain or abdominal distension, and the only
trouble complained of was “a soreness of the back passage.
Faecal matter and flatus were constantly passing through the
drainage-tube, but no bad symptoms appeared, and the patient
went on as if nothing had happened.
On September the 27 th, the eleventh day after the operation, and
the third following the accident with the enema, the patient
appeared restless, and had little or no sleep. The temperature
was 101*2, and the pulse 130. Later on in the day the tempera¬
ture rose to 102, when she began to talk nonsense, and at night
became delirious. As it was difficult to keep her quiet, the
drainage-tube was removed, and twenty grains each of chloral and
bromide of potassium given by mouth, and ordered to be repeated
every four hours if necessary.
September 2%th. —An ounce of castor oil was given by the mouth,
after which the bowels acted freely and without pain; but some
faecal matter came through the tube-opening in the abdominal
wall. Evening temperature, 101*8; pulse, 120. The patient had
had no sleep for twenty-four hours, and lay tossing about in bed
and talking wildly.
September 29 th. —On the thirteenth day after the operation, and
the fifth following the accident, the patient became maniacal and
made several attempts to get out of bed. Half a drachm of tincr
ture of opium was ordered to be given every third hour, but after
the second dose she became so excited that I ordered the drug to
be discontinued, and the chloral and bromide mixture, with the
addition of half a drachm of tincture of hyoscyamus, to be resumed.
She derived no benefit apparently from the change of medicine,
for she got no sleep and was extremely violent throughout the
night. Evening temperature, 101*8; pulse, 122.
September 30 th, —Patient worse, very restless. Morning temperar
ture, 101; evening temperature, 100*8; pulse, 140. She com¬
plained of pains in the “ stomach/* for which a drachm of tincture
of hyoscyamus and twenty grains of chloral were given.
October 1$£.—The afternoon temperature rose to 102*8, pulse 130,
and thready. Twenty grains of quinine were given by mouth, and
an ice-cap put on. A tablespoonful of champagne was directed to
be given every hour till further orders. The temperature fell to
100*2 within an hour and a half, and the patient had some sleep;
pulse 110, and stronger.
October 2nd. —She seemed to be slightly better, so the stimulant
was decreased, and more fluid food administered by mouth. Tem¬
perature lower and pulse stronger.
October 3rd, 4 th, and 5 th. —During these three days she appeared
to get worse. Faeces and urine were passed involuntarily, and she
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392
Clinical Notes and Cases.
[July,
became unmanageable. A sixth of a grain of morphia was injected
hypodermically, but apparently it increased the excitement, and
therefore was not repeated, 31 doses of tincture of hyoscyamus
being substituted.
October 6th. —Patient had a rigor. Afternoon temperature rose
to 103, pulse to 140. Twenty grains of quinine were given by
rectum, and the temperature fell to 100 in about two hours.
Faecal matter still issued from the abdominal wound. She was
extremely violent.
October 7 th. —The morning temperature suddenly dropped to
normal, but the pulse kept about 120. She was very excited and
savage, requiring constant watching.
October 8th. —Much exhausted. A mixture of ammonia and bark
was given every three hours, and a tablespoonful of brandy every
hour. She slept a little during the night, and was much quieter
the whole of the day. Afternoon temperature, 101*2; pulse, 120.
Skin dry, tongue moist, and urine normal.
October 9th. —Temperature this morning 98*2. A large slough
containing deep ligatures was extracted through the wound.
Patient much stronger, but mental symptoms worse. She refused
to take her food, and tried to bite her attendants whilst being fed.
Pulse, 120; evening temperature, 100*6. One-fourth of a grain of
morphia injected, but without much benefit. Stimulants, egg and
brandy mixture every hour in half-ounce doses.
October lOfA—Mental condition much the same. Morning
temperature 100*6, in the afternoon 98*6.
October Ilf A—Another large slough containing deep ligatures
came away. For the first time since her attack patient had several
hours’ sleep. Morning temperature, 99*6; pulse, 120. It was
noticed that she was passing large quantities of limpid urine,
alkaline, sp. gr. 1005, and containing a trace of albumen. Evening
temperature fell to 98*6.
October 13 th. —Large slough with ligatures extracted. Tempera¬
ture varying between 99 and 100*6 ; pulse 130, and small.
October 14 th. —Another slough containing ligatures came away.
Evening temperature up to 101*4. Patient very violent and
wakeful.
October 15 th. —Rectum cleared by enema, part of which
escaped through the tube-opening. Large quantities of limpid
urine drawn off by catheter. Morning temperature, 99; evening,
101 * 6 .
October 17 th. —Morning temperature 98*6, but at midday it rose
to 103*6, and the pulse to 120. She became wildly maniacal, and
restraint had to be employed. Twenty grains of quinine were
administered by rectum, and ten grains more three hours after¬
wards. In less than an hour after the second dose the temperature
had fallen to 100 and the pulse to 105; sixty ounces of urine
drawn off in twelve hours. Dtiring the next five days there was
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1893.]
Clinical Notes and Cases .
393
not much change in the patient’s condition. Her temperature
remained below 101, and pulse between 105 and 110. She refused
her food and had to be artificially fed. Slept from time to time,
but when awake was beyond control.
October 23rd. —Patient had an attack of diarrhoea and complained
of pains in the abdomen. The morning temperature fell to 97'4,
and the pulse was extremely feeble. The extremities were cold
and clammy, and she seemed to be in a state of collapse. Chalk
and opium mixture was given to check the diarrhoea, and hot brandy
and water administered by the mouth. Hot-water bottles were
placed to her sides and feet, and a mustard leaf applied to the
cardiac region.
October 24th. —Patient had a good night and slept well. She
awoke refreshed, and her mental condition showed marked improve¬
ment. She seemed to know when she was passing urine or fasces,
and called for the bed-slipper. The quantity of urine drawn off
in the last twenty-four hours amounted to sixty ounces. Highest
temperature 101.
October 25th. —Two ligatures removed from capsule. Patient
slept for four hours and seemed better in every way.
October 26th. —A small piece of mutton chop was given for dinner
and she seemed to relish it. Slept for five hours afterwards and
awoke refreshed.
October 27th. —The restlessness reappeared, and later in the day
she again became decidedly maniacal. Pulse 130 and bounding.
Afternoon temperature 101. She seemed to have great abdominal
pain, therefore half-an-ounce of castor oil was given by the mouth
and an enema administered afterwards, but without much result.
Evening temperature 100.
October 28th. —The afternoon temperature rose to 103*2, but no
rigor was noticed. Another large slough containing deep ligatures
was extracted through the abdominal wound. Twenty grains of
quinine were given by rectum, and the temperature fell to 100*8
within two hours, and the pulse was reduced from 120 to 100 beats.
The bowels were cleared out by castor oil, given by the mouth, and
the patient quieted down and had some refreshing sleep, and awoke
in a much better condition.
She improved mentally and bodily during the next three days,
but the temperature kept about 101, and the pulse varied between
120 and 100.
November 1st. —Temperature in the morning 98, in the afternoon
101*6. The bowels acted four times, and by night the temperature
had fallen to 100*4.
November 3rd. —The patient appeared much better, but seemed
rather dazed and unable to collect her thoughts. However, she
recognized her attendants, and was quieter than usual. Midday
temperature 98*2, pulse 110. Evening temperature 101. For
the next two days she continued to show marked improvement, her
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394 Clinical Notes and Cases . [July,
appetite increased, she slept well, and behaved in a reasonable
manner.
November 6th .—Her temperature rose in the afternoon from 99*6
to 103, and the pulse increased to 130. An ounce of castor oil was
given by mouth, and the lower bowel cleared out by enema. Twenty
grains of quinine were also given by mouth with good result, the
temperature falling in a few hours to 100*2, and the pulse being
reduced to 112.
November 7th .—For the first time since the attack she talked
sensibly, and even asked questions. She declared “ that during
her illness her impression was that she had been confined of twins,
and that they had been taken away and kept from her without her
consent. ,, She also maintained “ that if restraint had not been
used she would have injured her attendants.” Highest tempera¬
ture 100*8, pulse 120. During the next week she rapidly gained
strength and sat up in bed to meals and fed herself. With the
exception of slight outbursts of temper she appeared to be quite
rational.
November 14 th .—Menstruation came on without discomfort. She
had complete control over her rectum and bladder. The abdominal
wound was much smaller, but flatus and faecal matter still passed
through it. Pulse 100. Evening temperature 100.
November 27th .—Patient able to walk about her room and
remain up for hours. She is now perfectly sane and quiet, her
only trouble being the faecal fistula, which is, however, rapidly
closing. A few days later she returned home quite convalescent.
Remarks .—I venture to report this case not alone because
of the attack of mania following ovariotomy, but also to
record the unfortunate accident with the enema. Rupture of
intestine by enema is fortunately of rare occurrence, but the
fact of such an accident having happened serves to show that
rectal injections cannot be too carefully given at all
times, and especially in diseased conditions of the intestine,
or where drainage is being carried out in abdominal cases. In
this particular instance the probability is, that during the
enucleation of the tumour from between the layers of the
broad ligament the rectum had been exposed, and that the
glass drainage-tube had rested od the intestine, which gave
way under pressure of the copious enema injudiciously
administered.
There is little to be said about the treatment adopted
throughout this case. Morphia and opium failed to quiet
the patient, and, indeed, seemed to increase the excitement.
Chloral and bromide of potassium appeared to do some good,
but the doses had to be increased from time to time, as the
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1893.]
Clinical Notes and Cases.
395
drugs seemed to lose their effect after a few days’ use.
Tincture of hyoscyamus was tried alone and in combination
with the chloral and bromide mixture, and certainly soothecf
the patient when all else failed. Quinine in 20-grain doses,
given by mouth or rectum, seldom failed to lower the
temperature within two hours, and was invaluable in sub¬
duing the hyperpyrexia.
The question of stimulants is a vexed one, but in my
opinion much good was done in this case by the discreet
administration of alcohol. When the patient was at her
worst I gave large quantities with undoubted benefit, and I
feel certain that she owes her recovery in a great measure
to this treatment, for the discharge from the abdominal
wound was profuse, the emaciation rapid, and her exhaustion
extreme. The first symptoms of mental disturbance appeared
on the 11th day after the removal of the tumour, and the 3rd
following the rupture of the intestine. Two days later the
patient became maniacal and remained so for seven weeks,
after which time she recovered her reason and made a rapid
convalescence.
This was undoubtedly a case of acute mania, but the
question may be asked, to what was the attack due P
The fact that insanity has frequently followed operations
on the ovaries and uterus is abundantly proved. Keith, Tait,
Bantock, Thornton, Meredith, Barwell, Cullingworth, and
Dent have each met with one or more cases. Some of these
recovered, others remained incurable, and a few died raving
mad. In some of these instances the patients had shown
decided symptoms of insanity before operation, and with
these the subsequent attack was simply a recurrence; but
with the others it was different, for up to the date of opera¬
tion they had been perfectly sane and no history of insanity
could be discovered in their families. In the case here
recorded, beyond the fact that the patient’s brother died
from “ abscess in the brain,” there was no history of cerebral
mischief. Her husband, however, assured me that for some
time previous to the operation she had been in a very
depressed state and frequently said “ she would go mad and
die in an asylum.” This statement would seem to indicate
that anticipation or anxiety prior to the operation may
have had some influence in bringing on the attack. As
exciting causes, shock after the operation, or alarm at the
accident must not be overlooked.
It has been said that insanity may follow the administra-
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396
Clinical Notes and Cases .
[July,
tion of some anesthetics, but I must confess that I have
never seen a case of this kind, nor do I know of any instance
where insanity has been induced in a patient who beforehand
was perfectly sane, and in whose family history there was
no evidence of madness. In the case under consideration
the anaesthetic employed was ether.
The condition of the urine may have had something to do
with the attack, but it must be remembered that the
carboluria had passed off many days before the symptoms of
insanity appeared, and, moreover, at no time was there a
scarcity of urine, and only a trace of albumen was detected
occasionally during the period of polyuria.
Mental disturbance due to absorption of iodoform is, I
imagine, not of rare occurrence. I have seen three such
cases where there was delirium, high temperature, and com¬
plete prostration. All the patients were in extreme danger,
but recovered on the removal of the exciting cause. At the
same time the mental symptoms never went beyond slight
delirium.
Mr. Barwell, in a paper read before the Medical Society,
has pointed out *' that disturbance of the generative organs
might possibly be a cause of insanity following such opera¬
tions as ovariotomy and hysterectomy.”
Mr. Dent, however, in a very able contribution to the
“ Journal of Mental Science,” has clearly proved that
insanity may follow herniotomy, amputations, dentistry, and
has been frequently noticed after accidents. Mayo Robson
has also mentioned a case of acute mania following the
passage of a gall-stone. Hence it would seem that any
operation may bring about an attack of mania or some form
of insanity.
I am inclined to agree with Mr. Dent that many of the
cases of insanity following abdominal operations, especially
those cases where the symptoms have not immediately
shown themselves, but appeared a week or two after¬
wards, are of septic origin, and are similar to those cases
of puerperal insanity which are not infrequently met with
in practice.
In the case just narrated, the septic condition of the
patient, increased probably by absorption of faecal matter and
gases subsequent to the rupture of the intestine, would seem
to have been a potent factor in bringing about the maniacal
attack, for the accident was soon followed by mental
symptoms which culminated in acute mania.
Digitized by ^ooQie
Clinical Notes and Cases .
897
1893.]
Mrs. W. called on me in April, 1893. She is now a big
stout woman in the best of health and spirits. The fecal
fistula has quite closed, but there is a ventral hernia which,
however, does not cause her the slightest inconvenience.
There has been no return of the mania, her mind is perfectly
clear, and she shows no trace of any former mental trouble.
Acute Melancholia: Attempted Suicide by inserting a Needle
into the Abdomen . Death nearly thirteen months after .
By G. M. P. Braine-Hartnell, L.B.C.P.L., M.R.C.S.E.,
Senior Assistant Medical Officer to the Worcester County
and City Asylum.
I am indebted to the kindness of Dr. Cooke for permission
to publish this case.
E. W., aged 40, married, admitted into the Worcester County
Asylum on April 11th, 1891. This attack is stated to be the first,
of seven weeks* duration. Cause assigned, ill-health.
On admission. The patient is a thin, anaemic looking woman.
She has some superficial scratches on her abdomen and at the bend
of the left elbow, said to have been self-inflicted with suicidal
intent. Nothing abnormal in heart or lungs. No albumen in urine.
Mentally she is suffering from acute melancholia; is extremely
distressed and miserable. Says she cannot live. Refuses her
food and is restless at night. Two or three days after admission
she stated that she had run a needle into her abdomen before she
left home with the object of taking her life. Careful examination
failed to find any point of entrance. Her statements varied con¬
siderably as to where she had inserted it, and she sometimes
denied having done so. There was no pain on pressure and no
sign of peritonitis. On April 22nd a superficial abscess began to
form in the upper part of the hypogastric region, in the middle
line. Linseed meal poultices were applied and the patient kept
in bed. Sulphonal, gr. xx., was ordered night and morning. On
April 24th the abscess was opened, and about an ounce-and-a-half
of pus escaped. The wound was well explored with the finger,
but no trace of the needle could be discovered. The abscess
cavity was syringed out with lot. acid. carb. (1-40), and a drainage
tube inserted. Linseed meal poultices were applied over carbolic
lint. In the evening her temperature rose to 100° F. Owing to
her restless condition a nurse was placed with her night and day.
On the 26th her temperature was 101° F. Belly swollen, tender,
and tympanitic. Ordered chloral hydrate, gr. xxx., tinct. opii.,
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398
Clinical Notes cmd Cases.
[July,
TTl xx., night and morning. Her mind did not show any sign of
improvement; she kept restless, distressed, and perverted in her
habits. Tried to tear off the dressings. Required to he fed with
her food. The wound continued to discharge, and her temperature
was elevated for some time. The abdominal distension and
tympanites gradually disappeared. She had some attacks of
vomiting, which yielded to the ordinary remedies. She was
worse mentally in the beginning of May ; fighting the nurses and
spitting at them, threw herself about and could only with great
difficulty be kept in bed. On May 2nd the drainage tube was
left out. The wound soon closed. On June 1st another swelling
was noticed to the right and a little above the old opening. The
swelling was poulticed, and in a few days opened in the old place
and pus evacuated. Careful search was made for the presence of
a needle without avail. The same mode of treatment was adopted.
Her temperature rose to 103° F. By June 26th the wound was
healed, her temperature normal, and she was up daily. She
remained melancholic and very suicidally inclined. Refused her
food, and was perverted in her habits and violent to those about
her. She continued to complain of vague pains in her abdomen,
not localized in any particular spot. She gained flesh and looked
better. At the end of January, 1892, she had an attack of
pneumonia at the right base, which, under treatment, cleared up to
a certain extent, leaving a cough and general crepitations. Her
temperature did not subside. In April there was albumen in her
urine. Under the microscope, blood, pus, and epithelial cells
were seen, but no casts. She was losing flesh and was considered
to be suffering from phthisis. She complained of pain in the right
flank, which was tender on palpitation. No tumour could be made
out. Crepitations were audible over both lungs, principally the
right one. During the last two or three days of her life her
breathing was hurried, pulse quick and feeble, temperature
elevated. She became unconscious and died on April 28th, 1892.
The post-mortem examination was made on April 29th. There
was nothing of interest in the brain, except the presence of some
tubercles and the marked asymmetry of the optic thalami. The
right lung was intimately adherent to the chest wall and to the
diaphragm. There was a small opening in the diaphragm,
external to the psoas muscle, communicating with an abscess in
the abdomen. The lung was one mass of fine tubercle. The
bronchial glands were enlarged and caseous. The left lung was
not so far advanced in tubercular disease. On opening the
abdomen, the liver was noticed to be adherent to the parietes in
the region of the gall bladder and on the right side to the ribs.
It was also adherent to the transverse colon. There was a large
abscess, bounded above by the diaphragm and inferior layer of the
coronary ligament. It extended downwards over half the kidney,
and laterally to the right free border of the liver, slightly turning
Digitized by ^ooQie
Clinical Notes and Cases.
899
1893.]
to the upper snrface. On washing away the pus on the right
edge of the liver a darning needle, about two-and-a-half inches
long, was found partially embedded in the substance of the liver,
point downwards in the long axis of the body. Tubercles were
present in the kidneys and spleen. The abdominal glands were
caseous and enlarged.
This case is interesting as showing the length of time a
foreign body like a needle can be in the abdominal cavity
without causing death. It was probably inserted in the
middle line, and, after wandering about, found a resting-place
in the liver, point downwards. The death was due to tuber¬
cular disease, apparently concurrent with the abscess set up by
the irritation of the needle. Attention might be drawn to the
little reliance that can be placed on the statement of lunatics,
their apparent immunity irom pain, and the slight symptoms
often shown in serious illness. Great difficulty was experienced
in deciding whether her statements were the outcome of
delusions or not. Dr. Tate has recorded in the Jounal of July,
1888, a somewhat similar case, only in his patient a hair-pin
was used and death occurred sooner.
OCCASIONAL NOTES OF THE QUARTER.
The Good Asylum Chaplain .*
The Good Asylum Chaplain realizeth the importance of
the trust committed to his keeping; he entereth upon the
office in no mercenary spirit, but with the primary object of
“ ministering to the mind diseased,” so far as the exercise of
his own special functions is likely to do good. The Good
Chaplain hath a sympathetic nature—one which magneti¬
cally attracts the sorrowful and the depressed instead of
repelling them. A minister without magnetic sympathy
hath no business in an asylum; he hath chosen a vocation
for which the very word is a misnomer, for he hath no call,
and the sooner he findeth other work the better for him and
for the patients. If for filthy lucre he retaineth his office
while not in touch with the insane—perchance even disliking
* Some years ago a distinguished mental physician, the late Dr. Isaac Bay, of
Philadelphia, wrote some admirable sketches of the “ Good Superintendent,” the
“ Good Matron,” etc., but did not include the Chaplain for the simple reason
that this officer is not essential to asylums in the United States. We venture
to paint the portrait which Dr. Bay omitted to give— [Eds.]
Digitized by L^OOQle
400 Occasional Notes of the Quarter . [July,
bis duties—be is a fraud. The Good Chaplain enjoyeth his
work; it is his daily joy ; he carrieth with him an atmosphere
of hope and cheerfulness which tendeth to inspire those with
whom he cometh in contact with renewed faith and confidence.
The Good Chaplain bopeth all things when his ministrations
seem to be useless, or even repelled. He knoweth the way¬
wardness, the suspicion, the aversion which may mark the
inmates of an asylum. He maketh allowance for their
behaviour and seeming rudeness. He considereth their
distress, and not the irritation which it causeth.
The Good Chaplain regardeth it as a fundamental axiom
that the false beliefs or the sense of spiritual desertion and
the fear of impending damnation are the indications of
physical disease, and neither the work of the devil nor the
expression of Divine wrath. He is no exorcist, not only
because the seventy-second canon of the Church of England
forbiddeth a clergyman to attempt exorcism unauthorized,
but because he hath learnt to regard the lunatic as the
victim, not of demoniacal possession, but of a pathological
state. And yet in a truer and higher sense, the Good
Chaplain striveth to exorcise the unhappy patient of his fears
and terrors by his ghostly counsel and kindly words of
comfort and cheer.
Another fundamental axiom with the Good Chaplain is
the duty of loyalty to the Medical Superintendent. He
realizeth that their common object is the welfare and
encouragement of the patient, and that although they
approach man’s dual nature from different standpoints,
there is no occasion to clash; nay, more, that if they do
clash there is great danger of the spiritual adviser doing a
great deal more harm than good.
The Good Chaplain studieth the character and special
circumstances of any patient to whom he may minister, and
adapts his counsel thereto. For example, this might be
materially and beneficially directed by his knowledge that
intemperance had been an important factor in the causation
of the attack of insanity.
The Good Chaplain in his sermons remembereth the
peculiar class of persons whom he addresses, and escheweth
all theological disputations; he is simple in his language,
loathes affectation, is earnest in the manner and consolatory
in the matter of his discourse. A son of consolation and
not a Boanerges is the fitting occupant of the asylum pulpit.
Simple and uncontroversial preaching is, however, not to be
Digitized by ^ooQie
1898.]
Occasional Notes of the Quarter.
401
confounded with monotonous platitudes, which are not only
a poor compliment to the more intelligent patients, but are
intolerable to that portion of the auditory which consists of
the staff of the asylum. The model Chaplain is not only
good; he is also a reasonable being, and doth not fall into
the mistake of supposing that his utterances must be on a
level with the imbecile element in his congregation.
The Good Chaplain, thus realizing his responsible duties
and the sacredness of his calling, is saved from the deadly
apathy which clotheth the bad chaplain as with a garment,
allowing him to perform his work in a formal, perfunctory
manner, to the discredit of his cloth, the contempt of the
staff, and the detriment of the unfortunate inmates of the
institution in which he holds an office of which he is wholly
unworthy.
From such asylum chaplains, good Lord deliver us 1
American Superintendents of Asylums and Politics.
Tf on a change of Ministry in England the medical super¬
intendents of asylums—Broadmoor, for instance—felt uneasy
as to their continuance in office, and one here and there had
this uneasiness unpleasantly emphasized by dismissal from
the post, astonishment and indignation would be excited.
Happily politics have nothing whatever to do with the
retention of office by the head of an English asylum, but
Dr. Dewey has found that this is not the case in America.
The Illinois State Journal remarks that “a noticeable
feature is Governor Altgeld’s declaration that * I appointed
in Dr. Dewey’s place Dr. Clevinger, 5 when the law provides
that these officers shall be appointed by the trustees, who
alone have authority to make such appointments.”
A system which winks at dismissal from the post of
asylum superintendent on political and not moral grounds,
is keenly felt to be unjust and intolerable. With the affairs
of other countries than our own we are not concerned, except
so far as they involve injustice and wrong to the medical
profession, and more particularly that branch of it which
embraces psychological medicine. On this ground alone do
we feel at liberty to criticise the action taken by the
Governor of the State of Illinois in deposing, as he has
done, Dr. Dewey from the office he had so efficiently and
humanely filled as Medical Superintendent of the well*
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Occasional Notes of the Quarter . [July,
known Kankakee Asylum, because of the political changes
which have taken place in America in connection with the
late Presidential Election. “The American Journal of
Insanity ” has protested in no uncertain tones against this
proceeding. In our own country a similar protest has been
entered in the columns of the “ British Medical Journal.”
It seems to us an imperative duty to support our American
colleagues in the action which, with certain discreditable
exceptions, the medical press has taken in this affair.
The Kankakee Asylum has been a most important object
lesson in demonstrating the advantages of detached houses
for insane patients, in addition to the main building. The
experiment has been carried out by Dr. Dewey in a most
efficient manner, and his name will always be associated
with this system. All who have known him and his work
have formed the highest opinion of his devotion to duty.
Yet this is the man who has been summarily dismissed from
his post. Whether his successor is an able man or not does
not in the least affect the question.
The criticism of the Governor of Illinois by the medical
press has roused him to reply. His vindication does not in
any degree remove the unfavourable impression which his
unfair treatment of Dr. Dewey has produced. We judge of
the truthfulness of his statements rebutting the charges
brought against him, by the correctness of his reply
when he observes:—“No doubt the Englishman who has
just crossed the ocean and has been down and eaten some
good dinners with Dr. Dewey, and has been shown over the
institution under the good doctor’s wing, can give us points
not only on how to run charitable institutions, but on
Bepublican Government in general. They generally do do
this. Almost everyone of that class who come over here
rides over the country in a palace-car, attends a few swell
receptions, and is lionized in a few places, goes home, and
writes a book on America. This particular Englishman
seems to be an improvement on the rest of them in this,
that he at least speaks well of his host while he is yet in
this country. Some of the others who have preceded him
had not politeness enough to wait until they got back across
the water before they went to slandering the people in this
country.”
We have good reason to know that “ the Englishman ”
had not “ crossed the ocean ” for some ten years. As to the
doctor’s good dinners, they must have been good indeed tp
exert so potent a spell so long afterwards.
Digitized by ^ooQie
1893.] Occasional Notes of the Quarter . 408
Commenting upon an interview with the Governor of
Illinois (who is a Democrat), the Illinois State Journal
observes —“ A careful reading of this remarkable interview
will reveal some amazing declarations for a Governor to make.
For instance, he says that be was prepared to show up the
Kankakee Asylum in a bad light, but did not do so because
the Democrats there were trying to get the asylum vote for
the Democratic ticket, and to help them in this scheme he
refrained from attacking the institution. In this connection
the Governor says that the Democrats of Kankakee some¬
times arranged with Dr. Dewey and the managers to get the
vote of the asylum for the Democratic State officers, and yet
the principal reason he gives for removing Dr. Dewey is that
he ran the institution as a Republican machine, and that all
the employes voted the Republican ticket.”
It is stated in the same Journal that “ the Governor’s new
trustees of the Kankakee Asylum, after thoroughly investi¬
gating the situation, came to the conclusion that the best
interests of the institution required the retention of Dr.
Dewey, and informed Governor Altgeld that they had
decided to reappoint him, but were told very emphatically
that they must appoint Dr. Clevinger, a Democrat, which
they obediently proceeded to do.”
It is alleged by Dr. Dewey himself, and we have no doubt
with truth, that he kept the asylum free from politics, and
that he deplores that it is now to be run on a political
basis.*
The Inebriates Act .
The hope to which we gave expression in the last number
of the “ Journal of Mental Science ” that the Inebriates Acts
would, without further delay, be amended so as to render
them really a deterrent and curative agent, is on the eve of
full fruition. The Department Committee which the late
Home Secretary, Mr. Henry Matthews, appointed to inquire
* Since the above was in type we have read with satisfaction the published
letter of a supporter of the Democrats, and one who “ took both pride aud part
in the elevation of Altgeld to the governorship.” Dr. Biese, to whom we refer,
writes—“I voice the sentiment of many Democrats when I say that had 1
anticipated the involvement of well-managed charitable institutions in the
political upheaval, 1 would, perchance, have acted differently. The Governor’s
action in this matter is unjustifiable. The hospital at Kankakee deservedly took
highest rank for its humane and conscientious management'’—The Tribune,-’
April 22,1893.
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404
Occasional Notes of the Quarter . [July,
into the best mode of dealing with habit a al drunkards, and
which consisted of Mr. J. L. Wharton, M.P., as Chairman,
and Sir William Hunter, M.P., Mr. Leigh Pemberton
Assistant Under Secretary, Home Office, Mr. C. S. Murdoch,
and Dr. David Nicolson, of Broadmoor, as members, has now
presented its report, which proceeds substantially on the
lines we foreshadowed in April, and Mr. Asquith, on whom
the official mantle of Mr. Matthews has fallen, has under¬
taken the task of giving to its recommendations a legislative
embodiment. The efficacy of the Inebriates Acts of 1879
and 1888, as all students of this interesting and important
subject are aware, was paralyzed by five cardinal imperfec¬
tions. The procedure by which habitual drunkards obtained
admission to the retreats, whose establishment the Acts
legalized and regulated, was absurdly complicated, and it
was often found that before the two justices, whose presence
the statutes required, could be brought together, the appli¬
cant’s zeal for sequestration had oozed away. The procedure
to secure the recapture of fugitives was equally cumbrous.
There was no power of compulsory committal. The maximum
period of detention (twelve calendar months) was in very
many cases too short for the remedial treatment which was
necessary, and the proprietors of licensed retreats were
practically unable to enforce upon recalcitrant inmates the
exercise, regular work, and submission to discipline which
were essential to their cure. With each of these defects the
Departmental Committee deal.
(I.) They propose that the Home Secretary should be
empowered to make rules and settle the form of affidavits
regulating the admission and re-admission of voluntary
applicants to retreats, in addition to or in substitution
for those prescribed in the schedule to the Habitual
Drunkards Act, 1879. The Secretary of State is also to
be enabled (with the concurrence of the Lord Chancellor)
to make a rules regulating the length of period of deten¬
tion, the procedure on applications for committal,” the
inspection of retreats, the release in proper cases of any
inmate of a retreat before the period of his detention has
expired, the recapture of fugitives, and the enforcement of
more rigorous discipline in the case of refractory patients.
While the Committee leave the definitive settlement of
these points to the Home Secretary, they do not fail to
throw out or refer to several useful suggestions which
deserve Mr. Asquith’s consideration. (1.) That circulars—
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1893.]
Occasional Notes of the Quarter .
405
or perhaps we might without levity style them prospectuses
—on the subject of the Inebriates Acts should be sent out
to magistrates and other persons in official positions. (2.)
That in place of the present cumbrous procedure, involving
(a) appearance before two magistrates in the country, or a
stipendiary, (fc) the testimony of two witnesses, appearance
before one magistrate, or a County Court Judge, should be
sufficient, and that such appearance need not be in open
court. (3.) That a power should be given, especially if com¬
pulsion be established, for the liberation of the patient on
license before the expiration of the period of committal, if
it appears that he has so profited by the discipline of the
retreat that a cure could be reasonably reckoned upon ; and
(4) That the grounds of discharge under section 18 of the
Act of 1879 should be confined to reasons personal to the
patient.
In connection with this part of the case the Committee
refer to an instance brought before them where a husband
(a publican) succeeded by an application under section 18 of
the Inebriates Act, 1879, in getting his wife removed for the
purpose of assisting him in his business before the period of
her detention had expired, with the result that she relapsed
into drunkenness.
(II.) The positive recommendations of the Committee
may be summarized as follows:—
(a.) The maximum period of detention should be raised to
two years. This is a suggestion of whose value and utility
no person acquainted with the working of the Acts of 1879
and 1888 needs to be convinced.
(5.) Power should be given for the compulsory committal
to a retreat of persons coming within the definition of an
habitual drunkard, as laid down in the Act of 1879, on the
application of their relations or friends, or other persons
interested in their welfare. Such application to be made to
any Judge of the High Court, County Court Judge, Stipen¬
diary Magistrate, or Justices sitting in Quarter or Petty
Session, who shall decide on its propriety.
The property of the person committed should be liable for
his maintenance, and that the order for committal should
provide, when necessary, for the appointment of a trustee of
the patient’s estate during the period of committal, with
power to apply the same towards the support of his wife or
family.
. Any order made for the compulsory committal of an
xxxix. 26
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406 Occasional Notes of the Quarter . [July,
habitual drunkard should be subject to appeal to a Divisional
Court.
The absolute necessity for the introduction of compul¬
sory sequestration was clearly demonstrated by the Select
Committee of 1872, of whose labours the Acts of 1879 and
1888 were the direct, though tardy and imperfect, result, and
practically the only question which Mr. Matthews’ Committee
had to consider was hew to reconcile compulsion with indi¬
vidual liberty. We are of opinion that the suggested
procedure contains a satisfactory answer to this question.
It should, however, be remembered by those on whose
initiative the compulsory clauses in the new Inebriates Act
will be put in motion that compulsion is intended to supple -
vnent and not to replace the present voluntary system. While
we are dealing with this subject, it may also not be out of
place to suggest that persons bond fide putting the new
legislation in force should have, mutatis mutandis , the same
protection that medical men now enjoy under the Lunacy
Act, 1890. Mr. Matthews’ Committee, however, properly
went further afield than the mere text of the Inebriates
Acts, and investigated the case of “ habitual drunkards who
come within the action of the criminal law, and are appre¬
hended for and charged with drunkenness, whether accom¬
panied with violence or not.” With regard to this branch
of their inquiry they recommend :—
(1.) That authority, as in section 25 of the Intoxicating
Liquors (Ireland) Act, 1874 (37 and 38 Viet., c. 69), should
be given to the police to apprehend, without warrant,
persons drunk and incapable in public highways, places, and
buildings, and to detain such persons when their names and
residences shall be unknown to the police and cannot be
ascertained, until they can be brought before a magistrate,
and thereby to carry out the provisions of section 12 of the
Licensing Act, 1872 (35 and 36 Viet., c. 94), the first clause
of which is reported to have become largely inoperative.
(2.) That additional powers should be given to magistrates
to bind in sureties and recognizances for a considerable
period habitual drunkards coming before them.
(3.) That reformatory institutions should be provided,
aided by contributions from Imperial and local funds
towards the cost of their building and maintenance (as in
the case of existing reformatories and industrial institutions
for juvenile offenders), for the reception and detention of
criminal habitual drunkards who might be subjected to less
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1893.]
Occasional Notes of the Quarter .
407
rigorous discipline than in existing prisons, and to the
performance of such labour as may be prescribed.
(4.) That failing or pending the establishment of separate
buildings for this class of criminals the existing accommo¬
dation in prisons, lunatic asylums, or poor-houses might be
utilized for this purpose.
(5.) That magistrates should have the power to commit to
such reformatory institutions for lengthened periods, with
or without previous punishment of imprisonment, habitual
drunkards (a) who come within the action of the criminal
law; (b) who fail to find required sureties and recognizances;
(c) who have been brought up for breach of such recogni¬
zances ; (d) who are proved guilty of ill-treatment or neglect
of their wives and families; ( e ) who have been convicted of
drunkenness three or more times within the previous twelve
months.
We welcome this Report, not only as an addition of per¬
manent value to the literature of inebriety, but as an
approximate solution of the very practical and instant
problems to which inebriety gives rise. When the principle
of compulsory seclusion has been permanently admitted,
and the period of detention has been prolonged, we shall be
many degrees nearer the legislative consideration of the
doctrine of “ release on cure”—the analogue of the doctrine
of “ indefinite punishments 99 which has so long been
preached in Italy, and successfully reduced to practice at
Elmira.
Townsend and the Test of Criminal Responsibility .
The trial of Townsend for threatening to shoot Mr. Glad¬
stone throws a curious and not uninstructive light on the
English law as to the criminal responsibility of the insane.
Judged by “the rules in MacNaghten’s case,” Townsend
ought certainly to have been sent to penal servitude. He
knew that the weapon which he had in his hand was a pistol,
and that when loaded with powder and ball it was capable
of taking human life. He was well aware that the act which
he contemplated was wrong, and that he would probably
have to expiate his crime (if completed) upon the scaffold.
He was thus (according to the strict letter of the law, de¬
livered by the judges to the House of Lords, and by the
House of Lords back &gain to the judges and to the country)
perfectly acquainted with “ the nature and quality ” of his
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408 Occasional Notes of the Quarter . [July,
act. And yet he laboured under a degree of mental impair¬
ment which would have rendered his punishment a public
scandal. The most curious circumstance in the whole case
was the eloquence with which Mr. Justice Grantham, sub¬
limely unconscious of the incongruity to which we have
called attention, first laid down the rules in MacNaghten’s
case as undoubted law, and then practically proceeded to
direct the jury to acquit the prisoner. The rules in Mac¬
Naghten’s case are absurd in theory, but they may be
manipulated with such ingenuity as to secure substantial
justice in practice.
Townsend’s brain was just one of those susceptible organs
which assimilate inflammatory language and endeavour to
carry it out in a literal sense.
Instruction for Teachers in Physiological Psychology .
The varying mental status of children and its connection
with physical conditions has been carefully studied of late
years, and has attracted some attention among those guiding
public education. Science and the knowledge gained by
observation is slowly but steadily affecting the minds of
educationalists and those in charge of children. The school¬
master, under a strong pressure of cultivated opinion as well
as from his own necessities, is becoming more inclined to
join hands with the doctor as a scientific adviser, and our
profession in its turn may well depart from a position of
passive criticism and offer such training to teachers as may
enable them to observe with some accuracy the varying con¬
ditions of their pupils, the indications of a wearied or dis¬
ordered brain, and the signs of mental action which may
serve as useful guidance in their training.
A stimulus to the study of practical psychology, from an
educationist’s point of view, has been given by the syste¬
matic record of observations in schools commenced in 1888
by a Committee of the British Medical Association, which
resulted in a full report * on 50,000 children, prepared by Dr.
Francis Warner, dealing with many educational problems of
great importance. This work is being continued by a Com¬
mittee appointed by the International Congress of Hygiene
and Demography, 1891, who have issued a circular to the
Universities, Training Colleges, and other educational
bodies, drawing attention to the desirability of a systematic
* Published by Messrs. Swan Sonnenchein and Co.
Digitized by L 5le
1893.] Occasional Notes of the Quarter. 409
course of lectures and practical instruction in the study of
conditions leading to mental and moral status, and raising
such studies to a more scientific level than in the past. We
understand that suggestions as to such teaching will be
gladly received by the Secretary of the Committee, Mr. E.
W. Wallis, Partes Museum. Various questions have been
raised at various times which can only be settled by accurate
scientific study, e.g ., effects of deficient training, effects of
over mental training, the benefits or otherwise of high
schools for girls, the increase of neurotic cases with advanc¬
ing education.
The Report of the Royal Commission on the Blind
was the first official recognition of a class of children
“ feeble mentally ” without being imbecile; the recommen¬
dations for such children were founded upon evidence drawn
from the school inquiry referred to, and following thereon
the School Boards for London and Leicester have made
special provision for feeble children; the matter is also
under the consideration of the Local Government Board.
The London University grants a certificate in the art and
science of teaching, and the question of degrees in this sub¬
ject is being mooted. At the University of Cambridge, in
Training Colleges, and at the College of Preceptors, lectures
on mental science are given to those training as teachers;
in our opinion it is highly desirable that “ physiological
psychology and the grouping and classification of children
should be incorporated as a part of such course. The sub¬
ject needs to be cultivated as a practical science founded
upon minute observation of visible facts with inference as to
the neural action corresponding to the expression of mental
states rather than as a purely metaphysical science. Teachers
with the children ever about them as the material upon
which they work may be trained to observe for themselves
and to make inferences as to the lines upon which they should
proceed with individual children as well as with groups of
cases. Teachers are not always aware that nervous children
are quick, gregarious, and imitative; they do not always
differentiate the dull from the defective or know the relative
effects of dealing with the child through eye and ear respec¬
tively, or the uses of physical exercises adapted to mental
peculiarities, as in eye movements, regulation of muscular
sense,andinincreasingspontaneity rather than in suppressing
it. All these matters are capable of scientific treatment,
and the principles involved should be clearly explained to
those training as teachers of the young.
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410
Occasional Notes of the Quarter.
[July,
THE ASYLUM CHAPLAIN’S COLUMN.
[We have received the following communication from the
Chaplain of the Colney Hatch Asylum as the first contribution
to what we hope will be a permanent feature of this Journal
—the column set aside for the use of chaplains attached to
asylums and hospitals for the insane.
In a circular addressed to these officers we have stated
that :—“ We have decided to introduce into the 6 Journal of
Mental Science ’ an Asylum Chaplain’s Column. It is
thought that the chaplains of asylums would be glad of
this means of publicly expressing their views on any matter
affecting the interests of the patients, so far as it falls within
their province to consider them. We have reason to believe
that chaplains will value this opportunity of communicating
their opinions and wishes in regard to the office they hold.
The Rev. Henry Hawkins has kindly undertaken to receive
and arrange any matter falling under the proposed heading.
All letters should, therefore, be addressed to him, Chaplain’s
House, Colney Hatch, N. It. is unnecessary to say that the
Editors reserve to themselves the right of admitting or
returning any MS. forwarded for publication in the Asylum
Column of the ‘ Journal of Mental Science.’ ”]
“ TJt Cooperatores Simw .”
Chaplains of asylums for the insane should feel indebted
to you for your willingness to set apart a Chaplain’s Column
in your valuable quarterly, for subjects connected with their
own special department of work. We chaplains are in a
position of partial isolation, living at a distance from one
another, and rarely meeting. The duties of the parochial
clergy, our neighbours, differ in many respects from our own,
and their experiences do not qualify them to supply the
particular advice and counsels of which we may sometimes
stand in need. The conditions under which they and our¬
selves carry on our ministerial work are not altogether
analogous. As regards communication with one another
through the Press, asylum chaplains are too few in number
(rari nantes) to establish and support a periodical of their
own. No doubt some of those already in existence would
occasionally receive communications from chaplains on sub¬
jects relating to their own field of ministerial work. But
Digitized by ^ooQie
411
1893.] Occasional Notes of the Quarter .
such, topics would rarely interest the readers of an ordinary
journal or magazine, and an Editor could not be expected to
permit their frequent recurrence, so that your kind readi¬
ness to assign a limited space in your serial for the discus¬
sion of subjects bearing on the work of asylum chaplains
deserves their respectful recognition. That small section of
the “ Journal ” would, of course, like the bulk of its con¬
tents, be subject to the supervision of the Editors. There
could not be “ imperium in imperio” At the same time, the
management would, no doubt, allow of as much freedom as
could reasonably be granted in the treatment of subjects.
They are numerous, and might profitably, from time to time,
be brought under review. It may be allowable to indicate
some of the topics about which chaplains might, with
advantage, take counsel of one another, to the benefit of
their own work and of those to whom they minister.
Questions would arise about the best methods of conduct¬
ing, in their various details, the chapel services ; about the
most edifying length of Sunday and week-day prayers, and
of sermons; about the frequency of Communions, and the
selection, from among patients, of communicants; again,
the results of experience with respect to the influence of
religious services on the insane might be profitably noted;
information on the subject of the admission of so-called
refractory patients to public worship would be useful to many
of us, as well as opinions whether this class, in our com¬
munities, should have separate religious services, or should
be associated with others—different views are taken of this
question; services for the staff or household might be appro¬
priately discussed in a Chaplain’s Column. Such intra¬
mural congregations, assembling, perhaps, late in the even¬
ing, after long hours of work, are differently circumstanced
from evening congregations in parish churches. The compo¬
sition of the choir again, whether consisting of members of
the staff, male or female, or of patients, or of both
associated, whether assisted in some cases by friends outside,
might be communicated, with the probable result of the
improvement of asylum choirs, which, in many cases, con¬
tribute greatly to the devotion and attractiveness of the
services. It may be sufficient in this brief paper simply to
enumerate some of the topics, which, by favour of the Editors
of the Journal, might be from quarter to quarter discussed
within the space considerately allotted. Ward services and
general visitations, ministrations to clinics in infirmaries
Digitized by ^ooQie
412
Occasional Notes of the Quarter. [July*
and elsewhere, visits to “ airing courts ” (why not gardens?)
affording opportunities of more private conversation of
chaplains with patients.— Correspondence on behalf of patients
with absent, often neglectful, friends, with very satisfactory
results.— Visiting days , on which intercourse may be held
with patients 9 relations and acquaintances, and much useful
information obtained. — The chaplain’s duties towards
colleagues and other members of the staff.— Variety of pulpit
ministrations by invitation to clergymen outside.—Introduc¬
tion to friendless patients of visitors and correspondents.
The subject of “ After-care.” —These are but some of the
matters connected not only with a chaplain’s department,
but with the common good of the house, which may be
allowed to come under review in the place kindly assigned
by the Editors of the Journal.
P.S.—Opinions are respectfully invited, in the next issue
of the “ J.M.S.,” on the subject of the limits of time within
which, having regard to the circumstances- of our congrega¬
tions, Sunday and week-day services, respectively, should be
comprised ? and of the arrangements best calculated to com¬
bine the integrity of church worship with moderate duration ?
H. II.
PART II-REVIEWS.
Hereditary Genius . By Francis Galton, F.R.S. Second
Edition. London: Macmillan. 1892.
The second edition of this important and laborious work
has been published after the lapse of nearly a quarter of a
century. Since its first appearance it has become possible
to look at the matter dealt with from a somewhat different
standpoint, to the attainment of which Mr. Galton has him¬
self largely contributed. The author has, wisely, left his
book as he wrote it, but he has added a prefatory chapter
which is of considerable interest. In this chapter Mr. Galton
makes two admissions which entirely disarm certain criti¬
cisms to which we have long felt that this book lay open.
The first concerns the title. In using the word “ Genius ”
Mr. Galton opened the way for some misapprehension which
would have been quite avoided had he selected the title,
which he now admits would have been better, of Hereditary
Ability. “ There was not,” he tells us, “ the slightest inten¬
tion on my part to use the word ( genius ’ in any technical
Digitized by ^ooQie
1898.]
Review*.
418
sense, but merely as expressing an ability that was excep¬
tionally high, and at the same time inborn. 55 A genius in
this sense is “ a man endowed with superior faculties; 55 he
is, in short, the “ man of talent/* who, by non-scientific
persons, is always opposed to the u man of genius,” so that,
though Mr. Galton 5 s use of the word “ genius 55 is etymologi¬
cally sound, it is certainly confusing. The second point
concerns the relation of “ genius in its technical sense ” to
insanity. A s the book originally stood, there was no reference
whatever to the abnormal psychology of genius. Any
acknowledgment, indeed, of a morbid mental tendency in
genius would seem alien to the spirit and argument of the
book. Mr. Galton now remarks, in reference to the close
relation between genius in its technical sense (whatever its
precise definition may be) and insanity, which has been so
strongly insisted on by Loinbroso and others, that while he
cannot accept entirely the data or the conclusions of those
writers, “ still, there is a large residuum of evidence which
points to a painfully close relation between the two, and I
must add that my own later observations have tended in the
same direction, for I have been surprised at finding how often
insanity, or idiocy, has appeared among the near relations
of exceptionally able men. Those who are over-eager and
extremely active in mind must often possess brains that are
more excitable and peculiar than is consistent with soundness;
they are likely to become crazy at times, and perhaps to break
down altogether. Their inborn excitability and peculiarity
may be expected to appear in some of their relatives also,
but unaccompanied with an equal dose of preservative
qualities, whatever they may be. Those relatives would be
‘ crank/ if not insane/ 5
It seems clear that Mr. Galton 5 s conclusions apply to a
somewhat smaller and more special group of individuals
than he had at the outset imagined. He finds the greatest
amount of hereditary ability amongst the judges, and he
acknowledges that poets come out very badly from this point
of view. The English judicial bench is the very last place
where we should expect to find a man of genius in the
narrow and “technical 55 sense of the word; judicial functions
offer no scope whatever for that originality which is certainly
one of the most characteristic marks of genius, while a
lawyer who displayed such originality would be sedulously
avoided in the selection of a judge. Probably the only
English judge who could by general agreement be said to
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Google
414
Reviews.
[July,
have possessed genius was Bacon, who did not owe his judicial
position to his genins, and who, as a judge, was a lament¬
able failure. (It is perhaps worth noting that Bacon’s
mother, who belonged to a family possessing eminent ability,
appears to have been insane, at all events in later life.) The
poets form a very different group; here genius—with that
aboriginal individuality of character which finds it difficult
or impossible to follow recognized methods of thought—is
in the long run the one thing that counts. From Mr. Galton’s
standpoint we should expect the very greatest men of genius to
be surrounded by the largest number of eminent parents and
brethren and children. As a matter of fact it is precisely
the greatest men of genius—Socrates, Dante, Shakespeare,
Newton, Goethe, etc. (Darwin is perhaps the most notable
exception)—whose relations do not rise above mediocrity,
and perhaps as often as not sink below it. Were Mr. Galton
to re-write his book it is probable that he would now make
some attempt to exclude men of genius in the narrower
sense; he would be justified in this, and by so doing he
would distinctly strengthen his argument. What he has
really proved is that natural ability, coming short of genius,
may be inherited or become a family possession; he has also
proved, more indirectly, that genius in the special sense of
the word is never inherited; he has not furnished a single
instance in which genius has passed from father to son, nor
are we able to supply such a case; that of the elder and
younger Alexandre Dumas may perhaps form the nearest
approximation.
Mr. Galton’s book, valuable as it is, leaves untouched the
study of the man of genius proper. This study has perhaps
been too much in the hands of alienists like L61ut and Moreau
and Lombroso, who have been biassed in favour of the belief
that abnormal psychology is necessarily morbid psychology.
It certainly does not follow that because genius has certain
relationships to insanity, genius is itself a form of insanity.
At present it is not possible to give a sound scientific defini¬
tion of genius; it is probable that it will become possible
when anthropologists and psychologists in the broadest sense
have further worked at the matter. It is among the services
rendered by Mr. Galton’s book that it has largely helped to
clear the field, and to render possible the precise psycholo¬
gical study of “ genius in the technical sense.”
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Criminology . By Arthur MacDonald. With an Introduc¬
tion by Dr. Cesare Lombroso. New York: Funk and
Wagnalls Co. 1893. Pp. 416.
This book is noteworthy as the first comprehensive attempt
to deal with criminology from the modern point of view
which has yet reached us from the United States. It is
divided into three parts. The first is a condensed summary
of a few of the results reached by European criminal anthro¬
pologists, and does not pretend to any originality; it
occupies 116 pages. The second part is entitled “Special
Criminology,” and occupies 196 pages. The last part is a
very full and useful bibliography of criminological literature,
filling not less than 111 pages; in regard to this biblio¬
graphy Mr. MacDonald acknowledges his indebtedness to
the recent edition of Prof. Enrico Ferri’s great work,
“ Sociologia Criminale.” Part I. is the least original part of
the bopk, and also the least satisfactory. It is scrappy and
uncritical. We should have been glad to see some of the
statements of European criminologists discussed from a
shrewd if sympathetic American point of view, but there is
nothing here but reproduction. For example, it is surely
time that we heard the last of the criminality of in¬
sectivorous plants, which (following various European
writers) Mr. MacDonald here sets forth in full, without a
word of criticism. The “ criminality” of a plant which
absorbs an insect must, one imagines, be about on a level
with that of a man who absorbs a potato, and must be
infinitely less than that of a man who goes out of his way to
eat oxen and sheep. It is an abuse of language to apply the
term “ criminal ” to any organized life-giving process
common to a whole species. A number of the so-called
“crimes” of animals are in no legitimate sense crimes. A
truly criminal act must be anti-social and of such a nature
that it could not possibly be performed by the whole species.
There have been very few careful or competent observations
of crime in animals; the best that are known to us are
contained in a paper “ On Degeneration and Criminality
among Carrier-Pigeons,” in a recent number of the “ Archivio
di Psichiatria,” by Muccioli, who is one of the chief Italian
authorities on these birds, and has made careful and special
study of their habits. He has found that true criminality
and degeneration (including various sexual perversions) are
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Reviem.
[July,
found among pigeons in a certain proportion of cases; there
are some birds which this observer regards as genuine
“ instinctive criminals,” and it is interesting to note that
he is obliged to eliminate these from his flocks, as they are
unsatisfactory as carriers, being less active and intelligent.
Mr. MacDonald remarks that among savages crime is the
rule, and proceeds to quote a number of practices which he
regards as illustrations of this statement. A very large
number of these are, however, practised by the whole tribe,
and are for the good of the whole tribe; they are not anti¬
social. There is no reason whatever to suppose that
criminality is more common among the savage than among
the civilized. Part II. is the most original and interesting
portion of the work; it contains the detailed histories of
six criminals whom Mr. MacDonald studied as thoroughly
and scientifically as circumstances permitted. He was
allowed to be locked up with some of these criminals whom
it was considered dangerous to allow out of their cells, and
he reproduces his interviews with them. This is a useful if
troublesome method, as it brings out very clearly the psy¬
chological peculiarities of the subject. We may add that
Mr. MacDonald has pursued the same methods in a still
more elaborate and interesting manner in the study of some
cases of morbid sexuality now appearing in the “ Archives de
l’Anthropologie Criminelle; ” these studies are illustrated by
portraits, while in the present volume there is a complete
absence of illustrations. It is to be regretted that mis¬
prints are extremely numerous.
Le Degenerazioni Psicosessuali nella Vita degli individui e
nella storia delle societa. By Silvio Venturi. Turin:
Bocca. 1892. Pp. 519.
Dr. Venturi, Director of Girifalco Asylum, who is well known
as one of the most thoughtful and original of the younger
Italian alienists, has in this book brought together many of
his studies on insanity, and has allowed himself a somewhat
free range. He is not altogether in sympathy with the
tendencies of current psychiatry, and believes that it is im¬
possible to study morbid psychology fruitfully except in close
relation with the anthropological evolution of the individual
as well as with social and historical conditions. He proposes
a “ natural classification ” of abnormal mental conditions
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1893.]
(setting aside as of secondary importance the various tran¬
sitory forms of mental balance): immaturity of the mind or
mental evolutive alienations (the forms and degrees of imbe¬
cility) ; senility of the mind or mental involutive alienations (the
forms and degrees of acquired insanities); and monstrosity
of the mind or mental alienations of varied degenerative nature
(criminality and genius, together with those psychopathic
conditions which, in Dr. Venturi's opinion, sometimes serve
as a basis to these conditions—epilepsy, hysteria, and im¬
morality).
The book is somewhat discursive. The most interesting
of the original observations recorded is probably the narrative
of the author's experiments on the lines of Brown-Sequard’s
hypodermic injections of testicular fluid. The testicles
chosen were those of rams and goats in a fresh condition, and
four insane subjects were selected in various states of
dementia and stupor. The general conditions, and the state
of pulse, pupils, temperature, etc., were examined before and
after the injections. The results were not constant in all the
subjects, but on the whole a certain degree of vasomotor,
mental, and especially emotional excitement was produced;
there was no influence on the pupils, and no sexual effect.
Dr. Venturi thinks it would be worth while to make further
experiments. In the course of his investigations it occurred
to him that if the testicular juice of rams and goats was pro¬
ductive of influence in human beings, human semen ought
to have still greater influence. He, therefore, made a fresh
series of experiments with human semen from a youthful aud
healthy subject, on five insane persons (four men and one
woman) in conditions resembling those of the previous four.
The semen was injected a quarter of an hour after emission,
and was diluted with water. It cannot be said that there
was any marked or constant improvement in the general con¬
dition of the patients, but a distinct nervous influence of the
semen was shown by the constant and decided dilatation of
the pupils produced, sometimes lasting for thirty-two hours.
Control experiments were made with white of egg, the injec¬
tion of which produced no effect whatever, nor did the injec¬
tion of stale semen. Dr. Venturi suggests that semen may
have a physiological effect on the nervous centres through
the mucous membrane, and that this may possibly be con¬
nected with the therapeutic effects of marriage in certain
cases of chlorosis and neurasthenia.
A considerable portion of the volume deals with the
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author's investigations in the anthropometry of the insane;
the general drift of his observations is that the physiological
and anatomical characters of acquired insanity are mainly
those of premature senility.
The hook is largely concerned, as the title indicates, with
the normal and pathological psychology of sexual evolution.
It is impossible to summarize Dr. Venturi's numerous dis¬
cussions on this subject. His opinions are frequently quite
opposed to our English traditions; thus he regards mastur¬
bation as playing a normal and healthy part in sexual
development, provided it is not continued beyond the period
of youth; but the author expounds his views in a vigorous
and suggestive manner which compels the reader’s attention
and respect, though it may not obtain his assent.
Antroyologia e Pedagogia. Meinoria del Dott. Paolo
Riccardi. Parte Prima: Modena. 1892.
This is the first part of an introduction to the science of
education by a well-known Italian anthropologist and
psychologist, who has for some years been engaged in
investigating the school-children of Modena and Bologna.
With the help of the teachers Dr. Riccardi has collected
100,000 observations on 2,000 children, and in this first part
he presents his psychological observations and sociological
and statistical researches. Italian children, it is well known,
are very frequently ill-fed and undeveloped; Dr. Riccardi
brings out very clearly the superiority in all respects of the
children belonging to the fairly well-to-do classes. His
memoir, which will be of considerable importance when
completed, is of interest to all who are occupied with the
many-sided problem of the study and treatment of abnormal
children.
Syphilis and the Nervous System. Revised Reprint of the
Lettsomian Lectures for 1890. By W. R. Gowers, M.D.,
F.R.C.P., F.R.S. London: J. and A. Churchill. 1892.
A reprint of these admirable lectures should be welcomed
by all physicians as the evident production of a thoughtful
and accomplished observer. Dr. Gowers simply desires to
render more definite the knowledge that already exisits on
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the subject, but there is much originality here both in the
matter and in the arrangement, and within 'the short
compass of lectures we really find an extensive account of the
relations of syphilis to the nervous system.
The importance of distinguishing between the specific
and the simple changes due to syphilis is accentuated,
especially in its bearing upon treatment. Diagnosis in
itself cannot be overdone, justly says the author. Before
beginning treatment one must accurately picture to one’s
self the changes that have taken place; remedies must then
be well tried, but it is decidedly harmful to prolong their
administration if no improvement occurs. It is the tissue-
formation of syphilis, in its early stages, that we hope to
remove, and in intra-cranial cases Dr. Gowers pins his faith
upon iodide of potassium. As regards ultimate prognosis,
the author says “ there is no real evidence that syphilis ever
is or ever has been cured; ” we only remove some of its
manifestations, hence the importance of warning the
patient.
In syphilitic disease of the walls of the arteries it is so
important to intervene promptly that Gowers dwells on
some of the points of diagnosis. The most frequent
syndroma in affections of the brain is hemiplegia from
embolism of the middle cerebral artery, and the important
points to notice in this connection are the frequency of pre¬
monitory symptoms, especially headache, the deliberate
onset of hemiplegia unattended by loss of consciousness or
convulsions in a patient between the ages of 25 and 45 un¬
affected by cardiac disease. When once the artery is blocked
the evidence of therapeutics fails us. The unilateral
paralytic symptoms occasionally observed in general paralysis
of the insane may mislead us.
Gowers agrees with Erb and Marie in attributing a large
share of the causation of tabes dorsalis to syphilis; 75 or 80
per cent, is not far from the real truth.
Among the limited but very important lesions arising from
syphilis are mentioned the degenerative ocular palsies, simple
atrophy of the optic nerve, and isolated loss of the light
reflex of the iris.
We find in this book a very full resume of our knowledge
on the relations of syphilis to the nervous system.
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[J^
The Germ-plasm: A Theory of Heredity . By August Weis-
vann. Translated by W. Newton Parker, Ph.D., and
Harriett Bounpeldt, B.Sc. London : Walter Scott,
Limited. 1893.
This work, dedicated by Professor Weismann to the
memory of Charles Darwin, is a most valuable contribution
to the scientific literature of the day, and the English trans¬
lators are to be sincerely thanked for adding a masterpiece
to the " Contemporary Science Series.” To carry out con¬
sistently a mechanical theory of heredity is a gigantic task,
and although the book has been and will be widely criticized,
and probably much altered before its views are accepted
generally, it stands at present as the best work on heredity,
and a triumph of skill and erudition.
In order to explain the many and varied problems of
heredity, Weismann finds it necessary to assume the
existence of units of various degrees, the characteristics of
which must be thoroughly grasped in order to understand
the book. These are :
a. Biophors (Lebenstrager) are the smallest units which
exhibit the primary vital forces, viz., assimilation and
metabolism, growth and multiplication by fission; they are
groups of molecules, the bearers of the cell-qualities, and
correspond almost exactly to the pangenes of de Tries. In
addition, the biophors have a capacity of rearranging their
molecules; the number of possible kinds is unlimited, and
may depend on the varying number of their molecules.
According to Weismann they must exist, and they constitute
all protoplasm.
Determinants.— These are particles of the germ-plasm
corresponding to and determining the hereditary parts or
determinates, these being the cells or groups of cells which
are independently variable from the germ onwards. The
determinant is always a group of biophors, never a single
one, and it is a vital unit of a higher order than the
biophor.
7 . The next units (of the 3rd degree) are groups of
determinants, formerly called ancestral germ-plasms, but
now termed “ ids ” by Weismann; there are several or many
in each idioplasm, and they are capable of growth and
multiplication by division, i.e., they also possess the funda¬
mental vital properties.
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8 . It is probable that the chromosomes of the nucleus,
which Weismann proposes to call idants, are series or aggre¬
gations of ids, and that the ids correspond to the microsomata
seen in certain animals, e.g ., ascaris megalocephala. These
idants would be split longitudinally (and the ids halved) in
division of the nucleus.
The idioplasm is the nuclear substance controlling any
particular cell, and the germrplant is the first autogenetic
stage of the idioplasm of an animal or a plant. The ids are
therefore the first units appreciated by means of the micro¬
scope.
In trying to elucidate further problems of heredity—
regeneration, fission, dimorphism, etc.—Weismann has
further to assume the existence of a hypothetical accessory
idioplasm, supplementary determinants, and double deter¬
minants. We see how complicated his theory is, but it is
difficult to conceive a simpler mode of explanation in presence
of the facts requiring analysis.
Armed with these units, Weismann proceeds through
many interesting pages to ingeniously unravel the deep
mysteries of heredity, and after travelling with him through
the intricate maze we can but express admiration for the
power of his intellect and his logical acumen and scientific
enthusiasm.
In the chapter on “ formation of germ-cells ” we find a
clear exposition of the dogma of the continuity of the germ-
plasm and the hypothesis of germ-tracks hinted at by the
late Sir Richard Owen, and much in accordance with
Galton's views ; and the author devotes his skill to refuting
de Vries' objections on the point, such as the power possessed
by fungi and mosses of reproducing a new individual from
any bit of the plant, which Weismann looks upon as an
adaptation for ensuring the existence of a species surrounded
by dangers of all kinds. Though opposed to the doctrine of
epigenesis in heredity, he is a firm believer in Darwinism;
thus he looks upon regeneration as a phenomenon of adapta¬
tion produced by natural selection, upon fission as originating
from a capacity for regeneration. To explain u alternation
of generations ” iu its relation to the idioplasm, the author
is forced to the conclusion that there are two kinds of germ-
plasm which continually pass simultaneously along the
germ-tracks, and each of them becomes active in turn.
In the chapters on sexual reproduction we find fresh diffi¬
culties, owing to the complicated structure of the germ-
xxxix. 27
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Remem.
[July,
plasm. According to Weismann’s theory, the individual is
determined at the time of fertilization, and in no case can
more than half of the idants of one parent be present in the
germ-plasm of the fertilized egg-cell. The principles of the
€t struggle of the ids ” and “ reducing division ” are discussed
at length and introduced by the author to explain many of
the facts observed.
The chapter on reversion is most important and admirably
written.
As a rule Weismann touches but little upon the domain of
pathology, but when discussing dimorphism he ventures
upon an explanation of haemophilia, assuming the existence
of double determinants.
Xenia and infection of the germ, which the author calls
“talagony,”are quickly dismissed as doubtful phenomena, and
probably arising from misconceptions.
As regards cases of idiocy and insanity arising from
drunkenness in the father, he considers that they are due to
an “ affection of the germ by means of an external influence,”
but does not consider that drink modifies the process of
heredity; and in the case of the transmission of diseases it
is to be explained by a true infection of the germ-cell— e.g., by
the microbes of syphilis, and not as due to inheritance in the
true sense of the word—that is from the transmission of an
anomalous state of the germ-plasm itself.
In the last part of the book Weismann dwells upon the sup¬
posed transmission of acquired characters (or somatogenic
characters)—the crux of the theory; for if we prove that
acquired characters are really transmitted, his theory falls to
the ground. With regard to Darwin’s hypothesis of a circula¬
tion of gemmules, he says: “ The process of the fission of
the idioplasm in nuclear and cell-division seems to me
directly and conclusively to refute the whole idea of the
circulation of the gemmules.” According to Weismann
“ All permanent—t.e., hereditary—variations of the body
proceed from primary modifications of the primary con¬
stituents of the germ, and neither injuries, functional
hypertrophy, or atrophy, structural variations due to the
effect of temperature or nutrition, nor any other influence of
environment on the body can be communicated to the germ-
9 ells and so become transmissible.
The facts observed in climatic variation in butterflies are
rather in favour of his theory than against, and certainly
are capable of clear explanation according to his hypothesis.
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1893.]
Finally is the chapter on variation. The author’s conten¬
tion is that although the two forms of amphimixis—namely,
the conjugation of unicellular and the sexual reproduction of
multicellular organisms—are means of producing variation,
yet the cause of hereditary variation must lie deeper than
this; tc it must be due to the direct effect of external
influences on the biophors and determinants.” Minute
fluctuations—imperceptible at first—occur in the elements of
the germ-plasm; then greater deviations in consequence take
place in the determinants, until we finally observe individual
variations.
We have but touched on the most striking parts of the
book, which must be a basis in all future work on heredity.
To the philosopher, the biologist, the physician, it cannot but
prove a source of the deepest interest. It is probably not
too much to say that it is an epoch-making book, and worthy
to rank with Darwin’s “ Descent of Man.”
The Nationalization of Health. By Havelock Ellis. Lon¬
don : T. Fisher Unwin. 1892.
Mr. Ellis, argues well in favour of the organization of
health, the importance of which we must all recognize, and
in the various chapters of this book makes successive attacks
on the weak spots in our present system of prevention and
cure of disease.
That much of our mortality is preventible no one can
deny, and Mr. Ellis gives forcible instances in the chapters *
on typhoid fever, maternity, the diseases of the occupations,
etc.; moreover, by systematic medical supervision, it would
be easy to improve the eyesight and the teeth of our
children. In a well-conditioned state we should soon have
little or no infectious disease, little or no toxic disease, far
fewer accidents, etc. At the same time, each individual of
the community is, to a large extent, responsible for his own
health and that of his offspring, and education of the people
must of necessity be a great factor in the future in the
maintenance of the health of the nation. We cannot by
Act of Parliament compel a man to eat or drink so much, to
marry such a wife, to avoid such and such a disease.
Mr. Ellis is a keen critic of the evils associated with the
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[July,
present system of fighting disease; we all appreciate the
drawbacks of general practice, the unsatisfactory system of
dispensaries, and the weak spots in hospital administration;
moreover, the infirmaries might be reorganized with mnch
advantage. We might, perhaps, take exception to his refer¬
ence to private practice as a system which is “ based on the
casual tinkering of disease; ” the soundest therapeutist is
not unfrequently a good all-round physician, and we hear a
good deal about the evils of specialism, so that in all
probability there is still a future for the competent general
practitioner who can set a limb, diagnose a dislocation, a
malignant tumour, recognize diphtheria, and carefully ad¬
minister opium. Many general practitioners are ignorant
owing to the laxity of certain examining boards, which
enable them to “ slip through their examinations ” on a very
small amount of knowledge, but the tendency is to turn out
better men and to raise the standard.
Mr. Ellis has an ideal, in favour of which he argues ably
and with force, but the practical reform of our health system
is beset with great difficulties. The chapters on the now-
called “preventable disease” are the most telling in the
book, and it is in that direction that we anticipate the more
immediate and useful results. We commend the book.
A New Psychology . • An Aim at Universal Science . By the
Rev. George Jamieson, D.D. Edinburgh: Andrew
Elliott. 1890.
To say that the author has set himself a gigantic task is
no exaggeration, and one need not be surprised that in the
endeavour to formulate a comprehensive theory he has to
constantly cross swords with many eminent men who have
preceded him in the search of the unknown. An attempt
to clear away the mists which hang over heredity, evolution,
vitality, etc., to formulate a science of mind, a science of
causality, to discover the origin and foundation of matter, is
so burdened with difficulties that we should not judge the
author severely if he fails to convince; but we hasten to say
at once that t,he Rev. Dr. Jamieson, though not convincing,
is to be congratulated on having produced a thoughtful and
able book, and on the ingenious exposition of his views*
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1893.]
The first chapter consists in a bold attempt to deal with
the kernel of the problem—a philosophy of substance. We
are all familiar with the ether of physicists; an investi¬
gation of the phenomena of light and heat and electricity
leads many to conclude that such a substantial medium exists.
This ether, which is capable of assuming all the conditions
of matter, has the following characteristics, according to the
author:—
1. It is the mother-substance out of which all qualities
are derived.
2. It has the attribute of non-limitation, e.g ., in respect of
extension.
3. It has the two inherent attributes belonging to
primitive substance—quality and energy, both generic.
4. After obtaining conditions from a primordial con¬
dition, it assumes a separate existence—hence conscious¬
ness.
Further on he adds that, “ upon the constitution of spirit-
forms, there is a capacity in these of being transmuted into
the crass forms of matter. ,,
The difficulty of conceiving a substance with such extensive
attributes is to us enormous; but assuming its existence,
the author goes on to speculation, “ a tort et & travers,” and
with much skill.
In the chapters devoted to the philosophy of mind with
matter, the philosophy of the conditioned, and the philosophy
of natural law, we find a discussion of the foundation of
morals, free will, etc.
Absolute substance is a high-sounding word, and “ mind-
stuff ” an unpretentious one; we are not sure that the latter
is not the best to use in the present state of our knowledge.
Drumkenness. By Qeorge R. Wilson, M.B., C.M., Assistant
Physician, The Royal Asylum, Morningside, Edinburgh.
London: Swan Sonnenschein and Go. 1893.
This study of drunkenness, intended, Dr. Wilson tells us,
more especially for the student of social science, is a valu¬
able contribution to the subject.
Although alcoholism is, as a rule, a symptom of some
nervous disease, it is so often such a pronounced one that it
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Revima.
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may be said to constitute a disease in itself, and, like insanity
and the infectious diseases, it calls for the earnest attention
of both the physician and the legislator.
In the four chapters into which the book is divided, the
author treats successively of the physiology, the pathology,
the setiology, and the therapeutics of alcoholism.
In the first chapter we find a lucid description of the
effects of alcohol on the nervous system according as it
affects the highest, the middle, or the lowest functional level;
the symptoms generally appear in a given order, beginning
with the highest level, which becomes more and more affected
as intoxication proceeds; this order varies somewhat in
certain individuals and with the kind of stimulant indulged
in. When we consider the pathology we find very much the
same sequence in the manifestations of the alcoholic state.
There is a general deterioration of character coincident with
dissolution of the highest level; lying is a prominent
symptom and dementia generally the climax. The evidence
of dissolution in the middle and lowest levels is seen in the
tremors, incoordination of movements, perverted sensations,
disorders of the muscular sense, etc.
Dr. Wilson then briefly refers to various forms of insanity
with alcoholism as a symptom, and to the causation of
insanity by alcohol. The classification is good, and the
summary carefully drawn up.
The third chapter, on the setiology of drunkenness, is
perhaps the best in the book, and it is of course the most
important, as we can do much more in this disease by pre¬
vention than cure. The characteristics of subjects pre¬
disposed to alcoholism are, according to Dr. Wilson:—
1. An unusual desire for stimulation (cerebral).
2. A palate which appreciates the first taste of alcohol.
8 . A liability to be affected by small doses.
4. A fulminating or explosive (impulsive) mode of nervous
action.
5. We notice an unusual order in the development of
symptoms produced.
The conditions predisposing to alcohol are next discussed
and their importance dwelt upon. The treatment of
drunkenness is often a stumbling block, but if the early
symptoms are observed we can often do much. In the case
of children who are predisposed, we must remember that
“ the first duty to the child is to make him a good animal; ”
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1893.]
up to the age of seven his nutrition must be all important;
between the ages of seven and thirteen we must see to his
motor development as well; and in the third period of
development, i.e., between the ages of thirteen and twenty-
five, we must, in addition, cultivate his intellect; and it is
best to forbid alcohol in these cases up to the age of twenty-
five. Among the poor, as the author remarks, we cannot
hope to do much in this direction at present.
During the alcoholic state we rely on dieting, sleep,
exercise, and fresh air.
The moral treatment of drunkenness is most important,
and Dr. Wilson’s remarks on the subject are judicious and
sound. We must endeavour to strengthen the internal con¬
trol of the patient. Some primitive form of self-interest
may act as a strong motive for abstinence—religion, love,
family affection, etc.; each case must, therefore, be care¬
fully studied. However, sooner or later, and in many cases,
external control is needed, either by a firm companion, whose
task, we may add, is most difficult and often a thankless one,
or by placing the patient in a suitable home.
There are three proposals by which legislation may im¬
prove or to some extent remedy drunkenness. 1. Prohibi¬
tion. 2. Improvement of the drink traffic. 3. Restricting
the liberty of certain individuals. Opinions may differ with
regard to prohibition, but all those who take an interest in
the question of drunkenness will agree with us, we think, that
the drink traffic ought to be improved in this country. Many
think that the Gothenburg system has much to commend
it. Finally, Dr. Wilson refers to the need for such acts as
the “ Habitual Drunkards Bill,” and “ The Restorative
Homes Act; ” undoubtedly it would be the saving of many
drunkards and indirectly the means of preventing the ruin
of many homes.
We hope the reading of this book will teach the com¬
munity something of the nature of drunkenness and the
way to tackle the problem practically; it is carefully written
and methodically arranged.
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Etat Mental dee HystSriquee: lee Stigmates Mentavx. Par
Piebre Janet, Pro/esseur agrSge dephilosopkie an ColUge
Rollin. Rueff et Cie. Paris. 1892.
M. Janet supports the opinion that hysteria is in the main
a mental malady. He has enjoyed the advantage of study¬
ing the symptoms in the service of Professor Charcot, at the
Salpetriere. As would be expected by those acquainted with
the author's writings, the work is philosophical in its
character, but is also medical. He divides the study of the
mental condition of the hysterical into two parts, the first
being the analysis of the mental symptoms or stigmata, the
second an examination of the accidental mental phenomena
of hysteria. The former only is treated of in these pages;
the latter is reserved for a future publication, to which we
shall look forward with interest.
Chapter I. treats of hysterical anaesthesia. This subject
has rarely, if ever, been so carefully studied. We have a
classification into systematized, localized, and general.
Hysterical anaesthesia, whatever form it may assume, has
characters peculiar to itself. Whether systematized or
localized, it undoubtedly depends upon the patient's own
subjective ideas rather than upon the anatomy of the part
affected. When general there is very slight modification
of functions, frequently none. In short, the distinction is
very great between hysterical and organic anaesthesia. The
following points are especially noted under the mobility of
anaesthesia. Hysterical attacks modify considerably the
distribution of sensibility; sometimes it is restored. During
natural sleep tactile anaesthesia often disappears; thus a
patient with left hemianaesthesia, when pinched on the left
side during sleep, groans, and calls out, “ You pinch me; it is
cruel," etc. Insensibility is more or less removed by certain
intoxications, which induce temporary excitement, or states
resembling sleep. There are, as is well-known, numerous
changes in sensibility during artificial somnambulism. A
person's sensibility may alter even when awake. The effect
of electricity in establishing sensation when lost is instanced,
as also the effect of magnets, etc. Very important is the
influence of suggestion, although, as pointed out, it
frequently fails. Again, vivid emotions and absence of mind
increase anaesthesia. M. Janet especially notes the effect of
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1898.]
attention. With the hysterical it is difficult to fix or direct
it. Rapid changes in sensation render observations difficult.
Further, the phenomena are often contradictory. The
observations on unilateral amaurosis are critical and im¬
portant. They prove that “ hysterical anaesthesia not only
changes from moment to moment, but even at the same
instaut varies, and is manifested by contradictory pheno¬
mena according to the mode in which the subject is interro¬
gated.” We may record the following formula: “ Anaesthesia
is a very great and perpetual distraction, which renders its
subjects unable to connect certain sensations with their
personality; it is a narrowing of the field of conscious¬
ness ” (p. 44). The two principal opinions upon which M.
Janet’s view rests are:—First, the conception of elementary
sensations, real from a psychological point of view, but
not related to personal consciousness; and secondly, the
conception of a weakness and indifference, in consequence
of which the subject ceases to interest himself in his sensa¬
tions, or indeed to perceive them. We must realize the im¬
portance of sub-conscious sensations. External movements
indicate sensations, the simplest being reflex acts. We
usually regard most of these as organic in character, inde¬
pendent of mind. There are complex movements, which
can only be explained on the supposition of there being a
true sensation, and M. Janet instances cataleptic attitudes.
The sum of the conclusions arrived at by M. Janet may be
thus expressed. Hysterical anaesthesia does not seem to be
an organic malady, i.e ., a disease of the nerves or the lower
centres,* but a mental disorder. It is not situated in the
limbs or in the cord, or in the basal ganglia, but in the
mind—that is to say, the highest functions of the brain.
(To be continued.)
Evolution and Man’s Place in Nature. By Henry Calder-
wood, LL.D., F.R.S.E. London: Macmillan and Co.,
and New York. 1893.
We have on a former occasion reviewed in favourable
terms a work written by the accomplished Professor of
Moral Philosophy in the University of Edinburgh*
* 44 The Relations of Mind and Brain.’* 4 Journal of Mental Science, M 1880,
p. 76.
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480
Retima.
[July,
There can be little doubt that a demand exists for a
treatise on the relation between the doctrine of evolution
and religious belief, or, at any rate, a calm statement of the
evidence in support of the former and a dispassionate dis¬
cussion of the great problem of man’s place in nature.
" The main objects are to trace the evidence of man’s
relation to the continuity of life on the earth, and to
describe the distinctive characteristics of human life itself”
(Preface).
The author gives a careful description of the accumulative
proofs in favour of the theory of evolution. Of course, Prof.
Calderwood is indebted to the investigations and writings of
original observers, but the authors depended upon are
acknowledged authorities, Darwin, Wallace, Spencer, Huxley,
etc. We may pass over the greater portion of the volume
which is descriptive, and seize the prominent feature of the
work which grapples with the question of how biology is
placed, in view of the facts set forth in favour of evolution.
It is admitted that man belongs to Nature, but it is denied
by the author that this includes his intelligent activity; in
other words, the science of mind overlaps that of biology.
The writer, therefore, contends that the doctrine of evolution
is insufficient to explain everything. It suffices as a scheme
of organic evolution, but it is inadequate to explain the
activity of a rational being. The bearing of evolution
on responsibility is elaborately studied. He is careful to
explain that it is beyond his province to examine Christianity
as a supernatural religion, except so far as it is a spiritual
force aiding the progress of mankind.
Thus it is strongly insisted upon, and it is repeated again
and again, that man, and man alone, although confessedly
subject to the laws of growth and nutriment, moves in a
world of being to which they do not apply. This separate
world is then the rational life. The biological unity between
man and the lower animals is broken, so that while it is
granted that life, even in man, is dependent upon environ¬
ment, his rational life is not so, nor is it ruled by sensibility.
Man alone is self-regulated.
At first sight nothing, it would seem, could be stronger
than the following admission:—
“The boundaries of animal life include man. The be¬
ginnings of organic life in the egg, the stages of progress in
embryonic history, animal activity depending on sensory
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1893.]
Reviews.
431
nerves, brain, and motor nerves, and even dependence on
environment, all hold as to man ” (p. 263).
The author, however, holds, as we see, that, in contrast
with this animal life of man, there are manifestations which
indicate a distinct and self-regulated life. Passing from
embryonic life, in which it is admitted that there may be no
radical difference between ape and man, Prof. Calderwood
finds in mature life a rational guidance of man’s physical
existence. Even the passions are in their nature just what
they are in other animals. The restraining power, the
proprieties, in short, the will, are peculiar to man. It is
true that for the human brain no claim is made for any
functions which the cerebrum of the ox does not possess.
But “ to know, to consider, to plan for the future, to shape a
purpose for immediate action, and to execute it in word or
deed,” are functions which belong to no other being on
earth. The author maintains that to assert that this realm
of “mind” falls within that of organic activity—there¬
fore brain—is to contradict evidence to the contrary (p.
267 ).
Clearly the crucial question is the difference between man
and brute. A more complex organism? The ability of
biology to present a science of human life ? No, is the reply
to both questions. It is pointed out that modem discoveries
in regard to the functions of the brain leave no room for the
complicated activities of reflective life. Is it conceivable
that all the glorious mental attributes of a Shakespeare or a
Milton could find their material organism in the residuary
brain substance left after all the motor and sensory centres
have been provided for ? This demonstrates the insufficiency
of any theory of evolution in vogue, for that which has been
evolved is a material structure altogether inadequate for the
purpose. What remains is “ a poor living-place, every day
being narrowed, to the extreme discomfort of the tenant ”
(p. 279).
This is forcibly put, and it is, perhaps, the strongest
argument employed in support of the author’s contention.
If it be said, in reply, that the very highest mental and
moral faculties may be affected or suspended by injury to
the brain. Prof. Calderwood would say that it is only the
instrument employed by the mechanic—the organ used by
the rational being outside the organism—which is disordered.
It is admitted by the highest authorities that mind and
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432
Reviews.
[July,
brain are not identical; that we are nnable to conceive the
link which connects them or the boundary line by which
they are separated. The late Dr. James Anderson, whose
premature death we have had so recently to deplore, was
accustomed to lay stress upon this admission, as leaving the
door open to a belief in men’s continued existence, in spite
of the dissolution of his brain.
Prof. Calderwood would be satisfied, we imagine, to allow
the argument to rest here, and to leave to others the task of
building up any system of theosophy which can be erected
upon it.
The author must, however, be allowed to speak for himself.
“ Little more remains to be said, as we contemplate for a
moment life’s close, on coming towards the gates of death.
Around this closing moment all life’s mysteries gather in
most impressive forms. Nowhere does man more deeply
feel how ignorant he is; how uncertain as to what the
future may contain. This is a moment which must terminate
our relations with Nature; a moment when we shall take
our first glance on a destiny implied in our moral life here.
Faith and ignorance may then meet in undisturbed com¬
panionship ; faith guiding through ignorance into a larger
knowledge ” (p. 331). Again, “ There is a power operating
continually in Nature, which does not come within range of
the observation possible to scientific modes and appliances,
yet to which science is ever indirectly bearing witness.
This power has manifested itself at the most impressive
periods in the world’s history, first at the appearance of
organic life, again on the appearance of mind, and again in
the advent of rational life. . . . This power is no dens ex
machind .” The author does not accept a God dwelling
apart from Nature, but maintains that there must be “ a
God immanent in Nature—immanent, yet transcendent-
transcendent, yet immanent. The representation which
would place the infinite being ‘ afar off,’ as if he dwelt
apart from creation, is alien to scientific knowledge, incon¬
sistent with the records of natural history, at variance even
with the conditions of rational life. ... Of Nature, as
interpreted by science, there is no other key than is
found in recognition of an immanent and intelligent cause,
in the midst of all, and concerned with all, that belongs to
the history of being. This is the first cause—the eternal
personality—related to the spiritual life of rational souls, as
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433
1893.]
He can be related to no other type of existence within the
wide sphere of creation ” (p. 342).
We can commend the spirit in which this thoughtful
boot is written, although we are alive to the difficulties in
the way of accepting the author’s conclusions. We have
indicated his strongest arguments, and if asked which are
the weakest, we should reply, those having reference to
man’s “consciousness.” Here there is evidence of a lack
of acquaintance with mental physiology.
Protestant Hospital for the Insane , Montreal. Annual Report
for the Year 1892.
Interest will always attach to this institution from the
circumstances under which it was established. It marked
an important movement forward in the humane treatment
of the insane in the province of Quebec. Its success de¬
pended, in a large measure, upon the appointment of the
superintendent. Fortunately, Dr. Burgess was elected. The
Report before us is a proof of the excellence of the choice
made for the post, and the efficient manner in which he
has carried out his duties.
Since the opening of the hospital six years ago, 377 patients
have been admitted. Of these 23 were congenital cases.
In regard to the number of attacks, 223 were first attacks,
58 second, 23 third, 8 fourth, 4 fifth; 38 were unascertained.
Since the opening of the hospital 148 patients have been
discharged, of whom 98 have recovered, or 25*9 per cent, of
the admissions. There does not appear to be a record of the
number of deaths during this period. We would venture to
suggest that the statistical tables admit of improvement.
There is no distinction between “ persons ” and cases; no per¬
centages are given, and readmissions are not separated from
admissions. It would be a great advantage to present in
one table the admissions, recoveries, deaths, etc., which have
occurred during the period the asylum has been in operation
—a table, in fact, corresponding to No. 2 of the tables of the
Medico-Psychological Association. As the institution has
been opened for so short a time, it would be extremely easy
to add No. 2a. We not only require to know how many
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434 Reviews. [July,
recoveries bare occurred, but bow many patients bare
relapsed and re-recovered.
In his interesting report. Dr. Busgess very properly
objects to the veto put by the law in force in the Province
upon voluntary admissions. “ Few superintendents but at
some time have bad persons come to them, at their own
accord, praying to be taken in, and there are few more
painful duties than to have to refuse such prayers. Some¬
times it is the premonitory symptoms of a recurring attack,
sometimes the preliminary signs, such as insomnia and
lowness of spirits, of a first onset that lead to the
application. These cases are on the border-line of insanity.
They are not yet insane, but there is every likelihood of
their soon becoming so, and they would in most cases be
benefited by a course of hospital treatment, to which they
are quite capable of giving voluntary assent.” We hope to
learn in a future report that this absurd and mischievous
restriction has been removed.
We wish every success to this well-conducted institution.
May the present medical superintendent be spared many
years to preside over it!
Carl Westphal’s Oesammelte Abhandlungen. Edited by Dr. A.
Westphal. Two volumes. Berlin, 1892. August
Hirschwald.
It is with very great pleasure that we welcome the publica¬
tion of the collected works of the late illustrious Westphal,
which have been brought together in two large volumes by
his son, Dr. A. Westphal. The amount of work which the
late Professor achieved for neurological and mental science
was quite prodigious, and will be better understood when it
is stated that the first volume contains 580 pages, and the
second over 800 pages of original papers and descriptions of
cases.
The first volume is devoted to mental diseases, and con¬
tains papers on the relations of tabes dorsalis to general
paralysis of the insane; on observations on epileptiform
and apoplectic fits of paralytic mental diseases; on pro¬
gressive paralysis of all the ocular muscles in mental
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Reviews.
485
1893.]
diseases; on agoraphobia; followed by short papers on
subjects such as periodic mania; dipsomania, with autopsy,
showing multiple tumours in cerebral dura mater, soften¬
ing and haemorrhage in the pons; hypochondriasis in
a child aged 12; a case of theft, with a peculiar form of
dementia with thrombosis of the basilar artery and the
right Sylvian artery, chronic meningitis of the cerebral con¬
vexity.
The volume is completed by four medico-legal judgments
in insane cases, speeches, and reports.
In the second volume, on neuro-pathological wort, are
contained the papers which are the most original, and on
subjects so familiar to all neurologists. The first section is
on Disease of the brain with pathological lesions, and con¬
tains papers on syphilis of the brain; on cysticerci and
echinococci of the brain; a case of tumour in the left middle
cerebellar peduncle, causing bilateral deafness and left
hemiparesis; two cases of tumour of the hemisphere; on
the localization of unilateral convulsions and hemianopsia ;
and a case of tumour in the left temporal region without
aphasia in a left-handed person.
The second section is devoted to diseases of the spinal
cord and other communications in the domain of neuro¬
pathology, and contains no less than 46 different papers.
As it would not be possible to give even the titles of all
these, we can best give an indication of the matter contained
in them by saying that in the first place the history of
the so-called “ tendon-reflexes” can be traced in these papers,
as in 1875, Professor Westphal first described the “ phe¬
nomenal movement produced by mechanical action on
tendons and muscles/’ and which he states he had first
observed in a patient in 1871. This seems to have been his
first paper on the tendon reflexes in hemiplegia, and it is
interesting to note that Professor Erb published indepen¬
dently in the same year his observation of the same phe¬
nomenon. This was followed in 1877 by a paper on the
patella-tendon reflex and nerve-stretching, in which it was
shown that stretching the crural nerve in the rabbit
abolished the reflex.
In 1878 was published the article on a subject with which
Westphal’s name will ever be associated, viz., the loss of
patella-tendon reflex in tabes dorsalis, a symptom which
more than any other has facilitated the diagnosis of this
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486
Reviews.
[July,
disease, and which is here described as an early symptom of
tabes dorsalis. This was followed by a paper in 1881 on the
disappearance and the localization of the knee-phenomenon,
and in the next year by one on a source of error in observ¬
ing the knee-phenomenon.
In 1886 was published the paper on persistence of the knee-
phenomenon with degeneration of the posterior columns, in
which it was shown that the knee-jerk was not lost unless
the posterior root zone was involved in the disease, and the
same point was borne out by another case, with autopsy,
of failure of the knee-jerk on one side only.
Amongst other papers are the relation of syphilis to tabes
dorsalis, on nerve-stretching in tabes, joint diseases in tabes;
on a form of paradoxical contraction of muscles; on com¬
bined disease (lateral and posterior columns) of the cord;
two papers on syringomyelia, one of which was published in
" Brain; ” on multiple sclerosis in two boys; two papers
on paralysis agitans; on two cases of Thomsen’s disease;
on some cases of muscular atrophy, involving the face
muscles; and on two sisters, with pseudo-hypertrophy of
muscles.
Altogether there are in the first volume 28 papers, and in
the second volume, on neurological work, no less than 56
papers, and the variety of subjects treated on is shown by
the list described above. It will thus be seen that the two
volumes give some idea of the untiring energy and profound
clinical observation of the author, and they will remain for
all ages as a perpetual monument to the genius of the
illustrious Westphal.
Those who, like the writer, have had the good fortune to
work with the late Professor, will always cherish the most
pleasing memories of the extreme kindness which they
received from him in going round the wards of the Charit6
Hospital. The exhaustive examination which he there gave to
the most minute details of every case furnished a lesson in
exact observation which those who witnessed will never
forget.
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1893.]
437
PART III.—PSYCHOLOGICAL RETROSPECT.
1. Pathological Retrospect .
By Edwin Goodall, M.D.Lond., B.S., M.R.C.P., West Riding
Asylum, Wakefield.
The subjoined scheme, drawn up by the writer eighteen months
since, has been put to practical test at the West Riding Asylum
during that time, and found to answer its purpose. Several prac¬
tical suggestions made by Dr. C. H. Bond, Pathologist at Banstead
Asylum, have been incorporated with it, and are here acknow¬
ledged. The corresponding scheme for the spinal cord it is pro¬
posed to give in a later number.
EXAMINATION OF BBAIN AND COVERINGS,
hours p.m.
Examination
Temp. Room.
C more.
Atmosphere : Humidity of < less.
(.usual.
Scalp —Anomalies or Lesions of.
Skull-Cap (sawn at fixed level, e . g. t
3 centim. above root of nose).
Thickened or thinned.
If alteration, gen., local.
Transluoency, degree of.
Diploe at cut surface.
Amount.
Colour (vascularity).
Meshes open or filled up (incr.
density).
Hard or soft.
If alteration, gen., local.
Pacchionian indentations.
Size.
Depth.
More or less numerous.
Bosses or Spicules from Inner Table.
New Layering of Inner Table.
Bosses from Outer Table.
Colour (vascularity;.
Symmetry.
Weight.
Caries of bone.
Any lesion not coming under above.
Measurements.*
a . Diameters.
Antero-posterior.
Transverse
(Others if time permits).
b. Circumferences.
Antero-posterior.
Skull-Cap ( continued )
Transverse.
Horizontal.
Base of Skull.
Any lesion of, esp. caries.
Symmetry.
State of palate.
Membranes.
a . Dura Mater and processes of.
Adherent to skull-cap.
Extent of adhesion.
Site „ „
Degree „
Tense J normally.
lense \ unduly.
Flaccid (wrinklod).
Thickened or thinned.
If alteration, gen., local.
Colour (vascularity).
Any local congestion.
Adherent to arachnoid.
Undue amt. subdural fluid.
Quality of „ „
Semi-gelatinous, lymph-flakes.
Cysts.
Blood-effusion or new formation
on inner surface: N.E. cha¬
racters of.
Bony deposits in.
Sinuses of.
Capacity.
Contents.
* According to directions given by Topinard ("Anthropology *).
xxxix. 28
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438 Psychological Retrospect. [July,
Membranes ( continued)
Lining-membrane.
Undue adhesion to base of skull.
Any lesion not coming under
above.
b. Arachnoid (at parts distinct from
pia).
Undue granulation of outer sur¬
face.
State of Pacchionians.
Undue opacity (esp. white spots
and patches, indicative of
thickening).
Site of.
Degree of.
Swollen, gelatinous (site).
Blood-effusion in connection with
(site).
Sub-arachnoid fluid : quantity:
any notable alteration in
quality.
Amy lesion not coming under
above.
e. Lepto-meninges,
Undue opacity.
Site of.
Degree of.
Normal teniiity, or
Swollen, gelatinous.
Gen., local.
Vascularity: excessive, or pallor.
Gen., local.
Blood-effusion: site.
Adhesion to cortex.
Extent, site of adhesion.
Strength of adhesion.
If no adhesion, how does pia strip
from all parts : normally, or
in sheets.
Amy adhesion between hemi¬
spheres.
Amy lesion not coming under
above.
Cerebrum.
Size.
Average.
Small.
Large.
Diminution in size of individual
lobes.
Consistence.
a. Indications of gen. diminu¬
tion of.
(i.) On superficial inspection.
Collapsed state of hemi¬
spheres.
Undue separation of hemi¬
spheres.
Cerebrum ( continued ).
Laceration of corpus callosum.
Gaping sulci.
Etc.
(ii.) On Palpitation.
b. Firmness of C. as a whole,
average, or increased [degree
of increase].
Undue surface-greasiness.
Grey Matter and Gyri.
Diminished consistence (flabby,
yielding too readily to pres¬
sure, etc.).
General.
Local: old, recent (tint).
Firmness average.
Sclerotic changes, with site.
Arrangement main gyri.
Degree of convolution.
Atrophy of gyri.
General (state of sulci).
Local (convolutions sunken
below gen. level anywhere).
Colour (vascularity), on surface
and section: any patchiness
of colour.
Blood-extravasation: site.
Erosion from stripping pia: site.
Cheesy, chalky nodules, or other
focal lesions: seat.
White Matter.
Consistence : average possibly in¬
creased.
('Tested by touch.
Diminished J water-stream, sec-
Gen., local / tion: does subst.
cling to knife ?
Colour (vascularity).
State if local alterations.
Vessels coarse, bristly.
Blood-extrav.: seat.
(Edema (slighter degrees shown
by brilliance of exposed sur-
face).
Undue porosity (6tat cribld).
Indicative of atrophy.
Sclerosis : seat.
Scars, cysts, nodules, or other
focal lesions: seat.
Any recent softening about these.
Other lesions not coming under
above.
Basal Ganglia and Capsules.
Size (of ganglia) any shrinkage
laterally (atrophy).
Consistence.
If softening: seat.
If sclerosis „
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1893.] Pathological Retrospect . 439
Cebebrum { continued )
Colour (vascularity).
Blood-extrav.: seat.
Scars, cysts, nodules, or other
focal lesions: seat.
Etat cribld (of ganglia).
Other lesions, not coming under
above.
Ventricles (lateral and third).
Dilated.
Excess of fluid.
Appearance of fluid removed by
pipette.
(More precise examination in
special cases if desirable.)
State of ependyma.
Granular, thickened, macerated.
Anomalies of cornua.
Consistence of fornix, white and
grey commissures, septum
lucidum.
Abnormalities of choroid plexuses
and
Velum interpositum.
Congestion, exudation in, cysts,
etc.
Other lesions not coming under
above.
Corpora Quadrigemina, state of.
Pons and Medulla.
Size.
If diminution, gen., local (incl.
unilateral).
Consistence.
If diminution, gen., local.
Colour (vascularity).
Blood-extrav.: seat.
Ependyma of fourth ventricle.
Does pia strip normally.
Pons and Medulla ( continued )
Other lesions not coming under
above.
Base of Cebebbum.
Main vessels at base.
Relative size of corresponding
ones.
Arrangement.
Atheroma.
Occlusion.
Cerebral peduncles.
,, nerve-roots: optic traots.
Pituitary body.
Other lesions not coming under
above.
Cebebellum.
Size.
If diminution, gen., local (incl.
unilateral).
Consistence.
Normal.
Softening: gen., local.
Sclerosis: seat.
Colour (vascularity) of grey and
white matter.
Blood-extrav.: seat.
Corpora dentata.
Does Pia strip normally.
Other lesions (as growth) not coming
under above.
Weights.*
Whole Brain.
Bight Hemisphere.
Left „
Pons, Medulla, and Corp. Quadri¬
gemina together.
Cerebellum.
Amount of Fluid collected.
Lysol as a Preservative .—The writer’s attention was first drawn
to lysol by an article in “ Zeitschr. f. Hygiene,” 10 Band, 2 Heft,
1891, by V. Gerlach, who there demonstrates its strong antiseptic
power. He appears to use solutions varying in strength from 1-5
per cent. Lysol is composed of tar-oils which have been rendered
soluble in water by special treatment. That used by the present
writer is a dark-brown fluid, with an odour at once suggestive of
its origin. Al| per cent, solution is made with distilled water;
a little agitation produces a clear fluid with a yellow tint. In this
strength lysol has been employed tentatively in the laboratory of
this asylum as a preservative of fresh tissues. It has been found
to prevent decomposition altogether. Relatively speaking, the
odour is preserved well (fading of the blood-tint in notable degree
* And of individual lobes if desired.
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440 Psychological Retrospect . [July,
appears unavoidable, whatever the preservative medium employed).
Tissues acquire an unnatural translucency; this is a disadvantage
which applies to lysol. Recently Dr. Hime, of Bradford, showed
the writer the intestines and portions of other viscera from a case
of cholera. These had been in lysol 1 per cent, several weeks;
they were quite sweet, and presented an almost natural appear¬
ance. Lysol may be set down as non-poisonous in the strength
recommended (l| per cent.), and its odour (like that of creolin)
would probably be agreeable to most people—properties which
may be accounted advantageous where occasional handling of pre¬
parations is necessary. It may be mentioned that a one per cent,
solution serves to disinfect the hands entirely, according to Gerlach.
Thoma's Preservative Fluid. —This was brought to the writer’s
notice by Dr. Alex. Bruce. It is to be recommended for the pre¬
servation of the natural colour of organs. Thoma uses two fluids,
apparently indifferently. Fluid A is the one employed here, though
for no special reason. The formula are as follows:—
A. B.
Crystals of Sulphate of Soda
Chloride of Sodium .
... 100 grammes
60 grammes.
... 100 „
100 „
Chloride of Potassium
... 100 „
100 „
Nitrate of Potash.
... 10 „
10 „
Water ••• ... ••• ...
... 1 litre
1 litre
Tissues are washed as little as possible at the autopsy. Large
organs, such as liver and enlarged spleen, should be cut into slices
of the thickness of a finger. All pieces or organs should be hung
up in the fluid, so that opposite surfaces do not touch. After 18-
24 hours in A or B brush off any blood on the surface, and place
in spirit, which should be changed once or twice.
Qravitzs Preservative Fluid (for fresh preparations).—This has
been in use some time, but as the formula does not appear to be very
accessible. It is given here:—Common salt, 150 grm.; sugar, 40
grm.; saltpetre, 20 grm.; water, one litre. Add three per cent,
boracic acid, or some tartaric acid, until the solution is acid.
Fresh preparations are placed in the above solution, and then
this fluid is diluted with water until the preparations sink. Re¬
place by fresh fluid in 4-8 weeks.
Giacominis Process for Presetting Brain .—This process, the re¬
putation of which is well established, is referred to here, not with
the object of detailed description (for this see Lee’s “ Microtomist’s
Vade-Mecum,”) but simply to lay tress upon one or two practical
points. Book-teaching is to the effect that the brain should be
left in sat. aqu. sol. chloride of zinc for five days or so. Here the
zinc is employed for a much longer period, from 4-6 months,
because shrivelling of the surface and collapse of the organ in
mass have ensued when it has been used for a shorter time.
Should this shrivelling occur in specimens otherwise good it may
be removed by keeping the organ in glycerin for a prolonged
Digitized by ^ooQie
1893.] Pathological Retrospect. 441
period (weeks to months). Remove the varnish by spirit before
immersing in the glycerin.
Stieda's Process for Preserving Brain .—A modification of the pre¬
ceding. Place the brain in chloride of zinc, sat. aqu. sol.; leave
24 hours. Pia now removed. Transfer to 96 per cent, alcohol;
change latter every 5-6 days. Brain sufficiently hardened in 2-3
weeks. Place in turpentine; leave 2-4 weeks. This penetrates
the quicker the better the brain has been dehydrated; at least
two weeks needed. The organ becomes again rather soft, but
“ transparent; ” it acquires a brownish tint. Place in varnish
(so-called “ drying-oil”) for two weeks. Remove and allow to
dry thoroughly in air. Experience here shows that much more
shrinkage takes place by this method than by Giacomini’s, and
that a cheesy dryness of portions of the surface quickly occurs,
even when much more time than that recommended is spent over
the process. Dr. Adair, Pathologist at Wadsley Asylum, has also
failed to get satisfactory results with the method. By stopping
short of the varnish-stage and leaving the brain in the turpentine
the writer finds that very good museum-preparations may be
obtained.
An Axis-Cylinder Stain .—Quite recently Stroebe (“ Centralbl. f.
Allgem.,” Path iv., Band No. 2) has described a novel method of
staining the axis-cylinder which he has found very serviceable in
the study of peripheral nerve regeneration, but also quite satis¬
factory for staining this structure in the central nervous system
—a result which was to be expected, since the fine axis-cylinders
of the young nerve-fibres met with in the earliest phases of re¬
generation form severe test-objects for stains. The special feature
of this method is that a practically isolated stain of the axis-
cylinder is obtained. Effective contrast-staining is possible. The
procedure is as follows:—1. The tissue is hardened in Muller,
thereafter in alcohol (if desired), and sections cut as usual. 2.
Stain in fresh sat. aqu. sol. anilin-blue, 10 min.-l hour; sections
become blue-black, 3. Wash off excess of stain in water, then
place in. a small porcelain-dish of absolute alcohol, to which have
been added 20-30 drops of one per cent, solution of alkali-alcohol
(1 grm. caustic potash to 100 ccm. alcohol). In the alkali-alcohol
sections turn of a light-rusty colour, clouds of reddish colouring *
matter issuing from them. As soon as these cease to form, and
the sections are of a light red-brown colour and transparent, dif¬
ferentiation is complete (1-several minutes). 4. Wash in distilled
water (5min.) ; the sections acquire a clear blue tint. 5. Contrast-
staining in cone. aqu. sol. safranin, dil. with equal parts of water,
hour. 6. Place in abs. ale. to remove excess of safranin, and
to dehydrate; the sections now look red, with a tinge of blue.
Xylol, xylol-balsam. Axis-cylinders appear dark-blue, medullary
sheaths, cell-protoplasm, ground-substance, and cell-nuclei various
shades of red; the last-named sometimes retain the blue colour.
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442 Psychological Retrospect . [July,
iKulschitzky's Stain for the Central Nervous System. —Sections
made from tissues hardened in Muller or in Erlicki’s fluid are
stained for 18-24 hours in the following solution, slightly acidified
before use by the addition of 2-3 drops of acetic acid to a watch-
glassful of stain:—Hsematoxylin, grm. i.; abs. ale., a few ccm.,
sufficient to dissolve this; saturated sol. boracic acid, 20 ccm.,
dist. water, 80 ccm. The stain is at first yellow, but in 2-3 weeks
becomes deep-red, and is then fit for use. A simpler way of pre¬
paring the stain is as follows :—Dissolve 1 grm. heematoxylin in a
few ccm. alcohol, and add 100 ccm. of two per cent. aqu. sol. acetic
acid.
After staining, wash in alcohol; here differentiation takes
place. The medullary sheaths of nerves are stained deep blue;
other tissues remain unstained or acquire a yellowish tint. Stain¬
ing is particularly effective when the sections, after differentiation,
are allowed to remain 24 hours in sodium or lithium carbonate
(sat. sol.). By allowing sections stained after the ordinary
Weigert-Pal method to remain (after differentiation) in cone,
lith. carb. sol. awhile the staining is improved, a fact brought to
the writer’s notice by Dr. Adair.
Lissauer introduced the following method of conducting Wei-
gert’s process—distinguished by its rapidity. If reliable (the
writer has no experience to adduce) it is certainly worthy of
adoption. Sections as thin as possible, from tissues hardened in
Muller, are placed in one per cent. sol. chromic acid, w hich is care¬
fully warmed until bubbles begin to form ; they are then lightly
washed in water, and again warmed, in similar fashion, in Wei-
gert’s heematoxylin solution. The usual treatment with perman¬
ganate of potash and sulphurous acid is then proceeded with.
Medullated fibres are stained deep-black, and are brought out
uncommonly distinctly.
2. Retrospect of Criminal Anthropology .
By Hivelock Ellis.
The Elmira Reformatory.
The “ Year Book ” of the Elmira Reformatory for 1892 is an
admirably produced volume ; it contains, also, a very large number
of process illustrations from photographs, as well as 100 woodcut
portraits of inmates with accompanying histories. Like last
year’s “ Year Book,” it is the product of the intelligence, skill,
and industry of inmates engaged on the institutional journal,
“ The Summary.”
It is satisfactory to find that considerable space is devoted this
year to the interesting operations of the Physical Training
Digitized by ^ooQie
443
1893.] Retrospect of Criminal Anthropology .
Department, under the superintendence of Dr. Hamilton Wey.
This comprises a gymnasium and a Turkish bath, and in some
cases is associated with special dietary treatment. It has some¬
times been found a valuable substitute for the hospital. Last
year 132 inmates were assigned to this department for physical
betterment and renovation. Shallow respiration and pulmonary
insufficiency were found to be common defects in these men.
“ Incredible as it may appear, breathing exercises, with voluntary
forced expansion and contraction of the chest, are the most difficult
of accomplishment. These boys possess only to a limited degree
the power of conscious control over the muscles of respiration.
Almost invariably when told to draw in the breath, they practise
expiration, and at command to empty the chest, inflate it.
Swimming has frequently been found to bestow what conscious
efforts failed to yield.” The dull and stupid class received con¬
siderable attention. “ They are deficient in nervous energy,
easily taking on flesh, like a stall-fed ox, and displaying their
greatest activity in obedience to sensuous promptings. With this
class physical education inculcates habits of obedience, mental
concentration, and application, and forces into the background the
former man.” There are a number of photographs of men of this
and other types; a series of interesting nude full lengths is also
given, showing the condition before and after six months of
physical training (back, front, and side view, t.e., six photographs
of each individual) ; the improvement is equally obvious, whether
the subject was physically gross or emaciated at the outset.
“ Most of the men,” we are told, “ were of inferior stature,
small-boned, and indifferently nourished. For the reason that
they existed prior to and at the time of commitment, these condi¬
tions cannot in part be charged to the effects of prison life.
Certain effeminate traits—in facial lines, soft and low voice, and
diminished growth of hair in axillary and pubic regions—appear.
If certain ones were clothed in more attractive dress than the
severely plain prison garb, they would pass for artless and guile¬
less boys among confiding and unsuspecting people. At the
plastic age crime cannot be clearly read upon the face. Numerous
examples of gynecomasty have occurred, ranging from a rounded
development of bust and prominent nipple surrounded by a deeply
pigmented areola to well-defined mammary glands that have
periodic seasons of congestion and attempts at functional activity.
In one instance there was well-marked glandular secretion.”
The skin is usually found to be dry and harsh; there is im¬
paired tactile power; acne in all stages is extremely common.
Pronounced facial and cranial asymmetry also often exists, and
unequal contraction of thej muscles as in mild cases of facial
paralysis.
It is interesting to note that the emotional instability which in
England has been chiefly observed in female prisoners is here
Digitized by L^ooQle
444 i Psychological Retrospect. [July,
found in a marked form. “Waves of ascending nerve-currents
are frequently witnessed, manifesting themselves in passing
destructive tendencies, irritability, or sulks; or an unexpected
and unprovoked assault upon a fellow-prisoner may result from
accumulated nervous energy. Changes in manner and appear¬
ance convey to the trained observer, days in advance, the approach
of a nervous storm, and in extreme cases afford an opportunity to
confine Hie subject, that the attack may be modified and shortened.
These nervous storms are of common occurrence, but happen with
greater frequency in early spring and fall.”
A kindergarten was established last year. This was an excel¬
lent step, for at Elmira, as in every large convict prison, a con¬
siderable proportion of the inmates are still in the infantile stage.
“Few of them can distinguish between the days of the week,
between the months, seasons, or years.” The kindergarten was
founded on Froebel’s method, with a few variations. Twenty men
have passed through it, and “as a result, while in some individual
cases little or no success has been apparent, a vast improvement
has been noticed in others.” An examination was recently held,
which was on the whole passed satisfactorily. Here are a few of
the questions :—What is a circle ? Write down the five vowels.
Three are how many times one ? What number must I take from
three to have one left ? As seven months previously these unfor¬
tunate creatures “ were utterly incapable of forming the slightest
idea upon any of the subjects chosen, were practically soulless,
devoid of all mental perception, as untutored as the newly-born
babe, the progress made will not be judged as mean.” It is
possible that in the future a kindergarten will become an adjunct
of every large convict prison, as Elmira is now more than ever
being regarded as a kind of criminological laboratory in which
experiments are tried for the benefit of the world generally.
Among the 1,500 inmates of Elmira there are some, it need not
be said, of very different mental calibre from the kindergarten class,
and the experiment has been tried during the past year of allow¬
ing some of these to deliver lectures to their fellow prisoners on
various subjects. This seems to have been entirely successful,
and such lectures were listened to by many of the hearers with an
interest which would not have been given to a speaker from
without.
A word may be said as to “ The Summary,” the weekly news¬
paper published in the reformatory. It is now in the eighth year
of its existence, and it has a circulation of 2,500. It is in every
detail the product of inmate talent; editors, engravers, printers,
and pressmen are all prisoners. All items of a sensational or
criminal character are excluded from its pages, but it contains
valuable contributions from eminent criminologists in Europe and
America. “ The Summary,” therefore, not only contains informa¬
tion about Elmira, but also deals with the general problems of
Digitized by ^ooQie
445
1893.] Retrospect of Criminal Anthropology .
crime and the methods of dealing with them, and it has a deserved
circulation among criminologists throughout the world.
Criminality and Insanity in Women.
In the “ Zeitschrift fur Psychiatrie,” Band 49, Dr. P. Nacke, of
Hubertusburg, has lately studied, in a careful and detailed
manner, from the clinical, statistical, and anthropological points
of view, a number of normal, insane, and insane criminal women
(“ Verbrechen und Wahnsinn beim Weibe,” and in a subsequent
number of the “ Zeitschrift,” “ Die Anthropologisch-biologischen
Beziehungen zum Yerbrechen und Wahnsinn beim Weibe ”).
The investigation was not in every respect satisfactory; it did
not include any group of criminals free from insanity, the
“ normal ” women investigated (asylum attendants, etc.) seem to
have been singularly abnormal, and the general results have been
somewhat vitiated by Dr. Nacke’s inability to study each group in
an equally thorough manner. On the whole, however, Dr. Nacke’s
study is an important contribution to the rather scarce literature
dealing with the criminal anthropology of women. It is con¬
cerned with details as well as with the broader problems involved,
and there is constant reference to the results of previous investi¬
gators ; the list of books referred to covers nine pages. In the
first part of his work, Dr. Nacke gives the clinical histories of (1)
53 women who were brought to Hubertusburg Asylum from
prison, and of (2) 47 insane women who had undergone imprison¬
ment at some previous period. Later on these two groups are
statistically and anthropologically compared with (3) 42 insane
Women and (4) 100 normal women. The clinical histories are
necessarily somewhat condensed, so that they cover less than fifty
pages, but many of them are of considerable interest from the
psychological point of view. One defect may be mentioned,
because it is so important and so common. We are told in
reference to a very large proportion of the crimes of violence here
recorded that the woman was menstruating at the time; in the
other cases we are told nothing on this point, although it is just
as important to record the absence of the function as its presence ;
unless this is done the affirmative cases have no significance. It
is probable (as is suggested even by the histories here) that most
crimes of violence in women occur at menstrual epochs, but we
have at present no series of cases which conclusively shows this.
In recording the history of a criminal or insane woman, the
relation of any violent act to the menstrual cycle should be
noted as a matter of routine.
Of group I. nearly all belonged to Saxony, and not less than 77
per cent, were single, though they were mostly in middle or later
life; seven were described as prostitutes; 53 per cent, were
domestic servants. On analyzing their mental condition, the
author concludes that 15*1 per cent, were certainly insane at the
Digitized by ^ooQle
446 Psychological Retrospect [July,
time they committed the act for which they were punished, while
20*4 per cent, were in all probability insane ; that is to say, that
of these 53 women, at least 20 to 25 per cent., or from one-fifth to
one-quarter, were wrongfully punished. This is, as is here
observed, a “ colossal figure,” but in perfect accordance with the
results of other investigators. “ Langreuter asserts that in 1884-5,
in Prussia, of 1,200 insane persons received from prison, at least
one-third were insane at the time of the deed ; Mendel places it at
three-fourths; Sommer, among his insane criminals, found very
few who were quite normal before the deed; and Kirn, among 129
prisoners, only found 15 who were mentally sound.”
Of group II., the 46 insane women who had at some time in
their previous lives come into conflict with the law, 66 per cent,
were unmarried; they all belonged to Saxony, and to the poorest
class. Of these 19 2 per cent, were certainly insane at the time
they committed the act for which they were imprisoned, and 23’4
per cent, were probably insane, the total being, again, one-fourth
to one-fifth. The case is mentioned of a congenitally imbecile
woman, who was imprisoned 142 times without any suspicion as to
her mental condition occurring to the judge. Such facts furnish
strong evidence ready to the hand of those who seek to modify
judicial procedure in such a manner that the criminal anthro¬
pologist may sit beside the judge, or that the judge should himself
be a criminal anthropologist.
A very marked psychic characteristic of the women in group I.
is their nervous irritability. The extraordinary proportion of
62*2 per cent, are liable to outbursts of violence. Most, though
not all, of those who are violent are also destructive—45*3 per
cent, of the group. The worst class includes those who exhibited
unmotived outbursts of impulsive violence (“ Zuchthausknall ”) ;
these form 23 per cent, of group I. These outbursts (as Dr.
Nicolson found in England) usually occur at menstrual periods,
and, with two exceptions, only during the period of sexual life,
although the average age of the women is high. Other psychic
characters of the group are the grossest egoism, discontent with
everything, a tendency to lie that seems compulsory, and often a
tendency to steal, while they are fond of playing all sorts of
tricks, and are mostly ungrateful, envious, and jealous.
After a brief description of the various systems at present
adopted for the treatment of insane criminal women, Dr. Nacke
declares himself in favour of that adopted at Perth.
In the second article, the author records the average result ob¬
tained from a number of anthropometrical measurements—heights,
colour of hair and eyes, various head measurements, observations
on eyes, teeth, ears, etc.—on the 241 women included in his four
groups. It is impossible here to summarize all the results, which
are, however, very clearly and methodically arranged, with some
amount of general discussion on their significance and relations to
Digitized by ^ooQle
447
1893.] Retrospect of Criminal Anthropology .
the results of other investigators. Dr. Nacke appears to have
been in correspondence with some of the chief German anthro¬
pologists, many of whose opinions he here quotes. He found
large heads (as measured by horizontal circumference) most
common in group TY. and least so in group 1. In group 1Y. also
the anterior part of the head is larger and the posterior smaller
than in group III. All are mesocephalic, but more especially
group IY.
The author concludes that there is an intimate relationship
between criminality and insanity, both having a common root.
He attaches great importance to the social factor in determining
criminality, the common predisposition being given, and he will
not accept a “ criminal type ” in any sense. He considers that
the rare examples of “ congenital criminality ” (in Lombroso’s
sense) may be identified with “moral insanity” or, as Neumann
has termed it, social feeble-mindedness.” It must, however, be
added that the fact that the difference in the signs of degeneration
between the criminal, insane, and normal is only “ relative ” and
not “absolute ” cannot—as Dr. Nacke seems to think—be said to
make against Lombroso, who has certainly been guilty of ex-
aggerations, but has never claimed that there is any specific
physical sign of criminality, and would entirely agree with Dr.
Nacke that it is simply a matter of greater frequency of degenera¬
tive signs.
In a subsequent article, Dr. Niicke has given the results of the
examination of 16 female skulls, including those of at least eleven
criminals (murderesses, thieves, etc.) and one suicide (“ Unter-
suchung von 16 Frauenschiideln darunter solchen von 12 Yerbre-
cherinnen, incl. einer Selbstmorderin,” “ Archiv. fur Psychiatrie,”
Bd. xxv., Heft i.). The skulls belonged to the Dresden Anthro¬
pological Museum, and nothing is known of the subjects beyond
their names and the offences of twelve ; there is some reason to
believe that all sixteen were criminals; it may be taken for
granted that all the women belonged to Saxony. A very remark¬
able character of these skulls is their great breadth; even the
average cephalic index of the 16 is hyperbrachycephalic
(87*4), and in the four murderesses it reached nearly 90.
The average capacity was by no means small, 1332*5; this
is more than the average German female skull, but is probably not
large for the Saxons, who are a large-bodied people ; and Nacke’s
observations on the living go to show that the insane and insane
criminal women have smaller heads than normal women; the
thieves had distinctly larger heads than the murderesses, which
is contrary to the experience of Lombroso and some other ob¬
servers ; but, as usual, it was found that the range of variation
was very great (1165 cc.m. to 1520 cc.m.), and that there was a
preponderance of very large and very small heads, the medium¬
sized heads being in a minority. There have not been many ob-
Digitized by L^ooQle
448 Psychological Retrospect [July,
serrations on the skulls of women criminals, and it has been
asserted that they show fewer abnormalities than those of men, but
Dr. Nacke has found abnormalities to be extremely numerous.
Ten of the skulls were abnormally heavy from excess of bony
growth, and most of these, strangely, belonged to old women; the
tenth was a fairly normal skull, but of masculine character. Many
of the skulls showed rachitic signs; four of the twelve criminal
skulls were hydrocephalic, and other minor abnormalities were
numerous and well marked. Of the 16 skulls nine were distinctly
pathological, which seems to indicate that the brains they con¬
tained were probably pathological also, and suggests that a con¬
siderable proportion of these criminals were really insane. (Dr.
Nacke refers more than once to the sketches of criminal heads by
the late Dr. Yans Clarke in the present writer’s book, “ The
Criminal,” as surely exceptional. I may say that I merely selected
average examples from Dr. Clarke’s much larger series, and that
Dr. Clarke assured me that the portraits were not to be regarded
as exceptional; it must be acknowledged that they are not very
elaborate or skilful and that salient features have no doubt become
exaggerated. I would add that the composite photographs in the
same volume, which Dr. Nacke contrasts with Dr. Clarke’s
sketches, are of first offenders only; hence their comparatively
normal character.)
The Medico-Legal Journal,
This journal, the organ of the Medico-Legal Society of New
York, is developing in a vigorous manner. Although published in
America, it is largely international in character, and it devotes
considerable space to English affairs and English contributors.
Dr. Orange is the vice-president for England, Dr. Ireland for Scot¬
land, and Mr. Wood Renton (to whom were entrusted the legal
articles in the “ Dictionary of Psychological Medicine ”) is the chief
English legal representative. An International Medico-Legal
Congress is to be held at Chicago in August under the auspices of
the Medico-Legal Society, and a large number of well-known
European and American alienists, criminal anthropologists, and
lawyers will be present to read papers or join in the discussion.
The congress promises to be very successful, and if it should suc¬
ceed in supplying its British members with a sufficiently vigorous
stimulus to induce them to go home and found a society and a
journal which will give doctors and lawyers a common meeting
ground, it will have done good service indeed. In the meanwhile
“ The Medico-Legal Journal ” ought to find many readers in this
country. Its latest feature (and that of the Society whose organ
it is) is a special psychological section, with Mrs. C. van D.
Chenowith as chairman, and Mr. Clark Bell, the energetic editor
of the journal, as secretary. “ It is proposed to investigate every
branch of psychological $nd psychical inquiry by organized com-
Digitized by k^ooQle
449
1893 .] Retrospect of Criminal Anthropology .
mittees. The section of hypnotism will be merged in this section,
and investigations of hypnotism, psychical research, or psychical
phenomena, in all forms or phases, conducted under its super¬
vision.’* Among recent articles may be mentioned (beside several
elaborate and very fully and admirably illustrated papers on blood
and blood-stains in medical jurisprudence), “Criminal Responsi¬
bility in General Paralysis,” by Dr. Norbury; “ Criminal Respon¬
sibility in Inebriates,” by Mr. Clark Bell; “ The Criminal Insane,”
by Dr. Graham; “ The McNaghten Case,” and a report of the
International Congress of Criminal Anthropology, by Mrs. Louise
Thomas, the delegate of the Medico-Legal Society.
The International Association of Criminal Law.
This Association continues to make progress and to develop its
activities, although it cannot be said that it has exhibited much
sign of advance in our own country. There are now over 600
members, representing thirty different countries, and the Associa¬
tion contains within it three national groups—German, Norwegian,
and Belgian—with independent activities. The object of the
Association is to apply the knowledge of criminal anthropology
gained by medical science to the reform of criminal law, and
although this is a matter which primarily concerns lawyers, it is
one to which medical men cannot be indifferent, and for the accom¬
plishment of which their assistance is necessary. During the
coming autumn there will be a general reunion of the Association,
at which the following questions, among others, will be discussed :
What influence can sociological and anthropological studies have
on the fundamental conceptions of criminal law ? introduced by
Alimena, Garofalo, Gauckler, von Liszt, and Tarde; The indeter¬
minate sentence, introduced by Brockway, van Hamel, and Prins;
The method of organizing uniform and scientific statistics of
recidivism, introduced by Bodio, van Hamel, and Koebner. An
alienist will also introduce the discussion of moral insanity.
The Association is also engaged on an important but complicated
study—“ The Codification of Comparative Criminal Legislation.”
The first volume of this work will shortly appear.
3. Therapeutic Retrospect .
By Harrington Sainsbury, M.D.
At a recent medical meeting in Budapesth, Oct. 22, 1892, Dr.
Schreiber combats the view that electrotherapy is suggestion-
therapy, though he is obliged to admit the latter to be a potent
factor in the use of electricity. Amongst other differences, he
states that electricity is able to remove inflammatory products, to
cause their absorption, whilst suggestion is unable to effect the
same. We should be inclined to doubt the possibility of stating
Digitized by ^ooQle
450 Psychological Retrospect . [July,
so definitely what suggestion cannot do, but at the same time we
should be more than prepared to allow that electricity is able to
do something, for good or for evil, on its own account. To deny
this would be to affirm that an agent With very definite physical
powers, to which motor structures and sensory nerves respond
very readily, is without effect upon the organism as a whole.
Surely electricity is something more than the hospital mistura
flava\ at least, we must hope so.—“ Therap. Monatsh.,” Jan.,
1893, p. 32.
On By-Effects and Toxic Actions of Recent Medicaments. By Dr.
Richard Friedlander, of Berlin. “ Therap. Monatsh.,”
Jan., 1893, p. 43.
Dr. Friedlander discusses the action of Rental , C 5 H 10 , as an
anaesthetic, and draws attention to certain by-effects, which warn
us, at least, to be cautious. Pental, we fear, is in great danger of
losing its good name, if, indeed, it has not already lost it, for the
absolute safety of administration promised by Prof. Hollander is
contradicted by a death recently reported from Vienna. Cases
reported by Hollander himself, and by Brener and Lindner, indi¬
cate marked depression of the heart’s action or of the respiration
as of occasional occurrence. The choice of an anaesthetic concerns
us all, and, unfortunately, an absolutely safe one is yet to be dis¬
covered.
On Sulphonal Action. “ Therap. Monatsh.,” Feb., 1893, p. 57.
Dr. Emil Schaffer, Assistant Medical Officer at the Grand Ducal
Asylum of Heppenheim, gives a very interesting account of a
form of sulphonal intoxication which has only recently been
recorded in one or two instances. He describes the occurrence of
definite changes in the urine and in the blood. The urine acquires
a dark-red colour, due to the presence of the so-called liaematopor-
phyrin or iron-free-haematin. This body shows very definite
chemical and spectroscopic behaviour, which render its identifica¬
tion easy. The blood in Schaeffer’s case showed changes indicating
a poverty of red cells and of htemoglobin, but, unfortunately, the
number and the colouring power of the cells were not estimated.
Accompanying the above urine change was a diminished diuresis,
and further there were abdominal pains and tenderness, especially
in the regions of the stomach and liver, obstinate vomiting and
marked constipation; the tongue moist and red. The patient lost
flesh progressively, one-third of the body weight on admission
(41 kilogrammes to 27 kilogrammes), and there was great pros¬
tration, also an irregular pyrexia. After these had been noted,
the better known motor and sensory symptoms of chronic
sulphonal poisoning appeared, viz., unsteady gait and occasional
giving way of the lower limbs, with loss of patellar reflexes,
Digitized by A^OOQie
451
1893.] Therapeutic Retrospect.
ataxia and weakness of the arms, slow and difficult speech, and
great desire for sleep—paraesthesias were also present. The total
quantity of sulphonal taken was 180 grammes, and within the
space of 270 days. The daily dose when taken was one gramme
(15*5 grains). The author then refers to other effects which
have been recorded against sulphonal, e.gr., the sulphonal exanthem,
attacks of heart weakness, paralysis of the extensors of the fore¬
arm, exactly simulating lead poisoning (Jastrowitz), etc. In his
own case he thinks the obstinate constipation present facilitated
the accumulation of the sulphonal effects, but though the patient
did suffer from slight habitual constipation on admission, it is by
no means clear that the subsequent marked increase of this trouble
was not itself an effect of the poison. In the present case the
haBmatoporphyrinuria calls for special notice, for up to the present
only some twelve cases in all have been recorded. The moist and
red tongue observed by Dr. Schaffer, and the fact that indigestible
substances did not increase the severe epigastric symptoms,
demonstrates, he thinks, that there was no real stomach mischief,
and favours the view of Knoblauch that the vomiting of sulphonal
is cerebral. Having in our mind a recent case of marked
chronic sulphonal poisoning with epigastric pain and tenderness,
and with moist red tongue, we are tempted to combat this view
most decidedly. The tongue that we saw was obviously an
irritable tongue with thin epithelial layer, and along with the
anorexia present, there was a by no means tolerant stomach.
The author, in conclusion, admits that though heematoporphy-
rinuria has been noted in other affections, yet it has been recorded
(though with a small total) in sulphonal poisoning more often than
in any other morbid state. Its occurrence, he says, adds much to
the gravity of the prognosis.
Ethylic Chloride , C 2 B 6 Cl. “ Therap. Monatsh.,” p. 113, March,
1893.
Dr. Edgar Gans, of Carlsbad, reports on the value of this drug
in the treatment of neuralgias. He reminds us of the use in
France of the chloride of methyle (CH 3 C1.) for the same purpose
—this since the years 1884-1885—but adds that in the chloride of
ethyle, first introduced by Redard as a local anaesthetic, we have
an equally efficient and more easily applied remedy, as well as a
safer one. Ethylic chloride is a colourless liquid of ethereal odour,
boiling at about 10° C. (50° F.). It is supplied for therapeutic
purposes in small tubes about 5in. long, and drawn out at one end
into a fine point. At the time of using the capillary end is broken
off, and the tube held in the warm hand, the point directed hori¬
zontally -towards the part affected, and at a distance of about 12in.
The part thus treated is frozen. Dr. Gans reports successful treat¬
ment in the following cases:—Supraorbital neuralgia, neuralgia of
the breast, lumbago, migraine, pruritus scroti. The cases are few
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452 Psychological Retrospect. [July,
in number, but added to the evidence we already possess of the
value of ethylic chloride as a local anaesthetic in minor surgery and
dental operations they serve to establish the efficacy of the drug.
Efficient local treatment for neuralgias is a very welcome addition
to our armamentarium. By treatment we do not mean mere pallia¬
tion for the time being, but persistent benefit, such as is claimed for
his compound. Reports on ethylic chloride as a local anaesthetic
will be found in our journals for the last year or two.
Hyprial . “ Therap. Monatsh.,” March, 1893, p. 131.
In 1890 Bardet introduced a compound of chloral hydrate and
antipyrine as a hypnotic under the name of hypnal. The com¬
pound described by him contained about equal parts of the two
bodies, and inasmuch as hypnal was found effective in about the
same dosage as chloral hydrate, it was evident that the two con¬
stituents must co-operate in their soporific powers, whilst at the
same time the compound possesses analgesic properties. Further
investigations showed that there was more than one compound of
chloral and antipyrine, and that these differed much in physical
and chemical characters and therapeutic action. Reuter described
one such compound which was practically inert, and Filehne, in
the “ Berlin Klin. Wochensdhr.,” No. 5, of this year, describes
another such. Probably these two are one and the same. An
active hypnal, prepared by the Hochster Pigment Manufactory,
and tested by Dr. Herz under Filehne’s direction, is now described,
and it appears to answer to Bardet’s hypnal; it contains 45 per
cent, of chloral hydrate and 55 per cent, of antipyrine. It is re¬
commended in the milder forms of excitement, in commencing
delirium tremens, in chorea, and in “ essential ” insomnias. The
drug took effect in 20-30 min.; the dose for adults ranged between
15-45 grains. It is best given in 10 per cent, solution in water,
and its slight taste can be covered by a syrup of orange peel or by
an aromatic tincture. As the Quaker said about dirt, if we must
have it let us have it in the middle of the room and see it, so if we
must have these innumerable compounds let us endeavour to lay
bare the intricacies and impersonations of their bulky molecules.
Investigations into the Action of Trional and Tetronal. By Michael
HorvAth, of Budapesth. “ Therap. Monatsh.,” p. 135.
These confirm the results of Kast in classifying trional and
tetronal as qualitatively similar to sulphonal. They possess the
advantage over the latter of a more speedy action, producing
sleep within the hour. Quantitatively Horvath thinks that
tetronal is more active than trional, in opposition to Schultze’s
view, but this point is evidently not established. On the same
page we find a reference to Dr. Garnier of Dijon’s results with
these disulphones. He thinks they are rather more efficient than
sulphonal, but then he gives this as an impression only.
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1893.] Therapeutic Retrospect . 453
By-Effects and Intoxications of Modem Medicaments . By Dr.
Richard Friedlander, of Berlin. Paraldehyde.
This is a valuable summary of the results following the use of
paraldehyde, and we may note that the drug has undergone a very
extensive trial since its introduction. The first point calling for
notice, viz., the taste of the drug, is hardly a by-effect, but it is a
very practical difficulty in the way of the use of paraldehyde outside
asylums—de gustibus. . . . Next we have the elimination of the
drug in particular by the breath, the exhalations being very un¬
pleasant, both to the patient and to attendants, but we should
have thought this drawback was over-stated when it is said that
the breath of one patient is able to foul (“ verpesten”) the air of
a large dormitory. Paraldehyde is irritant to mucous membranes,
and is hold to be contra-indicated by all forms of respiratory
trouble, and, in particular, phthisis, with laryngeal complications.
In irritable states of the stomach and intestines it should be
avoided, for there are many records of the establishment of
alimentary tract irritation, independent of any pre-existing
mischief. It is true the statements on this point are somewhat
discrepant, Leech, for instance, denying that paraldehyde sets up
alimentary trouble, but the balance of evidence is against this
statement, and we must take pre-existing alimentary trouble as
indicating caution, if not contra-indicating. Diarrhoea is said in
some cases to have been caused by the drug. More interesting
and more important is the question of the influence of paraldehyde
on the circulation, for we may say almost that the stated absence
of circulatory depression by paraldehyde is its raison d'etre ; nothing
less could excuse its flavour and odour. Careful investigation
has practically established this statement, and we may disregard
the slight accelerations and retardations, dicrotisms, and
irregularities which have been noted. The blood pressure is un¬
influenced by small doses, and large doses exert only a slight
depressing action. Cases of peripheral vaso-paralysis have been
observed in the chronic use of paraldehyde, and a very remark¬
able case, recorded by Sommer, may be placed alongside of
Rehm’s case, in both of which extensive tracts of skin of the head,
chest and abdomen showed marked injection. The headaches and
the complaints of “ blood to the head ” and the vertigo complained
of by patients are possibly interpreted as vaso-paralytic.
In dyspnoeal states, with dilated heart, paraldehyde must be
used with much care. Rolleston cautions against it; collapse
and dyspnoea have followed even moderate doses under these
conditions. The harmfulness is here put down to the effect
on the respiratory centre, and it must be remembered that when
paraldehyde kills (experiments on animals) it is by respiratory
paralysis. The effect on the urine is unsettled : Morselli records
increased flow ; Berger and others have seen diminution—till this is
* xxxix. 29
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454 Psychological Retrospect. [July,
established it is, perhaps, premature to discuss the restrictions this
would place on its employment. Albumen in the urine was found
in two cases of prolonged use of paraldehyde, in one case by Krafft-
Ebing, in another by Jastrowitz.
The temperature suffers slight depression, two- or three-fifths of
a degree (F.). According to some this is the effect of large doses,
whilst small doses may cause slight rise.
The effect on the blood is what one would expect from the reduc¬
ing power of aldehydes; there results a certain amount of metheemo-
globinuria and methaemoglobinsemia, and the corpuscle changes
may recall the changes in pernicious aneemia. No case of pernicious
anaemia following its use has, however, been recorded.
The action upon the nervous system is a specific one; putting
asidp the desired effect, sleep, patients may complain of a feeling
of intoxication, of confusion, of headache even with small doses,
but it is the continued use of paraldehyde which swells the list
of nervous effects. Locomotor and speech disturbances, tremulous¬
ness, epileptiform attacks, delirium, hallucinations of vision and
hearing, loss of memory, and weakness of mind, emotional uncontrol,
irritability, exaggeration of the reflexes, sometimes marked, all
these separately or in various combinations have been observed.
Krafft-Ebing tells of a nervous woman who for a whole year had
taken at least 40 grammes daily (about 10 drachms), and who on the
third or fourth day of the withdrawal of the drug suffered from
epileptiform attacks and auditory and visual hallucinations. This,
of course, reminds us of the delirium of alcoholism; en passant we
may observe that we have seen symptoms closely simulating
delirium tremens follow upon the withdrawal of sulphonal. Par¬
aldehyde, like almost every hypnotic, loses its effects with continued
use, and it is necessary to increase the dose.
Not a single death from paraldehyde has been recorded.
On the Treatment of Morphinomania. “ Bulletin General de
Therapeutique,” April 23, p. 49.
M. Grellety here discusses the terrible progress of morphino¬
mania among medical men. He speaks of two recent deaths from
the poison, and that during the last few years some twelve cases
among medical men have come under his notice. He urges that
the victim’s only chance is to enter some hospital or asylum and
place himself unreservedly in the hands of the doctor. He
further advocates the abrupt stopping of the morphia. A recent
brochure by Charles Lefevre on the same subject is cited as
insisting upon the necessity of this “ under-care ” treatment, and
as advocating the establishment of special institutions for the
treatment of morphinists. In the discussion which followed, M.
Crequy thought that the taking of morphia was less to be feared
where it was used only for the combating of pain, and that it was
only where the drug was taken for the sake of pleasurable,
Digitized by L^ooQle
1893.] Therapeutic Retrospect. 455
emotional, or stimulant effects that it was dangerous. No doubt
this is so; morphia may be employed for months or years as
a sedative only, without the production of morphinomania, and,
indeed, one author advises that there should be a distinction in
name between such as use the drug in the treatment of pain only
and those who take it for its own sake, for positive pleasure
bestowed. But it is certain that morphinomania springs, for the
most part, out of the more legitimate use of morphia as an
analgesic. M. Bardet suggested that the subjects of this craving,
though they may have had good reason for commencing with the
drug, are in general mentally unstable, and if they get rid of this
vice, fall into another. This is, surely, saying far too much, for
though in general the type which succumbs will be the highly
strung, and, therefore, unstable, yet we know that they may put
this habit aside and acquire a stability which is able to restore
them as useful members to society. M. Bardet advised the use
of morphia and opium in full dose whenever it was thought fit to
use it in medicine; in this way the analgesic and narcotic effects
would be obtained, but with probable after-effects, nausea or
vomiting, which would not render it acceptable. But is this safe
practice ? He also advised the use of ati*opine along with the
morphia as a means of suppressing the pleasurable intoxication of
morphia. M. Constantin Paul urged, as the essential point, the
keeping of the syringe in the hands of the medical man prescribing
the injection.
On Exalgine in the Treatment of Hallucinations and on its Action
as Compared with Antipyrine. By Dr. E. M. de Montyel,
Superintendent of the Public Asylums for the Insane in the
Seine Department.
The question occurred to Dr. Montyel as to whether by the use
of analgesics the sensory perversions of the insane might be
treated. A statement made by Dr. Salemi, of Nice, in 1888, that
with antipyrine he had cured a patient suffering from hallucina¬
tion of hearing and sight of three years’ duration, incited Dr.
Montyel to systematic investigation. In sixteen cases he carefully
tested the drug, but the results were entirely negative. In 1891
the Italian observers, MM. Berarducci, announced success with
antipyrine in sensory perversions. The quantities they employed
ranged between 30-45 grains, as minimal doses, up to 90-120
grains. In his first researches M. Montyel had not exceeded 30
grains, and he, therefore, reopened the study with these larger
doses.. His results were more definite. In 19 per cent, there was
no effect, in 54 per cent, the patients’ troubles were greatly
aggravated, in some 17 per cent, the patients were decidedly
improved, in 10 per cent, the results were doubtful.
The explanation of the success in certain cases (17 per cent.) is
to be found, the author thinks, in a suppression of the reflexes on
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456
Psychological Retrospect .
[July,
which the sensory perversions depend, and all cases of hallucina¬
tions which are not dependent on a peripheral excitement or
irritation are, he considers, uninfluenced. The theory is plausible.
He next passed to the investigation of exalgine, and he made
use of the same material from which he had obtained his results
with antipyrine, in order to have a means of comparing these two
drugs. The exalgine was concealed in the patients’ wine, so that
they were unaware of the investigation, a point laid stress on,
because of the dissimulatory powers of these patients; the minimal
dose was 6 grains at the start, this was raised ultimately to 15
grains (pro die ?) The results with 29 cases are then detailed and
summed up. These were: Aggravation of the symptoms in 22
cases, no result in 7. Lest the previous treatment with anti¬
pyrine should have rendered the patients insusceptible, in spite of
a long interval of no treatment, ten other patients with halluci¬
nations, who had not been treated, were now submitted to exalgine.
The results now obtained showed that exalgine was able to
influence certain sympathetic or reflex hallucinations, but with
less certainty than antipyrine. Exalgine, moreover, often caused
much disturbance of nutrition. We should, therefore, in cases of
reflex or sympathetic hallucinations choose antipyrine and not
exalgine. Of the mode of administration, we may note that anti¬
pyrine may advantageously be concealed in soup, exalgine more
effectually in wine. Exalgine causes less general disturbance if
given along with food.
PART IV.—NOTES AND NEWS.
MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.
The Quarterly Meeting was held at the Rooms, 11, Chandos Street, Cavendish
Square, on Thursday, May 18th. In the absence of the President, Mr. Whit-
combe, ex-President, took the chair.
The minutes of the last Quarterly Meeting were taken as read and confirmed.
The ballot was then taken for the following list of candidates for election:—
Walter Reyner Brunton, M.B.Durh., Assistant Medical Officer, Borough
Asylum, Milton, Portsmouth.
Maurice Craig, M.A., M.D., B.C.Cantab., Clinical Assistant, Bethlem Royal
Hospital, London, S.E.
Henrv John Macevoy, M.D.Lond., 41, Buckley Road, Brondesbury, London,
N.W. "
James Middlemas, M.B., C.M., B.Sc.Edin., Junior Assistant Physician, Royal
Edinburgh Asylum.
Athelstone Nobbs, M.B., C.M.Edin., Assistant Medical Officer, Northumber
land County Asylum, Morpeth.
Cecil A. P. Osburne, F.R.C.S.Edin., L.R.C.P.Edin., Surgeon to the Admiralty,
Hythe, The Oaks, Hythe, Kent.
William^H. Rivers Rivers, M.D.Lond., Clinical Assistant, Bethlem Royal
Hospital, London, S.E.
Digitized by ^ooQle
Notes and News .
457
1898.]
H. 0. Garth, M.B., C.M.Edin., Brockham Green, Betchworth, Surrey.
[We regret that in the last number of the journal the names of Drs. Ernest
Wills and Eardley-Wilmot were omitted from the list of those who were elected
members of the Association at the Quarterly Meeting held at Liverpool, March
9th, 1893.]
The Chairman declared that the whole of the candidates had been unani*
mously elected.
Dr. Hack Tuke then proposed for election as a Corresponding Member Dr.
Rene Semelaigne, Secretaire des Stances de la Societe Mddico-Psychologique de
Paris. He said Dr. Semelaigne was a lateral descendant of Pinel, and as such
was present at the Centenary of the Retreat last year, took part in the meeting,
and at the dinner paid a very graceful tribute to the work which had been done
in England towards reforming the condition and treatment of the insane.
Apart from that, Dr. Semelaigne’s work in France in a literary way had been
considerable. He took great interest in English psychological literature, and
had translated for the use of the French the last English Lunacy Act. He
mentioned that as showing the interest taken by Dr. Semelaigne in our pro*
ceedings, whether the Act would be found of much use to the French or not.
Dr. Semelaigne was well acquainted with psychological literature, and had
himself written a good deal in French medical journals. Altogether, he was a
very suitable man to be elected as a corresponding member. Under the old
rules the Association could elect a corresponding but not an honorary member
at a Quarterly Meeting as well as at an Annual Meeting. Under the proposed
new rules, if they were accepted by the Association they would not be able—and
he (Dr. Tukel thought it was as well—to appoint corresponding members
at any other time than the Annual Meeting. The old rule being still in force,
he wished to avail himself of it, and to propose that Dr. Ren^ Semelaigne he
elected a corresponding member.
Dr. Outterson Wood seconded the motion, which was unanimously adopted.
A paper by Dr. Gilmore Ellis, on “ The Amok of the Malays,” was read by
the Secretary in the absence of the author. (See Original Articles.)
Dr. Blandford said if Dr. Ellis had been present he should like to have
asked whether there was any connection between this running amok and the
use of Bhang , or Indian hemp. As, however, he had made no mention of it in
his paper, it was to be presumed that there was not. The use of Indian hemp
led to results of a similar kind amongst those who were addicted to its use. It
had lately been brought under his notice in the Island of Trinidad, where there
was a very large coolie population. When those coolies first came over and
used the Indian hemp, murders and murderous attacks were frequently the
result. The result was that Indian hemp was now most strictly forbidden to he
either imported or grown, and any person attempting to grow it was heavily
fined. The consequence was that these attacks had almost died out, and the
admissions into the asylum from the use of Indian hemp were very much
lessened. It would be interesting to know whether there was such a use of it in
the Malay Archipelago, but no doubt if there had been Dr. Ellis would at any
rate have mentioned it. In the Island of Jamaica there was no law against the
use of Indian hemp, the fact being that the coolie population was so much
smaller that it probably was not thought worth while to look after them in the
same way.
Dr. Hack Tuke said he had always understood that the abuse of Indian
hemp was one of the chief causes of running amok, and he also was very much
surprised on hearing no reference to it in the paper. “Smoking” was
mentioned, and that might have referred to smoking Indian hemp, although,
taken altogether, there seemed to be no reference whatever to that drug.
Having had occasion some time since to make some investigations into this
subject, he found it extremely difficult to obtain definite information, and on
that ground the paper was one of very great interest and instruction. What
information he did get certainly was to the effect that attacks of extreme exoite-
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458
Notes and News .
[July,
ment and destructiveness did arise both in India and in the Malay Archipelago
from the abuse of Indian hemp. The cases suggested epileptic mania more dis¬
tinctly than anything else, and he had understood that epilepsy was one of the
recognized causes of running amok. The paper was a very great help towards
understanding the nature of the symptoms, and they were very much indebted
to the author for having sent it. He wished to propose that the thanks of the
Association be sent to the author for having forwarded this paper. It would be
understood that at his own request it will appear in the “ Journal of Mental
Science.”
Dr. Blandford said he should be happy to second the proposition. Agreed.
Dr. Morrison (of Hereford) said that the worship of a fetish in the East
very often led to running amok, in addition to the use of Indian hemp. It
seemed that the courts of law abroad did not recognize that men might act under
homicidal mania, but usually regarded the man as being perfectly conscious of
the commission of the crime. That was his experience in India. Of course, in
such countries it was very difficult to get the evidence of specialists, because
they were very few and far between.
The Chairman said his first impressions on hearing the early part of the paper
were very doubtful. The question arose in his mind as to whether they were
hearing an account of some peculiarities amongst the Malays, or whether they
were going to criticize the sentence which a judge had passed upon a man who
had run amok. The latter part of the paper brought to mind a case which had
been under his own notice recently, and which would, perhaps, add to the
interest which such cases had for all who were connected with asylums, or had
the insane under their care. He recently had a patient run amok in his asylum,
and he succeeded in killing two other patients, and it was only by the quick
intervention of an attendant that he was prevented from killing a third. The
man was under some hallucination of hearing. When he afterwards saw him
and questioned him as to his act he said that he had had a message from God,
using his own words, to “kill those other buggers.” They were accus
tomed to that kind of language in asylums, and, therefore, he had no
hesitation in repeating the man’s words. There was no doubt that every
individual item of his acts was most accurately remembered by the man. He
was perfectly conscious of everything that he had done, and related the whole of
the circumstances without any reserve. The man, without any history, came to
the asylum, and was placed in a dormitory with four others. He had at the
time delusions of grandeur. He was in a very benevolent state of mind; he was
going to give all the patients around him money and other things, and there was
not the slightest idea that he was at all dangerous to other people. Neverthe¬
less, within half-an-hour of his going to bed this sudden homicidal attack came
on. He pulled one patient out of bed, and either jumped upon him or kicked
him in the ribs just over the heart, causing death within half-an-hour. Another
patient he struck on the head several times with a chamber vessel, causing frac¬
ture of the skull, and at the time that the attendant caught hold of him
he had his arm raised with the chamber in his hand to hit another patient.
The fourth patient fortunately got under a bed, and he was able to give a
correct account of all the circumstances. Had it not been so, no doubt he, and
the Chairman in particular, would have been placed in a very awkward position.
That patient, curiously enough, suffered from melancholia; he could scarcely
speak; he had strong suicidal tendencies, and yet he got under his bed to save
himself from being killed, and was able to give a most graphic description of
the whole of the proceedings. That fact was undoubtedly the salvation of the
asylum, and the evidence of that man sent the culprit to Broadmoor. The case
was one of general paralysis. These homicidal attacks appeared to come on
remarkably suddenly, and the act followed the idea with such rapidity that it
was a matter of very grave consideration, even where they had no previous
history of insanity, whether cases of that kind should not be examined by
mental experts before there was any sentence passed upon them. The
Digitized by
Google
1893.]
Notes and News.
459
sentence of the judge in the first case that Dr. Ellis had referred to appeared to
be one of the greatest cruelty. There could be no doubt in that case that the
man was insane, and the harrowing words of the judge were, to his mind, far
greater cruelty than the hanging of the man.
MEDICAL SUPERINTENDENT’S RESIDENCE IN ASYLUMS.
Dr. Murray Lindsay, in opening a discussion on the question, “ Is it
necessary for the efficient working of a County or Borough Asylum that the
medical superintendent’s residence should be in, or immediately connected by a
covered way, with the asylum ? ” said the question was one of great importanoe
as affecting the health, happiness, and comfort, of the superintendent and his
family. It was, moreover, a subject which members of the Association were
perfectly competent to discuss. They were no doubt aware of the existence of
Buie II. in the “ Instructions to Architects ” issued by the Lunacy Commis¬
sioners in 1887, which said :—“ A good residence in, or immediately connected
by a covered way with, the asylum, and in a convenient position, should be pro¬
vided for the medical superintendent, with kitchen and other necessary domestic
offices.” That Buie, in his opinion, was very arbitrary, inconsiderate, unreason¬
able, and unnecessary, and he hoped that members present who were not already
convinced of the truth of his assertion would be so after hearing the facts that
he would place before them. He was well aware that it might be considered a
bold thing to oppose constituted authorities. He had been a peace man all his
life, and was never in the habit of advocating opposition to constituted
authorities, having only twice in a pretty long experience opposed the Com¬
missioners, on both occasions successfully, but there was a time when one ought
to speak out plainly, even at the risk of incurring official displeasure, and that
time had now arrived. They were no doubt a very meek, mild, and long-suffer¬
ing class of public servants, but they might go too far in the direction of sub¬
mission, and allow themselves to be crushed by the weight of officialism. He
had reached that stage now that it was a matter of no personal concern to him¬
self, because at Derby they had fought the battle and won, but he still thought
it his duty to assist if possible his medical brethren and others in getting the
Buie reduced to a dead letter, or expunged from the instructions altogether.
They were no doubt aware that the Lunacy Commissioners in the erection of
new asylums were insisting upon this Rule being carried out, and even at old
asylums where new houses were being erected for superintendents they were
trying to insist that the houses should be in or immediately connected by a
covered way with the asylum. Some exceptions were made. For instance, at
the Derby County Asylum the committee decided to erect a house for the
superintendent on a site only 68 yards from the asylum, which would also be in
telephonic communication with the superintendent’s house, and there would be
two assistant medical officers residing in the asylum. Yet the Commissioners
insisted upon a subway and covered way from the superintendent’s house to the
asylum, with a tunnel to get under the front carriage road, which was only 12
feet wide, and a covered way the rest of the distance, at a needless expenditure
of £250. He had argued the point before the Lunacy Board in London and
with the Commissioners at the asylum, but failed to convince them. The com¬
mittee, seeing no necessity for a subway and covered way, and acting on bis
advice, appealed to the Home Secretary, who was much more reasonable, as
Home Secretaries usually are when appealed to, in asylum matters at least, for
they have no antiquated fads or imaginary mountains to get over. The argu¬
ments of the Commissioners, as far as he knew, were only two. In their letter
to the committee they did not give one single reason why they insisted upon
the covered way; they simply issued a sort of peremptory mandate—a kind of
coercion—which he for one felt it a duty to protest against and resist as far as
possible. The only two arguments used by the Commissioners at two interviews
Digitized by L^ooQle
460
Notes and News.
[July,
were that the superintendent should be able to slip into the wards unobserved ;
and, secondly, that he should be protected from exposure to the weather, and
his visits to the wards facilitated by a covered way, the Commissioners, perhaps,
entertaining a fear and suspicion that his visits to the wards might not be so
frequent, and his duties might be neglected if he resided in a detached house.
Dr. Lindsay’s reasons for disagreeing with the Commissioners were:—(1) That
instead of facilitating unobserved or surprise visits by the superintendent, it is
more likely to have the opposite effect, if the superintendent is to be restricted
in this way and not be able to vary his visits by any means of ingress he pleases;
and that it is unnecessary for the requirements and efficient working of a county
or borough asylum. (2) It tends to surround the superintendent with an air
of suspicion and distrust, which is calculated to exercise an unfavourable influ¬
ence on the staff. It is also, in my opinion, subjecting the superintendent to a
kind of indignity, as well as casting a slur and reflection upon assistant medical
officers. (3) It is calculated to be distinctly disadvantageous, for it allows the
local authorities no freedom of action in a matter concerning which they may
be supposed to be very competent judges; it must limit the committee in the
choice of a site for a superintendent’s house, which will have to be placed some¬
times in a very objectionable position in order to meet the Commissioners’
requirements with regard to a covered way; it must tie the hands of architects,
and must interfere with privacy and the amenity of the surroundings; whilst it
is certainly not for the benefit of the superintendent’s family, his children and
servants, and even of himself, that his house should be in close connection with
the asylum and its inmates. In short, such an arrangement is not calculated
to promote the health, happiness, and comfort, of the superintendent and his
family; whilst it is very much better for all concerned that the superintendent’s
house should be detached, and at a reasonable distance from the asylum.
(4) The experience of Scotland conclusively proves that connecting tunnels or
covered ways from superintendents’ houses are not necessary for the efficient
working of asylums. To insist on a covered way is, in my opinion, an erroneous
idea, an antiquated fad, not in touch with the times, and entirely opposed to
the enlightened views and practice of the Scotch and Irish Lunacy Commis¬
sioners, who place no restrictions in this direction upon committees and archi¬
tects, and not only do not insist on a covered way or connection with the asylum,
but encourage the erection of detached houses for superintendents at some
distance from the asylum, where they can have that privacy and domestic
comfort so necessary for their welfare and that of their families. The
enlightened views and practice of the Scotch and Irish Lunacy Boards may be
gathered from the following authentic facts :—
Scotland .—Of 19 Royal and District Asylums at present existing in Scotland
there is no connection or covered way between the superintendent’s house and
the asylum in 13 cases; and at the three district asylums now being erected in
the west of Scotland it is not proposed that the superintendents’ houses should
have any connection with the asylums.
Ireland .—In Ireland the Board of Control of Irish District Asylums do not
insist on a covered way connecting the superintendent’s house. In many of the
Irish asylums, such as Londonderry, Monaghan and Clonmel, the medical
superintendent’s house is completely detached, and at some distance from the
asylum. It is further proposed to provide residences for the superintendent at
Letterkenny, at the new Antrim asylum, and at the new asylum for Dublin
district. In none of these asylums is it proposed to make any connection with
the main building. The Inspectors of Lunatics in Ireland share the opinion of
the Scotch Commissioners that a house should be provided for the medical
superintendent detached and unconnected with the asylum, as tending to the
health and happiness of that officer and his family, and to the satisfactory
working of the asylum. (5) In England, in certain instances, both old and
recent, as at Han well, Barming Heath, Worcester, Gloucester, Norfolk, and
Lancaster asylums, exceptions have been made by the erection of completely
Digitized by ^ooQle
1898.]
Notes and News.
461
detached houses for the superintendents at these asylums. For examples of
recent instances:—At Norfolk Asylum the superintendent’s house is completely
detached and at a considerable distance from both the old and new asylums.
At Lancaster Asylum the superintendent’s house is detached, 172 yards from
main entrance to old building, and about the same distance from annex. As an
instance of the distance of a Scotch superintendent’s house from the asylum
the Fife and Kinross District Asylum might be mentioned, where the superin¬
tendent’s house is 726 feet from the centre of the main building, and 560 feet
from the nearest point of that building. The foregoing were some of the argu¬
ments adduced by him against providing any subway and covered way between
the superintendent’s house and the Derby County Asylum, to which arguments
the Commissioners replied that they were unconvinced by them, and added
“ that they will be unable to recommend the plan for the superintendent’s
residence to the Secretary of State for his approval unless a covered connection
with the asylum is shown upon it.” As it was evident that further argument
with the Commissioners was useless, the Chairman of the Committee of the
Derby County Asylum submitted similar arguments and appealed to the Home
Secretary, who replied, “ That after carefully considering the representations
made by you and by the Lunacy Commissioners in this matter, he is not con¬
vinced of the necessity in this case of a covered way, and would approve of the
plan without it.” At another county asylum he believed this question of a
covered way upon which the Commissioners are insisting is being fought out,
and the committee seem disposed to resist the Commissioners’ demand, and he
hoped the committee would win. He produced a rough plan of his asylum,
from which it would be seen that the frontage was one of the features of the
institution. The Commissioners suggested that, in order to avoid a subway
under the carriage road, the road might be lowered, as at the Salop Asylum, to
permit of a covered way being made over it. This would have had the effect
of spoiling the lawn and the pretty frontage of the asylum. What he con¬
tended was that the committees and the local authorities should have freedom
of action in this matter. If they thought fit to have a covered way or to place
the superintendent’s residence in the asylum, well and good; but if, on the
other hand, they thought fit to select the best site for the superintendent, then
he maintained that they should have power to do so, and he thought it was high
time to protest and make a stand against arbitrary and unreasonable officialism,
and try to get some alteration of the Rule. He believed that if the committees
of all asylums proposing to build houses for medical superintendents were to
put their foot down firmly the Commissioners would be brought to reason in a
short time.
Dr. Rees Philipps asked whether the discussion was intended to embraoe
superintendents of registered hospitals ?
Dr. Murray Lindsay thought it did so. Every officer ought to be in the
hands of his committee to make him as comfortable as possible. He could see
no earthly necessity for putting a chain round the superintendents in the
matter.
Dr. Rees Philipps said he did not agree with the argument advanced by
Dr. Lindsay. He was very glad indeed for Dr. Lindsay’s own sake that he had
gained his point and got his house, and it was to be hoped that he would live
long to enjoy it and to give the county of Derby the great benefit of his
services. He (Dr. Rees Philipps) had, unfortunately, had to fight with the
Commissioners—in fact, they were frequently having a little amicable warfare
—but, still, on this matter of the residence of superintendents, looking at it
from the point of view of the superintendents of hospitals, he must say that he
agreed with the Commissioners. He thought, for the proper working of
registered hospitals, a super in tendents house should be in the middle of the
hospital or as near thereto as possible. At Exeter he found it of the greatest
possible advantage to himself, and he thought also to the funds of the institution,
that his house was in the middle of the hospital. In his present hospital he,
Digitized by ^ooQle
462
Notes and Nens,
[July,
unfortunately, had his house joined on to the building at one end; consequently
he was always on the run from morning to night. He no sooner got back to hw
house than somebody came across to see him or he had to go over to see some¬
body. The comfort of the superintendent in a resident hospital and the
interests of the hospital were vastly more safeguarded if he lived in the middle.
This was the opinion of Dr. Needham when at Barn wood House. Perhaps Dr.
Needham and himself were fortunate in one way, owing to the fact that they
had no families. That made all the difference, but on the whole, from the
point of view of the superintendent himself, he thought that residence in the
'middle of the asylum was infinitely to be preferred.
Dr. Mubbay Lindsay said he intended moving a resolution, which he hoped
the meeting would see its way to pass.
The Chaibman ruled that if a resolution were to be proposed it should be on
the agenda.
Dr. Mubbay Lindsay said if that was the ruling of the Chairman he would
give notice to propose it at the Annual Meeting. He did not mean to let the
matter rest. He failed to see the difference between the English and the Irish
and Scotch superintendents, or any good reason for such different treatment,
surely all of whom are fit to be trusted. Why, if they could manage their
asylums efficiently in Scotland (and no person conversant with the subject can
deny that Scotch asylums and their medical superintendents are second to none)
and Ireland without these restrictions, was it necessary that they should be im¬
posed in the case of English superintendents ? He claimed, for this occasion at
least, to be an Englishman by virtue of residential qualification, having resided
about two-thirds of his life in this country. He, therefore, felt it a grievance
that Scotland and Ireland were better treated and were under a much more
enlightened system in that respect than England. He did not wish to be put on
a superior footing to his Scotch and Irish brethren, but he would certainly con¬
tend for English asylum superintendents to be placed on an equality as regards
freedom in the erection of detached residences.
Dr. Conolly Nobman (Richmond District Asylum) said he was very
anxious to indulge in a little bad language—as bad language as the Chair¬
man would permit him—on this subject, but he found that their excellent
President-Elect had spoken so strongly about the action of the Commissioners
that'he was really at a loss to know what more could be said. Why the Com¬
missioners in England should, in the first place, insist on what was decidedly
retrograde, and should then refuse to give any reason for their action, was a
matter that was past human comprehension. It seemed to be the greatest mistake
in the world at that stage in their history that the action of Local Committees
should be trammelled in such a manner as the English Commissioners trammelled
their action in reference to this question of the superintendents’ houses. Seeing
that the local bodies generally were found not to be such dangerous wild beasts
as they were thought a few years ago, it was time for the English Commissioners
to give up what Dr. Murray Lindsay had so well called their “ antiquated fads,”
and also to relinquish that exercise of arbitrary and unreasonable authority
which they seemed so desirous to exhibit. Dr. Rees Philipps had spoken with
reference to registered hospitals. As far as he knew, though he was sorry to say
he was not as thoroughly acquainted with them as he ought to be, the patients
in registered hospitals were not, as a general rule, very numerous. They were,
perhaps, persons who, theoretically, at least, “ derived all the benefits of a home,
etc.,” and they were supposed to be the medical superintendent’s children. It
was absolutely different when they came to deal with a'large county, or even an
important borough asylum containing from 500 to 2,000 patients. It was diffi¬
cult to see what would be gained by the superintendent living in the midst of a
little town of 1,500 patients. One result of the superintendent having quarters
in the middle of the asylum was that he had the best outlook in the asylum, and
he got too well treated, because the Committee of course always endeavoured to
secure for him quarters as comfortable as circumstances would permit, and in
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1893.]
Notes and Nens,
463
order to do this the patients might have to suffer. He had not the pleasure of
privacy, and at the same time he would take from the patients the best position
in the whole place. This injustice was not inflicted on the patients if the super¬
intendent’s house was away from the asylum. His house in Dublin was situated
in the centre of the female wards, and, consequently, was about half-a-mile away
from the male house. If it had been detached it would have been much more
suitable for the very purposes which the English Commissioners proposed to
serve. It seemed to him that this question was like the old logical crux of which
it was said solvitur ambulando. The thing had been tried, and it had worked.
In numerous asylums in Scotland, for example, Dumfries, Montrose, and Perth,
the superintendent lived in a house situated several hundred yards from the
asylum, and no bad result had ensued. Neither were these institutions back¬
ward in their administration, as they ought to be if the unreasonable action of
the English Commissioners had any proper grounds. He (Dr. Norman) took,
perhaps, a little personal interest in the matter, because he was at present
endeavouring to induce his Committee to build a separate house for him, and he
was quite certain that his asylum would not suffer in its administration in con¬
sequence.
The Chairman said he thought this subject was one rather for individuals.
He had had the advantage of residing in a house attached to an asylum by a
covered way. He had no doubt of the advantage of residing in an asylum in
the centre of the building, because after all the superintendent stood in relation
to his patients in loco parentis. He had always endeavoured to feel that
wherever he had resided, believing as he did that the father of a family should
be in the same house and not away from it. If a man had a family of twenty
or thirty children, he would not take a small house for himself a mile away.
There were several points to look at in considering a question of this kind.
When he first saw the question to be discussed, he wondered whether some
people might not raise the inquiry whether there was any necessity for a
medical superintendent at all. In many of the asylums they had had the ex¬
perience of a sort of lay superintendent, but it was one which he hoped would
never be reverted to in asylum work. He believed that the medical super¬
intendent was an absolute necessity in an asylum. Then came the question,
where was the best place for him to reside so that he could best manage his
institution ? So far as his experience went he believed that the closer a man
was to his work the better he did it. He knew that in Scotland some of the
superintendents resided at a distance of half a mile or more, and the great
question arose whether they may not as well be a thousand miles away. (“ No,
no.”) They must all remember one great fact, namely, that asylums were
built for patients and not for superintendents; that the superintendent was a
man who could be put on one side and replaced at any moment. It did not do,
therefore, to take extreme views and to carry out an idea of that kind for
every asylum in the kingdom. It was entirely a matter that committees or
superintendents should have in their own hands. As to the action of the
Commissioners, personally he agreed with the rule laid down. He did so from
his experience of asylum management, and he should be very sorry to see a
rule laid down that the superintendents should live at a certain distance from
their asylums. In asylums as in everything else, whether in business or else¬
where, the nearer the head was in touch with everything going on the better
those things would go on.
Mr. J. Peeke Eichaeds said in the main he must agree with Dr. Lindsay
that it was much better for the welfare of the patients and the institution, as
well as for the comfort and the home life of the medical superintendent, that
his residence should be detached from the main building. By “ detached ” he
meant at some fair distance, because there were institutions where the medical
superintendent’s house was detached, and much was made of that circumstance,
whereas, in reality, it was at a comparatively short distance from the main
building. Dr. Lindsay, who was his predecessor at Hanwell, must know even
Digitized by ^ooQle
464
Notes and News.
[July,
better than he did himself, that though his house was detached it was uncom¬
fortably near to the main building, and he had found that many a time it would
have been much more comfortable if instead of having the house detached it
had been a portion of the main building, for this reason, that the house was so
near to the walls that neither he nor any member of his family could go out
into the garden without being overlooked by the patients, and all sorts of
objectionable remarks were made, more especially if he happened to put in an,
appearance in the garden. There were sure to be some benevolent remarks
made, probably couched in the classic terms that had already been referred to
by the acting President. Dr. Lindsay had spoken of the Commissioners in
Lunacy and their arbitrary conduct in the matter of rules. He did not think
that in this they as a bod} r stood alone. AVith regard to the Poor Laws, for
example, the rules and regulations laid down by the Local Government Board
were much more arbitrary than those of the Commissioners in Lunacy. He
believed that the plan for every workhouse or infirmary had to undergo the
scrutiny of the architect and of the Local Government Board most severely, so
that it was hardly fair to criticize the action of the Commissioners in Lunacy
in the rather harsh terms that had l>een used. The light in which he had
always looked upon this rule, and it was one that affected more immediately
the medical superintendents, was that it cast a slur upon them. In speaking
to the Commissioners in Lunacy upon the subject they had inferred that the
reason why they wished the medical superintendents’ houses not to be detached,
but part of the building, was that they would be much more frequently in the
wards, thereby implying that if the houses were detached they would, as a rule,
neglect their duties. That was the gravest matter of all, and it was one that came
more home to medical superintendents’ than any other point that Dr. Lindsay
had mentioned. On the other hand, another reason why he thought it was
well for the medical superintendent’s house to be detached was that it was not
well for the superintendents to be constantly going in and out about the wards.
They knew what the result was in a private house, if the mistress was con¬
tinually going into the kitchen or the servants* hall there would soon be
“ ructions.” It was just as well, therefore, that the medical superintendent’s
dwelling should be at some little distance from his work, so that he should visit
at irregular intervals. Thus he would be enabled to supervise and manage the
institution much more satisfactorily. Por these reasons he agreed with what
Dr. Lindsay had said with regard to the house being detached, and he also
thought that it should be at some little distance from the main building, at all
events sufficiently far to be out of the way of the noise and the objectionable
remarks to which he had already referred.
Dr. MORRISON said the important point seemed to be whether a medical
superintendent could get his house isolated, and whether he had a covered way
or not would not at all affect the matter. It was very arbitrary to say that
complete isolation could not be got unless there was a covered way. If it
could come within 200 or 300 yards and must have a covered way, it was a
very arbitrary rule to say it could not go ten yards further and not have a
covered way.
Dr. Murray Lindsay, in reply, said the Chairman did not represent him in
the way in which he wished to be represented. He had only claimed, what the
Chairman himself admitted, freedom of action on the part of committees to do
what they considered best for the superintendent or any other officer. He did
object to Commissioners overriding the local authority and saying, “ You must
put up a covered way, and you must put your house there.” He thought that
was arbitrary. His friend Mr. Richards, whilst strongly supporting his views
in favour of detached residences, called the statement harsh, but he saw no
harshness in it, though it would be easy for anyone to employ harsh language
who had had to go through the mill. Any harshness is more applicable to the
Commissioners and their arbitrary rule. Por upwards of twenty-one years he
had lived in the centre of an asylum, exposed to noises, smells, and other dis-
Digitized by ^ooQle
1893.]
Notes and News .
465
comforts, and without the privacy of a house. He had lived in a detached
house at Hanwell for seven years and a half; and in a detached house, at a still
greater distance, at Murray’s Royal Asylum, Perth, for thirteen months, when
acting as medical superintendent pro tem. for his brother during absence on
sick leave. He could therefore speak from experience, and he resented the idea
that a detached residence led medical superintendents to neglect their work,
and that they did their work better when the)* were in the centre of the build¬
ing. For his part he maintained that the work would be better done if the
superintendent was not stuck in the middle of the asylum, or close to the
patients, and perhaps exposed to all sorts of language and remarks.
(Since the foregoing discussion took place, another asylum, in addition to
Derby, has fought the point of a covered way and won. At the Durham
County Asylum the Lunacy Commissioners insisted on a covered way between
the medical superintendent’s new house and the asylum, and also insisted on a
room being provided for the use of the servants, saying that they could not
recommend the Home Secretary to sanction the plans without these two
additions. The Committee of the Durham County Asylum appealed to the
Home Secretary, who did not agree with the Commissioners, and replied inti¬
mating his sanction to the plans without either addition.)
A paper on 4 The Treatment of Myxoedema,” by Dr. Beadles, was taken as
read, and the discussion adjourned to the next ordinary meeting. A number
of photographs were exhibited showing the results of the treatment prescribed.
The Chairman said they were greatly indebted to Dr. Beadles for the
photographs of these most interesting cases showing the wonderful result of
the treatment. (See Original Articles).
A vote of thanks was passed to Dr. Beadles, and it was agreed that the di§-
oussion should be adjourned to the next Quarterly Meeting.
ANNUAL MEETING.
The Fifty-second Annual Meeting of the Medico-Psychological Association
of Great Britain and Ireland will be held at the Palace Hotel, Buxton, on Friday,
July 28th, at 11 o’clock a.m.
Council Meeting at 10 o’clock.
The President will deliver his address at Three o’clock p.m.
FLETCHER BEACH,
Hon. General Secretary.
11, Chandos Street, Cavendish Square, W.,
June 6th, 1893.
NURSING CERTIFICATES.
A list of persons who have obtained the certificate of proficiency in nursing
the insane at the examinations held in May, 1893 : —
Kirklands Asylum , Bothwell.
Males. Females.
Craig, Agnes.
Hooper, Florence J.
Johnston, Mary.
Digitized by ^ooQle
466
Notes and News.
[Joly ;
Larbert Asylum, Stirling.
Males. Females.
Boyd, Robert. Clark, Margaret.
Hendry, Donald. McNair, Mary Jane.
McCorquodale, Alexander.
McDonald, John.
Thomson, Samuel.
Roxburgh District Asylum , Melrose.
Leitoh, William. Craise, Helen.
Stevenson, Margaret.
Smith, Jane.
Fife and Kinross Asylum , Cupar.
Buchan, Helen.
Mitchell, Jessie.
McLean, Maggie.
Taylor, Ada Isabel.
Wallace, Janet.
Argyll and Bute Asylum t Lochgilphead.
Livingston, Neil.
Mitchell, Colin.
Mitchell, Peter.
Ramsay, William.
Brown, Marrianne.
Barnaby, Maude.
Beaton, Agnes.
Lochead, Ann.
McLeod, Margaret.
McCulloch, Christina
Gillies, Mary.
Momingside Royal Asylum t Edinburgh.
Mitchell, James.
Petrie, John.
Stove, John.
Burgess, Lizzie.
Byfield, Ann.
Currie, Janet.
Johnstone, Margaret Helen.
MacNab, Bella.
MacDonald, Jane.
McKeith, Katherine.
Shaw, Isabel Me William.
Smith, Isabella.
Wood, Jane.
Brookwood Asylum , Surrey.
Carpenter, Charles.
Harding, James T.
Peto, James.
Sutton, Walter.
Tompson, Charles.
Wilkinson, Alfred.
Donohoe, Mary.
Lyons, Clara.
Luckhurst, Ada.
Penna, Mary.
Rea, Mary.
Stevens, Mary Ann.
City of London Asylum , Stone.
. Haylock, Samuel. Cooper, Albenia.
Driver, Mary.
Jarvis, Emma.
Mertling, Charlotte.
Thomson, Mary.
Digitized by ^ooQle
1898.]
467
Notes and Netcs.
Derby Boro* Asylum, Rowntree.
Male s. Females.
Bodkin, Henry. Adam, Ida.
Bring, William T. Doughty, Mary Ann.
Flixon, Charles. Gomm, Grace E.
Froggatt, John Arthur. Morris, Annie.
Bethnal House Asylum , London , E.
De Pradines, Clara.
Heynes, Mary.
Bainhill Asylum , Lancashire.
Allen, Hugh.
Colwill, William R.
Fluck, Alfred John.
Howard, Hugh H.
Howitt, James.
Riley, William.
Smith, Frank.
Scriven, Frederick Charles
Thomas, Edward.
Wait, George.
Wakeling, John Samuel.
Holloway Sanatorium , Virginia Water.
Bishop, Alfred. Cox, Ellen.
Blades, William. Davis, Frances.
Montague, William. Daniel, Emma.
Heath, Rose.
Jones, B. Topham.
Johnson, Katherine Elizabeth.
Roylance, Mary.
Royal Asylum , Dundee.
Dick, Francis. Swanson, Mary.
Mitchell, William.
Nicholl, James.
Simpson, John.
Stewart, James.
Walker, William.
Wameford Asylum , Oxford.
Swadling, Frederick John. Warland, Sara.
Prior, Emily.
Winson Green Asylum , Birmingham.
Banford, John. Berks, Julia.
Crawford, William. Coles, Hannah.
Jones, Edwin Thomas. Cullam, Emily.
Underhill, Charles Henry. Moore, Emma.
Keen, Kate Emily.
West Riding Asylum , Wakefield.
Allen, Harriett.
Backhouse. Lilian.
Deamley, Alice.
Gregson, Agnes.
Lyle, Emma.
Sellar, Annie.
Weller, Mary.
Digitized by Google
468
Notes and News.
Mai".
West Riding Asylum t
Addy, Thomas Ellis.
Boag, William.
Byenand, Ernest.
Coopland, Harry.
Crickmer, Gerald McCauld.
Greenwood, Sam.
McCreadie, Alfred Thomas.
O’Dowd, Thomas.
Sunley, Harry.
Thompson, George.
Tonks, Samuel Hale.
Whitehead, Alfred.
Wood, Frederick.
Females ,
Lindsay, Alice.
Megson, Nellie.
Penty, Maria.
Talbot, Emily Mary.
Wadsley, Sheffield.
Bar well, Zillah.
Cash, Lizzie.
Turner, Elizabeth.
Wright, Mary Jane.
Wheatley, Kate Elizabeth.
West Riding Asylum , Mens ton , Leeds.
Bennett, John William.
Hearn, Henry.
Illingworth, Charles Henry.
Myers, John.
Terry, George.
Watkinson, John William.
Ayres, Esther.
Gates, Constance Kate.
Hampshire, Louisa.
Jones, Sallie.
Plummer, Clara.
Mitchell, Annie.
Viney, Kate.
The following questions were on the paper:—
Examination for Nursing Certificate.
May, 1893.
1. Mention the causes of lung disease.
2. By what means ( i.e ., by what channels) is the refuse or waste matter of the
body drained from the circulation ?
3. What symptoms would lead you to expect that a patient is losing weight ?
4. What symptoms would lead you to expect that a patient is gaining weight ?
5. ( a ) What is a sensory nerve ? ( b ) What is a motor nerve ?
6. Name the special senses.
7. (a) What is a drawsheet ? (J) Explain how you would use it. (c) What
are its advantages ?
8. (a) What observations would you make regarding the passing of urine,
and ( b ) the appearances of the urine ?
9. (a) Why is occupation important in the treatment of the insane ? ( b) What
rules should be observed in promoting the occupation of patients P
10. (a) What patients are most likely to escape? ( b) What circumstances
would make you suspicious ? (c) How would you guard against escape ?
11. (a) In what way should attendants conduct themselves towards patients ?
(6) What do you understand by “ showing a good example ” ?
12. (a) What are the risks in treating cases in private houses compared with
Asylums ? What precautions would you take ? (b) What are the difficulties
with relatives in private houses, and how would you endeavour to meet them ?
Three hours allowed to answer this paper.
The first six questions are valued at 10 marks each; the last six at 20
marks each.
Two-thirds of the possible total of marks are required to pass.
Digitized by L^ooQle
1893.]
Notes and News .
469
PASS EXAMINATION AND GASKELL PRIZE.
The examination for the Certificate of Proficiency in Psychological Medicine
will he held at Bethlem Hospital on the 18th of July, 1893, at 11 o’clock a.m.
The examination for the Gaskell Prize will take place on the following day at
the same time.
Por further particulars, apply by letter to the General Secretary, 11, Chandos
Street, Cavendish Square, W.
EXAMINATION IN SCOTLAND.
The Examination for the above certificate in Scotland will take place
Oral.
Written.
Edinburgh Royal Asylum .
July 21)
July 20.
Glasgow. .,
„ 24V
Aberdeen .
„ 22)
All at 10 a.m.
MECHANICAL MEANS OP BODILY RESTRAINT.
The Commissioners in Lunacy having in- their regulation of April 9th, 1890,
defined “ mechanical means ” of bodily restraint to be and include all instru¬
ments and appliances whereby the movements of the body or of any of the
limbs of a lunatic are restrained or impeded, it cannot fail to be of importance
to the superintendents of hospitals and asylums for the insane to know exactly
what is understood by the Commissioners themselves to be included in this
definition. Just before the Lunacy Act of 1890 came into force I wrote to ask
whether they considered that soft padded gloves, fastened at the wrist and
leaving the movements of the arms as a whole free, were to be considered as
restraint under their definition. The answer was that they considered them
“ instruments ” of restraint, the use of which must be recorded. At the same
time I commenced to make use of a dress for patients of the class who are des¬
tructive at night to bed clothing or to night clothing, or who tend to constantly
throw off clothing at night, and so are liable to the effects of exposure to cold,
or who may have some wound upon which no ordinary dressing can be left
without interference on the part of the patient, or who have a tendency to some
forms of self-mutilation, or who are actively suicidal, and yet not fit to sleep in
a dormitory, or who would be made worse if held by attendants—a dress in
which the sleeves, instead of ending in an opening at the sleeves in the ordinary
way, were prolonged beyond the extremities of the fingers, and the ends then
closed. This did not in my opinion exercise any mechanical restraint on the
patient, as all the movements of the limb and hand could be perfectly performed,
while it had the advantage of preventing a great deal of unnecessary destruction
of clothing, assisted materially in keeping restless and excited patients warm,
and was often useful in surgical and in some suicidal and self-mutilating cases.
The Commissioners who visited the hospital at various times have seen patients
wearing these dresses, and have not considered that they came within the mean¬
ing of mechanical restraint, and, in fact, upon one occasion a Commissioner said
to me, “You don’t consider that restraint? ” to which I naturally replied “No.”
At their last visit, however, they made the following entry in the report:—
“ This is not here recorded as restraint, but as it might be construed by our
Board to come within the statutory meaning of restraint we consider it to be
our duty to mention the matter.” After a short interval in which no communi*
xxxix. 80
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Notes and News.
[July,
cation was received from the Commissioners I wrote for information as to the
opinion of the Board, and received the following answer:—
Office of Commissioners in Lunacy,
19, Whitehall Place, 0th April, 1893.
Sir,-In reply to your letter of yesterday I am directed to Inform you that when the copy
of the recent entry in the Visitors’ book of Bethlem Hospital was read at the Board meeting
of the Commissioners the Board did not consider that the special kind of dress to which
the Visiting Commissioners called attention came within the meaning of mechanical means
of bodily restraint as defined by the Commissioners’ regulation of the 9th April, 1890.
I am, sir.
Your obedient servant,
Gt. Harold Urmson,
Secretary.
It is, of course, important that if a dress of this kind be used for some cases,
such as those I have referred to, care should he taken that the movements of
the limb and hand should not he at all restrained, and in the event of shrinkage
taking place after washing, with shortening of the length of the sleeve, it might
happen that the limb or hand could not be fully extended or opened, and then
the patient would be “ mechanically ” restrained. As some who have visited
the wards of Bethlem Hospital have considered that such a dress as I have
described, although perfectly harmless and often very beneficial to the patient,
should be called mechanical restraint, I have thought it well to put on record
this authoritative opinion of the Commissioners’ Board. It will be noticed that
padded gloves, though differing very little from the dress I have described, and
leaving the arm, and in many cases the fingers, free to move in every direction,
are dignified with the name of “instruments.”
R. Pebcy Smith.
Obituary .
JOHN HITCHMAN, M.D., St. And.; F.R.C.P., Lond. ; F.R.C.S., Eng.
Dr. Hitchman was horn in 1815, at Northleach, Gloucestershire. Passing
through the usual medical apprenticeship and the ordinary course of medical
study in London, he obtained qualifications to practise in 1838. His work in
lunacy began at Fairford, where he lived for a few years. He was singularly
fortunate in his marriage to Miss lies of that place, a union which was the
source of great happiness to both of the persons concerned. Kind, sympathetic,
loving, and beloved, she had a benign influence on the life of the deceased
physician.
The most important part of Dr. Hitchman’s life and work falls naturally
into three periods—that spent at Hanwell, that in Derbyshire, and that in
subsequent retirement.
Late in the morning of life he obtained the appointment as one of the
medical superintendents of the large county asylum at Hanwell. This threw
him into contact with Conolly, between whom and himself a lively friendship
existed, and whom he always afterwards spoke of with warmth and affection.
Whilst there he also did much useful pathological work, and made careful
post-mortem examinations, at that time so generally neglected in institutions
for the insane. He also gave courses of lectures on mental disease, which he
delivered at Hanwell, and illustrated by clinical examples in the wards. In
that work he was one of the early pioneers in this country. He also contributed
a number of articles to the periodicals devoted to the subject of insanity, of
whioh the most important, perhaps, was an attempt at a pathological classifies
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Notes and Nevus.
471
1893.]
tion of mental diseases. At Hanwell he had as a colleague, or fellow medical
superintendent. Dr. Begley, and their friendship was maintained for many
years afterwards. Amongst other life-long friendships he made now was one
with Dr. J. T. Arlidge, of St. Luke’s Hospital, and subsequently of Newcastle-
under-Lyme. After having held the appointment there for four or five years.
Dr. Hitchman left Hanwell about the beginning of 1851, having been invited to
take the superintendency of the Derbyshire County Asylum, which was being
built at Mickleover, near Derby. In this way, he brought to a close a prospect
containing great possibilities which proximity to the Metropolis offered to one
who had entered so vigorously into scientific work as he had.
At the Derbyshire County Asylum he held office for about twenty-one years,
and proved himself to be an able medical superintendent, a good administrator,
and a humane physician. He started the new asylum well and maintained it
in a high state of efficiency. His mental activity now took on a some¬
what different phase. Although his reading in medical literature continued to
be wide and varied he did not do so much now in original medical investiga¬
tion, and published only a few articles in the contemporary medical periodicals
on his special subject, and these chiefly addresses. But he gave addresses also
on the scientific raising and breeding of cattle, and took an important part and
place in the Derbyshire Agricultural Society. Latterly, also, he sought exercise
and air in coursing, and was an enthusiastic admirer of the sport and of the
hounds, in whose honour he wrote a spirited hunting song. Dr. Hitchman also
made other contributions to the periodical general literature of his time. He
took a good place in the county, and was highly esteemed as a personal friend
by many members of his committee. In 1855 Dr. Hitchman took the F.R.C.S.,
Eng.; in 1858 the M.D., St. And.; in 1859 the M.R.C.P., Lond.; and in 1871
he attained the distinction of being elected a Fellow of the Royal College of
Physicians of London. In 1856 he was President of the Medico-Psychological
Association. The annual meeting that year was held at Derby, and many
years afterwards one who was present spoke of the striking eloquence of Dr.
Hitchman’s presidential address on that occasion. Having become subject to
frequent vertigo and for other reasons he thought it well to retire from his
post in Derbyshire. This he did in 1872, and was awarded a well-deserved
pension, on the recommendation of the Justices forming the Committee of
Management of the asylum, who were very loth to lose his services.
For some three years he now settled in Cheltenham, and then went to live at
Fairford, Gloucestershire, where Mrs. Hitchman had many relatives, and where
he spent the rest of his life. Here, in 1884, he lost his wife by death, an event
which to him was a source of profound grief, and the beginning of greater
failure in health. In still later years his afflictions confined him more and
more to home, and, in April, 1893, the end came. During this retirement Dr.
Hitchman was not idle. He read much, and wrote much, and chiefly on points
of controversial theology. Besides many minor contributions on this subject,
and public addresses, articles, or published letters on various matters of social
interest, he published an important theological work. This he altered, and
brought out in a much fuller and different form in 1887, under the title of
“Christianity versus Ecclesiasticism,” (Williams and Norgate, London, 1887).
This was the most important literary effort of his life, embodying the results of
much thought, and conclusions wrought out by many an inward contention and
victory; a well-written work, in which the results of scientific research are
skilfully brought to bear on the solution of burning questions.
Dr. Hitchman was a man of good presence and delivery, an able speaker,
rising without effort to eloquence, and an effective public reader or lecturer.
He was a generous, warm-hearted friend and comrade, full of a large and
charitable spirit, and possessed of wide sympathies. His chivalrous nature oc¬
casionally led him to write perhaps just a little impulsively when he thought
any friend of his had been slighted, or that what he held to be supremely
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472
Notes and News.
weighty and important had been treated with indifference or neglect. He
belonged to one of the most excellent types of Asylum Superintendents, was a
well-read physician, of wide and varied culture, and one who obtained distinc¬
tion not only in his profession, but also in other spheres.
Appointments.
Bond, C. H., M.B., C.M.Ed., appointed Pathologist and fourth Assistant
Medical Officer to the London County Asylum, Banstead.
Culunan, H. M., L.B.C.P. & S.I., appointed Pathologist and third Assistant
Medical Officer to the Richmond Asylum.
Hill, E., L.R.CP.Lond., M.R.C.S., appointed second Assistant Medical
Officer to the Leavesden Asylum, King’s Langley.
Mills, John, M.B., appointed Assistant Resident Medical Superintendent
of the Ballinasloe Asylum.
Offobd, J. A., L.B.C.P., M.B.C.S., appointed Assistant Medical Officer to
the Dorset Asylum.
Robebtson, W. F., M.B., C.M.Ed., appointed Pathologist to the Royal'
Asylum, Morningside.
Stansfield, T. E. K., M.B., C.M.Ed., appointed Senior Assistant Medical
Officer to the London County Asylum, Clay bury, Woodford.
Symmebs, W. St. C., M.BAber., appointed Pathologist to the County Asylum,
Prestwich.
Wills, E., M.D.Lond., M.R.C.P.Lond., appointed second Assistant Medical
Officer to the London County Asylum, Claybury, Woodford.
Note. —The Attendants’ Handbook, issued nnder the authority of the
Medico-Psychological Association, will be published in July.
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THE JOURNAL OF MENTAL SCIENCE.
[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland .]
No. 167. NB ^ 0 8 m res * OCTOBER, 1893. Vol. XXXIX.
PART 1.—ORIGINAL ARTICLES.
Presidential Address delivered at the Fifty-Second Annual
Meeting of the Medico-Psychological Association , held at
the Palace Hotel, Buxton , 28 th July , 1893, by J.
Murray Lindsay, M.D.
Gentxemen, —The difficulties connected with the selection
of a suitable subject for the Presidential Address of our
Association, which is holding its 52nd annual session, are
increasing year by year, for it can readily be imagined that
almost every conceivable subject has been well threshed out
by my numerous predecessors. After the careful and
elaborate work of Dr. Hack Tuke and others there is very
little to add to the history of psychological medicine.
The history and work of our Association have also
received of late years considerable notice at the hands of
previous Presidents. I propose to continue the history up
to date, to touch on some points in connection with the
organization and work of our Association, to offer some free
criticisms on lunacy administration, indicating some altera¬
tions and reforms in the lunacy laws and the management of
asylums, drawing to some extent upon a somewhat varied
and moderately long experience. In this way I hope to
rouse some slumbering spirits and to stimulate discussion
which I trust may serve some useful purpose.
In 1861 Professor T. Laycock, in his Presidential Address,
in speaking of the objects and organization of our Associa¬
tion, referred to its shortcomings and defective organization.
But we have moved forward since then, and there can be no
doubt that the Medico-Psychological Association, a title
adopted in 1866 under the presidency of Dr. W. A. F.
Browne, Lunacy Commissioner for Scotland, whose memory
I revere and warmly cherish, has progressively advanced in
xxxix. 81
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Presidential Address ,
[Oct.,
certain directions, especially during the last five or ten years,
in proof of which, if any were needed, I would point to the
work of its various Committees, to the successful efEorts with
regard to the study of mental diseases and clinical teaching
of insanity so ably advocated by Dr. Maudsley, Dr. Clouston,
and others, a subject now made compulsory and adopted by
several teaching and examining bodies, including the
London, Edinburgh, and Victoria Universities, to the
numerous lectures now being given in asylums, to the certi¬
ficate granted in psychological medicine, the training and
certification of attendants and nurses, the handbook for
attendants, and to the excellent scientific work now being
done by Dr. Sevan Lewis, Dr. Wiglesworth, Dr. Edwin Good-
all, and other pathologists and assistant medical officers in
some of the larger asylums, thereby helping to remove a
long standing reproach levelled at asylums that very little or
no really scientific work was done in them. I would also point
to the editorship of the Journal, which was never !n better
hands and never better conducted, in my recollection at
least, for our Association has good reason to be proud of its
present Editors.
Formerly it was not an unusual thing to hear ourselves
sneeringly called u mad doctors,” who in the opinion of an
ignorant and prejudiced public were considered a set of
specialists only half-educated. I had occasion some time
ago to make an investigation with regard to the qualifica¬
tions and distinctions of medical men engaged in our
specialty with a result which must be considered very satis¬
factory. During my inquiry, which was confined to England
and Scotland, with which countries I am best acquainted, I
noted the number of men who had distinguished themselves
during their student career at Medical Schools and
Universities, and subsequently, when I was agreeably sur¬
prised to find that the proportion was wonderfully high,
being higher in the English County Asylums than in the
Borough Asylums, and as might have been expected the
proportion was highly creditable in that industrious little
country north of the Tweed. Our English private asylums
and lunatic hospitals, whose management is so enlightened
and liberal, can also show a very good record in this respect,
for many of our most able and distinguished men are or have
been connected with them. I venture without fear of contra¬
diction to assert that there is no public service, such
as the Army, Navy, or Poor Law Medical Service, which
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475
1893.] by J. Murray Lindsay, M.D.
contains a higher or even so high a proportion of men who
have distinguished themselves. This should, once for all,
dispose of the taunt occasionally thrown at us that our
specialty is filled with and recruited by inferior men.
But whilst fully admitting that much has been done by
our Association and members thereof, it must also be
acknowledged that much still remains to be done, and the
question may reasonably be asked, Has it done all it might
have done ? It is matter for regret that our Association has
certainly failed to assert itself before the public; it has not
carried the weight, and has not occupied the position it
might legitimately claim. I have long been of this opinion,
and I quite agree with Dr. Mercier when he says that “ The
Medico-Psychological Association should be the ultimate
authority on all matters connected with insanity,” and he
adds, “ But none of them could claim that the Association
occupied that position.”
Our Committees are now engaged in doing some good
work, but some time should surely be found for such other
practical and at least equally important matters as increas¬
ing the weight and authority of our Association before the
public, creating an increased interest on the part of a
larger number of our members by keeping fully in touch
with the times and adapting our rules to altered circum¬
stances, thereby encouraging a much larger attendance at
our quarterly and annual meetings. For, gloss it over and
ignore it as we may, it cannot be denied that there is
smouldering under the surface a certain amount of dis¬
content and dissatisfaction with some points in the manage¬
ment of the Association. I do not mean to say that this is
altogether fairly attributable to the doings of the Council, for
I believe the fault lies in a great measure at least with the
members 'themselves, but the indubitable fact remains that,
considering the largeness of the membership, now numbering
nearly 500, a comparatively small share is taken by the
provincial members in the proceedings of the Association,
and the meetings, quarterly as well as annual, are not so
largely attended as it is desirable they should be.
Whatever may tend to promote membership, to encourage
an interest in the Association, to strengthen confidence in
the Council, and to increase the attendance of provincial
members at the meetings is deserving of our serious con¬
sideration. In this connection I may refer to the proposal
made in June, 1892, to allow members to vote by proxy. I
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Presidential Address,
[Oct.,
am one who favours proxy voting, if properly safeguarded,
but as many of the members feel that there are serious ob¬
jections to adopting it, perhaps not without good reason, I
am prepared to accept the proposal in the new rules (Chapter
IV., Rule III.) that “ Any Member unable to attend an
annual or special meeting of the Association may communi¬
cate his views in writing to the General Secretary, and
demand that they be read at such meeting when the subject
to which they refer is discussed.” This rule, along with
Rule XY. of the same chapter, would appear to be a reason¬
able and fair compromise which, it is to be hoped, will be
generally accepted, even by those favourable to proxy voting.
Another mode which, in my opinion at least, might
probably tend to create a greater interest in the proceedings,
and a greater feeling of responsibility to the Association, as
well as to result in a better attendance, would be by payment
of railway expenses to members of Council resident at a
greater distance than 50 miles from London. When our
rules were undergoing revision in 1879 the principle of
paying railway expenses to members of Council who resided
50 miles beyond London was embodied in a proposed rule,
Chapter IX.,which, however, met with strong opposition, and
an amendment moved by me was lost by a large majority.
Nothing daunted nor disheartened by this defeat, having
frequently had occasion to realize the fate of reformers and
being not unaccustomed to find myself occasionally in a
minority, which is sometimes eventually converted into a
majority, I still adhere to this principle as just, judicious,
and sound, if financially practicable. The principle of pay¬
ment of railway expenses to members of Council being
representatives of branches has since been adopted by the
British Medical Association at the annual meeting at
Leeds in 1889, the agitation for this reform having taken
five years for its successful accomplishment.
One of the chief objections to the proposed payment was
that it would ruin our Association. This objection can best
be answered by our worthy Treasurer, and ought to be met
in other ways. If the Association funds do not at present
admit of meeting such legitimate payments, it may become
a question whether the annual subscription should be raised,
or some other means taken to obtain additional funds.
Perhaps the appointment of a Finance Committee might
lead to some economy or reduction in the spending depart-
ment.
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1893.]
477
by J. Mubbay Lindsay, M.D.
I have indicated one way in which, in my opinion, our
Association affairs may perhaps be improved by the appoint¬
ment of a Finance Committee to regulate our finances and
supervise the spending department.
There is yet another way, by the appointment of an
Administrative Committee, in which I think much practical
good might be effected. We are piling on the agony by way
of examinations, and now requiring, or at least expecting,
from assistant medical officers and attendants a higher
standard of special qualifications.
But what, I may ask, is the Association doing to improve
their position and emoluments ? Very little, it seems to me.
I am well aware that the salaries of assistant medical officers
and the wages of attendants have here and there gone up,
but without much encouragement or help from the Associa¬
tion.
There are other practical matters which might be rele¬
gated to an Administrative Committee, such as
(1) The inadequacy of the medical staff in asylums, and
necessity of additional assistant medical officers and qualified
clinical assistants, as pointed out by Dr. Yellowlees in his
Presidential Address in 1890.
I am disposed to think that the Care and Treatment Com¬
mittee, in their Report of 1891, rather under than over
stated the proportion of assistant medical officers needful in
asylums, considering the margin that should be allowed for
absence, necessary leave and relaxation, extra work, illness,
or other necessity. I think the proportion should not be
less than one medical assistant for every 250 patients in a
county asylum receiving both recent and chronic cases, if
the work is to be thoroughly done and accurate records kept.
With regard to the tenure of office of assistant medical
officers, anew departure has lately been taken by two county
asylums on the occasion of filling up vacancies, the period
of appointment being limited to three years.
“ The Hospital ” of 6th May last, in referring to this sub¬
ject, says :—“ This limitation of the term of office is probably
destined to become general in asylums, but we think a three
years* limit somewhat short. 5 * I am inclined to agree with
the latter remark as to a limit of three years being rather
short.
(2) Proportion of attendants to patients in pauper
asylums. This varies considerably in different asylums, as
much as from 1 attendant to 8 patients up to 1 to 144 for
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Presidential Address ,
[Oct.,
men; and 1 nurse to 10 patients np to 1 to 18 for women,
according to the latest available return, prepared in March,
1890, by Dr. J. A. Campbell, which showed a remarkable
variation to this extent. It is manifest that such a dispro¬
portion can hardly be considered consistent with efficiency.
The proportion of 1 day attendant to 10 patients in a county
asylum may, by some, be considered a liberal allowance, and
is, I believe, considered a fair and adequate allowance by
the Lunacy Commissioners, but when a fair margin is
deducted for illness, absence, leave, night pr special duty,
the actual proportion of 1 to 10 is seldom maintained. The
proportion of 1 to 14 or 1 to 18 cannot be considered ade¬
quate, and yet comparisons are often made by County
Council and Union Authorities between one asylum and
another without taking into account such important factors
in calculating the weekly maintenance rate, to reduce and
keep down which there is too often a questionable and un¬
healthy rivalry.
(3) Attendants’ hours of labour and duty. This is a very
difficult and expensive question, which will, in all probability,
sooner or later, come to the front, and be forced upon our
consideration, for it is very likely that the eight hours’ labour
Wave, which is rolling along, will in time surround asylum
attendants, whose long hours on duty, 14 hours, from 6 a.m.
to 8 p.m., have often been the subject of remark and pity
by asylum medical officers. The only effectual remedy for
this would be an addition to the staff of attendants, so as to
obtain shifts and shorter hours, involving, however, a con¬
siderable outlay and an additional burden on the ratepayers,
which they might be rather reluctant to incur.
I believe that Dr. T. W. McDowall has given considerable
attention to this subject, and it will be interesting to know
from him what practical conclusions he has arrived at.
It is well-known that the work of all attendants is not
equally hard and trying, and it is a matter well worthy of
consideration whether special service, for example, in in¬
firmaries and other wards for the epileptic, suicidal, and
most trying class of patients, should be recognized by in¬
creased remuneration or in other ways.
There is another way in which their position might and
should be improved, and their comfort promoted by the
erection of separate blocks or homes for attendants and
nurses, as at some of our large asylums, and now becoming
' so general in connection with hospitals and infirmaries. ...
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479
1893.] by J. Mubray Lindsay, M.D.
(4) Greater accuracy and uniformity in asylum farm
accounts, which do not appear to he affected by agricultural
depression, but almost invariably show a wonderful balance
to the credit of the farm account and a high proportion of
profit unknown to the British agriculturist.
(5) The better equipment of county asylums by providing
pathological rooms for research, a gymnasium for exercises
and drill, swimming bath, Turkish and other baths for certain
classes of patients.
(0) The best means of interesting, brightening, and cheer¬
ing patients on Sundays by the introduction of pleasant
musical Sunday afternoons, and in other ways.
With regard to the regulations for the nursing certificate
examination, it seems to me there is room for improvement*
The mode of appointment of the assessor is open to objection,
the selection should not be in the hands of the asylum
superintendent, subject to the approval of the President,
but in the hands of the Council or the Association, in which
case the selection could be made at a quarterly meeting.
This would tend, in my opinion, to enhance the value of the
nursing certificate in the eyes of the public and of the
attendants themselves.
There is room, too, for improvement in the questions
placed before candidates, for some rather indefinite and
too professional questions, 1 think, are occasionally set by
those attempting to aim too high. Care should be takeu
not to disgust or terrify attendants by high sounding and
too strictly professional questions.
Another questionable point in connection with the nursing,
certificate examination is the number of marks required to
pass, viz., two-thirds, or 66 marks out of the possible total
of 100. Is this proportion not too high ? It seems to me
that it is higher than the pass-rate for medical diplomas !.
Judging from the number of attendants who pass, it is diffi¬
cult to avoid arriving at the conclusion that the system of
marking has been somewhat elastic and accommodating.
With regard to the training of nurses, a suggestion was
made by Mr. Snape, M.P., that Parliament be asked to
authorize County Councils to pay for the training of nurses.
If his suggestion were carried out, our Association funds
might then be relieved of the expenses connected with the
training and certification of nurses, including the railway
expenses of examiners or assessors. An application was
made by the asylum of which I am superintendent to the.
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480
Presidential Address ,
[Oct-,
Technical Education Committee of the. Derbyshire County
Council for a grant of money to defray the expenses con¬
nected with ambulance and first aid lectures to attendants
and nurses, the result of which application was that we
succeeded in obtaining a grant of £6 6s. for this purpose.
In connection with the revision of the rules the important
question of female membership of the Association will no
doubt engage your serious consideration, for it is an entirely
new departure and ought not to be decided without full
opportunity for discussion, the rule on this subject being
made sufficiently clear so as to leave no room for doubt. For
my own part I think that we should keep abreast of the
times, and I doubt whether it is advisable to shut our doors
against the admission of legally qualified women, as I
believe there is a legitimate field of usefulness open to them
in the female departments of some of our large asylums
having several assistant medical officers, and where suitable
arrangements could be made for resident medical female
assistants. Such appointments under certain conditions and
properly safeguarded would, I think, be calculated to exert a
beneficial influence upon the staff of nurses, and probably be
attended with some advantage to the female patients.
Indeed, I cannot see how in common fairness or on what
valid ground legally qualified women can be excluded from
membership if they wish to join the Association on the
same terms and subject to the same rules as men, and do
not expect any exceptions to be made in their favour. If
freedom of discussion is likely to be threatened or marred
by the presence of women, I should then be inclined to
doubt the advisability of their election and to think that
too great a sacrifice was being made for female membership.
Quite recently I had an application from a legally qualified
woman with good credentials for the post of resident clinical
assistant, without salary, at the Derby County Asylum, but
for a variety of reasons it was impossible to entertain it.
After three years’ acquaintance with the new Lunacy Act,
which came into operation in May, 1890,1 am not enabled
to look upon it with more favour than at first. Each year’s
experience of it only leads me to join in the general con¬
demnation of it by asylum medical officers as in many
respects a piece of hasty, vexatious, and ill-judged legisla¬
tion, not only attended with little or no benefit to the insane
poor, but depriving them to a considerable extent of the
attention of the medical officers, whose time is now largely
Digitized by t^ooQle
1893.]
481
by J. Murray Lindsay, M.D.
taken up with increased clerical and reporting work in order
to satisfy the requirements of an unnecessarily exacting,
complicated, and confusing Act, the chief redeeming feature
of which is the consolidation of various previous enact¬
ments. If the effect of the said Act had really been, as
intended, to provide additional safeguards and protection to
the public, or to confer substantial benefit upon the insane
by facilitating early treatment, asylum medical officers
would assuredly have been the last to condemn it, instead
of which, they are now to a large extent converted into
recording and certifying machines, a considerable portion of
their time being now frittered away in writing useless
reports, signing certificates, and other clerical work, to the
exclusion of work attended with more real benefit to the
patients in the direction of promoting their cure and
amelioration.
There is no need, in my opinion, to fear any injustice or
detriment from prolonged or unnecessary detention ; on the
contrary, the danger would rather appear to be in the ten¬
dency to premature discharge, which the public and union
authorities may some day realize after suffering from its
effects.
One of the chief objects of the new Lunacy Act was said
to be to secure speedy treatment. Has this object been
attained? I think the answer must be in the negative, as
Dr. Maudsley and others have clearly shown.
Another principal object of the Act was to furnish safe¬
guards against the improper confinement of persons as
lunatics. Was there any real danger of this happening
either in private or public asylums? I think not, for no
proof was forthcoming to this effect, and no authenticated
case could be brought forward. One result in the opposite
direction and of a questionable nature has been the tendency
of the Act to cause the premature discharge from asylums
of patients not thoroughly recovered, some of whom relapse
and soon return to the asylum at an increasd cost to the
unions.
A further object was to enable pauper asylums to make
provision for private patients at moderately low rates of
board. There can be no doubt that some provision of this
kind is much needed, but I am not aware that any county
has yet taken advantage of the merely permissive sections
(66 and 67) of the Act of 1890 relating to this subject.
Asylum Visiting Committees are naturally and not un-
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482
Presidential Address ,
[Oct.,
reasonably reluctant, when not compelled by statute, to
apply to County Councils for funds to enable them to
embark upon what, at the first onset at least, must neces¬
sarily partake of the nature of a speculation, for it must be
expensive to start with, and may not be self-supporting
for some time. It is very desirable, however, that some
means should be found of meeting this recognized want,
either partly at least from County Council funds, or in
some other charitable way.
Another recognized want is some provision for young idiots
and imbeciles in connection with county asylums, or con¬
jointly with other counties, so as to give them the benefit of
special training and care, for assuredly a lunatic asylum is not
the best place for young idiots and imbeciles, some of whom
at least are to a certain extent educable and improvable.
The Act still leaves something further to be desired in the
way of protecting medical practitioners in the performance
of their duties, for Section 11 has been found not to be
sufficiently protective. It is not at all to be wondered at
that many medical practitioners still decline to have any¬
thing to do with signing lunacy certificates, and in thus
declining I think they act wisely for their own pockets and
peace of mind.
It was only the other day that a medical practitioner, Dr.
Frederick J. Smith, in referring to the case of Morton, the
Hackney murderer and suicide, in a letter which appeared
in the “ British Medical Journal” of 1st July, stated that
he was consulted about this case seven months previous to
the murder, diagnosed mental disturbance, and advised
either an attendant at home or immediate removal to an
asylum.
Dr. Smith remarks : “ At that date insanity was obvious,
but such is the unprotected state of the profession under
our lunacy law that I did not feel inclined to run my head
into a noose by signing a certificate.”
Dr. W. Orange draws attention to Morton’s case in a
letter which appeared the following week in the u British
Medical Journal,” and refers to remarks recently made by
Mr. Justice Grantham, at the Central Criminal Court, at the
trial of Townsend for threatening the life of the Prime
Minister, “ that it was a great misfortune that, in con¬
sequence of the disinclination of doctors to sign certificates
—although he did not say that such disinclination was not
quite justifiable under the circumstances—there were a
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number of persons at large who ought to be under control
and care.”
The abolition of the power of an officiating clergyman
and an overseer or relieving officer to sign an order for the
admission of a pauper patient has been attended with
decided disadvantage in at least one county, Derbyshire, and
probably also in other counties, by delaying speedy treat¬
ment, retarding the removal of the patient to an asylum
owing to the difficulty in obtaining the signature of a justice,
for the long distances occasionally to be travelled before
obtaining the justice's order and the refusal of some justices
to have anything to do with signing lunacy orders (although
every justice in Derbyshire is authorized to sign such orders)
caused great inconvenience which is also attended with
increased cost to the unions, and as far as I can see with no
real benefit to the poor lunatic, on the contrary. In Derby¬
shire the old plan of the workhouse chaplain or officiating
clergyman and the relieving officer—who were usually better
acquainted with the patient’s case than the justice—being
empowered to sign the admission order worked very well, for
I have never known a single instance of any evil or draw¬
back arising from such procedure.
Since this power on the part of the officiating clergyman
and relieving officer has been abolished it seems to me very
advisable that the Lord Chancellor should avail himself of
and put in operation the 25th section of the Lunacy Amend¬
ment Act of 1891 (54 and 55 Vie.), empowering the Chairman
of the Board of Guardians to sign orders for the reception of
persons as pauper lunatics in institutions for lunatics,
thereby conferring powers of Justice of the Peace on such
representative of the Board of Guardians.
I am among those, the large majority, I believe, who
have hitherto failed to see any benefit to the lunatic or the
public from the operation of Section 38 with its ten sub¬
sections, especially Sub-Section 4, relating to the duration of
reception orders, the chief effect of which is to add to the
already excessive amount of reporting and clerical work
imposed on the medical officers, without any compensating
advantage to the lunatic or the public.
Under the present system the clauses (Sections 25 and 26)
relating to the reception and detention of chronic lunatics
and imbeciles in workhouses do not work smoothly or
efficiently so far as relief to the overcrowded asylum is
Concerned, experience showing either that workhouses are
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not adequately provided with suitable arrangements for
such cases, or the workhouse authorities will not take the
least trouble with the patients, who, though comparatively
harmless and inoffensive but requiring attention and looking
after, are frequently sent back to the asylum after a short
residence in the workhouse.
Unfortunately of late I have had ample experience of
this, that little or no relief to the overcrowded asylum need
be looked for from workhouses. I believe that other super¬
intendents have had a similar experience. For the present,
however, I fear there is no remedy for this state of matters
until the practice in England is assimilated to that of Scot¬
land by extending the Government grant of 4s. a week to
Boards of Guardians for pauper lunatics, chronic, imbecile,
idiotic, and demented cases in workhouses, or boarded out
under arrangements to be approved by the Lunacy Commis¬
sioners ; or until workhouses are placed under one con¬
trolling authority, the County Council, and all classes of
the poor, whether sane or insane, are brought under one
and the same jurisdiction, which I believe would also be
attended with decided advantages in other directions.
When the Lord Chancellor was amending the Lunacy
Laws it is matter for regret that such a golden opportunity
was lost of effecting a long-looked-for and much-needed
reform, a reform contemplated in the Act of 1890, and
referred to in strong terms by the Select Committee of 1878
in their Report. I refer to the advisability of strengthening
the Lunacy Commission by an increase of the medical staff,
and by an amalgamation of the Lunacy Departments,
as provided in Section 837, which empowers the Lord
Chancellor to effect such amalgamation. The explicit and
significant remarks of the Select Committee made fifteen
years ago are applicable with even greater force now, con¬
sidering the large increase during this period of about
23,000 in the number of lunatics, idiots, and persons of
unsound mind under official cognizance in England and
Wales, who, on 1st January, 1892, numbered 87,848.
The conclusions and suggestions of the Select Committee
of 1878 may be thus summarized
* (1.) The best security against the undue detention of patients
consists in personal examination such as that by the Chancery
Visitors.
(2.) There seems no valid reason why the possession of property
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1893.] by J. Mubbay Lindsay, M.D.
should make any difference in the personal treatment of lunatics,
or in the supervision exercised over them.
(3.) Either the Chancery lunatics, who number less than a
thousand, have too much care bestowed upon them, or the others,
who exceed sixty-five thousand, have far too little.
(4.) The property might still be under the care of the masters
in whatever way may be considered best; but it seems reasonable
that all lunatics should be treated on the same system as far as
admission, detention, supervision, and release are concerned.
(5.) Though it may be true that the lunacy of the majority of
patients in an asylum is self-evident, yet it seems physically
impossible that with the present strength of the Lunacy Com¬
missioners minute supervision of those who require it can be
efficiently exercised.
(6.) It may be that by some amalgamation of the two depart¬
ments waste of power in visiting might be obviated, and the delay
and expense frequently attending the discharge of Chancery
lunatics be avoided, and stricter supervision exercised over single
patients, who are said to require it more than others, and yet are
only visited once a year by the Commissioners, and for visiting
whom there is no statutory obligation.
It is very remarkable, and not easily explained, that, not¬
withstanding the great increase in the number of the insane
and the additional work thrown upon the Lunacy Commis¬
sioners in consequence of this increase and owing to recent
legislation, the number of the Lunacy Commissioners—three
medical and three legal—has remained the same since 1847,
when the number of lunatics, idiots, and persons of unsound
mind was less than a fifth of the present number. In the
Report of the Metropolitan Commissioners in Lunacy, 1843
and 1844, the names of seven medical and four legal Com¬
missioners are given, but whether all or only some of them
were Visiting Commissioners I am unable to say.
Although the work of the Commissioners has greatly
increased, and their duties have become more arduous com¬
pared with former years, their work has not been recognized
by Government as it ought to have been, they have received
no additional remuneration, whilst the salaries of asylum
medical officers have been gradually rising, until both in
England and Scotland some superintendents are better paid
and making larger incomes than the English Lunacy Com¬
missioners.
I am at present most concerned with the foregoing con¬
clusions 3 and 5 of the Select Committee of 1878, with
which I believe all those most conversant with the subject
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Presidential Address ,
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will entirely agree. It cannot be denied that the Lunacy
Commission has long stood in need of being strengthened,
that it is certainly undermanned if the work of visitation
and inspection is to be thoroughly done and with sufficient
frequency, for it is obvious that the visitation of public
asylums and single patients by the Commissioners only once
a year, as required by statute, is insufficient. There ought
to be at least two visits yearly to public asylums, as in Scot¬
land and Ireland.
At a time when the Lunacy Commission requires to be
strengthened, the removal of such a highly distinguished
physician as Dr. T. Clifford Allbutt to the more congenial
sphere of usefulness of Kegius Professor of Physic in the
University of Cambridge is cause for regret, and I feel sure
none regret his loss to the Department of Lunacy more than
asylum medical officers.
The Lunacy Commission might be strengthened in three
ways, firstly, by amalgamation of the two lunacy departments
as suggested by the Select Committee, the Chancery Visitors,
who are probably not overworked like their brethren on the
Commission, might be able to devote some of their leisure
time to help the Commissioners ; secondly, by an addition to
4he medical staff of the Commission by the appointment of
Assistant or Deputy Lunacy Commissioners as in Scotland,
which was recommended 33 years ago by the House of
Commons Select Committee of 1860; and, thirdly, by the
removal, on the occasion of a legal vacancy as opportunity
offered by retirement or death, of the present anomaly of
barristers writing reports and expressing opinions on medical
matters requiring a special training, and the substitution of
a visiting medical for a legal Commissioner, thereby assimi¬
lating the practice to that of Scotland and Ireland, where it
works very well. One legal member on the Lunacy Commis¬
sion would probably be found quite sufficient for all necessary
purposes of advising the Boards
I am in thorough accord with Dr. H. Bayner, who, in his
Presidential Address in 1884, referred to the necessity of
strengthening the Lunacy Commission. It stands to reason,
and ought to be sufficiently obvious to ordinary intelligence,
that if it required six Commissioners in 1817 to supervise
16,634 lunatics and idiots in England and Wales, it surely
required more than six Commissioners to supervise five times
that number, 87,848 in 1892 !
The same rule of dual visitation in England by a legal
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487
1893.] by J. Murray Lindsay, M.D.
and medical Commissioner has been in operation for half a
century since 1843. I have hitherto failed to see any
advantage in such dual visitation, which is contrary to the
practice prevailing in Scotland and Ireland, where more
frequent single visitation by a medical Commissioner answers
very well indeed, and is attended with greater advantage to
the insane and to asylum management than the antiquated
English system, which is out of touch with the times and is
contrary to the report of the Select Committee of 1860
which recommended single visits by one Commissioner. In¬
deed I see no need of and no advantage whatever in the
visitation of asylums by barristers, who are not supposed to
be competent to express opinions on medical matters, and
who would be the first to resent intervention by medical
men in their legal affairs.
If the Lunacy Commission could be strengthened and
brought into touch with the times in the way indicated the visi¬
tation of asylums could be more frequent and the supervision
of patients more thorough, for the Commissioners, relieved
from the over-pressure of routine duties and from over-strain,
would be enabled to approach their visitation duties with
increased calm and less impatience, for even Commissioners
are but human and are not free from the weaknesses incident
to our common humanity. It occurs to me that if the Com¬
missioners were not so over-worked and were subject to less
strain, the tone and spirit of their reports written at asylums
would occasionally be very different and would at times be
more free from ill-considered and petty fault finding. It is
not by irritable effusions and needless petty fault-finding nor
by persistent adherence to antiquated fads that their reputa¬
tion will be maintained or their authority increased.
County Councils have now been sufficiently long established
and so far settled down as to enable us to form some opinion
of their working and their influence upon asylum administra¬
tion. There can be no doubt that the prospect of a Local
Government Bill, which was for years dangled before the
face of the electors by both parties in the State, had the
effect in many counties of retarding necessary improvements
in and additions to asylums, thereby avoiding expenditure
and promoting so-called economy. And it is equally certain
that their predecessors in office, the county magistrates, of
whose enlightened and liberal management of asylums I
desire to speak with all respect, naturally left considerable
arrears in the way of necessary improvements to be carried
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Presidential Address ,
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out by their successors, the County Councillors. Whilst I
believe that County Councils are now beginning to better
understand asylum wants and the requirements of the insane,
and showing a disposition, though somewhat tardily in some
cases, to take an enlightened and comprehensive grasp of
their new duties as regards asylum administration, I still
think that the process of education is not yet complete, and
therefore it seems to me to be matter for regret that so few
visits are made by County Councillors to other asylums for
the purpose of comparing notes and seeing what is done
elsewhere. Such visits by County Councillors to other
asylums should be encouraged, and it is to be hoped that
they will in the future be more frequent.
Considering the few years County Councils have been in
operation, I think there is on the whole every reason to be
satisfied with the progress made and with their administra¬
tion of county asylums, which will eventually derive greater
benefit under their regime , for, fortunately, there can be
little doubt that more money has of late years been spent
upon asylums than for years previously.
If English County Asylums are to continue to maintain
the deservedly high reputation so loug enjoyed by them they
will have to forge ahead and look to their laurels, for Scot¬
land is assuredly in advance with regard to lunacy adminis¬
tration, whilst it must be admitted that Scotch asylums are
second to none.
In Derbyshire we are particularly fortunate in having an
excellent County Council, by whose hard working committees
much good and practical work has been done and many im¬
provements carried out. In illustration of this I need only
allude to the excellent work done by the Finance, Technical
Education, Public Health, and Asylum Committees, who have
successfully endeavoured to progress and keep in touch with
the times.
As a model of efficiency and thoroughness of details in the
working of asylums, combined with liberality and considera¬
tion to the staff of officers and attendants in the matter of
pay, pension, and leave, I would point to the London County
Council as in the front rank in these respects, so far as I am
able to judge. I would also desire to embrace this oppor¬
tunity, as an old officer of Han well Asylum, of expressing
my grateful recollection of the liberal and considerate spirit
always shown by the Visiting Justices towards the asylum
staff. This I always considered one of the great features of
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1893.] by J. Murray Lindsay, M.D. 489
Hanwell, and it is pleasing to me to note that the manage¬
ment of my old asylum by the London County Council is
still characterized by the same considerate spirit.
There is one subject, in conclusion, to which I may be
permitted to make a passing reference—I allude to the im¬
portant question of superannuation. This subject is a very
long story, having engaged the attention of the Association
from time to time during the last 33 years. Dr. Bucknill, in
his Presidential Address, having, as tar back as 1860, made
some very forcible and appropriate remarks on the question
of pensions. At the annual meeting in 1863 a Committee on
Superannuation was appointed, consisting of Dr. Lockhart
Robertson, Dr. J. Kirkinan, Dr. Sheppard, and Dr. Maudsley.
Dr. W. Wood, in 1865, in his Presidential Address, also
referred to the question. At the annual meeting in 1879
some superannuation resolutions I brought forward were
carried; but a compulsory retirement resolution, proposed
by me, was lost at the meeting, although I stated that of
the replies I had received, 79 per cent, from England, 94 per
cent, from Scotland, and 82 per cent, from Ireland, were in
favour of the resolution. I may mention that this principle
of compulsory retirement after a certain age has since been
adopted by the Northampton County Council in their asylum
pension scheme; it is the rule in the Government service, and
would most likely be adopted in any general pension scheme
which may hereafter be framed for asylums.
Another principle I then advocated, of transferred service,
from one county to another, of not less than three years*
duration, counting towards pension, has since been adopted
in the Police Superannuation Act. This principle was
also taken up and advocated on behalf of asylums by
the Parliamentary Committee of the British Medical Asso¬
ciation, and through that Committee brought under the
notice of Government and Parliament by Dr. Farqu-
harson, M.P., and Sir W. Foster, M.P., to whom our
best thanks are due. At the annual meeting in 1882 I
again returned to the charge, with the result that resolutions
were passed drawing the attention of Government to the
necessity of placing the question of superannuation on a
more certain basis than at present, and instructing the
Parliamentary Bills Committee to consider the best mode of
giving effect to the resolutions. At the annual meeting in
1887 the subject was again referred to.
Such is a brief account of the history of this question, and
xxxix. 32
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Presidential Address ,
[Oct.,
it may now be asked. Where are we; how much further has
this question advanced P Well, it has certainly advanced and
reached an important stage, for a fair and liberal asylum
pension scheme has been adopted by the Northampton
County Council, the only County Council, so far as I know,
which has yet adopted a special asylum pension scheme,
although 1 am aware that another County Council Asylum
Committee, for the West Riding, prepared an excellent
asylum pension scheme, with report, which was nearly
carried at the County Council meeting, and was only lost by
a small majority. I believe that a few other County Asylum
Committees have considered the question and prepared
asylum pension schemes, which, however, have not yet
received the sanction of the County Councils.
It is the permissive principle and the uncertainty with
regard to pension which are considered by the staff of
asylums to be the real grievances, on account of being so
unsettling and attended with suspense and anxiety, and even
in some cases involving considerable hardship.
In my opinion a reaction has set in of late in favour of
superannuation, and I am disposed to think that the present
is a favourable opportunity for bringing the subject before
the notice of the County Councils Association, in the hope
that within the lines of the Local Government and Lunacy
Acts they might be willing to consider and frame a special
pension scheme applicable to county asylums.
In connection with this subject it is noteworthy, and must
be considered very satisfactory, that County Councils, in the
matter of superannuation, have not receded from, but are
advancing on the lines of their predecessors by following
the spirit and letter of the Superannuation Clauses of the
Local Government and Lunacy Acts, in proof of which the
following significant fact may be mentioned, that of five
asylum medical superintendents pensioned by County
Councils, being the last five medical superintendents who
have retired on pension, four received the maximum retiring
allowance of two-thirds, and one received a half of the total
value of office, including salary and allowances.
Before leaving the question of superannuation, I feel it to
be a pleasant duty to refer to the kindly, considerate, and
graceful recognition of the claims of asylum officials to
superannuation allowances, warmly expressed by the Lunacy
Commissioners in their 45th Report for 1890, who speak
strongly in favour of granting retiring allowances, and
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1893.] by J. Murray Lindsay, M.D. 491
offering adequate remuneration as a means of attracting
well qualified persons to the service of asylums and retaining
them therein, when, by the experience they have gained,
their service has become valuable.
As far as 1 am aware, our Association has not expressed
any gratitude or passed any vote of thanks to the Com¬
missioners for this timely expression of their opinion and
their kind assistance in promoting our cause. If so, I think
the Association has been rather remiss, and I trust that
before this annual meeting draws to a close some member
will propose a cordial vote of thanks to the Lunacy Com¬
missioners, who are certainly entitled to our gratitude in
this matter.
The Out-Patient System in Asylums .* By Dr. F. St. John
Bullen, Assistant Medical Officer, West Biding Asylum,
Wakefield.
The object of the paper to be now read is to evoke discus¬
sion on certain questions connected with the above scheme.
Inasmuch as the system has received but a limited trial in
this country, but few facts concerning its actual working are
to be expected as yet. It is, however, deserving of con¬
sideration in this its embryonic period. An out-patient
clinique was started at the Wakefield Asylum in January,
1890, and also adopted at the other West Biding Asylums.
I can only speak of the results in the first-named institu¬
tion.
The total number of cases there treated up to the present
amounts to 116. Out of the number recommended 20 have
proved unfit for treatment. In 16 the condition has been
alleviated; in 12 recovery has occurred (I should state that
the small-pox epidemic in the West Biding, which obliged us
to close our doors to out-patients, seriously lessened the
number of applications). Of the remainder, several continued
under the care of their own medical men, .advice being
tendered ; 23 ceased to attend, and 14 were admitted; 27 are
still on the books. I would add that many patients were
unable to follow out treatment, by reason of their poverty
and inability to attend on account of leaving their daily
* Paper read at the Quarterly Meeting of the Medioo-Payohologieal Aaflocift*
tioD, held at Liverpool, March, 1898.
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492 The Out-Patient System in Asylums , [Oct.,
work. A considerable proportion ceased to attend from such
stress of circumstances.
So far it must be confessed that the results have not been
over-promising, but before condemning the practicability
and efficacy of the scheme it is necessary to carefully review
and, where needed, revise the working and conditions of the
system.
At the outset one would ask, Is an out-patient clinique
needed P Putting aside the question of practicability for the
moment, and considering only that of a requirement to be
met, it may be admitted that such system is needed. It is
true that if medical men generally were fairly versed in
mental diseases the need would be less, but at present
it must be accounted probable that a large proportion of
general practitioners have -not an extensive acquaintance
with this branch of medicine. Even had they, the time
needed to deal with mental disorders, and the anxiety for
their safe care, which an extended knowledge perhaps only
increases, would prove a heavy tax upon them.
It is a matter of common experience amongst asylum
physicians that many cases are certified and sent to asylums
which might have been treated outside, and I consider that
the effect of as j lum residence on patients is not one of un¬
mixed benefit. Nowadays, when our institutions have so
many of the comforts of home (and, indeed, injudiciously, in
some instances are furnished with comparative luxury), there
is a danger of depriving the patient of a salutary dread of
loss of liberty and domestic life, and of diminishing his
sense of personal responsibility to the community. In other
words, there may result a tendency towards pauperization,
and it is far too frequent to hear a patient on discharge to
refer jocularly to a possible return.
Hence I think that a struggle should be made to treat
patients outside the walls of an asylum and preserve to them
their sense of responsibility and freedom, cultivating rather
a spirit of opposition than one of subjection, which latter,
forcible removal from home and detention elsewhere, is liable
to breed.
The stigma attaching to those who have had an attack of
insanity is, of course, much less noticeable amongst the
lower classes of society, but even here I think that fairly
marked differentiation exists between cases treated without
and within the asylum, apart from the relative seriousness
of the attack. And, however false such may be, yet so long
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1893.] by F. St. John Btjllen.
as the patient’s welfare is benefited by the fiction, it is due
to him to essay home treatment.
Thus it appears justifiable to argue that there is some in¬
dication for a system of out-patient treatment of the insane
to be tried.
The next question to be discussed is that of the prac¬
ticability of the scheme.
Theoretically, the difficulties and objections are not few,
neither are they lessened in practice. Such are connected
with—
(1.) The home-care of the patient.
(2.) The application of treatment at a distance, and pro¬
bably under unfavourable circumstances.
(3.) The distance which patients may have to traverse in
order to attend at an asylum, and probably the indisposition
to attend there at all.
(4.) The efficiency of means to deal with the examination
and treatment of patients.
The first of these objections is a serious enough one. In
many caseB the surroundings of the patient have fostered,
even excited, the attack of insanity. And although the
anxiety of the relatives to benefit the patient may be
evident, their efforts are so often ill-judged and ignorant as
to be but harmful. I take it that the difficulties under this
heading of home-care are so obvious as to scarcely need
indication—notwithstanding which, to some extent, remedial
measures may be adopted.
The second point of objection is almost one with the first.
In no few cases the patient is found to be left nearly or
absolutely to his or her own resources, not only unassisted,
but hampered by children and domestic cares of various
kinds. Under these circumstances the administration of
drugs becomes a serious difficulty, if they possess any toxic
nature; also various other dangers present themselves, such
as free access to lethal weapons and suggestive methods of
injury to self or others. Without assistance, too, it becomes
nearly certain that matters of dietary, under circumstances
of mental depression, for instance, will not be attended to.
In such cases the responsibility of the asylum physician is
considerable, and he needs much experience to decide upon
the propriety of accepting them as out-patients. And yet, if
he refuse them, a large proportion of his applicants will be
disqualified, and the scheme of asylum extra-mural treatment
receives a serious check.
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The Out-Patient System in Asylums , [Oct.,
The third objection is an important one also. Where the
county asylum is the centre for out-patient treatment, the
distance for the patient to traverse and the difficulty of
transit may be in some cases serious impediments—even
excluding expense.
Moreover, patients are likely to shrink from the precincts
of an institution which they regard from the nature of their
condition with especial dread, and to harbour a feeling that
upon some visit they may be swallowed up within its gates.
I have heard the relatives confess to the unwillingness the
patient displays towards attending at the asylum.
With regard to the efficiency of means to deal with the
examination and treatment of patients, it is not sufficient
that out-patients should be received into the ordinary
waiting-room of an asylum, to be herded amongst in-patients
and their friends, and to receive, perhaps, hurried notice
amidst the press of other work. It is obvious that they
should not be brought into any contact with such persons,
and also that the asylum physician should be able to give
sufficiently lengthy and undivided attention to his case.
Where, too, there is any number of cases, there are sure to
be no few who will need careful and varied forms of physical
examination, the whole of which could not be well-performed
without assistance from an adequate staff. In fact, it is
evident that there must be no scant time allowed for the
examination of this class of patients, when we consider the
time occupied in the examination of a new admission into an
asylum, where we have not at the moment to enter into the
difficulties of treatment, which are, of course, infinitely
multiplied in the case of persons for the while out of our
observation. Leaving this subject, we must allude briefly to
the class of cases fit for treatment. At Wakefield we have
always considered it preferable to have the patient recom¬
mended by a medical man, so as to avoid clashing in any
way with the interests of the outside practitioners. Apart
from this, all cases not having some distinct mental
symptoms existent or threatening are excluded.
When recommended for treatment, the propriety of ac¬
cepting the responsibility of the case has to be considered.
And although there is no statutory power vested in the
physician to commit patients to an asylum, yet, in most
cases, his advice will be adopted by the relatives, or even
voluntarily by the patient, so that he practically becomes
the disposer of the freedom of the latter. I need not allude
to the kind of cases fit to be accepted as out-patients, since
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495
1893.] by F. St. John Btjllen.
their choice will be the result of experience. It is certain,
however, that unless additional means of treating those who
do attend are taken, the number which will be available will
prove small, and probably consist of the more unsuitable and
chronic kind.
As to improvements in the working of the system, certain
suggestions may be made. Firstly, I think that where
feasible it is far preferable to hold the ciiniques away from
the asylum. Where the latter is closely situated to some
large town the public infirmary or dispensary form most
suitable places, if arrangements can be made with their
committees for the use on certain days of their out-patient
rooms. In the case of the larger institutions obvious
benefit would result from the opportunity of consulting with
their medical staff, where advice as to conditions other than
mental may be welcome. And, on the other hand, advan¬
tages might accrue to the students in the way of studying
mental diseases.
If there are difficulties in the arrangement of the above
suggestion an alternative would be to hold the clinSjue in
town chambers.
Improvements in the home treatment of patients must be
directed towards—
(a.) Relief of temporary pecuniary straits.
(6.) Proper nursing supervision.
(c.) Isolation.
The first, for the most part, will only be needed when the
bread-winner of the household is the patient and needs with¬
drawal from work. I cannot here offer suggestions as to
through what source such relief is to come, although it
would seem that the union authorities might well consider
the propriety of making some allowance which might equal
or be less than—as occasion demanded—the sum charged by
the asylum authorities for maintenance.
As regards the provision of nursing, without attempting
to maintain a severely acute case out of the asylum, there is
yet no small number of patients who could be safely trusted
to tide over an attack of insanity at home, provided they
were under moderate supervision and management. In some
few, no doubt, almost constant companionship would be
needful; in the majority occasional visitation would be
enough. This could only be done by having a nurse or
attendant staff on the system of district nursing, and would
be only practicable in the case of the large towns.
Or there is the alternative (3) of temporary isolation. It
Digitized by ^ooQle
496
[Oct.,
The Out-Patient System in Asylums ,
appears to me a desideratum that an institution after the
kind of a convalescent home should exist, into which the
poorer class might be admitted, as voluntary patients, in the
earlier stages of mental disease, by recommendation of the
asylum physician. This would by no means pose as an
asylum, and the complete freedom of the patient would
relieve him from all fear of compulsory retirement from the
world. The building and nursing accommodation would
only need to be of a simple kind. It would be situated
preferably in the locality in which the out-patient clinque was
held, and would be visited by the physician on his ordinary
days of attendance. There would probably be no need for
constant medical supervision, but if the size or require¬
ments of the place demanded such, charge might well be
taken by a clinical assistant from one of the county asylums,
where such an officer exists.
I am aware that the foregoing suggestions would present
many difficulties in their carrying out, nor can I indicate the
method for putting them into effect, even supposing them,
that is, to be sufficiently feasible to demand further con¬
sideration. But in order to push the scheme to its limit of
practical trial, I have felt bound to mention needful ex¬
tensions of the system as at present pursued.
In connection with the development of the out-patient
scheme, I am enabled, through the kind offices of Dr.
Savage and Dr. Goodall, to obtain the opinions of some
distinguished alienists in Germany upon the mental
" Irrenkliniks ” there.
Their views will go far in helping us to estimate the value
of the scheme, actual or prospective.
Prolessor Eulenburg, of Berlin, writes to the following
effect:—
“ Out-patients with mental symptoms are treated in the
department fbr diseases of the nervous system, and not in a
special clinic. The class of cases attending consists of the
milder forms of functional psychoses, i.e., mania and melan¬
cholia, as well as organic diseases, especially in their early
stages; also cases of hysteria and alcoholism.
“ Often patients are brought to the out-patients’ room to
be certified, or for advice as to their responsibility under
certain mental conditions.
Most of the patients are drawn from the lower classes,
but some are from the middle class, e.g. 9 minor officials,
artists, teachers, etc.
Digitized by ^ooQie
497
1893.] by F. St. John Bullen.
“ There is no difficulty in the certifying of a patient,
any qualified physician, together with a magistrate, being
sufficient authority in the case of paupers, and the latter
person’s interference being waived in urgent cases until
after the incarceration of the patient. Another certificate
by a physician specially-authorized (by Government pro¬
bably) is needed in the case of patients sent to a private
asylum (again to be waived in an urgent case).
“ The treatment is conducted only on general principles,
dietary, tonics, mild sedatives, electricity, and massage being
employed.”
Professor Eulenberg emphasizes that treatment inside
an institution is much preferable , and that an out-patient
system can only be looked upon as supplementary.
Professor Knecht (who translated Dr. Savage’s book
on “ Insanity” into German) has a more favourable opinion
of the use of these clinics, asserting that they are undoubt¬
edly valuable in giving advice to the lower classes. The
same persons, as regards social status, attend, as before
mentioned. Medicines are supplied on reduced terms.
Treatment as before.
Dr. Levinstein Schlagel, of Berlin (who edited the last
edition of Griesinger’s book), gives the following informa¬
tion :—“ The department for diseases of the nervous system,
in connection with the University, receives patients naving
transitional forms of disease from neuroses to psychoses, and
with pure psychoses as well. Both are received for treat¬
ment, but members of the latter class, if in a state dangerous
to themselves or others, are sent directly to an asylum.” Dr.
Schlagel does not express himself enthusiastically about the
treatment of the pure psychoses as out-patients. In his
opinion they take up much time and soon relapse. The
clinics are largely attended, and by both the poor and
better class. He also mentions a system of ‘‘patient’s
funds,” which enables the treatment to be carried on outside
the clinics.
All these authorities concur in the opinion that these
clinics are of proven value for the purpose of teaching to
the students.
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498
[Oct.,
A Chronicle of Infant Development and Characteristics. By
Sir W“- G. Simpson, Bart.
(Continued from p. 389 .)
Child Odo, born 8th February, 1885.
July 15M.—The following differences between James and
Odo were noted in the first few months of the latter’s
existence:—James’s eyes from the first were noticeably wide
open, and seemed to look. They seemed much larger than
Odo’s. Now they are soft and languid. James was some¬
what delicate during infancy, but grew out of it; stomach
easily deranged. Softness of eyes in some measure due to
very long lashes; but I find comparative brightness or lan¬
guor of eyes a sure guide to his state of health. Odo’s eyes
have steadily grown in apparent size, because (the converse
from James) the older he has grown the wider he has opened
them. They are now wide, round, and bright (blue). James
has very large pupils; Odo not. Odo apparently healthy,
can partially raise himself up; has cut thirteenth tooth;
has a placid temperament; does not cry much, i.e., will lie
awake for long periods, which James never would do; sleeps
all night for most part, which James seldom did. In short,
thus early the one shows an excitable, the other a placid
temper. Odo objects to being taken by a stranger, although
he very soon gets over his misgivings. At this age James
showed no distrust of strangers. Odo has a distinct manner
to the three persons he knows best—nurse, mother, and
father. He coos and smiles to mother when she comes to
take him. He only smiles to father. Stfiiles more but talks
less than James did at same age. By talking I mean saying
“ coo,” “ ug-gug, and the expression called “ crowing.”
Cries at once on being scolded. James did not understand a
scold at same age. Odo always tries to seize father’s
moustache when taken by him. In the case of women it is
the hair he goes for in preference to anything. Odo makes
use of smiles at five months old, and used them uncon¬
sciously at four months, which James (see notes on him) did
not do till his seventh month. On the other hand, Odo uses
his hands only to grasp things, or at most to put them to
his mouth. At the same age James always put them to his
mouth and could play with them, that is, pull them about.
September 6th .—He has become eagerly interested in, and
Digitized by A^OOQie
1898.] Infant Development and Characteristics. 499
has made great and sadden progress in grasping things and
conveying them to his mouth; he wishes not only as Before
to handle what is put in his hands, but stretches them out
for unoffered objects. In a jerky way he can shake a rattle,
and has begun to recognize the rattling as the result of the
shaking. The power of producing this sound at will seems
to afford him intense satisfaction. The wish to get a hold
of things and examine them is his first clear symptom of
reaching out voluntarily for knowledge. Until now he has
accepted amusement passively. He is now reaching out
after knowledge. This active pursuit of things shows itself
to be still a very feebly developed desire by the fact that he
will not cry, however abruptly anything is removed from
him. Of course this does not apply to food* the unwished-
for removal of which has caused screams since his first day.
The sense of meum in food, and desire for it, is as fully
developed in the new-born infant as in man. Besides food,
in the matter of comfort, a child’s senses are fully developed
from the first. Fain, I suspect, is, however, long in being
localised. His brother, now three years old, barked his shin
the other day. I took down his stocking that he might see
the wound. He failed to find it, searching his knee (the usual
place for hurting himself), and finally accepting an old bruise
thereon as the wound, which nevertheless must still have
been smarting.
As showing the same feebleness of active intelligence in
matters of sentiment or knowledge, Odo —besides not mind¬
ing the removal of objects he is grasping—does not yet
show temper when taken from one person to another, even
though much amused, and although the person he is taken
from is a favourite, provided always the person taking him is
not a stranger. He will cry at being takeo by an absolute
stranger under any circumstances.
He distinguishes people he knows, and has, I believe, done
so from a very early age. There are slight distinctions of
manner to his different familiar friends not easily described.
To his father he holds out his hands more demonstratively
than to others, probably because he sees him less, and be¬
cause he is made more of by him and more played with in the
few minutes he has him.
A fortnight ago he could uot recognize anyone attracting
his attention from outside, he being at the nursery window
(second floor). He stared vacantly without a smile. Now
he does, but still imperfectly. There is no sign of recogni-
Digitized by ^ooQie
500
Infant Development and Characteristics, [Oct.,
tion if the person merely stands below the window. He or
she must call to him. It is evidently more by ear than eye
that he knows them at this distance. On being called to
he looks about searching the direction of the sound. But
when he has once caught sight of the person, he sees him
and smiles, and keeps his eye upon him.
James, October , 1885.—His understanding of conversations
not directed to him is very considerable. Within the last
month he has not only voluntarily told to third parties what
had been said to him when no third party was present, but
also things grown-up people had said to each other in his
presence (both new developments). A curious instance of
understanding conversation, and of the conservatism, of
childish minds, is: A girl of ten or eleven had been in the
habit of repeating rhymes to him. Amongst these she taught
him that “ Humpty Dumpty went to town upon a little
pony.” Hearing this I explained that Yankee Doodle was the
gentleman’s real name, and in his presence had an argument
with the girl about her version, calling it wrong. This she
would not admit. Now when he wishes “ Yankee Doodle ”
he asks for “ Humpty Dumpty,” and gets angry if either of
us gives him the correct version.
Odo , 28 th October, 1885.—Has been ill with a bad cold
for some weeks. Recovering, he has suddenly developed in
many ways. This seems often to follow illness with children.
He has within one week learnt (1) to clap his hands, (2) to
interest himself in toys (he wishes to handle all his brother’s
toys, and does not take them exclusively to mouth as before,
but examines them), (3) has developed more pronounced
tastes for people, in that he will now cry if not taken by the
person he for the moment prefers, and (4) most noticeable of
all is the first attempt at speech. He has no articulate sounds
which can be positively regarded as words unless we except
“ mum, mum,” “ dad, dad.” “ Mum, mum ” does not mean
mother. In my opinion these are not more than mere
animal cries of the same class as “ug-gug,” “coo,” etc.,
referred to above. He has not yet identified any word,
but appreciates that communication is made by sounds, and
has begun to try to make himself understood by what may
be called nonsense words. He varies the sound, because to
his ear we vary, and is inclined to believe that so expressing
himself, taking the sounds at random, the meaning he in¬
tends will be understood. Grown-up people who constantly
say “ You know what I mean,” when, they have not expressed
Digitized by ^ooQie
501
1898.] by Sir Walter G. Simpson, Bart.
but only felt a thing, are for the moment in this stage of
Odo’s in regard to language. In other words, I feel sure he
thinks that so long as he talks, no matter what he says, he
will be understood.
James 9 1st November , 1885.—He has no conception of death.
u If Tim eat num meat Tim die and go to Holy Father.”
“ Tim want to die.” Asked why. " Tim like to go high
high up above chimney in the sky.” He answered in the
same tone when asked why he wanted to go by train to
London. There was no distaste for “num num meat”
(kidneys); wanted them all the same. It is noticeable that
he is not logical. Believed meat would kill him, and wanted
to go to skies ; but no idea of insisting on getting the meat
in order to go.
Playing hide-and-seek with child of ten; has no idea of
inventing hiding-place; always hides where she last hid.
Accepts the hiding turn about, but has no idea of searching
for her in new places. Looks at all the old ones, and asks
elders " Where to ? ”
Same child often plays the game with him and enjoys it.
She amuses him when he hides, by pretending not to know
where he is; but when her turn comes she amuses herself;
she really hides, and triumphs if he fails to find her. Though
not an infant, she is nearer one than a grown-up person,
which we often forget about a clever child, who, like her,
is in advance of us in many points—arithmetic, geography,
etc. This child of ten got three birthday cards clumsily ad¬
dressed by me, two in envelopes with the monogram torn
off. She saw that the monogram was torn off, but did not
detect the fraud. One better disguised as to writing and
make-up she detected, because I enclosed it in the paper I
write articles on.
James , 18 th April , 1886.—A period mainly characterized
by inquisitiveness , i.e. 9 having learned to use his own senses
he is now acquiring skill in’profiting by the experience of
others. At dawn of activity the predominant idea is touch .
He is very far advanced in observing things. Sees and ob¬
serves a new thing almost more quickly than seniors, because
always looking for them, e.g., at once noticed a new cigar
cutter on my watch chain which was lying on my dressing-
table, although it was partly hidden among a bunch of
trinkets with which he is familiar. The new one he first
examined very minutely, then after some time asked
u What’s it for ? ” I had to submit to a pertinacious cross-
Digitized by ^ooQie
502 Infant Development and Ckaracteri8tic8 9 [Oct.,
examination as to its use. A fire escape which he saw
standing unobtrusively he was equally exhaustive in ques¬
tions about, but he became inattentive when I pointed out
that his playing with matches might entail its use.
He likes to be told stories or have things explained, but is
very imperfect in telling or explaining. Sometimes he
drops a hint as to what he has been doing, but if asked
directly cannot or will not tell the simplest matter that has
happened a few hours ago. Seems to forget unless it is
part of subject at present before him. Although he cannot
tell a story he can repeat a rhymed story he has learnt by
heart. The other day I happened to say something was a
change. He repeated eight lines of a hymn, the last two
being “ changeless sky,” evidently seeing some analogy.
Although evidently incapable of recalling what he has
done even a few hours before, his memory is most retentive
when circumstances repeat themselves, e.g, 9 on Sundays (no
other night) I put him to bed. I have to go through the same
routine every Sunday as I happened to go through on the
first, viz., to lay him down, to hold his hand, hear his prayers,
go over and kiss the baby, and then come back and hold his
hand till he is asleep. On the second Sunday night when he
said u Go and kiss baby ” after his prayers I did not go,
not understanding. He sat up and insisted. It was only
then I remembered that I had done so on the previous Sun¬
day. I could give many other striking examples of ritualistic
tendency in a child’s mind.
The conscious wish for mischief is developing. He throws
things over the stairs in a general way because it annoys,
but what he longs most to do is to turn on the gas, because
having done so and filled my room, I showed real alarm.
When he did it a second time I had to be really cross with
him. He looks at the gas now with unutterable longing,
and evidently measures this great pleasure against the great
pain of what he seldom sees—my solemn displeasure. This he
dreads and hates. A child seems to me to understand
character in a very high degree. When I am cross and
speak really more roughly than when wishing to correct him
he is not disturbed. He says “ Father got a head-a’ ”
(headache), and goes away unconcerned.
As an illustration of the development of minuteness of
observation, he at once noticed the difference between a pack
of political caricature cards which I gave him to build
castles with and an ordinary pack.
Digitized by ^ooQie
1898.] by Sir Walter 6. Simpson, Bart. 508
He cannot connt beyond three. The rest is twelve, four¬
teen—anything.
Odo, 18/A April , 1886.—Having been seriously ill from
teeth and upsetting of stomach has gone back in every way.
He is emaciated and lighter than at last notice. He is
slightly livelier within a week, but he does not try to speak ;
in short, he seems to have relapsed every way. Intellectually
he has gone back to nine months or further. The last
notice about him is of his advance in every way.
Odo, April , 1887.—After illness developed rapidly, making
up to mental stage at which he was before it about August,
1886. Did not recover in health till July. In bodily matters,
e.g.> walking (in which no one can give assistance), he was
actually retarded, not walking till September, i.e., eighteen
months of age.
I have made no notes about mental development because
it was less emphasized than his brother***, the reason, I think,
being that learning from a child, his brother principally, the
process of learning was less noticeable to seniors. It is
noticeable that he does not learn except from him, that he pays
attention to copying him, and does not try to learn when I
wish to teach him. The consequence is that he has been some¬
what earlier on the whole in acquiring the points mentioned
under “ James ” than “ James ” was. In other words he is not
quaint. (Is this a reason why an only child is often original,
and almost always has points in character when grown up ?
Is this why an only child when grown up is often said to
have been spoilt, and yet that many of them are remarkable
men ?) Although bold, James, as observed, does not often hurt
himself. Odo, less impulsive, learning by copying or by
trying to copy his brother, and therefore with less reflection,
is prone to bruises.
Odo is not so excitable as James, who, I believe, is excep¬
tionally so. He easily goes into a pet at being frustrated,
but cries merely because frustrated, cries sooner and stops
sooner. His liking for me (perhaps this is because I do not
spoil him, i.e., make such a favourite of him as I did of
James) is more intellectual, less lover-like. The other day,
after, or rather during, a dispute, I persuaded him to make
it up by bribes and threats of not taking him downstairs.
Bribes always failed with James. His affections were
wounded and could not be bribed.
In referring to notes on James, I find that Odo is further
advanced in language than James was at same age. At
Digitized by ^ooQie
504
Infant Development and Characteristics , [Oct.,
this date Odo uses sentences of three or even four words
(see James at same age). This (greatest use of words) is due
I think to two causes. Odo learns from his brother more
than from seniors, e*g. 9 never will say “ dada,” although
encouraged to do so by parents, but “ fa-fa,” an imitation
of “ father,” which James uses perfectly now. At the same
stage James said “ dada.” James says sometimes Nenna ”
(his own word), sometimes “ Nursey ; ” Odo says “ Nennu.”
Yet he says “ ma-ma,” not “ mother,” like James, and occa¬
sionally “ mum-mum.”
The most marked points of difference between them is in
eating. James is omnivorous. They both sit beside me at
breakfast, yet Odo does not imitate James in his desire to
have a share in anything I am eating. He prefers to play,
and asks for nothing, if allowed to play with the salt.
James , April , 1887.—Within three weeks he has made two
new departures. 1st. A desire of fiction, that is not to tell the
truth. After a walk he plots with me to tell his mother he has
been to some place he has not been at, and circumstantially.
To-day he told me circumstantially that his tricycle was in
the drawing-room. Yesterday he described how the dog had
eaten my nail scissors. He is not lying. He has discovered
story-telling, and takes a keen pleasure in it. Lying he has
not taken to much (i.e., telling an untruth to save himself),
though I am told children usually discover it early.. 2nd.
He enters into the personalities of others and therefore into
sympathy with them, and imagines their conversation. This
is a very interesting development. Some of the most highly
developed, or at least the greatest men, never have even the
rudiments of it; they never can see as others see, and
cannot but call them rogues. James supplied two girls in
a picture with conversation for half-an-hour. I gathered
that he was quite abstracted from himself. At last I asked,
u Are you speaking to the girls in the picture ? ” He
answered decidedly, “ No ! don’t you see! It’s me as speak¬
ing what the girls think.”
James , August , 1887 (nearly five).—Cannot be made to
feel for others completely ; will sympathize with a person
who cries, or a beaten dog, but thinks it fun to put a pin
into me or to dismember flies. However, I being unwell
(rheumatism), he began to exercise a certain forbearance,
and to avoid hurting me without that repulsion which, as
a child, he exhibited when I was bad with lumbago. It
took a long time, as my sufferings were not demonstratively
before him.
Digitized by ^ooQie
505
1898.] by Sir Walter G. Simpson, Bart.
Can count in the sense of naming figures up to twenty or so,
but only up to six does he apply the symbols to things and
use them. Up to six knows the combinations two and two,
two and three, etc. Is learning to read voluntarily. Learns
by printing words. The other day he recognized his own
name u James ” on a cab.
Odo, October, 1887.—Compared with James at same age I
have only again to repeat that he is more advanced, but
that there is little to note, the process of learning not
being visible, i.e. } he picks up things from his brother
without effort, unconsciously. His acts and deeds are all
acquired by imitation, not by thinking them out. His
vocabulary is fuller than James’ was at his age, because
he learns from him. In the same way he climbs, jumps,
etc., better than his brother at the same age, although he
does not promise to be nearly so athletic a man. As the
gap between a child and a senior is too great in everything
for a child to learn by direct complete copying, so where
James does a thing Odo recognizes as utterly beyond him
he gives no attention to it, e.g.> riding a tricycle, writing
words, climbing over a fence.
An Improved Reaction-Time Instrument .* By Dr. Bkvan
Lewis, Medical Superintendent of the West Riding
Asylum, Wakefield.
I thought it might prove of some interest to demonstrate
at the psychological section the instrument I have hitherto
used at the West Riding Asylum for the purpose of register¬
ing the reaction time to a sight and sound signal. The
instrument in its original form, as made by the Cambridge
Scientific Instrument Company, may be familiar to you, but
lately I have so far modified it and extended its utility that
I think it will be well to indicate the changes introduced in
detail. The original, with minor alterations, has been de¬
scribed so fully in Dr. Hack Tuke’s new “ Dictionary of
Psychological Medicine ” that I shall only briefly refer here
to the general scheme of its construction, referring those
who seek more minute particulars to this article.
* Paper read at the Psychology Section of the Annual Meeting of the
B.MjLj held at Nottingham, July, 1892.
xxxix. 33
Digitized by ^ooQle
506
An Improved Reaction Time Instrument , [Oct.,
You observe, then, gentlemen, we have here a square
standard of pitch pine supported on a tripod, with levelling
screws adapted. A rectangular piece of teak or mahogany is
screwed into the standard about three feet from the floor, at
a convenient height for reading off upon it the registry of
the falling rods.
At its farther end is a horizontal table, upon which rests
the hand of the party operated upon, whilst along the centre
of the cross-piece jou observe a horseshoe or stirrup secured
by an electro magnet, which, released on interrupting the
current, is drawn back by a powerful spiral spring, and so
clamps the registry rod in falling.
At the summit of the vertical standard you see an arrange¬
ment whereby the rod was formerly suspended on a steel bar,
which being released by turning a screw, swung round and
started the rod.
The rod itself, made of box or lance-wood, was accurately
graduated along its edge into hundredths of a second—the
complete fall of the rod occupying -j^-ths, or ^ths, of a
second. After falling through a short distance, a brass plate
which rides astride the top of the rod encounters a dia¬
phragm, and so gives a sound signal by its impact. To this
diaphragm, however, there is adapted an arrangement for
the make and break of an electric current, so that an electric
bell conveniently gives the sound signal.
For a sight signal you observe the rod has a vertical slit
which corresponds, when the rod hangs suspended in a state
of rest, to a small window in the ledge projecting from the
standard.- After the usual distance the further fall of the
rod suddenly shuts off the light seen through the slit, at the
same moment at which the sound signal would have been
given had we not removed the brass weight above.
This, gentlemen, is the instrument as first constructed,
and its application is described in a few words:—For a
sound signal the subject sits with his right hand resting on
the horizontal table, his forefinger upon the interrupting
button of the clamp-magnet. An attendant standing behind
released the rod, which, falling a short distance, gave the
sound signal, whereupon the finger is instantly depressed,
the stirrup released, and the rod firmly clamped. The ob¬
server, sitting in front, reads off the figure at which the
clamp secures the rod.
For a sight signal the brass weight giving the sound signal
Digitized by ^ooQie
1898.] by Db. Bevan Lewis. 507
is removed, and the subject, sitting as before, keeps his eye
fixed at the light seen through the slit of the rod. Tne
instant this disappears he again clamps the rod in like
manner.
And now as to the novel features introduced. The release
of the rod frequently caused a very perceptible click, which,
with a strained attention , was most likely to be taken for the
subsequent sound signal. Observe the fallacy. The initial
slow fall of the rod to the level at which the sound signal
was given was computed to occupy 0*1 second, or -j^ths; it
was therefore of considerable moment that the release
should be a perfectly silent one. This was effected by intro¬
ducing an electro-magnet, to which the graduated rod
swung, attached by a short cylinder of soft iron.
Then arose a further desideratum. The fall of the rod
occupied but T 3 ^ths of a second, whereas several of my sub¬
jects required a far longer interval for their reaction. You
see how this end has been secured. Four electro-magnets
suspend as many rods by means of soft iron keepers attached
to each of the latter. The rods are exactly alike in gradua¬
tion.
Below, on the footboard, you observe a series of four keys
which are introduced into the circuit of the respective
electro-magnets above. When the first rod falls it strikes
the first key, breaks the circuit of the second electro-magnet,
and so starts the second rod; it, in its turn, strikes the
second key, breaks the circuit of the third electro-magnet,
and starts the third rod, and so on through any number it
may be desired to utilize.
I find four rods all that is requisite for practical purposes.
For securing these rods a much more powerful spiral spring
was requisite, and a lengthened clamp of four stirrup
divisions.
The fall of the rods in succession on the disconnecting
keys introduced, as you may suppose, a most undesirable
clatter; and here you see the method adopted to minimize
this disturbing element—an ingenious contrivance, which I
owe exclusively to my friend Dr. Bedford Pierce. Each rod,
you will note, has a short horizontal arm at its lower end, to
which is suspended a soft light weight, which, with the
gentlest touch upon the key, breaks contact and releases the
next rod, whilst each rod in turn falls, not on the key, but
upon a paid stuffed with sand, which notably deadens the thud
i
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508
An Improved Reaction Time Instrument. [Oct.,
and diminishes the rebound of the rod. Dr. Bedford
Pierce has thus provided an almost silent fall for the rods,
whilst the arrangement above secures an absolutely silent
release.
You will also observe the first rod is so suspended as to
fall through a distance of 4*875 cm. ere the signals for sound
or sight are given. The object of this is that the rod should
acquire such a degree of velocity as to afford convenient
divisions for time registry; otherwise, when starting from a
position of rest the initial movement is so slow that divisions
of hundredths of a second would require too fine a gradua¬
tion for practical purposes. This initial fall of the three last
rods is accounted for exactly by the distance of the suspended
pads below the rod itself—in other words, the pad touches
the key and breaks contact before the rod has completed its
fall, so that by the time the rod has reached the baseboard,
the second rod has just fallen through the initial space
alluded to and has acquired the desired momentum.
This feature adds immensely to the value of the contri¬
vance suggested by Dr. Pierce, as it eliminates the period of
fall which would be registered with difficulty if not un¬
certainty.
One further change I have introduced. The brass weight
astride the first rod has been dispensed with for the sound
signal, and in lieu thereof a fixed weight is placed upon the
diaphragm, just sufficient to make circuit with a single¬
stroke electric bell. The weight is kept up by a small cork
wedge, which is secured to the rod by a thread. When the
rod has fallen through the initial distance it pulls out the
wedgd*, releases the weight, and a signal is instantly given.
I find this a great improvement upon the older method
adopted.
Those who are familiar with psychometric methods will
recognize the importance of having both a single-stroke and
an ordinary continuous electric bell in circuit as a sound
signal.
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1893.]
509
The Treatment of Myz&dema and Cretinism , being a Review of
the Treatment of these Diseases with the Thyroid Gland,
with a Table of 100 Published Cases. By Cecil F.
Beadles, M.R.C.S., L.R.C.P., Assistant Medical Officer,
Colney Hatch Asylum.
(Concluded from p. 355.)
A Criticism of Published Cases .
(8ee Tables la and 15.)
For the benefit of those who have not followed the recent
discussions I have compiled tables of the cases of myxoedema
treated by thyroid injection and feeding that have thus far
been published in this country. These, I trust, will be
found useful and easy of reference. The main points of
each case are arranged under a few convenient headings,
viz., the sex and age of the patient, the duration of the
disease, the length of time the treatment had been carried
out at the time of reporting, the dosage and method of
administration employed, the results obtained, and, where
such existed, any ill effects that were seen to follow or occur
during the course of the treatment. In all there are details
of 100 cases shown. A glance at this summary will bring
out certain points of interest and importance.
1. The female sex largely predominates, there being only
eight male cases, but then it is to be remembered that the
disease is far more common in women than in men; the
Clinical Society’s Report gives the proportion as one to six,
but this is undoubtedly too high. The table shows, how¬
ever, that we may look for equally favourable results in
both sexes.
2. There is no limitation of age; the thyroid gland
appears to exert the same remarkable influence alike on the
young, middle-aged, and those past the prime of life. With
regard to the very young I shall have occasion to speak
shortly when dealing with the subject of cretinism, and I
shall return to the subject of the administration in elderly
persons.
3. The length of time during which the disease had
existed is seen to make little or no difference. For instance,
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510
The Treatment of Myxcedema and Cretinism, [Oct.,
in Dr. Corkhill’s case* * * § the patient is said to have only
exhibited signs of the disease five months, whereas in one
of the cases reported by Dr. Dunlopf it was of twenty years’
duration; between these extremes all stages exist. This is
contrary to what might have been efxpected, and, certainly,
at first sight, one would scarcely have hoped to obtain the
same marked results where the disease has been a long time
in existence. It is, however, in the extremely marked cases
that the change is most pronounced, and, on the other
hand, the cases in the very earliest stage of the disease
seem less noticeably influenced even after a prolonged course
of treatment. This point was brought out in the cases
published by Dr. G. E. Hale,{ who wrote me last October:
“ In three, considerable improvement occurred after periods
of seven or eight weeks, all three being able after the course
to do a good day’s work. In the fourth case, an early case
in a young woman, little or no improvement has occurred,
although the treatment has been perseveringly followed out
for more than six months.”
The same applies to two early cases on whom the treat¬
ment has been tried in Colney Hatch. They improved
slightly after a time, but there was not the rapid change
so uniformly noted in advanced cases as being at once
observable.
4. The period during which the treatment has been
carried out at the time of publication has varied consider¬
ably in different cases, from a few weeks to many months,
but in all there is the same result recorded. Dr. Murray’s
is the longest, it is now over two full years, he having begun
treatment in April, 1891.§ A most singular point is the
rapidity with which a change in the patient’s condition is
first recognizable, and even a cure may be said to have
taken place. The treatment owes its origin to the change
that was recorded as occurring within a few hours of the
transplantation of the thyroid. The patient under my care
seemed brighter within twenty-four hours of the first injec¬
tion. In Dr. Napier’s patient || a change for the better
was first noticed after the fourth injection, and the patient
* “ Brit. Med. Joura./’ Jan. 7, 1893.
f “ Edin. Med. Joura./* May, 1893, p. 1012.
J 44 Brit. Med. Joura.,” Dec. 31,1892.
§ “ Lancet/* May 13, 1893, p. 1131.
|| 44 Notes of a Case of Myxcedema Treated by means of Subcutaneous
Injection of an Extract of Sheep’s Thyroid,” with photographs. “Glasgow
Medical Journal/* Sept., 1892.
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511
1898.] by Cecil P. Beadles, M.B.C.S.
was discharged in two months, after sixteen injections of one
gramme of a watery extract of the thyroid, with disappear¬
ance of all the characteristic signs of the disease. Again,
in M. Bouchard’s two patients the improvement is said to
have been “extraordinarily rapid.”* Dr. Mackenzie’s first
patient “ had very considerably altered for the better ” t at
the end of a fortnight’s feeding with thyroid glands, and Mr.
Shapland’s case expressed herself as “ feeling better than
she had done for years” after taking half an underdone
gland every morning for a week. { Two days after the first
injection of nixxx. of fluid extract a patient whose photo¬
graph and case is published by Dr. Henry, of Lewisham,§
showed distinct signs of improvement. The changes brought
about in one month to eight weeks are always well marked.
Again, with two of the more recently exhibited cases, viz.,
Drs. Wood’s and Johnson’s, “ distinct improvement was dis¬
cernible on the third day.”|| The length of time during
which it may be necessary to continue the treatment is a
point as yet unknown. The probabilities, however, are that
it may be necessary to continually give a small dose at more
or less prolonged intervals in order to maintain the im¬
proved state which has been brought about.
5. As to dosage there has been no uniformity, and
almost every observer has given according as he thought
best. This want of uniformity is, of course, due to the
fact that we are still (so to speak) in the experimental stage
of the drug, and it has not been found possible as yet to
fix the correct dose—that is to say, an amount of the extract
which is capable of producing a curative effect without at
the same time giving rise to toxic symptoms. The quantity
and frequency of administration, however, are points that
will probably be shortly decided. At the same time, they
will probably depend on the stage of the disease and the
age of the individual; moreover, they may possibly vary
with individual cases and the idiosyncrasies of the patient.
With these varying factors special care will be needed in
its employment.
Another point that cannot be decided as yet is the best
mode of administering the thyroid gland, or, rather, its
• 44 Lancet," Oct. 1,1892.
f 44 Lancet,'’» Jan. 21, 1893.
j 14 Brit. Med. Joorn.,” April 8,1893.
i ldem.
“ Brit. Med. Joum.,“ May 6,1893, pp. 954 and 955.
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512 The Treatment of Myxoedema and Cretinism, [Oct.,
active principles. As is shown in the list of published cases,
various minor modifications of the original method have
been adopted. These, which already have been referred to,
have each been lauded as the best by those who first intro¬
duced them, and it is only from the experience of others
and their more extensive trial that we can arrive at a
correct estimation of their proper value. There is no doubt
that some of these methods have advantages over others,
and that with some there are distinct objections to their
use as being more liable to be followed by ill-effects. At
the same time, it may be that what is preferable in one
case may not be so in another. To this subject I shall
return.
6. But what is clear from all the cases that are here
collected together is that this special mode of treatment is
invariably followed by an improvement in the patient’s
bodily condition, by a rapid change in the appearance of
the patient, and within a remarkably short space of time
(measured by a few weeks) the patient has so far recovered
from the disease that it is impossible in many cases to
recognize the case as one of myxoedema. The general
puffy, cedematous-like swelling disappears, and the coarse,
dry skin is replaced by one that is smooth, soft and moist,
and the blunted, thickened features so characteristic of
myxoedema are rapidly lost; the hands become smaller;
within a comparatively short space of time young hair com¬
mences to grow on the scalp and eyebrows, so that in place
of the thin, scanty crisp hair the head is soon covered by a
thick healthy crop of hair, which causes a most noticeable
alteration in the appearance of the patient. The body-
weight rapidly diminishes, often as much as a stone a
month, until it has reached a certain point, when it again
tends to slightly rise. This loss of weight is probably due
to the absorption or conversion of the mucin in the tissues,
and the increase which afterwards occurs may be due to a
deposit of healthy fat in its place. The special senses all
become more acute, eyesight and hearing improve, and
general tactile sensation becomes more natural; the bodily
functions assume their normal action, the bowels and
catamenia become regular, and there is often an increase of
urine passed; the voice loses its peculiar slow, thick,
monotonous form, and assumes its original type. The
patient becomes warmer and feels more comfortable, and
there is a rise of the body temperature, which nearly or
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513
1893.] by Cecil F. Beadles, M.R.C.S.
quite reaches the normal point. Both mind and body
become more active. The patient becomes brighter and
more cheerful, and is able to get about and attend to his
duties, in which he now takes an interest. This, in short,
is only another way of saying that there is a complete trans¬
formation, and that the patient has ceased to be a patient,
and appears a new individual. Such, briefly, are the results
that have been attained.
7. But this startling result has not always been obtained
without the occurrence of some grave and unpleasant
symptoms. These have doubtless been due in the majority
of the cases to an excessive dose of the preparation, mani¬
festing a toxic action, and are capable of, and to a great
extent have been overcome by more careful regulation of the
dose.
As a rule, when occurring they have been of a mild
nature, such as general weakness, faintness, nausea,
vomiting, slight giddiness, headache, and aching pains in
the neck and shoulders, which have rapidly passed off on
reducing the dose, but occasionally the symptoms have
assumed a more serious nature, and, at least in four
instances, death resulted. This happened in the early days,
of the thyroid treatment, and such a result it is to be hoped
will not again occur. Amongst the more severe forms of
symptoms to be guarded against are loss of consciousness,
tonic spasms, collapse, urgent dyspnoea, and cardiac failure.
These have been prevented by greater care in regulating the
amount and allowing it to be administered more slowly.
With a more accurate knowledge of the power and action of
the new remedy they are lessened or altogether avoided.
The liability to irritation, erysipelas, abscess and induration
sometimes following subcutaneous injections has been
lessened by greater antiseptic care, and by the more recent
administration of the extract by the mouth has been entirely
prevented.
As the discomforts and risks of the treatment have been
so fully gone into by other writers, notably by Dr. Lundie*
and Prof. Grainger Stewart,f I will abstain from further
entering on the subject. The latter observer gives some
useful advice for the treatment of urgent symptoms that
may arise.
But still, I may remark, it is clear that in the active
• “ Edin. Med. Journ. ” May, 1893.
f 44 The Practitioner,” July, 1898.
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514
The Treatment of Myxoedema and Cretinism , [Oct.,
principle contained in the thyroid gland we have an exceed¬
ingly powerful chemical body, and too much care cannot be
exercised in its proper use. In persons suffering from very
advanced disease, and in elderly subjects, great caution is
necessary, and with returning strength and rigour modera¬
tion in all forms of exercise should be insisted upon.*
The Treatment, with Special Reference to the “ Insanity of
Myzcedema”
The actual number of recorded cases of myxoedema in
which definite insanity ensued in the course of the disease
is comparatively few/f and only one or two have been
published by medical officers of our asylums. But if we
remember the mental state which patients who are the
unfortunate subjects of myxoedema invariably develop as
the disease becomes advanced, we can understand how a
considerable number of them eventually find their way into
lunatic asylums. It is probable that these institutions are
the last home of a large percentage of cases, and there are
probably few asylums of any size where such patients do not
exist, and, owing to the chronicity of the disease, are
probably resident for a long period.
Myxoedematous patients invariably become demented.
Dr. Savage, in his review of the Clinical Society’s Report on
myxoedema in Dr. Tuke’s recently published admirable
“ Dictionary of Psychological Medicine,” says :—“ In a
rather large proportion there is more or less imperfection of
• It would seem impossible that the condition described by Dr. James
Whitwell (“ Brit. Med. Journ,Feb. 27, 1892), as found by him in the oortical
cells of the brain in a case of myxoedema, can be present except in perhaps
the rarest instanoes, even in the most advanced cases of the disease. Other¬
wise, how is it possible for the cells to recover to the extent which one would
judge must occur with the change in the patients bronght about by the thyroid
treatment ? In like manner it is not easy to explain how the vessels of the
brain oonld recover from such advanced endarteritis and periarteritis as was
found to be present in a case of myxoedema by Dr. Robert Boyce and myself
(“ Journ. Path. Bact.,” No. 2, Oct., 1892). It is clear there is much yet to
learn of the pathology and cause of the disease. That such a diseased state
of the vessels sometimes exists proves that great care should be exercised in
the use of the thyroid juice.
f The following may be referred to:—Clouston, “ Clinical Lectures on
Mental Diseases,” 1883, p. 603. Blandford, u Insanity and its Treatment/’
1884, p. 86. Savage, “ Journ. Ment. 8c.,” Jan., 1880, p. 417. J. C. Mackenzie,
* Journ. Ment. Sc./* July, 1889. Ernest White, “ Lancet,” i., 84,974. Urquhart,
“ Lancet/’ i., 84, 1079. Jurgens, “ Lancet/' i., 90, 484. Cecil F. Beadles,
u Journ. Path, and Bact./’ No. 2,1892. John Macpherson, “ Edin. Med. Journ.,”
May, 1892. James-Whitwell, “ Brit. Med. Journ./* i., 92, 430.
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515
1893.] by Cecil F. Beadles, M.R.C.S.
mental processes, the defect being one of retardation or
sluggishness.” The development of actual insanity with
delusions, sometimes with attacks of excitement, is not
uncommon. “ Delusions and hallucinations occur in nearly
half the cases, mainly where the disease is advanced.
Insanity as a complication is noted in about the same
proportions. It takes the form of acute or chronic mania,
dementia, or melancholia, with a marked predominance of
suspicion and self-accusation; exalted ideas may occur.
Memory is usually impaired from an early period. It is
recorded as deficient in forty-six out of seventy-one cases.”* * * §
The authors of many of our text-books on insanity make
no reference to myxoBdema in its relation to brain disease,
and the remainder pass it over in a few words. Dr. Clouston,
however, refers to three cases that were under his care at
the Royal Edinburgh Asylum for the Insane, “who were
positively insane,” and adds, “all the examples of the
disease I have ever seen were more or less affected mentally,
if they were not technically insane.”f
No work on insanity to which I have referred speaks of
any special treatment for these cases; this is undoubtedly
due to the only recently thoroughly recognized, and even
then considered incurable disease, and is a feature which
will probably receive attention in future editions.
I have already spoken of and commented on a case in
which thyroid grafting was adopted with a partial amount
of success (see ante , page 350).
There are now several recorded cases of myxcedema with
insanity that have been treated by the subcutaneous injection
of the thyroid juice or by feeding.^ Dr. Ernest Carter, of
Whittingham Asylum, was one of the first to report upon
the treatment^ His case was that of a female lunatic aged
43, with myxcedema of over four years* duration, and whose
insanity had existed five years. After a three months* course
of injections the patient’s bodily condition was much
improved, but, at the time of writing, complete recovery of
her mental power had not taken place. In Dr. Claye
* Tuke’s “ Dictionary,” Vol. ii, p. 828 j art., “ Myxcedema and Insanity
t “ Clinical Lectures on Mental Diseases,” Clouston, 1883, p. 603. In a note
in the “ Edin. Med. Jonrn.” of May, p. 1057, Dr. Clouston makes mention of
eight cases which have been admitted into the asylum.
J At Newcastle Dr. Clouston reported two cases of insanity in whioh im¬
provement was manifest from thyroid feeding; one curbed in four months, the
other in six.—“ Brit. Med. Journ.,” Ang. 26tb, 1893.
§ “ Brit. Med. Journ.,” April 16,1892.
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516
The Treatment of Myxcedema and Cretinism, [Oct.,
Shaw’s case,* however, the patient was discharged from
Banstead Asylum, recovered, after a treatment of two
months. This also was a female who had showed myxcede-
matous signs four years, and been the subject of recurrent
melancholia for a period of ten years. The case that was
under my care at Colney Hatch Asylum, and of which I
have elsewhere published the early notes,f had greatly
improved in little over a month, if we count from the time
the injections were commenced regularly. The change in
her mental condition was even more pronounced than that
in her bodily, and was one that I never thought it possible
to attain.
Dr. Melville Dunlop, of Edinburgh, has published a series
of six cases of myxcedema treated by thyroid feeding.^ One
of these (Case II.) was undoubtedly insane at the time. It
is a particularly interesting case, and I make no excuse for
referring more fully to it.
The case was one of a lady who had shown signs of myxoedema
over 12 years, and in whose family there were others affected in
the same way, viz., her mother and a twin sister. She had been
a complete invalid, and unable to move either her hands or legs
for something like eight years. Memory had become defective
and she wandered in her talk. A few months before treatment
was commenced she became much worse, especially mentally,
becoming childish, with hallucinations of sight, smell, and hearing,
sleepless, restless, and refused food. At length acute mania
supervened, when she was excited and dangerous, and for six
weeks had to be under the care of special mental nurses. On
October 18th, while in this state, the thyroid feeding was begun.
TTjxx. of thyroid extract were administered thrice weekly. “ By
the 30th of October the excitement had quite gone, and the
patient was resting and sleeping quietly. She had no longer any
hallucinations, and was speaking rationally.” By November 12th
there was some improvement in her bodily condition, and the
extract was reduced to twice a week. A month later there was a
marked change. In January the extract was given only every
alternate week. She continued to improve mentally and bodily,
and in the early part of February (a four months' course) many
of her friends could scarcely recognize her.
Dr. Hamilton C. Marr, of Woodilee Asylum, also reports
a case treated by feeding. §
* “ Brit. Med. Journ.,’’ Aug. 27, 1892 (communicated by Dr. Stansfield to the
annual meeting of the B.M.A. at Nottingham).
f “ Brit. Med. Journ.,” Dec. 24, 1892.
t “ Edin. Med. Journ.,” May, 1893.
§ “ Glasgow Med. Journ.,* Aug., 1893.
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517
1893.] by Cecil F. Beadles, M.R.O.S.
This is a 'woman aged 51, whose mental aberration dated from
Christmas, 1887, but whose bodily weakness commenced three
years previously. She was incoherent and subject to attacks of
excitement and violence, at which times she would make false
accusations against her attendants. During the intervals she was
melancholic and refused to speak. Her health had become very
feeble and she had taken to bed. Treatment was commenced in
February, 1893, by giving a quarter of a sheep’s thyroid mixed
with bread crumbs and sherry. After three weeks this was
replaced by a glycerine extract, two ounces of which represented
one whole gland; of this one drachm was given thrice daily.
“ The patient gradually improved under treatment,” and now it is
said that she can converse quite intelligently and is very cheerful
in disposition, giving a helping hand to the nurse. Hearing has
improved and the swelling of the body has gone down.
Quite recently I have heard of another case of myxcedema
with insanity that has undergone the treatment. It is the
case which Dr. J. F. Woods, of Hoxton House Asylum,*
showed at the Hunterian Society on April 12th.
A female, 32 years of age, with myxcedema of 15 months'
duration, of whom it was said that she “ began to improve on the
third day.” Concerning this patient, Dr. S. Whitaker kindly
informed me, on August 3rd, that, before treatment was com¬
menced, she had physically most of the signs of myxcedema and
“ mentally her speech and mental processes were slow, she often
heard voices and saw spirits, she was very obstinate, and used to
stand or sit about all day and never employed herself. Her
weight was 9st. 6£lbs. at the commencement of treatment on
January 20th. The treatment w r as discontinued on June 8th,
when her weight was 8st. 61bs., she had lost most of the physical
signs of myxcedema, and mentally she was bright and talkative
and employed herself, but she still occasionally heard voices and
saw spirits, though not so much as formerly. Since June 8th
there has been no apparent change, and to-day (August 3rd) her
weight is 8st. 81 bs.”
As regards the special mode of administration employed, Dr.
Whitaker says that at first the medicine was given twice a week
as hypodermic injections of the thyroid extract, but afterwards,
and “ with better effect,” she took White’s powders by the mouth.
After the first three months the powder was only given occa¬
sionally, and during the latter part of the time, in place of the
powder, a “ thyroid mixture ” in |ss. doses,t each ^ss. being equal
to ^th of a gland, and that this* seemed to agree with her the best.
• “ Brit. Med. Journ.,*’ May 6, 1893.
t The extract for hypodermic injection was obtained from Brady and Martin,
and the “ thyroid mixture * prepared by Mr. Chas. Allen.
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618 The Treatment of Myxcedema and Cretinism , [Oct.,
It is now proposed to let the patient have a dose about once a
month.
Under this heading I may perhaps as well call more
pointed attention to the change following upon the treat¬
ment that has taken place in the mental condition of those
patients who have not been regarded as insane, bnt who
have shown the more or less marked dementia that is
characteristic of advanced myxcedema. Thought, like
speech and actions, is slow, and memory is impaired or lost,
and sometimes there are distinct delusions of a suspicious
nature, which yet are not sufficient to have the patient
certified as a lunatic.
In all these cases, as I have already said, the patient
becomes brighter and the mind more active ; memory returns
and delusions have frequently been lost. Some of these
cases will be found referred to elsewhere in the present
paper. Drs. Murray, Mackenzie, Davies, Maude, and others
all bear testimony to the unquestionable mental improve¬
ment that invariably occurs, and as Dr. Hingston Pox says
of his patient, “ not only has the physical condition altered,
but mentally the change is also great. She feels much
lighter, less burdened, as she says, and the depression of
spirits has largely passed away. 55 * In a note I received on
May 18th Dr. Davies tells me that in one of his cases the
mental activity for carrying out arithmetical calculations
was greatly increased by the treatment, and in others the
hearing has been very markedly improved.
Seeing what has thus been done in this line, it appears to
me only right that an attempt should be made in these pases
to allow the patient the benefit of a trial of one or other of
the methods employed in the treatment, and in our asylums
should certainly be carried out as a treatment for the
insanity of myxcedema.
* Although I do not intend to enter on the pathology of
myxoedema in the present paper, one cannot help remarking
that we can see, in the results that have recently been
obtained, strong evidence in favour of the view that the
insanity of these cases is dependent primarily, if not entirely,
on the disease or atrophy of the thyroid gland and not on a
primary change in the brain.f
* “ Trans. Hunterian Soc.,” 1892-3.
t I would suggest that in those few cases where insanity antecedes the
appearances of myxcedema, the presence of the two diseases is a mere coin¬
cidence.
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1893.]
by Cecil F. Beadles, M.R.C.S.
519
The Thyroid Gland in the Treatment of Cretinism .
(See Table II.)
Just a word or two on the subject of congenital myxoe-
dema, or sporadic cretinism, as it is more commonly called
in this country. Fortunately such cases are of less frequency
than myxcedema in the adult. Of the number in this country
I have no idea, but there are probably some in all our im¬
becile asylums. I have seen two quite recently at Leavesden.
They were both males, and showed the disease in its charac¬
teristic form. Children born in that condition have been
thought hopelessly imbecile, and quite incurable. They have
lived a wretched, automatic existence for a variable length
of time, rarely reaching beyond 30 years of age, as a rule
being ultimately carried off in the winter months. No
treatment beyond attempting to keep them warm by cloth¬
ing and surroundings has hitherto been considered of use.
Victor Horsley, who contributes an interesting article on
cretinism in the “ Dictionary of Psychological Medicine,”
says: “ A good deal can be done in the direction of pallia¬
tion ” by keeping the patient very warm in a hot atmos¬
phere, thoroughly clothed, the employment of hot air and
Turkish baths, and the internal administration of pilocar¬
pine or tincture of jaborandi.
Now we can look for a better result. Horsley, writing on
the same subject, remarks: “No treatment of cretinism has
ever been attempted from the point of view suggested by the
pathology, for the reason that until recently the latter has
been so extremely obscure. It is obvious, however, that
where the idiotic condition can be shown to be originated
by loss of function of the thyroid body, an attempt should
be made to restore that function. The only way in which
this would be possible would be by the method originally
suggested by Prof. Scliiff, viz., transplantation of the thyroid
gland.”*
Cases have lately been published in which the thyroid
treatment has been carried out with a marked change in the
condition of the patient.
Dr. John Gibson, of Brisbane, records the following case
Male cretin, aged seven years, on whom he had twice grafted
the thyroid gland from a lamb, first into the right mammary
region on July 20, 1891, and again on May 20,1892, he introduced
* '* Dictionary of Psychological Medicine,” Hack Take, 1892.
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The Treatment of Myxcedema and Cretinism , [Oct.,
a gland into the peritoneal cavity. The paper which he originally
read before the Intercolonial Medical Congress of Anstralia last
year was published in this country last January.* The numerous
accompanying illustrations, reproduced from photographs, show a
marked change in the appearance of the child, a brighter and
more intellectual look is especially noticeable. He had grown
two inches. Four months after the second grafting Gibson con¬
cludes his remarks by, “ To all appearance he is now merely a well
nourished baby boy, with soft, natural skin, and firm limbs, with
somewhat thick features and lips, but no myxoedematous swelling.
The grafting, to sum up shortly, has cured his myxcedema, and
has lessened his cretini8m. ,,
Only a few months ago the following case was published
by Dr. Edward Carmichael, of Edinburghf:—
Cretin about nine years of age. Patient was treated with the
hypodermic injection of thyroid extract. Commencing in April,
1892, the injections were continued until October, when feeding
with the raw gland was substituted. The accompanying photo-
graphs show a marvellous effect, and the observer states that
“ The result of the thyroid treatment was continuous improve¬
ment. As week by week passed some mark of improvement was
always seen. Marked improvement in intelligence was seen in
many little actions/’ The patient could not be recognized by
friends as the same child.
These two cases show what may be expected, no matter
which mode of introducing the thyroid is preferred. In
addition to these, Dr. Affleck J showed at Edinburgh " a
case of sporadic cretinism in a young man which had been
greatly improved by implantation of thyroid on three occa¬
sions.” Dr. John Thomson § has treated a couple of cretins,
aged respectively four and 18 years, by feeding, with “ won¬
derful success.” Dr. Byrom Bramwell showed a girl aged
8£ years at the Edin. Med. Chir. Soc., on February 16,
whose “ mental condition had become completely trans¬
formed,” and who had grown an inch in height after five
weeks of thyroid feeding. || It was on a case of adult female
* “ The Function of the Thyroid Gland, with Observations on a Case of
Thyroid Grafting,” “ Brit. Med. Journ.,” Jan. 14, 1893.
f “ Cretinism Treated by the Hypodermic Injection of Thyroid Extract and
by Feeding,” “ Lancet,” March 18th, 1893.
$ “ Brit. Med. Journ.,” Feb. 25,1893, p. 411, and “ Edin. Med. Journ., ,, May.
| “ Brit. Med. Journ.” and “ Lancet,” Feb. 25,1893, and “ Edin. Med. Journ.,”
May. The latter case is reported in full on p. 1022, and is accompanied by
illustrations.
|| ” Edin. Med. Journ.,” May, 1893, p. 992.
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521
by Cecil F. Beadles, M.R.C.S.
cretin that Vermehren, of Copenhagen,* used, with success,
the preparation which he has called “ Thyroidin,” and he has
since used it with like result on another. Dr. A. G. Francis,
of Hull, has informed me of a case of congenital myxoedema,
as much as 36 years of age, whom he has under his care,
and who “ is improving immensely ” under thyroid treat¬
ments
There is one more case recorded in which the thyroid has
been employed in the treatment of cretinism. This was the
case of Dr. Y. Robin, of Lyons.} The fresh juice from
sheep's thyroids was injected daily into a child of seven
years of age. “ Improvement was immediate. In fact the
child is quite unrecognizable to those who knew it before
treatment.” The injections were afterwards supplemented
by successfully grafting two lobes of a sheep’s thyroid in
the submammary region.
Dr. William Robinson, of Darlington, has not been so
successful. He informs me that the case of sporadic cretin
that he referred to in the “ Brit. Med. Joura. ”§ as being
slightly improved by thyroid extract was a female aged lOj
years, who had weekly injections of an extract prepared in
accordance with Dr. G, Murray’s directions. The dose was
given beginning with six and increasing up to thirty minims
for two months, after which one thyroid gland was eaten
weekly for several weeks. The result was only very slight
improvement—“ not sufficient to justify further treatment.”
In a second case, a male semi-cretin, aged 28 years, there
was “ no visible improvement ” after a similar two months’
course of hypodermic injections.
Although the result here was disappointing, and also in a
male cretin, aged eight, who was referred to by Mr. Evans
at a meeting of a medical society on March 24th, “who
for six weeks had taken one thyroid lobe twice a week with¬
out any improvement,”|| such a result appears to be rather
the exception than the rule, and we may expect to see great
benefit derived from the new treatment in this supposed
incurable disease. It is possible that by applying thd remedy
after the manner of Robin the best results are to be obtained.
* “Brit. Med. Journ.” (Epitome), April 15, 1893, and “Dent. Med. Woct.,**
March 16, 1893.
t “ Brit. Med. Journ.,” April 8, 1893, and Private Letter dated Ang. 5tb.
t “ Brit. Med. Joarn.” (Epitome), 8ept. 10,1892, and '* Lyon. M6cL,” Ang. 7,
1892.
§ “ Brit. Med. Joura.,* Jan. 7, 1893, p. 38.
H “ Brit. Med. Jonro. ” April 8, 1893, p. 767.
xxxix. 34
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The Treatment of Myxoedema and Cretinism , [Oct.,
Personal "Experience of the Treatment m Myxoedema with
Insanity .
It has been my good fortune to see four cases of myxce-
dema treated by this modern method in Colney Hatch Asylum
during the past twelve months, and so I have been able to
notice closely what changes and improvement actually took
place in the patient's condition, both bodily and mentally.
Of the four cases in Colney Hatch, one is that of a woman
in an advanced stage of myxoedema, whom I myself treated,
and whose case I reported in the “ British Medical Journal ”
for December 24, 1892, two were women in an early stage
of the disease, and the remaining case is that of a man pre¬
senting all the well-marked characters of fully-developed
myxoedema.
I. First let me refer again to my case of M. B. She was a
woman of 60 years of age, with myxoedema of at least eight years*
existence, and whose insanity, which took the form of religions
melancholia, was of 4^ years* duration. After treatment by sub¬
cutaneous injections of thyroid extract, extending' over three
months, there was great change in her bodily appearance, but the
improvement in her mental condition was even more marked.
She was cheerful, bright, usefully employed, free from all
delusions, and might be considered quite sane; if there had
been friends anxious to take her out of the asylum there is no
reason why they should not have done so.
After October 4th the injections were discontinued, and unfor¬
tunately nothing was done to maintain the improved condition
brought about. In a short time the patient slowly but steadily
relapsed—that is to say, there was some return to the myxcede-
matous appearance that she previously possessed; her voice became
somewhat thicker, hearing less acute, puffiness of face more marked,
slower in movements, and she did not feel in such good health, and
with this a drop of the temperature again, nearly to its original
low position. But she never reached anything like the stage pre¬
sent before the injections were commenced. It is featisfactory to
note that her mind was still clear, and has remained so all along.
On February 28th the treatment Was renewed in another form.
On that day Dr. Seward gave the patient a thyroid powder, repre¬
senting £ of an entire thyroid gland of a sheep.* Between then
and May 9th the patient took l7 similar powders. She then had
her photograph taken, which is reproduced as Fig. 2, and for con¬
trast to show the striking change that has taken place in the
t
* Supplied under the direotion of Mr. Edmund White by C. B. Allen, Phar¬
maceutical Chemist, Kilburn.
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JOURNAL OF MENTAL SCIENCE. OCT 1893.
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523
1898.] by Cecil F. Beadles, M.R.C.S.
patient’s condition Fig. 1 is reproduced from a photograph that
was taken of the patient before any treatment was commenced,
exactly 12 months previously. It may be mentioned that at that
time the patient was quite unable to open her eyes owing to the
swollen state of her eyelids, and her mind was such that she did
not know what was being done, and she has since had no recollec¬
tion of the event. Her earlier days in the asylum are a perfect
blank, from which she was first awakened by the thyroid injec¬
tions, only, however, to recall events that took place before her
admission. In the last photograph taken she has much the same
appearance as she had when the hypodermic injections were first
discontinued, an appearance which she still maintains.
The patient has now (Aug. 5) had the powders on 33 occasions
first at intervals of two or three days, then every fourth day, and
now for the last six weeks not oftener than every fifth day. This is
found to keep the temperature as nearly as possible at normal; in
fact, during the past week there has been a tendency to rise above
it. The last three months she has had three grains of a powder
obtained from another firm of druggists,* which has answered
equal lv well. She has always taken the powder in jam after
breakfast, and on those days remains in bed until mid-day.
The patient’s improved condition is maintained, and she now
shows only a very slight degree of the myxoedematous facies, but
she is somewhat crippled owing to the old rheumatoid arthritis
from which she suffered before the myxoedematous process started;
she jp, however, able to get about and make herself useful in the
ward. She is quite sensible in her speech, and is very cheerful,
and she regards her present condition as a happy release from her
former wretched state.
Mentally she would be described only as somewhat weak-
minded.
The action of the drug upon her joints is remarkable. She
suffers intense pain in all her joints after the powders are taken,
although recently, perhaps, to rather a less degree. This comes
on shortly after the powder is swallowed, and continues for the
greater part of the day. This has not been noted in any pre¬
viously recorded case, and is probably due to the chronic rheuma¬
toid affection of her joints, which remain permanently enlarged
and deformed.
The patient’s weight, which, after a month’s regular injections,
fell from 9st. I21bs. to 8st. 81bs. (August, 1892), has since
gradually increased, and on May 18th had reached lOst. 81b., not¬
withstanding the absence of much of the oedema. This has been
maintained.
From charts, with a complete record of the patient’s tempera-
* Prepared by Ferris and Co., of Bristol, who with a number of other firms
now supply several preparations of the thyroid.
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524
The Treatment of Myxcedema and Cretinism , [Oct.,
ture since she first went tinder the thyroid treatment (May 10th,
1892), it is seen that the original subnormal temperature gradually
rose and remained about normal so long as the injections were
continued, and for a few weeks beyond, after which it again fell to
its previous low position, to again ascend when the powders were
administered. On a separate chart there was recorded the rise of
temperature that followed in the course of the day after the
powder was given, the temperature being taken every two hours.
It is interesting to note that (as in the case with injections \ after
the early administrations, there is a very sudden rise and fall again
of the temperature, which after a time becomes much less as the
normal is maintained, and recently it has only risen a few points
during the day.
The two early cases of myxcedema were treated in different
ways.
II. —The first is that of L. B., a female, aged 51, who was
admitted into Colney Hatch, April 8th, 1892, for melancholia.
She was irritable, restless, and quarrelsome, with delusions of
suspicion. She had attempted to commit suicide. She was a
Jewess and had been married. She presented the signs of the
disease in an early stage; there was slight puffiness of her face,
the skin somewhat thickened, dry and rough, and her hands large
and swollen. Hair scanty and rough. Her voice was inclined to
be thick, slow and monotonous, and she was somewhat deaf. Her
temperature was sub-normal, never reaching the normal line.
Weight, 9st. lllbs.
While this patient was under my care I treated her by the
hypodermic injection of the fluid extract, obtained, as in the case
of the other, from Brady and Martin, of Newcastle. Between the
29th August and 4th October she was given 14 injections of tt^xx.
each, there being an interval of a day between each, with a few
exceptions. She objected strongly to the injections, not because
they hurt, but because, she said, that she was “ marked for life,
and would be turned out into the streets as a thief.” At the end
of this time there was an undoubted slight degree of change
noticeable, although she could not be said to have recovered her
senses. Her body temperature rose to a more normal position,
and her mental faculties were much clearer. It is possible that
further improvement might have followed if the treatment had
only been persisted in, but unfortunately it was allowed to drop,
and what little improvement had been produced has more or less
disappeared, and she is now in nearly the same condition as she
was in last August.
III. —The other female patient, M. S., was treated by my
colleague, Mr. H. G. Shaw, by the ingestion of raw thyroids. She
had been resident in the asylum since December, 1890. She was a
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525
1893.] by Cecil F. Beadles, M.R.C.S.
single woman, 45 years of age. She was restless, complained of
noises in her head, and had aural hallucinations and optical
delusions, and others of suspicion. It had been noticed that her
features had been gradually assuming a rather more thickened
aspect, and her voice was thicker and more monotonous in
character than on admission. She was becoming more languid
and slower in her movements, and she suffered much from cold,
always being worse when the day was chilly. Her temperature
was found to be seldom much above 97°.
It was decided, therefore, to try the effect of the raw gland on
her. Commencing in October last, she continued to have them at
intervals of one and then two days, for a period of six weeks, on
eight different occasions. She took them minced in the form of
sandwiches. After the first once or twice she complained of
headache and giddiness, but after the later three administrations
the ill-effects assumed a more grave form; she had violent pain in
the abdomen, followed by loss of consciousness. The administra¬
tion was, therefore, stopped. For a fortnight the patient re¬
mained in bed in a somewhat critical condition, and as during this
short course of treatment she lost considerably over two
stone in weight, there cannot be the slightest doubt but that the
drug was too rapidly pushed, and that better effects might have
been expected from a smaller dose. But it is by such experiences
that we learn. On November 21st, 1892, it is noted that “ a con¬
siderable improvement, both mentally and physically, has followed.”
This patient is now in very good health, but still shows some
signs of the myxoedema, although to less degree than last October.
She says herself that she is certainly feeling better than she did
at that time; she has also been gaining in weight, and in May a
luxuriant crop of new hair sprung up on her head. Her mind is
clear, she is useful in the ward, and is always willing to oblige.
IV.—I now come to the case of the man suffering from advanced
myxoedema, who is now under the care of Mr. F. Bryan, and who
will publish the case in full. The patient, J. T., is 33 years of
age, and has been an inmate of the asylum six years, being
admitted for melancholia, with aural hallucinations and suicidal
attempt. In the original certificate it is stated that this condition
seems to have arisen from concussion of the brain, the result of
accident. From the note made on admission it is evident that
myxoedema was present, but not recognized, and it is said that his
condition was “suggestive of chronic kidney disease.” From
further notes it is clear that the myxoedema became more marked,
and still remained unsuspected until September 1892, when it was
proposed to let him undergo a course of treatment by the thyroid
method (injections), but some difficulty arose in having the patient
photographed before commencing the treatment, ana it was con¬
sequently postponed for a time. Meantime the administration of a
powder had been proposed, and proved to be followed by as marked
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526
The Treatment of Myxmdema and Cretinism , [Oct.,
results as that following the injection method, and so it was
decided to carry ont this mode of administration on the patient.
Treatment was commenced on February 25th of this year, and
is being continued at the present time. During the three months
that had elapsed, up to May 6th, the patient had taken 23 powders
(White’s) similar to those used in the case of M. B.; for the first
three weeks he had a powder every other day, afterwards one
every fourth day. From May 8th to May 28rd half a powder every
other day was taken. On May 25th it was altered to five grains
(Ferris) every other day, which was continued until June 18th,
when the temperature rose to 101°, and there was severe vomit¬
ing. For three days the patient felt very ill, and his temperature
remained high ; it then fell to 96*4°. Similar powders were com¬
menced again on June 26th, and he had one a week, which has
lately been increased to two. Up to the present time (August
5th) he has had the drug on 52 occasions, when he has remained
in bed during the morning.
At the time of commencing the treatment the patient had the
appearance of a typical case of fully-developed myxoedema, so
that there is no need to repeat a minute description of his appear¬
ance. By May he had altered to a wonderful extent; he was more
healthy-looking, and had lost the characteristic look almost
entirely. His hair had grown so that it was quite thick; his
voice was clearer, his eyesight improved, and he did not have
sudden attacks of blindness, of whioh he formerly complained.
The patient said himself that he was feeling much stronger and
better in health, warmer and more comfortable. He had now lost
the weakness of which he complained at first after taking the
powders.
This condition is being fully maintained. The man is sensible,
and appears to be almost if not quite free from delusions. He says
that six years ago he was taken to the Middlesex Hospital owing
to an accident that befell him, and he remembers being spoken of
at that time as a oase of myxoedema.
The patient’s weight gradually fell from lOst. 121bs. on February
25th to 9st. 71bs. on April 2§th. Since that date it has been
rising, and has now reached lOst. 31bs. Before treatment his
temperature was almost invariably below the 97 line; after the
commencement of the treatment it rose to the 98 line, and for
some time remained between 98° and 98 4°, but now it varies
between 97° and 98°. It is also interesting to note a distinct
increase in the urine passed during the 24 hours ; the amount has
gradually risen from about 50ozs. in February to 70ozs. in
August.
Beyond the first weakness and the attack of vomiting, with rise
of temperature that once occurred, the patient has been quite free
from ill-effects.
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1893.] by Cecil F. Beadles, M.R.C.S* * * §
527
Other Cases of Myxcedema treated with Thyroid Preparations .
Besides the cases just described, which we have and still
are treating in Colney Hatch, I can speak from personal
experience of the great change and benefit which I have
seen in several others thus treated.
I am able to add a few short notes of one or two cases
that have not yet been published.* The first of these is
particularly interesting on account of the patient’s family
history, where close relatives were affected either witn
insanity, imbecility, or Graves’ disease. For these notes I am
indebted to Dr. A. Maude, of Westerham, who is the author
of several papers on Graves’ disease. In the second case
the patient herself had been the subject of this disease only
a short time previously. Dr. Wilkin Stabb, of Torquay,
kindly sent me the notes. In connection with the subject
of Graves’ disease, it may be mentioned that Dr. Duke’s f
patient had a goitre on the right side, and Dr. Putnam’s
second case J had an enlarged thyroid, and suffered from
tachycardia, but had no exophthalmos. In the latter case
we are told that the thyroid decreased in size with the rapid
improvement that took place, and also that there was a
strong history of myxcedema in the family.
I.—Mrs. J., a labourer’s wife, aged 60, has been under the
observation of Dr. Maude § since June, 1887. The onset of
myxcedema was very gradual, apparently beginning in 1888. In
December last the case presented a large number of the symptoms
of the disease as given in the Clin. Soc. Report, but the facial
change was never very highly marked. She may be described as
an early, slow case of myxcedema, whose mental state was that of
chronic dementia with suspicions of neglect and conspiracy rather
than the usual mental state. She had some ohronio arthritis and
emphysema, and at intervals attacks of “ stupor ” had occurred.
* In the “ Table of Published Gases ” it is to be noted that where an asterisk
is affixed to a number it indicates that additional information has been added
to those oases than is obtainable from the references given. For these extra
facts, now for the first time published, I am indebted to the physician whose
care the patient was under, and who reported or showed the case in the first
instance.
t “ Birmingham Med. Rev.,’* Aug., 1893.
J “ American Journ. Med. Sc.,” Aug., 1893. Dr. Putnam also refers briefly
to three oases of acromegalia who were improved by taking thyroids, and he
quotes from Drs. Barron and S tat tuck that they had used the gland with
benefit in simple obesity.
§ The patient was shown at the South Eastern Br. B.M, A. on May 11, 1893.
See u Brit. Med. Journ.,” May 6,1893.
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528
The Treatment of Myxcedema and Cretinism, [Oct.,
The family history of this patient was very neurotic, and may he
thus represented:—
Insane (?)- Mother: insane- Brother: insane snioidal.
Congenital Imbecile^ Patient: myxcedema.
IUeg. Daughter: Daughter: Graves’ dis. Son: Goitrous
Cong, imbecile. (? Graves’ disease).
Treatment was commenced on December 10th, 1892, by thyroid
feeding, raw sheep’s thyroids being given pounded as follows:—
Dec. 1(T)
14
” g One thyroid at 11 a.m. The pulse always rose to
IQ >•* over 100, and occasionally the patient sweated
1 ^ freely after the dose.
24 .
Jan.
Feb. 1.—Two thyroids. The patient became very faint and
collapsed, and her pulse increased to 130, and became very
irregular.
Feb. 7.—Has lost flesh considerably. Skin warm and moist.
Mental state improved.
April 1.—Relapsing rapidly.
May 4.—Very lethargic.
May 5.—Treatment was begun with Burroughs and Well come’s
tabloids. Two tabloids, representing 5grs. each, every
day, and continued for ten days.
With regard to the ill-effects, both the raw glands and the
tabloids produced great occipital headache, faintness, and a general
sense of discomfort, but the former alone caused sickness. The
arthritis, which was always of a slight and passive form, with no
marked articular effusion and pain, but great knottiness and
thickening of the fingers, was not affected by the treatment (as in
my case of M. B.). The pain produced by the thyroid extract was
not in the joints, but apparently a general muscular pain. As
regards the occipital pain, an exceedingly common symptom, Dr.
Maude remarks that it does not seem to be superficial, and sug¬
gests that it is probably due to distension of the torcula and
sinuses at the back of the skull.
Dr. Maude will not express a decided opinion as to whether his
patient was insane apart from the myxoedema or whether insanity
pre-existed, as the onset of the mental state and the swelling, etc.,
were both so gradual. He says that he had an impression quite
two years before he made up his mind that she had myxoedema,
that she had primary dementia, but he goes on to remark that
primary dementia in a woman of that age is unlikely, it being
more likely that the dementia was myxoedematous all along.
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529
1893.] by Cecil F. Beadles, M.R.C.S.
Although the improvement that has so far occurred in the
patient’s condition was not as marked as in many that have been
reported, yet her mental state is much improved. “ She can now
(Aug. 10) work in the house, keep up a sustained conversation on
simple matters such as the weather, her health, or the conduct of
her neighbours, and has no delusions at all, though she remains
very grumbling and complaining. A point worth noting is that
as she improves under treatment she acquires more of that fatuous
bonhommie which myxoedematous people often have.”
Pilocarpin had previously proved a complete failure.
II. —A female (spinster) aged 22, who has been under the care
of and been treated by Dr. Wilkin Stabb,* had had exophthalmic
goitre for eight years. This, however, disappeared after an attack
of measles, and was followed by the slow development of a con¬
dition which was diagnosed by Dr. Ord in December, 1891, as that
of myxoedema. The symptoms of this latter probably commenced
in the beginning of 1890. Dr. Stabb commenced treatment on
December 20, 1892, and is still continuing it in a modified form.
At first he gave half a gland (one lobe) twice a week, coarsely
minced and covered with port wine and water, 2£ hours after a
meal. On three occasions a whole gland was given at a time, and
once she had four glands within seven days. Sometimes treat¬
ment was omitted for a few days, and tonics given in place of the
thyroids, on account of a feeling of malaise and rapidity of pulse.
The patient is now (August 5) taking “ White’s powders,” being
equivalent to £ gland once a week.
The results obtained so far are briefly thus:—The skin acted
slightly after the first, and freely after the second dose. As
regards weight, the patient lost 13^1bs. in just a month, but has
regained it since. Her pulse rose from 70 to 100 and 120, speech
became normal, lips thinned, hair less dry, malar flush departed,
and she ceased to feel cold. The temperature, which before treat¬
ment varied irregularly between 94° and 97°, was the last symptom
to show any definite improvement, but it is now always above 97°,
and is generally about 98°. She seems now to be a healthy
person. The only ill-effect noticed was an increased lassitude
during the first month of treatment.
III. —Dr. A. Barron says of his first patient,t after having the
juice of half a sheep’s thyroid subcutaneously once a week for
four months, that she appeared to have returned to her normal
condition, and that her weight fell from 12st. 71b. to lOst. 21b.
The treatment was begun in May, 1892, and now (August 10,
1893) she appeared to be perfectly well, and has a fairly respect¬
able head of hair. There have been no ill-effects. The injections
* Who referred to the case at the South Western Br. B.M. A on April 13,
1893. See “ Brit. Med. Journ.,” May 6, 1893.
f “ Brit, Med, Journ.,” Deo. 24, 1892,
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530
The Treatment of Myxoedema and Cretinism , [Oct,,
have been given up, and in their place the patient takes six
Burroughs and Wellcome’s tabloids every Sunday.
IV.—Mr. William Dobbin says that his case, who was referred
to in the “ Brit. Med. Journ.,” * was a female of about 40 years of
age, with myxoedema of from four to five years’ duration. For
about six months he prepared an extract of the thyroid according
to the formula of Dr. G. Murray, and administered it twice a
week hypodermically. After trying minced raw thyroid, which,
however, could not be borne as it produced diarrhoea, he used the
juice prepared after Hector Mackenzie’s method, viz., thyroid
macerated in tepid water, strained through muslin, and given in
beef tea. Lately tabloids of Burroughs and Wellcome, three
twice a day, have been substituted. There have been no ill-effects,
except once there was an abscess after injection.
The result has been that the swelling has diminished, unsteadi¬
ness of gait removed, and very fair health recovered. The patient
can now (August 10, 1893), after about thirteen months of treat¬
ment, attend to her domestic duties ; she enjoys life, and considers
herself well.
Dr. Mackenzie has informed me that amongst cases he has
seen treated, in one, that of an old lady, where the disease
was of old standing, very little improvement took place, but
there was really very little amiss with the patient. In
another case improvement was only partial, and although
the swelling disappeared and the hair grew, the patient re¬
mained very feeble. He adds that u in every case the mental
improvement has been unquestionable.”
Dr. Arthur Davies, who has had considerable experience
with the new treatment, has kindly sent me the following
brief notes of the seven cases of myxoedema whom he has
treated by thyroid extract given hypodermically and by
feeding with dried thyroid powder or tabloids. As will be
seen from the “ Table of Published Cases,” most of these
have been shown or described elsewhere, but in these notes
there is contained some additional information of interest,
and at the same time they are brought up to date (Aug. 10,
1893). We thus know the present condition of the patients.
I.—G. W., male, married, age 43; duration of disease 12 years*
Treated by hypodermic injections of thyroid extract. Improve¬
ment very remarkable after three months, and the patient was
scarcely recognizable. Tendency to relapse after six weeks*
interval, but again improved under treatment. No bad effects
whatever. Under treatment one and a half year.
IX.—Alice A., married, age 46; duration seven years. Greatly
-v * “ Brit. Med, Journ.,” Feb, 4,1893,
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1893.] by Cecil P. Beadles, M.R.C.S.
improved after three months’ treatment by hypodermic injections.
Tendency to relapse after five weeks’ cessation, then put on
tabloids and improvement again marked. No bad symptoms.
Under treatment one year.
III. —Ada B., single, age 47 ; duration six years. Treated by
thyroid powders. Very great improvement and patient hardly
recognizable. No tendency to relapse after five weeks. Rapid
loss of weight—four stone in 10 weeks. Under treatment seven
months.
IV. —Joseph M., married, age 45; duration five to six years.
Treated with thyroid powders. Very marked improvement and
patient not recognizable. All trace of myxoedema was gone in
three months. No bad symptoms. Under treatment seven months.
No tendency to relapse as yet.
V. —May B., married, age 59; duration 10 years. No trace of
myxoedema after three months’ treatment by thyroid tabloids.
No bad effects. Tendency to relapse after six weeks, but again
improved under treatment. Total time of treatment seven
months.
VI. —Alice T., married, age 54 ; duration four years. Improved
markedly after taking thyroid tabloids. Under treatment four
months.
YII.—Susan P., age 43; duration eight years. Improved at first
for six weeks under injections. Patient lost sight of for two
months, then put on thyroid tabloids and again improved. Under
treatment on and off for 16 months.
Comparison of the Various Methods: General (inclusions.
There can be no doubt as to the advantages which the
thyroid treatment holds over every other drug or mode of
treatment in this disease, and in conclusion it only remains
to say a word or two as to the best method of administering
this new but powerful remedy.
Already I have passed in review with more or less fulness
the various methods that have been proposed. They may
be summarized as follows:—
1. Thyroid grafting.
2. Subcutaneous injection of an extract of the thyroid
gland.
3. Ingestion of an extract (aqueous or glycerine) of the
thyroid gland.
4. Ingestion of thyroid gland, raw or slightly cooked.
5. Ingestion of a dry extract obtained from the thyroid
gland, in the form of a powder, tabloid or capsule, or pill.
6. Ingestion of thyroidin.
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The Treatment of Myxcedema and Cretinism , [Oct,,
Of thyroid grafting I think I have said sufficient to show
that so far the results obtained have, in a manner, been dis¬
appointing and scarcely what at one time was hoped of it.
They have certainly not been followed by the same striking
results as those ensuing from the more recent methods
adopted. At the same time considering the fact that the
treatment by these latter is not a permanent cure, and that
the drug has to be taken at certain intervals in order to
maintain the improved condition brought about (a fact which
is easy to understand), it would seem that our only hope of a
permanent cure for myxcedema lies in some method by
which transplantation can be brought to greater perfection
and the graft made capable of living in its new position.
Professor Horsley, at Newcastle, has lately called attention
to this when he said * that “ it would appear more reasonable
to perform transplantation after a prefatory treatment by
feeding or injection so as to provide that the grafted gland
should be embedded in normal connective tissue and not in
diseased tissue.”
By the injection of a fluid extract subcutaneously the
treatment became at once more simple and free from the
many risks of a large operation. It was a small operation
that no physician would mind undertaking, and its immediate
effects were much more striking. Moreover, it has been
shown that the cure could be maintained by the occasional
use of a smaller amount than that first employed, and the
ill effects that followed its use in many of the earlier cases
have been shown to be much lessened or avoided by the more
careful use of the fluid and by paying greater heed to the
regulation of the dose, and to the subject on whom it was
being used.
A watery or a glycerine extract appears to be equally
efficacious, and either can be made without a great amount
of trouble, although it is perhaps better to obtain it at
regular intervals from some druggist of repute, several of
whom now supply it at a moderate cost.
With regard to the best dose to employ this would depend
on circumstances, such as the age of the patient, duration
of the disease, and various other small points that can only
be decided in individual instances. Dr. Murray, at the
Clinical Society, said he now injected about ttjxv. at a time,
very slowly, which caused less irritation than a larger dose,
* Report of Annual Meeting of Brit. Med. Assoc, at Newcastle-on-Tyne,
“ Lancet,” Aug. 6,1893,
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533
by Cecil F. Beadles, M.R.C.S.
and in order to maintain the patient in health he recom¬
mended the use of a much smaller dose. # In this latter,
which he called the second stage of the treatment, he had
also given the extract by the mouth—daily doses of n\x. given
in water—and on another occasion + “ he urged a small
dose daily rather than a large dose at longer intervals.”
Although the ingestion of thyroid glands, whether raw or
slightly cooked, appears perhaps the simplest method
possible, it certainly is not without drawbacks. The principal
of these is the difficulty of giving a fixed dose. In some
cases in which this method has been employed bad symptoms
have followed. And as the thyroid glands vary greatly in
size, not only in different animals, but also in the same
species,t and probably also vary in their activity with the age
of the animal and other circumstances, if the patient be
allowed to procure the gland themselves their eating may
be followed by results of a very unfavourable nature. It is
essential, therefore, that when used they should be ordered
by the medical attendant, and whilst being employed the
patient should remain constantly under his observation.
When the raw glands are given they should not be more
than one lobe of the thyroid two or three times a week, as
recommended by Drs. Pasteur and Calvert.§
Dr. Hector Mackenzie does not now allow the raw gland
to be eaten, as it has given rise to gastro-intestinal
symptoms, but gives his patient a freshly-made extract.
Writing with regard to his first case, in a private letter on
May 5th, he said, “ My patient is keeping very well. I don’t
think anyone seeing her now would suspect her to be a case
of myxcedema. In fact, within a few weeks of the com¬
mencement of the treatment the characteristic appearance
of symptoms had disappeared. She continues to have a
freshly prepared liquid extract of the gland once a week.
She comes up to the hospital where the nurse prepares the
extract for her, simply mincing it up finely, letting it stand
for a time in some beef tea and then straining. The
catamenia have lately returned after an absence of five
years.”
* “ Lancet,” Feb. 4,1893, p. 248.
t “Brit. Med. Journ.,” Feb. 25, 1893, p. 411. See also Dr. Murray’s illus¬
trated paper on “ The Treatment of MyiaBdema and Cretinism,” “ Lancet,”
May 13,1893.
J See “ Lanoet,” Feb. 4,1893, p. 274.
§ “ Clinical Society,” Jan. 27,1893 j “ Lancet,” Feb. 4,1898.
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Again, on August 5, he says that his “ original patient 99
was in very good health and there were no signs of
myxcedema whatever. Lately she has been having the
expressed juice of a whole thyroid gland once a week, and
occasionally “ White’s thyroid powders 93 were substituted
(three a week, the equivalent of half a gland). She, how¬
ever, preferred the fresh extract.
The use of the extract in the form of a powder is a distinct
advantage in several respects. It is a grey tasteless powder
which will keep good for a sufficient period. It can be given
in a variety of vehicles. It is prepared in a scientific way,*
so the dose can be accurately measured. The results from
its employment have been as satisfactory as those otherwise
obtained. Or, if preferred, tabloids prepared by compress¬
ing the powder can now be obtained, each being equivalent
to five grains of the fresh thyroid.f They have received
considerable favour.
Dr. Arthur Davies wrote me under date May 9th:—“As
regards the cases I have treated solely by giving the dried
thyroid extract, each one is still in a vastly improved state;
indeed, one may now say that there is no sign or symptom *
of myxcedema in them. I am keeping up the treatment,
but by degrees gradually lessening the frequency of the dose.
I formerly gave White’s powders, but now use Burroughs
and Wellcome’s tabloids, which I find equally efficacious,
though perhaps slower in action. Of course, as regards
rapidity of treatment, the subcutaneous injection is the most
quick.” Whichever way is preferred, the rapidity of the
recovery appears to depend upon the amount of the extract
employed. It is possible, however, that by giving the extract
in smaller quantities over a longer period that a less rapid
recovery will be found to be more beneficial to the patient,
and lead to a more lasting improvement.
At the time when the drug is exerting its power most
actively the patient often feels weakened and out of sorts,
and it is then that the use of tonics in combination with the
new treatment, as suggested by Dr. McCall Anderson,J is
not amiss, and may be employed with advantage. Nitro-
* Each powder representing the sixth part of a sheep’s thyroid as supplied
by Mr. Allen, and 60 grains of the powder being equivalent to one fresh gland
as supplied by Ferris, of Bristol. The latter tirm also make the powder up
into capsules.
t Prepared by Messrs. Burroughs and Wellcome. See “ B. M. J.,” April 1
p. 701.
X “ The Treatment of MyxoBdema/’ “ The Practitioner,* Jan., 1808.
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1393.] by Cecil F. Beadles, M.R.C.S.
glycerine, too, has been found by Mr. C. J. B. Johnson to
a promptly relieve the headaches which came on when the
thyroid was freely given.”*
1 will now quote from a letter I received from my friend
Dr. Murray on the 7th May, in which he gives the latest
conclusions as regards treatment at which he has arrived.
“The treatment consists of two stages—first, removal of
symptoms; second, maintaining improved condition. The
first stage can be carried out by injections or by the mouth.
If injections are used not more than rnxv. at a time should
be injected, as larger doses are apt to cause irritation. In¬
jections may be repeated two or three times a week. If
given by the mouth it is best to start with a daily dose of
about nix.; if not sufficient give it twice. If there is undue
acceleration of the pulse diminish the dose. In the secondary
stage it is best to give by the mouth, and give the smallest
daily dose which keeps the temperature normal or above 97°.
I find my original glycerine extract, with carbolic omitted,
made by Brady and Martin, most satisfactory to give by the
mouth. 3 iss.=one whole sheep’s thyroid.”
Writing to me again a few days later (May 14th) with
regard to his first case—that which has borne the test of
time the longest—he says :—“ My first case has now no
symptom of myxcedema left, and is as well as she could be,
both in mind and body, leading an active life as a working
man’s wife. She takes regularly si. of the thyroid extract
each week in daily v\x. doses. As it is now more than two
years since the treatment was first started I think we can
fairly conclude that the improvement may be maintained
indefinitely.” He also stated, concerning the patient whose
photo was reproduced in the “ Brit. Med. Journ.,” August
27, 1892, that she was kept in the improved condition by a
daily dose of irvv. of the extract, and that the photograph
taken a year ago represents the present condition very well,
except that some of the hair is now seven inches long.
In conclusion, I will quote a remark of Dr. Murray’s with
which I feel sure many will agree. “ If all cases of myxce¬
dema are put on the treatment as soon as diagnosed the
insanity of myxoedema ought to cease to exist, and if cretins
are fed on some thyroid preparation from youth up they
should develop into more useful members of the community.”
I think it is the duty of all, who in future have the oppor¬
tunity, to test the truth of what has been said regarding
* « Brit Med. Journ./’ May 6,1893, p. 955.
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536
The Treatment of Myxcedema and Cretinism . [Oct.,
this new and wonderful remedy, one which has rightly been
said to be “ one of the greatest therapeutic triumphs of the
age.”*
REFERENCES.
Reproductions from photographs of patients who have undergone the thyroid
treatment may be found in the following journals:—Brit. Med. Journ. t ” Aug.
27, 1892; Jan. 14,1893, p. 64; April 8, 1893, pp. 737 and 738. “Glas. Med.
Journ.,** Sept., 1892. “ Clin. Soc. Trans.,” Vol.xxv., 1892. “ Lancet,” Mfcy 13,
1893. “ Sheffield Med. Journ.,** July, 1893, etc.
I have to acknowledge my indebtedness to Drs. Murray, Davies, and Mac¬
kenzie for the use of some excellent photographs showing myxoedematous
patients before and after treatment by the thyroid, which were shown at the
meeting of the Medico-Psych. Assoc, on May 18th, 1893.
“The Function of the Thyroid Gland: A Critical and Historical Review,”
Victor Horsley, “ Brit. Med. Journ.,” Jan. 30,1892, and Virchow’s u Festschrift,”
1891.
Discussion on Myxcedema at the Edinburgh Mpdico-Chirurgical Society, Feb.
15 and 16, 1893. See “ Edinburgh Medical Journal,** May, 1893.
Discussion on the Treatment of Myxcedema at the Annual Meeting of the
Brit. Med. Association at Nottingham, July, 1892. See “Brit. Med. Journ., 1 ’
Aug. 27, 1892.
“ The Treatment of Myxcedema and Cretinism,” Dr. Geo. Murray, “ Lancet,”
May 13, 1893.
“ Myxoedema and the Recent Advances in its Treatment,” Dr. Hector Mac¬
kenzie,/ 4 Lancet,* 1 Jan. 21, 1893.
“The Treatment of Myxoedema by Thyroid Feeding: Its Advantages and
RiskB,” Prof. Grainger Stewart, “ The Practitioner,’* July, 1893.
“ Myxcedema and the Thyroid Gland,*’ being a short account of the supposed
uses and functions of the gland, Dr. Lorrain Smith, The Medical Magazine,”
Aug., 1893.
“Cases of Myxcedema and Acromegalia Treated with Benefit by Sheep’s
Thyroids: Recent Observations Respecting the Pathology of the Cachexias
following Disease of the Thyroid: Clinical Relationships of Graves* Disease
and Acromegalia,” Dr. James T. Putnam, “American Journ. Med. Sc.,** Aug.,
1893.
For Tables see Appendix.
CLINICAL NOTES AND CASES.
Hypertrophy of Scalp. By George Foy, F.R.C.S., Dublin.
Dr. McDowall will find a case of extraordinary develop¬
ment of the scalp reported in John Bell's article "On the
Unlimited Growth of Tumours,” which is reprinted in his
“ Principles of Surgery,” Yol. iii., 4to., 1808 a.d., published
by Longman, Hurst, Rees, and Orme, London. The book is
now scarce, and the case is so remarkable that I give a
summary of it.
Eleanor FitzGerald, a native of Ireland, born in the
* “ Lancet,” Feb. 4,1893.
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Clinical Notes and Cases .
537
1893.]
County Carlow, and now about fifty years of age, was carried
by her parents when a child to Charlestown, in South
Carolina, to which place they emigrated. There when grown
up she married a ship carpenter, and lived with her husband
in Charlestown fourteen years, where she bore him seven
children. She is a woman of a very singular appearance;
her face of a gipsy, or rather Tartar cast, with thick lips,
a peaked nose, small eyes, small wrinkled forehead; bears
the marks of a variety of climates; her complexion is of a
deep yellow or dingy colour, sunburnt and freckled. Her
hair is very black and matted 5 the skin of her body fair
and healthy, but studded over, especially on the arms and
shoulders, with small tubercles, like berries. The enormous
growth of skin, which hangs from her neck and breast, and
which, when she opens her tattered clothes, rolls out like the
bowels, one turn over another, is at once disgusting and
horrible. Were she not alive and known to thousands,
wandering at this moment and begging her bread, I should
be afraid even to expose this drawing, which is a true
portrait, much more to relate her tale.
" About five years ago she embarked with her husband for
London, his native place, at Charlestown, in the ship
Charming Nancy , Captain Stewart, a store ship, crowded
with more than 150 people, passengers and crew. After
they had been three weeks at sea, and after they had
accomplished, as she imagines, half their voyage, they were
overtaken by a dreadful storm of thunder and very vivid
lightning, with rain and hail. The ship was struck about
mid-day; the numbers who were struck down and never rose
again, and the numbers who were deprived of sight, I fear,
she, in the fervour of impressing her pitiful tale, exaggerates
very greatly; butshe^erself was struck down, and her husband
was among the killed. How long she lay upon the deck she
never knew, but upon recovering she was sensible of a smart
burning pain on the left side of her head. The part felt
heavy, and on putting up her hand she found that a soft and
baggy tumour had arisen all at once as big, she says, as the
crown of a hat, which filled every day more and more, and fell
lower towards the shoulder, for it was a tumour of the back
part of the hairy scalp behind the ear. The voyage lasted about
three weeks, and before the ship entered the Thames this
tumour burst, and continued for a long while to distil a pure
limpid serum, the bag having by this time descended so low
as to be flapping upon the shoulder; but the ear was not yet
xxxix. 35
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Clinical Notes and Cases.
[Oct.,
elongated, and the tumour was still limited to that part of
the hairy scalp which is distinguished in the drawing by
a blacker colour. The serum* continued to distil hot and
acrid from this thick flap of skin, excoriating the neck and
breast, and still the tumour continued to be elongated,
hanging over the shoulder, and extending over the breast.”
She showed the tumour to the surgeon at St. Bartholo¬
mew’s and Guy’s Hospitals, who were unwilling to operate.
Next she became an inmate of the H6tel Dieu, where M.
Dessault excised the heaviest and most pendulous part of the
tumour. But it did not fail to grow again, and increased
very rapidly, and took the singular form of longitudinal
plaits. From France she travelled to Ireland, and lived
there by begging until frightened by the Rebellion of 1788.
She sought refuge in Scotland. Bell thus describes the
tumour:—
“ The chief volume of the tumohr certainly begins in that
part which hangs thick and baggy from the back of the
head, and its origin in the lowest part of the hairy scalp is
denoted by its black colour, proceeding from the roots and
stubs of her dark hair. This coloured part, indicating its
origin from the scalp, is extended now as low as the shoulder.
It has a firm surface, large tubercules, a scaly hardness, and
a blue colour; the stubs and roots of her black hair are seen
growing in it. From this descends a great and voluminous
roll of skin, which hangs over the breast and belly, to the
length of a yard and a half, like a bundle of intestines, and
from her ear, which is elongated to a prodigious length and
size, still hangs another corresponding roll of skin, which, fall¬
ing from the neck and face, constitutes a great part of the
volume of enlarged skin, which, as she sits, hangs over her
knees. Betwixt those voluminous rolls of soft and flaccid
skin are the scars of those incisions made in the Hotel Dieu.
One large and voluminous fold, taking the rolls of skin down
"to the ribs, serving like ligaments to suspend them, and
drawing them into the convoluted forms of intestines, hangs
from the neck, and her epaulet-like fold comes from the
shoulder, falls over the left breast, and forms the boundary of
the tumour on that side. . . . This immense volume of
skin is thin where it hangs from the occiput, neck, chin, and
shoulders, but it is very thick, massy, and doughy-like at its
lower parts. . . . This monstrous growth of skin, the most
voluminous that stands upon record, is simply skin, without
the slightest taint of ulceration on any part of its surface, or
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Clinical Notes and Cases.
539
1893.]
the slightest tingling of pain. It is skin, luxuriant, healthy,
extremely vascular, with its cellular substance loosened and
evolved, so as to give a doughy feeling when the whole
tumour is handled. ...
“ When she travels about on her begging excursions she
carries her tumour in a sling made of an old tablecloth, as a
sower of corn carries the seed in the bag before him. When
she sits down, opens her cloak, and unfolds this disgusting
and horrible tumour, you can hardly be persuaded that
you do not see her belly open and her bowels in motion, for
the rolls of skin, fleshy and red, roll over each other as she
handles them, and the slightest handling at one fold of the
tumour puts the whole into this vermicular kind of motion.
The whole volume would roll over her knees but that she
contains it in her lap by putting one or both her arms round
it"
Two Cases of Abnormal Development of the Scalp . By John
J. Cowan, M.B.,C.M., Assistant Medical Officer,Roxburgh
District Asylum, Melrose. (With Plate.)
(By Permission of Dr . J, Carlyle Johnstone.)
The two cases here noted and illustrated were referred to
by Dr. McDowall, Morpeth, in his communication to this
Journal of 1st January, 1893. One of the cases shows con¬
siderable resemblance to his.
Case I.—P. GL, aged 39 years, was admitted into this asylum a
year ago. He is a genetous and paralytic idiot. There is no direct
hereditary predisposition to insanity ; but his mother and brothers
are distinctly neurotic.
The patient is an enormously stout, broad-shouldered man. He
measures 50 inches round the chest, 14 inches round the arm over
the biceps (at rest), 19 inches round the mid-thigh, and 12 inches
round the calf, which is atrophied and wasted. His weight is 16
stone 541bs. He has never been able to walk, as he suffers from
congenital double talipes egrino-varus. His mode of locomotion,
when he is called upon to use it, is dragging himself along on his
knees by means of his large and powerful arms. Estimating h(s
height it should be over 6ft. (his brothers, one of whom is younger
than him, are very tall and stout). His cranial development is
notably small in proportion to his face and body generally; fore-
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Clinical Notes and Cases .
[Oct,,
head sloping,* cranium oxycephalic. He is not, however, micro-
cephalic. The cranial measurements are given later along with
those of Case II. He suffers from alternating squint. The palate
is broad and rather highly arched, teeth not crowded, fairly healthy
and regular. His body organs are healthy, save that the circu¬
lation is weak, chiefly owing to his corpulence. In his movements
he is clumsy and awkward; he has the paralysis above named, the
legs being wasted and feet deformed; but there is no arrested
development. The sense of touch and hearing are fairly acute,
but sight, taste, and smell are sluggish. Superficial reflexes are
exaggerated; knee-jerks much dulled.
On looking at the scalp one notices at once that it is abnormally
lax and redundant, and can even be plucked up; its surface is
irregular and furrowed. The hair generally is thin and fine; in
the furrows, however, it grows quite thickly; on the crown of the
head the hair is scanty and the scalp becomes smoother, the
furrows being more shallow. The furrows are thirteen in number,
ten of which run antero-posteriorly; these are roughly sym¬
metrical, there being five on each side. The remaining three are
transverse in direction and situated at the back of the head. The
two central antero-posterior furrows commence three inches above
the external occipital protuberance, and run forwards, that on the
left side for If inches, and that on the right side for five inches,
becoming more shallow as it nears the forehead. On either side
of these central furrows, at intervals varying from lfin. to fin., run
the other four antero-posterior furrows ; these are more curved in'
shape and more irregular, and reach farther anteriorly. In length
they vary from 2f in. to 4f in. The depth of the furrows varies from
fin. to fin. There is. also a short and shallow furrow about If in.
long, running back from the junction of the skin of the forehead
with the hairy scalp on either side to the inner side of and
behind the ill-marked frontal eminences. This furrow runs in
between the diverging second and third furrows. On the left side
of the head the antero-posterior furrows are markedly more
shallow and ill-defined, the scalp being less redundant.
In the occipital region run the transverse furrows, which are
long and deep, and quite unaffected by the position of the head,
even if craned forwards. Beginning at the uppermost, they
measure in length, respectively, 3f in., 6fin., and 3in.; iii depth,
fin., fin., and fin. The highest runs transversely, with a slight
inclination upwards on the right side at a level of lfin. above the
external occipital protuberance ; the other two run lfin. and 2in.
below this. The two upper ones are deepest and best marked on
the right side. Beyond rendering the furrows slightly more
• His profile resembles remarkably that of Antonia Grandoni, a micro-
cephalic idiot portrayed in Dr. Ireland’s book “ Idiocy and Imbecility,” p. 104,
with the exceptions that his forehead slopes rather more and the scalp is
furrowed. See also “ Diet, of Psych.-Med.” Art. “ Microcephaly.”
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1893.]
Clinical Notes and Cases .
541
prominent, the occipito-frontalis muscle has no action on them.
Electricity gives negative results.
Mentally, P. G. has about the same amount of intelligence as a
child who has just begun to speak. He is very observant of all
that goes on round him. The voice is high pitched and babyish.
The slightest trifle amuses him and makes him chuckle, crow, and
swing himself to and fro in his chair with delight, and he calls
to his friends to share his amusement. He has many childish
ways, e.gr., hangs out his tongue when performing actions which to
him are difficult, but he also has a way of letting it hang out as
if it were more comfortable out than in. He puckers and contorts
his face; is fond of babyish tricks, such as making noises with
his mouth; is very imitative and often parrotlike; he repeats
words and phrases (usually acquiring those least desirable) with¬
out knowing their meaning. Owing to his imitativeness, his tone
of voice has altered considerably since his admission, and resembles
in certain words that of his attendants or fellow patients. His
articulation is badly performed ; notably, he avoids all labials, e.g .,
“ henny ” for “ penny ”; his vocabulary is limited to the names of
a few familiar animals and a few simple adjectives and expletives
and objects. Like a child also, he has words of his own construc¬
tion to express objects or actions. He exhibits great motor
restlessness, is always doing something, chattering, singing, pre¬
tending to read, playing with his toy fiddle, making remarks on
what he sees; by way of amusement also, he has a habit of grind¬
ing his teeth. As a rule he is in the best of tempers and spirits,
but now and again, on being teased, in a moment he gets very
angry and tries to strike, or spits. Once, when in a rage, he
threw a hatchet at some children (formerly he used to chop
sticks). He has a notion of right and wrong. In habits he is
clean and tidy, and able to indicate his wants. Since his admis¬
sion he has shown educability and has considerably added to his
vocabulary and general knowledge.
Case II.—J. M., aged 41 years, was admitted 12 years ago.
His mother was insane, and a patient here for a short time. No
other particulars known about him. This patient also is a genetous
and paralytic idiot, but of a much more degraded type. He
suffers from paralysis of the right arm and withering of the fore¬
arm and hand, with wrist drop ; the right leg is weaker than the
left, and drags slightly in walking; the feet are ill-formed, broad,
and shortened antero-posteriorly. His cranial development is
small, but not so visibly out of proportion to the features and rest
of the body as in P. G.; cranium is round and bullet-shaped;
features coarse and irregular ; palate narrow and highly arched ;
teeth badly formed and rather crowded; lips thick, coarse, and
everted, allowing the saliva to dribble out. He has a squint of
the right eye due to a corneal opacity following an injury. He has
a considerable stoop in the shoulders ; if straight, would be about
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Clinical Notes and Cases.
[Oct.,
5ft. 6in. in height. His weight is lOst. 9Jlbs. Chest ill-formed,
owing to stoop; circulation feeble. Motion is slnggish, gait
clumsy and shuffling. Sense of touch is acute, but the other
senses are dull. Superficial reflex action is exaggerated, especially
on the right side; knee-jerks exaggerated on right side.
The hair is very thick generally, but is thinner over the crown
of the head, where the scalp is less furrowed. The scalp is not so
lax and mobile as in Case I., but still is abnormally so. The
furrows, which in their situation and disposition resemble Case I.
remarkably, run both antero-posteriorly and transversely; but
they are more crooked and irregular, and their continuity is in¬
terrupted in places. The antero-posterior furrows are thirteen in
number, six on each side, which are roughly symmetrical, and a
short one on the left side. The two central antero-posterior
furrows commence about the same site as in Case I., but are more
equal in length, and extend forwards to near the forehead; they
are more wavy in the outline and more shallow over the crown.
On either side of these are the other furrows, varying in length
from 4-8in., disposed much as in P. G’s. case. The average depth
of the furrows is somewhat less than in Case I. There are two
transverse furrows in the occipital region, both best developed,
and deeper on the right side. The upper commences in a curious
depression, fin. deep, about lfin. above the exterior occipital pro¬
tuberance ; it seems to penetrate through the bone partly. The
furrow runs downwards to the left, its continuity being interrupted
for about 1 Jin.; on the right side it runs down for 2Jin. to within
3Jin. of the right mastoid process. The lower transverse furrow
runs lfin. below the upper for a length of 2|in., two-thirds of it
being on the right side. This furrow is much shallower than the
upper one. The occipito-frontalis muscle is extremely well
developed, and is constantly in use, but has no action in either
obliterating or deepening the folds. On tickling the skin of the
neck behind, the two central pairs of furrows were seen distinctly
to be drawn together and deepened. This movement was pro¬
bably involuntary, for it has only been obtained twice and at con¬
siderable intervals; one cannot obtain it at will nor with
electricity.
This patient mentally is quite idiotic, and has very little intelli¬
gence. He only knows his attendants; pays no attention to any¬
one or anything save his food, which he eats like an animal; is
quite harmless, inoffensive, and stupid; but is irritable, and
resents interference, especially from strangers. He speaks in a
half-articulate mumbling manner; his vocabulary is practically
limited to his own name and two foul words which he has picked
up. When pleased and happy he bursts into guffaws of idiotic
laughter; or he howls by way of agony. As in P. G., there is con¬
siderable motor restlessness, and he is never at rest save when
asleep. He requires to have everything done for him save feed*
Digitized by L^ooQle
Clinical Notes and Cases .
543
1893.]
ing, and in habits is dirty ; is addicted to masturbation. Although
he has been here a long time, and many attempts have been made
to educate him in habits, etc., he has not responded to the efforts
made, and remains the helpless, degraded idiot he was on
admission.
Cranial Measurements.
P. G.
J. M.
inches.
inches.
Circumference.
...
.
21*
21
From root of nose to occipital protuberance, over vertex ...
HA
hi
do. do.
do.,
on right side ...
10f
10*
do. do.
do.,
on left side ...
101
10*
do. do.
do.,
calliper
7*
From ear to ear, over vertex ...
...
.
11
10*
do. do., calliper
...
.
6*
6*
On the Possible Use of Sulphonal as a Means of Inducing Insane
Patients who Refuse Food to Eat Voluntarily . By Dr.
Bbough, LL.B., L.R.C.P.Ed., etc., Assistant Physician,
Argyle and Bute Asylum, Lochgilphead.
It is unnecessary to remind those to whom the practical
care and management of the insane are entrusted how dis¬
agreeable and painful it is, not merely to the patient, but
also to the operator, to be obliged to resort to forcible feed¬
ing, and any safe drug which will obviate to any extent this
necessity will be welcomed.
As our experience in this asylum during the past six
months has led us to believe that sulphonal may, at all
events in some cases, have the desired effect, I have con¬
sidered myself justified in communicating this paper, and
by the kind permission of Dr. John Cameron, Medical
Superintendent, I send notes of our cases.
During the period mentioned, only five of the 400 patients
in this asylum have actually required to be fed forcibly, and
in each of these cases the use of sulphonal has been followed
by voluntary eating on the part of the patient. It is at
present premature to say that the sulphonal was the cause of
Digitized by Google
544
Clinical Notes and Cases .
[Oct.,
the resumption of voluntary eating, and we can only point
to the fact that after it had been administered each patient
began to take food of his own accord, the sudden change of
demeanour being very striking in the persistent and intract¬
able cases referred to.
No markedly evil effects have been recorded as following
the use of sulphonal for long periods, and even if some
detriment may result from its long-continued administration
nothing yet known suggests that this is likely to exceed the
admitted evils of forcible feeding, especially when the
liability to septic pneumonia is borne in mind.
This letter is written merely in the hope that those who
have more extensive opportunities of observation will give the
drug a fair trial in cases of this class.
It would not be proper to go into the cases at length, and
so I merely send notes indicating their nature, and shall be
happy to give more detailed information to anyone who may
desire it.
Case I.—D. B., male, aged 38. Melancholia with strong
suicidal tendencies. Patient, a very respectable man, who bore an
excellent character, thinks that he has offended the Almighty be¬
yond forgiveness, and has always given as a reason for refusing food
that he is “ a devil in wickedness, and that as such he has no right
to eat, and that he only further offends and defies God by so
doing.” Patient was admitted in August, 1892. On 27th
November he refused food, and had to be fed with the stomach
pump. Forcible feeding twice a day had to be continued until
21st December. On the evening of 20th December, the patient
having been sleepless and restless, 50 grs. sulphonal were given.
On 21st he was quiet and somewhat sleepy, but towards evening he
took some tea and toast voluntarily. On 22nd the effects of the
sulphonal had apparently worn off. He refused to take breakfast,
but at mid-day, after much persuasion, he was induced to take an
egg, some meat, and toast. He refused positively to eat anything
that evening, and on the following day forcible feeding had to be
resumed, and was continued regularly until 31st December. On
30th, owing to sleeplessness and excitement, 40 grs. sulphonal had
been given. On the morning of 31st he had to be fed by the pump,
but he voluntarily took dinner and tea. The use of sulphonal was
continued all through January, the patient continuing to take his
food regularly of his own accord during the time. On the 31st
January, however, the drug was discontinued, as the patient had
become somewhat somnolent and lethargic. On 7th February
forcible feeding had again to be resorted to, the patient refusing
food and having been very irregular in his eating for two or three
days, sometimes missing one meal altogether, and at other
times taking an insufficient quantity. From this time forcible
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Clinical Notes and Cases .
545
1893.]
feeding with the pump was continued regularly twice a day until
25th February. On 26th February, although the patient waa not
showing excitement and was not sleepless, it was considered
desirable, in view of what we had seen in this and other cases, to
try the effect of sulphonal on the refusal to eat, and accordingly 40
grs. were given at bed time, and 40 grs. more on the morning of
26th. Patient on that day ate his dinner of his own accord, and
has continued to take his food voluntarily ever since; sulphonal, in
doses varying from 30 to 40 grs., according to his state, being given
every morning two hours before breakfast. This quantity of
sulphonal does not cause sleep during the day.
Case II.—J. McA., male, aged 46; admitted October, 1891.
Melancholia with marked suicidal tendencies. From the time of
his admission this patient declined food, and had to be fed by the
stomach pump almost continuously. He would, for instance, have
to be fed forcibly for ten days or so, then he would take food
voluntarily for a day or two, and then forcible feeding would have
to be resumed again, and so on. The alleged cause of refusal to
eat was that all food given him “ contained filth.” Patient, who
was then being forcibly fed, was owing to excitement and sleepless¬
ness given 40 grs. sulphonal on 25th January last, and a like dose
on the morning of 26th January. On the evening of the latter
day he took his tea voluntarily. Sulphonal was continued daily
until 2nd February, and patient during that time and until 4th
February continued to take his food regularly. On the last-named
day he again refused to take food, and forcible feeding had to be
resumed, and was continued until 12th February. On the morning
of that day 40 grs. of sulphonal had been given, and in the
evening he took his tea. Sulphonal, in doses of about 30 grains,
has been given him daily ever since, and the patient has ever since
continued to take his food voluntarily.
Case III.—C. McE., female, aged 50. Melancholia with very
strong and most persistent suicidal tendencies. This patient had
made several very determined attempts to destroy herself, and
believes that she on one occasion succeeded in so doing, and that
she is now in hell undergoing torment. As she was very restless
and excited, sulphonal had been administered to her daily for some
considerable time in doses varying from 15 to 26 grs. During the
months December, January, February, and March the administra¬
tion of the drug was stopped for a period of a few days on five
different occasions, the patient having shown cataleptiform signs
and some stupor. On each of these five occasions, after the drug
had been stopped for a day or two, the patient refused her food,
and forcible feeding with a spoon had to be resorted to, but as soon
as the administration of the drug was resumed, she again, in a day
or two, on each occasion, began to eat voluntarily, and continued to
do so until the drug had been again stopped.
Case IY.—A. McL., male, aged 69. Melancholia. Always
thinks that he is about to be tortured by someone, and also that
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546
Clinical Notes and Cases.
[Oct.,
his soul will be eternally lost unless be can secure tbe “ Book of
Life,” for which he is constantly searching. Doubtful whether
suicidal. Refused food in February, and was forcibly fed with the
stomach pump for two days. On the morning of the second day
50 grs. of sulphonal were given, and he took his tea in the evening.
The sulphonal was continued for some days, and the patient con¬
tinued to eat. On a subsequent occasion in March he became dis¬
inclined to take food, but by persuasion he was induced to take a
small quantity. Sulphonal in 50 gr. doses was given as soon as
the disinclination appeared, and this passed off on the following
day, the patient voluntarily eating with apparently good appetite.
The drug was continued for several days.
Case V.—N. S., male, aged 26. Melancholia with hallucina¬
tions of hearing. Hears voices telling him “ to be good,” and to
“ do penance by not eating.” This patient had to be forcibly fed
for three days in February and for two days in March. On each
occasion sulphonal in 50 gr. doses was given, and on the day fol¬
lowing its administration the patient resumed voluntary eating.
The sulphonal in diminished doses was continued on each occasion
for several days after the patient had commenced to eat.
The last two cases do not prove much, for the refusal to
take food had not been long continued and persistent as in
the other cases, and might have ceased apart from the use
of the drug, but so far as they go they tend to confirm the
other cases.
Two Cases of Pachymeningitis Hcemorrliagica Interna . By
Hubert C. Bristowe, M.D.Lond., Second Assistant
Medical Officer, Somerset and Bath County Asylum,
Wells.
Through the kindness of Dr. Wade, I am permitted to
publish two cases of pachymeningitis heemorrhagica interna
which recently died in the Somerset and Bath Asylum. The
first case was of a fairly common type, whereas the second
presented some very unusual appearances. Both seem
worthy of record, and suggest the question—Were they due
to haemorrhage ?
The patients were men past the prime of life, who
suffered from the usual symptoms of general paralysis. The
duration of the first case was about one year; that of the
second four or five years. I regret that I saw neither case
in its earlier stages, and also that in neither was a complete
history to be obtained.
Case I.—T. J., eat. 44, married, labourer. Admitted December
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Clinical Notes and Cases •
547
1893.]
15th, 1891. His father died in the asylum. One brother also was
insane. He had never been a man of much mental capacity, but in
that respect had been up to the average of a Somerset labourer.
No cause could be assigned for his illness. No history of injury.
State on Admission .—Well nourished; right pupil larger than
left, both acting sluggishly. Tongue tremulous; knee jerks
exaggerated; speech hesitating and slurred. Expression dull and
fatuous. He was in a state of dementia, had no idea of time or
place; was very emotional, crying or laughing at the least thing;
expressed himself as feeling exceedingly well, and was dirty in
habits. He continued in much the same condition until July 25th,
1892, when he had an epileptiform seizure, from which he rapidly
recovered. Shortly afterwards he became so weak that it was found
necessary to keep him in bed. On August 18th, at midday, he had
another fit, in which the right arm and leg were quite flaccid, but
after a short time they became extended and rigid. The knee
jerks were much exaggerated, and ankle clonus was present in
both legs, but more marked in the right. He apparently lost con¬
sciousness. The temperature rose slightly. At 9.30 p.m., another
fit, attended with convulsions, carried him off.
The post-mortem examination was made 30 hours after death.
The calvaria was healthy, and the dura mater not adherent to it.
When the skull cap was removed the dura appeared to be tense
and of a dark colour. It was incised, and carefully peeled off from
the substance beneath, to which it was adherent. The only portion
of brain covered by the pia mater then visible was the median
area. Surrounding this area was a dark horseshoe-shaped sac of
false membranes, which was adherent to the pia mater. The con¬
vexity of the horseshoe pointed forwards. The sac wall was
formed of tough fibrous tissue, and the cavity contained blood
which was fluid, with the exception of one or two small recent
clots. The brain substance was compressed and flattened on each
side by the sac, but more so on the right than on the left.
Laterally and in front the sac extended to the base of the skull,
but did not encroach on the under surface of the brain. Behind
it reached as far as the tentorium cerebelli.
On removing the sac the pia mater was found to be opaque, but
not oedematous, and thickened, especially over the frontal lobes,
where it was as thick as the dura mater itself. An unusual
number of Pacchionian bodies were present. The membranes were
adherent to the brain substance. The ventricles were of normal
size, but their floors were roughened. No naked-eye lesion was
detected in the brain substance.
The false membranes were examined microscopically with great
care, and portions were embedded in celloidin before manipulation.
They were found to vary in thickness from 1*3 to 0*5 mm., and
were composed of fully-formed fibrous tissue. No trace, of epithe¬
lium could be found on any portion of it. The fibrous tissue was
vascular. Fibrous processes which passed from the pia mater to
Digitized by ^ooQle
548
Clinical Notes and Cases .
[Oct,,
the false membranes were found to contain arteries and veins.
There were no signs of old clotting, and no crystals of hsematoidin
could be found. In fact, everything pointed to the haemorrhage
being recent. The sac walls were scarcely blood-stained. The
surface of the pia mater was destitute of epithelium. Nothing
unusual was found in the brain substance or cord. The arteries
at the base of the brain were slightly atheromatous. All the other
organs of the body were healthy, except the kidneys, which were
slightly granular.
Case II.—J. K., ®t. 53, clerk, single. Admitted January 7th,
1892. No family history of insanity or other hereditary disease.
Had never had any serious illness. During the preceding four or
five years had been becoming queer in the head and had been com¬
pelled to give up work.
State on Admission .—A well-nourished man; tongue furred and
tremulous; right pupil larger than left, and both sluggish in
action; expression vacant and dull; seldom speaking, and appear¬
ing not to understand what was said to him; resisting examination
in a. passive manner; noisy and restless at night, and exercising
no control over his emunctories. By May 23rd he had apparently
improved; his ideas were exalted, and the state of bien etre was
well-marked; his knee jerks were exaggerated ; on attempting to
sign his name he made the first letter clear but shaky, the rest
was unintelligible. His eyes were examined by the ophthalmo¬
scope, and the fundi found to be quite healthy. He continued in
much the same condition until the beginning of August, when he
had to be confined to bed. He then had clonic spasms of the left
arm; knee jerks could not be obtained. On August 16tK he was
noted to be weaker; superficial reflexes could not be obtained; he
did not seem to appreciate a pin prick on any part of his body ;
temperature rose to 100° at night and became normal in the
morning. He died on September 1st, having gradually become
comatose.
The post-mortem examination was made 31 hours after death.
Calvaria healthy and dura mater not adherent to it. On removing
the skull cap, the dura was seen to be tense and dark. It was
adherent to the substance beneath, and had to be stripped off.
Beneath it on either side was found a sac of false membranes. The
two sacs were quite separate, and were of similar shape and extent.
In front they were adherent to the roof of the orbit, and then
completely covering the frontal lobes, passed backwards, and
covered the parietal and occipital lobes, as in the other case, and
left the parts adjoining the great longitudinal fissure uncovered.
They were slightly adherent to the pia mater. The brain was
compressed by them, especially on the left side.
The sac on the left side, as in the other case, contained fluid
blood, with one or two recent clots in it. The right sac, however,
was far less tense, and contained only a few drachms of colourless
serum. The false membranes on this side were very thin and
Digitized by L^ooQle
1893 ,] Clinical Notes and Cases . 549
semi-transparent. The pia mater was thickened and opaque, but
not oedematons, and was adherent to the brain substance. There
was an unusual number of Pacchionian bodies. The brain substance
was generally infected. The vessels at the base were slightly
atheromatous.
The false membranes were examined microscopically with the
same precautions as in the other case. The right sac wall was
composed of completely formed fibrous tissue, which was only
slightly vascular. There was no trace of epithelium or blood. The
left sac wall was more vascular, was blood-stained, and contained
no trace of blood-clot or haematoidin crystals. In this case there
were no large vessels leading from the pia mater. The surface of
the pia mater was destitute of epithelium. With the exception
of excess of fibrous tissue in the grey matter and roughening of
the floor of the 4th ventricle, nothing further abnormal was de¬
tected in the brain or cord. All other organs of the body were
healthy.
The view that this condition is due to a compensatory
haemorrhage after shrinkage of the brain substance has been
fully discussed by Dr. Wiglesworth. More recently Dr. G.
Robertson has suggested that inflammation is probably the
commencement, and haemorrhage, with organization of clot,
the continuation. It is neither my wish nor intention to dis¬
cuss these views. All I ask is—Can these two cases be satis¬
factorily explained by any haemorrhagic theory?
In the first case there was but one membranous sac which
contained fluid blood, but no signs of organized clot, unless
the sac itself consisted of it. At the same time, we must
admit that the appearances, both naked-eye and microscopic,
were quite compatible with the results of old standing in¬
flammation.
In the second case there were two membranous sacs—that
on the left contained fluid blood, and that on the right only
clear serum. The right sac wall was thinner than the left,
and presented no appearance of ever having come into con¬
tact with effused blood. Of course, it may be maintained
that the colourless sac was a decolourized sac, and that it
originally resulted from haemorrhage. In answer to this, I
ask—Why was the sac wall so thin and delicate in com¬
parison with the sac containing blood ? Why, if it was due
to old haemorrhage, was it a sac at all ? Why did it contain
only clear serum? And how was it that all traces of blood
had disappeared?
Both cases were clinically cases of general paralysis, and
presented no peculiarities until the time of death, when the
Digitized by ^ooQie
550
Clinical Notes and Cases.
[Oct.,
symptoms in each were compatible with those of cerebral
compression, and I believe the immediate cause of death
was haemorrhage into the sac in both cases. Surely the
amount of haemorrhage sufficient to form false membranes
was sufficient not only to cause immediate symptoms, but, in
all probability, immediate death.
I would suggest that the appearance presented in these
two cases are as much the appearances of old inflammation
as of haemorrhage; and, further, it is exceedingly difficult
to account for the conditions found in the second case by any
theory of haemorrhage.
OCCASIONAL NOTES OF THE QUARTER.
The Annual Meeting .
The characteristic feature of this year’s annual meeting
was the large amount of business arising out of the reports
of Committees appointed the year before. The most impor¬
tant of these had reference to the proposed new rules of the
Association. Much labour and time had been expended
upon their revision, and it was hoped by many that they
would be adopted. As, however, some members had not
received their proofs of the rules till within a short period
of the meeting, it was decided to postpone the consideration
of their adoption until the date of the quarterly meeting in
November. A resolution was passed on an important subject
—the extension of the sittings of the annual meetings from
one to two or three days. We are glad to be able to record
this, for although the meeting was not prepared to make this
course compulsory, but permissive, there can be no doubt
that this permission will be acted upon, and that when once
the proposed plan is adopted it will become a permanent
institution. Papers on medical psychology will be read and
discussed, and we may hope that the result will be the
advancement of knowledge in our special department. It
is very doubtful that the Journal will be able to find room for
the articles, in addition to those which are prepared or are
read at the quarterly meetings of the Association in Great
Britain and Ireland. It may be that a separate volume of
annual transactions may be rendered necessary. Among
other subjects discussed, the question of the admission of
lady doctors afc members led to an animated debate, and
Digitized by L^OOQie
551
1893 .] Occasional Notes of the Quarter.
although the general wish was in favour of this innovation,
it was found that the existing rules did not permit it. The
decision had, therefore, to be postponed until the existing
rule is modified.
The President’s Address was the eminently practical one
which was to be expected from so experienced and success¬
ful a medical superintendent. Dr. "Murray Lindsay passed
in review the most important subjects now or recently upper¬
most in the minds of the members of the Association.
Giving full credit to the work it has already done, he con¬
tended that it had yet much to do, and must be more self-
assertive in the eyes of the public if it wished to fulfil its
mission effectively. In fact, the whole tone of the address
had a distinctly Radical ring about it, which always sounds
better, and comes with more weight from a man growing
grey in asylum service than from the youthful critic.
We cannot say in this instance with Lord Bacon that
“ men of age adventure too little,” however true it may be
that “ young men in the conduct and management of
actions embrace more than they can hold, stir more than
they quiet, and fly to the end without consideration of the
means and degrees.” Speaking of the new Lunacy Act the
President observes (and we are sure that no member of the
Association acquainted with its working will consider
this criticism too harsh), tC I am not enabled to look back
upon it with more favour than at first. Each year’s ex¬
perience of it only leads me to join in the general condemna¬
tion of it by asylum medical officers as in many respects a
piece of hasty, vexatious, and ill-judged legislation, not only
attended with little or no benefit to the insane poor, but
depriving them, to a considerable extent, of the attention of
the medical officers whose time is now largely taken up with
increased clerical and reporting work in order to satisfy the
requirements of an unnecessarily exacting, complicated, and
confusing Act, the chief redeeming feature of which is the
consolidation of various previous enactments.” Dr. Lindsay
might have added that some of the clauses are so. ill-
expressed as to appear to mean precisely the opposite of
what the lawyers, who are consulted by the Commissioners
in Lunacy, decide to have been the meaning of those who
framed them. Most truly does the President say in his scath¬
ing condemnation of this unhappy attempt of the lawyers to
legislate on a subject of which they have no practical know¬
ledge, that it converts the asylum Staff into u recording and
certifying machines, a considerable portion of their time
Digitized by C^ooQie
552
Occasional Notes of the Qua/rter . [Oct.,
being now frittered away in writing useless reports, signing
certificates, and other clerical work.” At a quarterly meet¬
ing of the Association, held at Bethlem Hospital soon after
the Act came into operation, Dr. Percy Smith vigorously
attacked it, and showed by actual examples the annoyance
and injury it occasioned. It is greatly to be regretted that
no practical action has 'been taken by the Association since
the passing of the Act to redouble its opposition to the
objectionable clauses it contains. That the medical superin¬
tendents of asylums should tamely submit to the yoke which
has been put upon them may be creditable to their forbear¬
ance and law-abiding qualities, but manifests a want of spirit
which can hardly secure the respect of our legislators.
Bather may they interpret it as pusillanimity. The Address
at Buxton may be taken as an indication and a promise that,
under the presidency of its author, the Association will show
its hand and succeed in mitigating, if not in altogether
removing, an intolerable burden upon all who are engaged,
whether in or out of asylums, in lunacy practice.
Dr. Lindsay regrets that the Lord Chancellor has not
amalgamated the two Lunacy Departments as provided in
Section 827, which empowers him to effect it, and he
enforces the necessity of an increase in the number of
Medical Commissioners. “ One legal member on the Lunacy
Commission would probably be found quite sufficient for all
necessajy purposes for advising the Board .... Indeed, I
see no need of and no advantage whatever in the visitation
of asylums by barristers, who are not supposed to be com¬
petent to express opinions on medical matters, and who
would be the first to resent intervention by medical men in
their legal affairs.”
The great importance of the establishment of County
Councils has naturally led to the consideration of their
success or otherwise by the President, not only of our
Association, but of the Psychology Section of the British
Medical Association this year. It is highly gratifying to
know that their united verdict is distinctly in their favour.
After all the gloomy forebodings as to the terrible injury
they would inflict upon the administration of the county
asylums of England and Wales, it is a relief to find that
Dr. Murray Lindsay and Dr. McDowall, after ascertaining
the experience of other superintendents, are able to unite
with them in regarding the change as salutary, there being,
“ on the whole, every reason to be satisfied with the progress
Digitized by ^ooQle
1893.] Occasional Notes of the Quarter . 553
made, and with their administration of county asylums, which
will eventually derive greater benefit under their regime,
for, fortunately, there can be little doubt that more money
has of late years been spent upon asylums than for years
previously.” Dr. Lindsay points to the London County
Council as in the front rank in these respects. The whole
Address is in the hands of our readers, and we refer them
to it rather than dwell further upon its references to the
topics of the day in the realm of psychological medicine. We
cannot conclude this brief notice of its salient points without
remarking that its delivery was followed by some excellent
observations by the President-Elect, Dr. Conolly Norman.
Classes for “ Special Instruction ” in connection with the
London School Board .
We are glad to find that the classes instituted by the
London School Board for the special instruction of children
incapable, by reason of physical or mental infirmity, of
being taught in the ordinary elementary day school, are
making good progress under the superintendence of Mrs.
Burgwin. From her report for the year ending March,
1893, we learn that 265 such children had been under
special instruction at six centres, these having been opened
in July, 1892, in poor and populous districts of the metro¬
polis. The pupils have as a rule been selected from those
attending the ordinary schools, upon the recommendation of
head teachers, with the approval of the Medical Officer to
the Board and the Superintendent of Special Instruction.
More centres are in contemplation ; indeed, it is hoped ulti¬
mately to provide u special classes ” at convenient distances
throughout the metropolitan area. From a personal visit to
two of these centres, in Clerkenwell and St. Luke’s respec¬
tively, we are able to speak very favourably of the methods of
instruction, and of the results so far as they could be
gathered from the first nine months’ experience. To deal
successfully with groups of children more or less abnormal
demands, of course, a comparatively large teaching staff,
and we are glad to find that the ratio of teachers to pupils
is about 1 to 30. Considering that individual study of each
pupil’s peculiarity is called for, even a larger ratio of teachers
would be justified. The system of teaching adopted follows
somewhat on the lines of that found serviceable in institu¬
tions for imbeciles; sense culture, manual training, and
xxxix. 36
Digitized by ^ooQie
554
Occasional Notes of the Quarter . [Oct.,
above all, the development, by enticing methods, of the
faculty of attention, forming important items. Lessons are
brief and of a practical character, and the afternoons are
devoted chiefly to manual occupations, such as modelling in
clay, weaving in papers and cane, macraute work and needle¬
work, “ great care being taken that these occupations shall
not develop into a mere mechanical process, but each have a
definite object to be reached. “ Lessons in articulation and
gymnastic exercises are of frequent occurrence.’ 5 We did
not see any evidence of “ musical drill,” but considering the
beneficial influence music has, specially upon this class of
minds, we venture to think that the provision of pianos in
connection with these special classes would not be an un¬
pardonable extravagance.
Mrs. Burgwin states that tc some of the pupils after the
Government examination will be able to return to the
ordinary day school, whilst others will have to be excluded
from the classes, having proved themselves incapable of
making progress in any branch of work. These can only be
classed as imbeciles/’
We are glad to be able to congratulate the London School
Board on the progress made in this work of special instruc¬
tion of exceptional children, the importance of which the
readers of this Journal will remember we drew attention to
in January and April 1888. (See “ Occasional Notes,” Yol.
xxxiii., p. 552; Yol. xxxiv., p. 80).
We learn from the report of Mrs. Burgwin that the six
centres already mentioned are in the following localities:—
On Roll.
B. G.
Chelsea Division, Park Walk ... 8 6 with 1 teacher
Finsbury „. The Hugh Myddleton 28 24 „ 2 teachers
Finsbury „ Bath Street ... 88 31 „ 2 teachers
Hackney „ Snmmerford Street .. 4 17 11 „ 1 teacher
Lambeth „ East Street ... 24 13 „ 1 teacher
Sonthwark „ Pocock Street ... 38 27 „ 2 teachers
158 112 9
She states that “ many of the scholars are untruthful, in
fact seem utterly devoid of conscience, and a great deal of
time is spent in inculcating the virtue of truth and honesty
in word and deed. Whilst a few are gentle (often through
feebleness) many are very spiteful, and discipline is a source
of much anxiety to me. Over-indulgence by the parents,
who think they are thus showing their love to their afflicted
offspring, is at times accompanied by very rough treatment
when a boy is just past bearing with, and this method of treat-
Digitized by ^ooQie
555
1898.] Occasional Notes of the Quarter .
ment makes the power of controlling them a very difficult
matter indeed.”
With regard to the subjects taught, it is stated that the
“Morning Session” is devoted to Scripture teaching, the
three E.’s, drawing, with play, singing, gymnastic exercises,
each lesson occupying about twenty minutes. In the after¬
noon the children are employed in the way already stated.
44 Articulation lessons are given daily, and, though
apparently a very slow process, yet the reading of many
bears evidence of the good resulting therefrom.”
Crime and Punishment .
When Pantagruel arrived at Myrelingues he found that
Judge Bridoye, after carefully considering all the circum¬
stances of a case, was accustomed to decide it by the dice.
The results produced by the application of this singular
method of administering justice, although, doubtless, suffi¬
ciently remarkable, could hardly be more contradictory and
perplexing than the sentences which at the present day are
inflicted upon criminals in England. 44 Day by day,” says
Mr. Justice Hawkins (who, in conjunction with Mr. Poland
and Mr. Hopwood, discusses the question of 44 Crime and
Punishment” in the current number of the New Review ),
“attention is called to some inequality of sentence so glaring
that one falls to wondering how such things can be. For a
cruel and violent injury inflicted on the person, perhaps, of
a woman or child, a comparatively nominal punishment is
awarded, while a trifling act of dishonesty is visited with
extreme and merciless severity. Nor are sentences,” the
learned judge proceeds to observe, 44 imposed by different
Courts for offences of the same kind congruous among them¬
selves. For a trifling act of theft one Court will assign a
few weeks’ imprisonment as sufficient expiation, another
under similar circumstances will assign a term of penal
servitude.” In spite of the complacency with which
Pantagruel regarded the combined humility, piety, and
impartiality of the 44 Bridoye ” judicial method, we agree
with Sir Henry Hawkins that the continued working of its
English analogy is highly detrimental to the interests of
justice. It is by no means a simple matter, however, to
find a satisfactory remedy for the evil. The Council of
Judges recommended the establishment of a Court of
Criminal Appeal, and a considerable section of legal and
Digitized by ^ooQie
556 Occasional Notes of the Quarter. [Oct.,
public opinion declared itself in favour of this recommenda¬
tion ; but the time of Parliament is too fully occupied with
contentious party measures to permit a Bill for the consti¬
tution of a Court of Criminal Review to come at present
within the range of practical legislation, and the opinions of
the minority of lawyers and laymen who dissent from the
proposal are both too pronounced and too forcible in them¬
selves to render its speedy enactment probable, even if the
Legislature had been in a position to entertain it. It
becomes necessary, therefore, to cast about for some remedy
capable of immediate application, and to the discovery of
such a specific each member of the legal triumvirate to which
we have referred devotes himself. Mr. Hopwood's contribu¬
tion to the inquiry is of little value. We have the old
statistics to show the marvellous efficiency of the short-
sentence system as administered by the present Recorder
of Liverpool, the old hardy and unproved assertions as to
the failure of any rival mode of dealing with crime, and the
old farrago of fallacies and washy sentimentalism with
which students of Mr. Hopwood's dialectical methods have
long been familiar. Mr. Poland, whose eminence as a
criminal lawyer qualifies him in a peculiar degree for
expressing an opinion upon the subject in question, raises
the argument to a far higher level; he concludes that the
present system cannot be altered with advantage, except,
perhaps, by a return to the practice which prevailed at the
Central Criminal Court till about 1860 of deputing all the
Queen's judges on the rota—generally three, sometimes
only two—to sit together on the trial of important cases.
This suggestion is an excellent one if the existing staff of
common law judges and the exigencies of common law
litigious business will permit of its adoption. Its merits
are admirably summarized by Mr. Poland in the following
terms: “ If the case was a capital one the Home Secretary
then had two or three advisers instead of one to consult as
to carrying out the sentence. Moreover, the judges, by
sitting together from time to time, and consulting as to the
sentences to be passed session after session at that Court,
were enabled when acting separately on circuit to pass
sentences which were much of the same character.” To
the decision of the Home Secretary, informed and fortified
by the advice of such a body of judges, Mr. Poland says that
he would far rather trust than to the judgment of a Court
of Criminal Appeal, and there is not a little to be urged in
favour of this declaration. But if the domestic forum of
Digitized by 30Qie
Occasional Notes of the Quarter.
557
1893.]
the Home Office is to be retained, it ought, like other
tribunals, to be made subject to the law of publicity, and
not merely the fact and the terms of the Home Secretary’s
decision, but the reasons for it, and, if need be, the expert
reports on which it is based, might be disclosed. It is
desirable that there shoald be no repetition in England of
the incident which occurred in the case of Laurie, the
Arran murderer, who, after having been solemnly convicted
and sentenced to death, had his punishment commuted by
the Secretary for Scotland on the private report of three
distinguished experts giving effect to a plea of insanity
which had not been brought forward at the trial. That
the Scottish Secretary in that celebrated case, whose denoue¬
ment gave rise to so much murmuring north of the Tweed,
acted with perfect propriety under the circumstances, and
that his professional advisers—Dr. Qairdner, Dr. Yellowlees,
and, if we remember aright, Sir Arthur Mitchell—came to a
correct conclusion as to Laurie’s insanity, there is no ground
for doubting. But if the Home Office is to discharge
regularly and permanently the functions of a Court of
Criminal Appeal, and if verdicts and sentences are to be
submitted to its revision, the public are entitled to know the
grounds on which its judgment proceeds. It is, however,
in the paper of Mr. Justice Hawkins that the most original
and noteworthy contribution to the settlement of the long
or short sentence problem is to be found. Grasping with
all his wonted clearness the fact that the inequality of
criminal sentences is largely due to the varying conceptions
that judges entertain of the objects of punishment, his
lordship observes: “ One would think that a Commission
composed of competent persons (not all lawyers) having
knowledge and aptitude for dealing with the subject, would
experience no insuperable difficulty in framing such a code
(of guiding principles) as would render substantial assist¬
ance to those upon whom the duty of inflicting punishment
devolves.” Whether a Court of Criminal Appeal is or is not
to be ultimately established, the appointment of such a
Commission as Mr. Justice Hawkins suggests could be pro¬
ductive of nothing but good, and we trust that the learned
judge’s recommendation will receive the attention which it
deserves. Perhaps the scope of the Commissioners’ duties
might probably be so enlarged as to include an inquiry into
the doctrine that all criminal sentences should be of
indefinite duration.
Digitized by ^ooQie
558
Occasional Notes of the Quarter.
[Oct.,
THE ASYLUM CHAPLAIN’S COLUMN.
Religion, and itt Influence on the Insane.
By the Her. Thomas Downie, Chaplain, Boyal Edinburgh
Asylum, Morningside.
( Abbreviated .)
The principal work of the asylum chaplain is to preach
and conduct the other exercises of worship in the institution,
and, in his visits among the different wards, present the
truths and consolations of religion to such of the inmates as
are capable of comprehending them or being influenced by
them. This is not, indeed, his whole work. If he is
worthy of his position he will ever seek to be the friend of
the patients, sympathizing with them in their troubles,
talking with them on any matter in which they show an
interest, and inviting their attention to such subjects as may
divert their thoughts from themselves. But the chaplain
must always remember that his distinctive ministerial
duties constitute his main work. An idea, I find, prevails
largely in the outside world, that religion is one of the
prominent causes that lead to insanity. Frequently is the
remark made to me by clergymen and others when reference
is made to my work in the asylum. Many of the patients will
have had their reason upset by religious influences. My reply
to such an assertion is that, in very rare instances indeed,
have I found religion the real cause of insanity. The origin
of the widespread idea, to which I have referred, is not
difficult to trace. When the brain, which is the organ of
the mind, is in a diseased state, all subjects that come under
contemplation are presented in a distorted or topsy-turvy
aspect. It is therefore not surprising that religion, which
appeals so powerfully to the intellectual and emotional part
of man’s nature, should sometimes be viewed by the insane
with feelings of gloom or terror, the reverse of those which
it awakens when the mental faculties are in their normal
condition. The morose or diepressing views which some
patients take of religion are, I believe, in the vast majority
of cases, the result and not the cause of their insanity.
AH whose work calls them to minister to minds diseased
know how powerfully the truths and consolations of religion
Digitized by L^ooQle
Occasional Notes of the Quarter.
559
1893.]
oftentimes exert a sustaining and enlivening influence on
the patients of an asylum for the insane. It is true, indeed,
that the mentally afflicted often show an utter indifference
to religious subjects or are incapable of taking any interest
in them. Some, again, will become rude and insulting in
their language at the bare mention of religion in their
hearing, and, in such cases, the chaplain will act wisely by
guiding the conversation into subjects that have no religious
reference. Bat, in many instances, the truths and comforts
of religion are addressed to welcome ears, and often exert a
soothing and curative influence. Frequently have patients
who had recovered from their illness, and were about to
leave the institution, expressed to me their gratitude for the
benefit they had derived from the religious services held
in it.
As illustrating the impression with which some patients,
after they leave the asylum, look back on the religious
exercises conducted in it, I may give a short extract from a
letter which I received from a gentleman of high intelli¬
gence and culture, who had been for some time in the
asylum, but had recovered. “I cannot close,” he writes,
“ without expressing the pleasure I had, during my stay at
Morningside, especially in the Sabbath services, which were
to me like streams in the desert, or rather, I should say,
like wells of living water. I am much impressed with the
importance of your sphere there, and the noble opportunity
of serving the Master in a position requiring much tact ana
wisdom. I know that not a few there are looking to you
for spiritual advice.”
I conclude by stating that I consider it most desirable
that the religious services connected with an asylum should
be conducted in a church or chapel, specially set apart for
the purpose, and detached from the other buildings of the
institution. When I began my work as chaplain at Mom-
ingside, divine worship was conducted in the amusement
hall. To this arrangement I often heard the patients
object as incongruous. A church was afterwards erected in
the grounds, and the result has been most satisfactory. The
walk out to church, instead of, as formerly, passing from one
compartment to another—the sound of the Sabbath belli
and the sight of the pulpit and pews, all tending to call up
the associations of bygone days, have had a quieting
influence on the patients, and invariably the utmost
decorum pervades the service.
Digitized by ^ooQie
560
[Oct.,
PART II.—REVIEWS.
The Forty-Seventh Report of the Commissioners in Lunacy ,
7th June , 1893.
The forty-seventh annual Report of the Commissioners in
Lunacy yields in no particular to its predecessors in point of
statistical interest, while much may be gleaned from its
pages of the efficient and careful manner in which the
interests of the insane are at the present day safeguarded,
and of the conscientious and scrupulous zeal which the
heads of asylums, both public and private, show in the per¬
formance of their arduous and frequently dangerous duties.
The information which last year we had looked for by which
an interesting comparison could have been drawn between the
number of registered insane and the actual number of exist¬
ing cases of unsound mind, recorded by the census of 1891,
is not yet forthcoming. The number of insane registered
on the 1st of January of this year was 89,822, and they
were classified and distributed as shown on p. 561.
These figures are of great interest when compared with
those of previous years, but they show rather the scope of
work attached to the duties of the Commissioners than the
actual state of existing and occurring insanity in England
and Wales, and for purposes of statistical deduction they
are, as we have frequently maintained, apt to be misleading.
The public press, and through it the public, leap to the
conclusion that such tables take cognizance of every case of
mental affection occurring or existing in the kingdom, and
alarming inferences are drawn in highly-coloured verbiage
expressive of the great increase in insanity year by year,
blind to the fact that the increase of cases largely represents
the encroaches or raids on the total number of insane in the
country. The actual state of lunacy in our midst is misrepre¬
sented, and it is unreasonable, apart from other considerations
which are generally overlooked, to draw deductions merely
from a comparison of tables of successive years. The public
believe that because more insane come under official cogni¬
zance year by year, the ratio of fresh cases of insanity to the
general population is enormously increasing. A comparison
of succeeding decennial census returns of existing insanity,
contrasted with the Commissioners’ tables, is very instructive,
but the space at our command will not Allow of our pursuing
Digitized by ^ooQie
1898.]
Smews,
561
i
H
1 I HU 8 | 3 2
N C9 <N «X S 10 10
I
N
II U >3 ISIS
|
5
*
§ S |§ls S | 2 2
Jjj CS < 51
ii
Criminal.
H
a * 5 * * 1 : ; i 5
2
a - : s : 3 : : : 5
S
S
2 M S " 5 J : : : :
2
1
2
H
| 9 II:: §1:2
S 8 • “*
T
.
IN
| 3 SI:: * § : 3
S « w w
8
3
X
in U : : 6 | 1 |
a v a «
§
8
si
I
H
8 3 ||2: : : 3 :
*0
I
N
18 IS:: : : 1 :
2
3r
S
3 1 8 S 8 : : : * :
H
i
i
i
i
43
oa
a
o
9
8
&
1
w
£
In County and Borough Asylums.
In Registered Hospitals .
In Licensed Houses :—
Metropolitan.. ... ..
Provincial ..
In Naval and Military Hospitals..
In Criminal Lunatic Asylum (Broadmoor)
In Workhouses
Ordinary Workhouses ... .
Metropolitan District Asylums ...
Private Single Patients .. .. ...
Out-door Paupers ... ...
Total.
Digitized by ^ooQle
562
Reviews.
[Oct.,
the subject further. Taking the statistical tables as repre¬
senting the number of the insane, so far as official super¬
vision extends, we note that there is an increase for the year
of 2,055 (1,146 males and 909 females) among the pauper
patients, a total decrease of 73 among the private class, and
a decrease of eight among the criminal patients. The net
increase of the year in the number of patients under care
(1,974) shows a higher ratio of increase than usual, and as
the admissions during 1892 were only 445 in excess of those
of 1891, this increase has to be explained in some other
manner than merely by an increment in the number of
occurring cases. In their Report the Commissioners in
Lunacy attribute this annual increase in the number of the
insane under cognizance mainly to the accumulation of
chronic incurable cases in public asylums, and the inference
seems, as we pointed out last year, a just one. The number
of private patients under official supervision has decreased
in all institutions save registered hospitals, where they have
increased by five. Pauper patients have increased in county
and borough asylums by 2,029, in registered hospitals by
188, in Metropolitan licensed houses by 43, in Metropolitan
district asylums for imbeciles by 43, and as outdoor paupers
by three, while the decrease affects provincial licensed
houses by 188, and workhouses by 102. The large propor¬
tionate diminution in provincial licensed houses, and the
increase to the same extent in registered hospitals, is due to
the registration early last year of the Western Counties
Idiot Asylum as an institution under the Idiots* Act instead
of being, as heretofore, a licensed house for the reception of
idiots.
The statistical tables in this year’s Report are, with one
exception, the same as last year. In the summary showing
the number, classification, and distribution of all reported
insane, we find that the average annual increase for the
decade 1883-1892 was 1,301. The increase for the past year
(1,974) is the largest yet recorded.
The ratio of registered insane in England and Wales to
the population reaches the high figure of 30*21 per 10,000.
This again is the largest on record, and shows a differential
increase of *33 on the ratio of last year; such differential
increase has not been so high since 1888. For the last
decade the average ratio was 29*55, that for the previous
ten years having been 27*39. The ratio of the number of
patients who have been added to the list of thos^e under
I . • •
* ~ ‘ ' i
Digitized by ^ooQie
Reviews.
563
1893.]
official cognizance (admissions into asylums, etc.), to 10,000
of the whole population in England and Wales, estimated for
the middle of each year, has increased to 5*73, or an in¬
crease of *09 on that of last year. The increase of course
marks the excess of that due to the increase in popula¬
tion. It is not only increase in population which affects
this increment; a little consideration will show that
relapses and recurrences augment its influence. Allowing
for such increase in population, the number of cases of
occurring insanity coming under official cognizance should
be 16,867, or an increase of 184 on that of last year. The
true increase has, however, been 445, or 261 more, a number
which could mainly be accounted for by relapses. It will be
found that the calculated number due to increase in popula¬
tion year by year compared with the actual number of
admissions shows a remarkable variation. In 1884, 1885,
and 1888 the actual number of admissions fell below the
number calculated on an allowance for increase of popular
tion. During the last four years, 1889 to 1892 inclusive, the
actual number has been greater than the calculated number
by 821, 973, 307, and 261 respectively. By thus investiga¬
ting one factor only of those which we have hitherto urged
should be considered in estimating the actual existence
and amount of an increase in insanity, we find that there
is a remarkable irregularity. If other factors, such as the
number of transfers, were allowed for in these calculations,
the number of first admissions per annum (accepting this as
an approximation to the actual number of cases of occurring
insanity) would be found to bear a nearer ratio to the in¬
crease of population. We assume here that what is meant
by increase in insanity is that the number of fresh subjects
attacked is larger. It must always be remembered that th,e
ratios of admissions to population as set forth in these tables
do not give the real state of affairs, because no returns are
made of the numbers admitted into workhouses and as out¬
door insane paupers during the year. The total numbers in
detention alone are given.
The ratio per cent. (10*32) of pauper lunatics, idiots, etc.,
to paupers of all classes shows a slight diminution on that
of last year (10*35), but the total number of paupers to the
population has increased to 2*64 again, so that the real
diminution, taking into consideration this latter increase, is
•24 per cent. Of the total number of pauper insane under
official cognizance we find from another taole that 72*08 per
Digitized by ^ooQle
664
Reviews.
[Oct.,
cent, are in asylums, hospitals, and licensed houses, 20*86
per cent, in workhouses, and 7*06 per cent, with relatives
and others. During the decade the first of these three has
increased by 5*61 per cent., the others having diminished by
3*98 and 1*63 per cent, respectively, the numbers thus balan¬
cing* accurately. The number of patients under detention in
asylums, registered hospitals, etc., on the 1st of January,
1892, was 65,244, an increase of 1,253 on that of last year.
The following table shows the increase or diminution nnder
the various forms of care:—
County and
Borough
Asylums.
Registered
Hospitals.
(II
3
Ill
Naval and
Military
Hospitals and
Royal India
Asylum.
/-s
111
«
.3
If
fl
S
|
Total.
Increase ...
1,058
44
62
49
-
15
7
40
1,275
Diminution
-
-
-
-
22
-
-
-
22
The total net increase is 1,253.
The admissions during the year (excluding transfers and
those readmitted on fresh reception orders, owing to the
lapsing of previous reception orders, Sec. 38 of Lunacy Act)
show an increase or diminution in the different classes of
institutions according to the following table:—
The total net increase is 409.
There is certainly a favourable diminution in the number
of fresh reception orders rendered necessary by the expira¬
tion of previous reception orders, but it will be a long time
before matters work so smoothly as to warrant the with¬
drawal of a special table. Fresh certificates were needed in
112 instances in county and borough asylums, in 20 cases in
Digitized by ^ooQle
Reviews .
565
1893.]
registered hospitals, in 16 in Metropolitan licensed houses,
in 35 in provincial licensed houses (14 of these, however,
being in one licensed house through a misconstruction of
the terms of the Act), and 10 among single patients, making
a total of 193, against 353 last year.
The discharges during the year as “ recovered” show a
diminution of 76, numbering 6,670 as against 6,846 last year.
The diminution in county and borough asylums was 147, in
Metropolitan licensed houses 49, and in provincial licensed
houses 10, while an increase occurred in registered hospitals
of 20, in naval and military hospitals of three, and among
private single patients of seven. Other discharges,“relieved ”
or “not improved,” and those due to expiry of reception
orders, number 4,672. The proportion per cent, of stated
recoveries to the admissions fell to 38*94, a number some¬
what below the average for the last ten years. It would
hardly be fair to deduce from the percentage averages of
recoveries to admissions for the last decade the value of the
various methods of treatment, as numerous factors would
have to be taken into consideration which would tend to
minimize the value of the more favourable sets of figures.
We, however, append a table of such
hi
IB
;
U
ft
111
a __
|||
M
PI
111
HI
3973
46*93
36*91
86*63
66*28
17*46
14*72
i
The deaths during the year numbered 6,485, or only one
in excess of last year, and a decennial increase of 1,350.
The average number of deaths per annum for the decade
(1883-1892) was 5,831. Tables similar to those of last
year give the percentage proportion of deaths to the daily
average number resident and the percentage proportion to
the total number under treatment, and a table specifying the
death-rates at different ages, and the number at different
ages living in all institutions on December 31st, 1891.
The death-rate of the officially recognized insane at various
ages, compared with the death-rate among the general popu¬
lation for the same period and at the same ages, furnishes
us with the accompanying summary (p. 566).
Digitized by ^ooQie
tteviem .
666
[Oct.;
The death-rate per 1,000 of the reported insane is
101*25, the sane death-rate being 20*25, an improve¬
ment on the figures of last year, when the former stood at
102*0 for a sane death-rate of 19*5; the real diminution,
allowing for the difference between the two sane death-rates,
being 8*67 per 1,000. Besides the evidence which this table
offers of the diminishing death-rate in the reported insane
and its approximation to the sane death-rate as age advances,
accounting thus for the accumulation in asylums of aged
Am
Periods.
Death-rate per 1,000 Reported
Insane.
Death-rate per 1,000 Sane
Population.
Proportion
of Deaths,
Sane to
Insane.
Reported.
Under 6 £
—
Males 64*5
Females 53*6
}
59*0 .
—
5-9
{
Males 44*4
Females 101*1
}
72*7 ..
•••{
Males 4*7
Females 4*7
}
4*7 .
1 to 15*4
10—14
{
Males 45*2
Females 65*0
\
55*1 ..
-{
Males 2*6
Females 2*9
}
2*7 .
1 to 20*4
15—19
{
Males 55*8
Females 76*1
}
65*9 ..
-1
Males 4*2
Females 4*3
}
4*2 .
1 to 15*6
20—34
{
Males 82*7
Females 59*1
*
70*9 ..
■}
Males 5*7
Females 5*2
\
5*4 .
1 to 13*1
25-34
{
Males 81*0
Females 55*4
}
68*2 ..
•••{
Males 7*9
Females 7*1
}
7*5 .
1 to 9*0
35-44
{
Males 117*7
Females 59*7
\
88*7 ..
■{
Males 13*5
Females 11*1
}
12*3 .
1 to 7*2
45-54
{
Males 109*2
Females 64*8
}
87*0
...{
Males 22*4
Females 17*2
}
19*8 .
1 to 4*3
55-64
{
Males 134*9
Females 88*5
}
111*7 ..
•••{
Males 41*1
Females 33*4
}
37 *2 .
1 to 3*0
65-74
{
Males 228*7
Females 162*9
}
195*8 ..,
Males 81*2
Females 70*6
1
75*9 .
1 to 2*59
75-84
{
Males 403*4
Females 252*1
}
327*7 ...
...{
Males 168*0
Females 148*3
\
158*1 .
1 to 2*07
if
3 !
Males 666*7
Females 401*7
\
634*2 ...
-{
Males 327*1
Females 300*6
}
313*8 .
1 to 1*70
chronic cases and the increase in the number of cases of
existing insanity, we find with regard to the number of
females living on December 31st, 1891, in all asylums, and
the number of female deaths during the year, the following
interesting facts :—Up to the age period 25-34 the number
of females living remains about equal to that of males, but
with increasing years the difference between the sexes
becomes more and more marked, the number of females
living predominating over males until at the age period 75-
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1893.]
84 and upwards the number of females living is double that
of males. The percentage death-rate, on the other hand
(while in the sane population the numbers approximate
closely for the sexes up to the 35th year, and after that
period diminish slowly for females, the differences pro¬
gressing arithmetically up to 75, and after that diminishing
more rapidly until there is a difference of 27*1 at 85, in the
reported insane population), shows a marked predominance
of female deaths over male up to the 20th year, after which
there is a steady decline, the ratio of male deaths at the 75th
age period being nearly double that of the female. These
facts will help to explain the higher proportion of females
in the number of reported existing insane, as well as the
question whether insanity is more prevalent among women
than men, as a casual inspection of the aggregate of reported
insane would lead us to believe.
The number of boarders admitted into registered hospitals,
Metropolitan and provincial licensed houses during the year
reached the total of 278 ; 87 of these had to be certified as
patients, nine died while under care, and 178 left during
this period, the number in residence on January 1st being
133. The percentage ratio of certification to admissions has
increased from 27*1 last year to 31*8 this.
The usual statistical tables, showing the distribution and
total number of pauper insane in the several union counties
of England and Wales, the annual returns from institutions
for the insane, tables of transfer, statistics of criminal lunatics,
and summaries of the expenditure in county and borough
asylums and in registered hospitals, furnish valuable infor¬
mation, but space does not permit us to enlarge on them.
The following interesting items may, however, be gleaned
from the Commissioners’ remarks when dealing of the various
institutions under their supervision.
The number of county and borough asylums remains at
67, the patients in which on January 1st, 1893, were classi¬
fied thus:—
Hale.
Female.
Total.
Private.
433
569
991
Pauper.
36,392
31,051
56,443
Criminal.
59
26
84
26,883
31,635
57,618
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568
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[Oct.,
Comparing these figures with those in the table given last
year we find that the number of private patients has dimi¬
nished by 112, and the criminal class by eight. The dimi¬
nution in the number of private patients does not show that
there is as yet any zealous inclination on the part of county
and borough asylums to take advantage of the clauses of the
Act making the reception of private patients permissive.
The percentage of post-mortem examinations made in these
asylums shows a slight increase upon the percentage of last
year, 76*8 and 76*3 respectively.
Including the new asylum at Claybury for the county of
London, preparations were being made during the year for
the addition of eight new asylums to the existing number of
67, viz., a second joint asylum for Somerset and Bath, an
asylum for the county borough of Sunderland, one each for
the county borough of Blackburn, for the county of Stafford,
for the Isle of Wight, the county of West Sussex, and the
county borough of Middlesborough. Improvements on a large
scale are also noted in various county and borough asylums.
We have the usual complaint, one which a glance at conti¬
nental asylum reports will show is by no means restricted to
England, that asylums are almost everywhere overcrowded,
and that accommodation for the insane is in many places so
inadequate as to amount to almost a crying disgrace. From
the remarks made by the Commissioners we find that 33 of
the 67 existing asylums are overcrowded, and that but 13 of
these have prospects of relief in the near future. This is a
state of things which the Commissioners very rightly make
a point of urging upon the notice of local authorities, and
many of them appear alive to the requirements of the com¬
munity, but it will not be until some enactment enforcing
better accommodation for the insane is promulgated that we
shall see a more satisfactory and speedy method of dealing
with this congestion of existing institutions.
Defective sanitation in 11 asylums appears to have origi¬
nated epidemics of diarrhcsa, dysenteric diarrhoea, enteritis,
typhoid fever, erysipelas, and diphtheria. Most of these
were traceable to defective soil pipes, w.c. fittings, etc., as
well as to contaminated water supply. The spread of small¬
pox at one, asylum was promptly stopped by a revaccination
of all the patients.
The suicides in county and borough asylums numbered
14, and one also occurred while the patient was absent on
leave. Though slightly in excess of the number last year
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" it shows ” (we quote from the Report) “ that so far as this
dauger is concerned the supervision of the insane in institu¬
tions where the number of persons either admitted with or
developing a suicidal disposition is very large is not unsatis¬
factory Details of these suicides (five females and ten
males) occurring in 13 asylums are given. Six of these (two
females and four males) were by hanging, two (males) by
cut throat, one (female) by a leap from a dormitory window,
one (female) by burning, one (female) by drinking a large
quantity of carbolic acid lotion, one (male) by the infliction
of abdominal wounds, one (male) by self-suffocation—stuffing
a piece of flannel down his throat, one (male) by running
his head against a wall by which the 5th cervical vertebra
was fractured, and the patient on leave (a male) by drown¬
ing. Misadventure other than suicides accounts for 38
deaths. Fifteen of these were due to suffocation in epileptic
fits. “ It is many years,” say the Commissioners, “ since
we have had to record so many deaths from epileptic suffo¬
cation, the greatest number of such deaths during any one
of the previous five years having been 10. On reference
to the details of their occurrence it will be seen that while
some of them were probably unavoidable, in some the relaxa¬
tion or disregard of necessary precautions contributed to the
fatal result.”
The average weekly cost of maintenance per head in county
and borough asylums was as follows :—
s. d.
In County Asylums . 8 Ilf
In Borough Asylums. 10 0
In both taken together. 9 2
The number of registered hospitals remains the same, for
though the Royal India Asylum at Ealing was closed last
summer, the Western Counties Idiot Asylum has been regis¬
tered as an institution for idiots. One suicide after escape
is recorded, and a patient absent on leave drowned himself,
but there is no notification of death by misadventure.
The number of licensed houses is diminished by four, being
reduced to 30 in the Metropolitan district and to 52 in the
provinces. The remark is made that “ it is but fair to the
licensees” in Metropolitan houses “to say that our re¬
quirements are, as a rule, more favourably entertained
now that the existence of their establishments is no
longer threatened.” We may be wrong, but so far as
xxxix. 37
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570
Reviews.
[Oct.,
wfe know, the Commissioners 5 recommendations in licensed'
houses receive far prompter attention than in any hospital
or county asylum. In metropolitan houses there have been
one suicide (of a female by forcing a piece of stick down the
throat) and three fatal casualties (impaction of meat in the
glottis, burns, and fractured ribs). In provincial licensed
houses there have been no suicides, and but one fatal casualty
—death from suffocation in an epileptic lit.
The number of single patients shows a decrease to 434,
about one-third of which (148) are chancery patients. One
accidental death (pneumonia after burns) is recorded.
It seems to us a remarkable circumstance that while the
new Lunacy Act permits one or more certified single
patients in the same house, the Commissioners do not give
their sanction to this arrangement.
Of the lunatics in workhouses the total number (16,878)
shows a decrease of 20 as compared with the number last
year.
The rest of the Report is made up of the usual entries by
the Commissioners at county and borough asylums, and in
their visitations to registered hospitals. From these much
useful information may be obtained. A peculiarity which
has often occurred to us in perusing these reports is that
while a meed of praise is always, when deserved, .granted to
the medical officers in county asylums for the efficient manner
in which the case books are kept, none such is ever accorded
the medical officers in hospitals or in licensed houses (when
entries of the latter appear in the Report). We can
hardly suppose that the work in these institutions is less
conscientiously done, and it* is certainly due to assistant
medical officers, whether in hospitals or licensed houses, that
proper mention should be made of efficient work, if merited,
when neglect of such duty is promptly visited by censure.
In one of their entries the Commissioners define seclusion as
u compulsory isolation by day/ 5 This in another place is
made to include the setting apart of a patient in a railed-off
portion of an airing-court.
From the fulness and accuracy of this report it will be
gathered that there is no lack of zeal in the Lunacy Depart¬
ment. It is an interesting summary of a year’s work.
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5 11
Utat Menial dee HystSriques ; les Stigmates Mentauz. Par
Pieehe Janet. Paris, 1892.
(Concluded from p. 429 .)
Passing on from hysterical anaesthesia we proceed to notice
M. Janet’s observations upon hysterical amnesia. Here,
“ The elements of remembrance, the preservation and repro¬
duction of images are intact, but there is a defect in the
actual synthesis of the mental elements, a defect which more
or less completely prevents the assimilation of the memory
and the personality ” (p. 111). Loss of memory and amnesic
localization in hysteria depend sometimes upon (1) the state
of the subject the monient he acquires memory; (2) his state
when he attempts to reproduce it; (3) the nature and the
development of the phenomena which had been forgotten;
and (4) modifications of sensibility.
(1) Insufficient memory may depend upon its having been
badly acquired and organized from the beginning. This
proposition is indisputable.
(2) The second statement is also undeniable. “ Marguerite
has ordinarily only a slight loss of memory; she can by an
effort of attention recover almost all that she tries to re¬
member, except events occurring during her attacks and the
state of somnambulism. But at certain moments her memory
appears to be completely destroyed; she no longer remembers
anything; she forgets even the current events of her life.
With this loss of memory, as with the narrowing of the
visual field, the approach of an attack can be foretold.
She afterwards describes the state, thus : * I well know now
why I could not remember anything; it is because I could
not follow or retain an idea; my head was empty.’ Here
the present condition of the mind determines the forgetful¬
ness of the past ” (p. 114).
(3) M. Janet refers next to the peculiar loss of memory
which promises to be for long “ the torment of psycholo¬
gists ”—retrograde amnesia. Eecent memories are, every¬
one knows, less stable than old ones. M. Sollier believes
that this is due to the more frequent repetition of the acts of
memory which occur in the latter. The author feels that
this is not a universal explanation of retrograde amnesia, but
he is unable to offer a more satisfactory account of this
familiar phenomenon. With him it remains a mystery.
Bernheim observes that almost all cases of induced somnam-
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[Oct.,
bulism,that even the shortest, are accompanied by retro¬
grade loss of memory. The subconscious phenomena of
automatic writing not only involve forgetfulness of writing
itself, but also of the surrounding acts performed before,
during, or even immediately after performance (p. 115).
(4) As to the modifications of sensibility associated
with loss of memory, they are more influential than is
generally supposed. M. Janet records a striking case in
point. M. Janet, as the result of experiment, finds that fre¬
quently, when a hysterical patient has completely lost a cer¬
tain sensation, she has lost at the same time the perception
of images which depend upon it. Thus a patient was the
subject of complete dyschromatopsy, in fact did not perceive
any colour by either eye. Hence it was impossible to induce
any coloured hallucination. She said she saw flowers which
he suggested to her, but she always saw them grey and
white. If it was very strongly suggested to a subject that
he had a particular tactile sensation in a limb which was
anaesthesic, it sometimes happened that the suggestion suc¬
ceeded ; pinching the arm showing that its sensibility had
entirely returned. The image could not be evoked without
restoring at the same time the sensation itself in the personal
consciousness. These experiments may be indefinitely varied,
and in most instances a fairly regular law can be established;
sensations and the images of the same kind seem assured;
they are at once present or absent in personal perception.
However, M. Janet frankly confesses that he is far from
being able to explain fully the problem of the localization of
losses of memory;
Hysterical aboulia is very fully considered.
Motor troubles, including weakness of the voluntary move¬
ments, partial catalepsis, and contracture are analysed.
Perhaps the most important of all the chapters in this
book is that which treats of the modifications of intelligence
and the emotions.
Summarily the characteristics of hysteria are its mobility
and contradictions—that is to say the patient never rests
long in the same mood. She passes momentarily from affec¬
tion to indifference, from gaiety to sadness, from hope to
despair. In short, her equilibrium is altogether uncertain;
now this way, now that. There is no one trait of character
which may not be at any moment contradicted by some
apparently different act. Hysterical patients are by turns
apathetic and emotional, hesitating and obstinate. The
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573
author recognizes in all the same meaning—the want of
mental unity, but the preservation of automatic phenomena
in an exaggerated form.
We fail, however, to do justice to our author by this rapid
analysis of an original treatise. The mental condition of
the hysterical is an enigma which the philosophic mind of
M. Janet is well fitted to solve. We must leave to the reader
the fuller study of a book which, of unpretentious size, is
nevertheless a thoughtful contribution to a subject too often
treated in a superficial manner, but which in reality affords
exceptional opportunities for psychological research. Hysteria
repels us, it may be, because it deceives us by its exquisite
mimicry. It has again and again caused the ablest and most
experienced to trip. It has well-nigh destroyed a reputation.
No wonder the physician is shy of tackling it lest it turn
again and rend him. But the more difficult the diagnosis,
the more is he put on his mettle, and the more interesting is
the endeavour to distinguish between the true and the false.
The common phrase, u only hysteria,” while convenient as
indicating that no organic disease has been discovered, is
misleading when employed to mean that the disorder has no
interest for the psychologist. Happily M. Janet does not
fall into this error.
Die Psychopathischen Minderwertigkeiten. Yon Dr. J. L. A.
Koch. Dritte Abtheilung. Ravensburg. 1893.
This is the third and concluding part of Dr. Koch's work,
the preceding parts of which we have already noted on their
appearance. It is, as he remarks, the only recent attempt to
deal in a comprehensive and methodical manner with all those
mental conditions which lie on the borderland of insanity—
degeneration, hereditary neurosis, “ insane temperament,”
neuropathic constitution, neurasthenia, obsession, epileptic
character, hysteria, etc. As such it is deserving of consider¬
able credit, and may prove a useful handbook for those who
do not desire to study these outlying districts of morbid
psychology in full detail. It must be added that those who
are familiar with the present position of abnormal psychology
will not find much that is new in Dr. Koch's book beyond
its method, and that it cannot come into competition with
the numerous elaborate works, already in existence, which
deal with various portions of the large field here covered.
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Reviews .
[Oct.,
li a Donna Delinquente, la Prostiluta e la Donna Normale . By
C. Lombroso and G. Ferrero. Boux and Co., Turin
and Borne. 1893. Pp. 640.
In this book Prof. Lombroso has added a companion
volume to his great work, “ L'TTomo Delinquente.” In his
present task he has had a collaborator to whom he generously
attributes what he terms “ the most laborious and robust
part of the work,” that dealing with psychology and with
history. In one respect the book differs from its predecessor
by a very admirable feature—the very large amount of space
devoted to the study of normal women. We cannot know
the abnormal unless we know the normal, and the first part
of this work (including the first 180 pp.) is rightly devoted
to the biology, anatomy, physiology, and psychology of
normal women and various characteristically feminine
emotions, such as modesty, vanity, compassion, etc., are
very subtly and skilfully analysed; we are then taken on to
the study of criminal women and of prostitutes, who are
dealt with in the same elaborate % and detailed manner in
which criminal men are dealt with in “ L'Uomo Delinquente.”
Even to a greater extent than was the case in that work,
the author is summarizing and presenting the results of in¬
vestigations which have been carried on either by his own
pupils or else, directly or indirectly, at his instigation. It
is impossible to attempt to reproduce these results. The
book is one of extreme interest. It will, no doubt, soon be
brought rather nearer to the English reader by means of a
French translation, although we can perhaps scarcely hope
for an English edition at present.
II Romanzo di vn Delinquente Nato . Mi}an, Chiesa e Guin-
doni. 1893.
This book, which has attracted considerable attention, is
a notable addition to an interesting department of psycho¬
logical literature. The insane and the neurotic often delight
in trying to find literary expression for their experiences,
though it is not often our good fortune to discover that they
are very successful in these attempts. Criminals, on the other
hand, rarely possess either the courage or the skill to “ write
themselves down.” This book is the autobiography of a
criminal, but it is noteworthy that even in this case it is the
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575
1898.]
insane tendency in the roan (for his is not a case of pur&
criminality) rather than the criminal tendency which has
furnished the motive for his literary effort. He has delusions
of persecution, and it is for an attempt on the life of his
brother that he is at present leading a convict’s life. These
delusions can scarcely, however, be said to amount to insanity,
and the very careful investigation which Antonioo M. has
undergone at the hands of alienists has not resulted in the
conclusion that he is insane.
The whole life of Antonino M., who is a southern Italian
from Calabria, has been a long series of offences. Usually
these offences have been of an explosive character; during
his career as a soldier he was frequently guilty of insubordi¬
nation ; his offences were not, however, necessarily bound up
with any ideas of persecution, although he cherished ideas
of revenge against various persons for trifling or imaginary
wrongs. He was placed for several months by the author¬
ities in the Girifalco Asylum, in order that he might be kept
under Prof. Silvio Venturi’s observation, and the question of
his insanity thoroughly investigated. During this time
Prof. Venturi made a very careful and elaborate examina¬
tion of the man’s physical and psychical characters, and he
has thus been enabled to supply a detailed study which adds
very greatly to the value of the introduction to this volume.
No anatomical abnormality of importance was discovered,
but there were various physiological anomalies such as blunt¬
ness of sensation. Prof. Venturi concludes that Antonino
M. is a congenital criminal, but not a typical congenital
criminal on account of his ideas of persecution and of the
almost epileptic character of which he gives evidence.
There is considerable vigour and force in the auto¬
biography ; its style, so far as it can be said to have any, is
characteristic of the man. He is profoundly egotistic; he
sees in everything only its relation to himself; he is deeply
impressed by the wrong deeds of others; it is clear that he
has never realized the guilt of his own deeds, and even when
there can be no suspicion of revenge, as in narrating an
episode of paederasty, it does not seem to occur to him that
there is any occasion for shame or remorse. His history
shows very clearly the close relationship between instinctive
criminality and moral insanity, if, indeed, the two names do
not refer to the same psychic state. He reveals himself in his
autobiography without any suspicion of the nature of the
revelation. He has not the faintest power of self-analysis;.
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576
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[Oct.,
in this he is quite different from the interesting crimin al from
whose autobiography passages were quoted in the u Retrospect
of Criminal Anthropology 55 in this Journal for last January.
The two criminals have much in common, both being instinc¬
tively criminal, so far as can be judged, and both with a
taint of insanity, but Bragg possesses the power of remem¬
bering and faithfully recording his own mental states.
The publication of the book is due to Sig. A. 6. Bianchi,
who writes the introduction and who has already done much
to further the study of morbid psychology and to create
general interest in its modern developments.
PART III.-PSYCHOLOGICAL RETROSPECT.
1. Pathological Retrospect.
By Edwin Goodall, M.D.Lond., B.S., M.R.C.P., West Riding
Asylum, Wakefield.
Note on a Chinese Brain.
Derkum (“Journ. Nervous and Mental Disease,” 1892, xvii.)
gives an anatomical description of a Chinese brain, the seventh
which has been carefully examined. In this the features
characteristic of the other brains were again noted, namely, un¬
usual degree of convolution, disposition to anastomosis in the
perpendicular and horizontal directions, and marked obliquity of
the orbital surfaces of the frontal lobes (with the last-mentioned
may probably be associated the peculiar position of the eyes in the
Chinese). Blending of the central and Sylvian fissures is said to
be a frequent feature of such brains. For other details see the
original paper.
Histology of the Nervous System in Paralysis Agitans and Senility.
Eetscher (“ Zeitsch. f. Heilkunde,” Bd. xiii., JEL 6, 1892;
abstract in “ Neurolog. Centralbl.,” March 1, 1893) has examined
the central and peripheral nervous system in three cases of
paralysis agitans. In all there were morbid changes. The specific
tissue-elements showed various degrees of atrophy; the cerebral
ganglion cells were strongly pigmented, rounded, and here and
there in a state of granular degeneration ; the spinal nerve-fibres,
especially in the posterior columns, were degenerate and atrophied,
and here and there had disappeared, so that holes were present;
the same applied to the peripheral nerve-fibres. The interstitial
tissue was much increased in the cord and nerves. Vessels much
altered, walls thickened, miliary aneurisms, and haemorrhages here
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1893.] Pathological Retrospect . 577
and there, adventitial sheaths bulging in places, and the spaces
filled with round cells and lymph. These changes agree with
those described by other authors. Conjecturing that they might
be due merely to senility, Ketscher examined the nervous system
of ten old persons free from paralysis agitans. He found changes
which did not differ qualitatively at all from those present in the
cases of paralysis agitans, though they were less marked. He is,
therefore, of opinion that this affection is merely the expression of
unusually pronounced and possibly premature senility.
Van Oieson* s Stain for the Central Nervous System .
V. Kahlden (“Centralbl. f. Allgem. Path.,” 2 June, 1893)
speaks highly of this stain, which is especially adapted for the
demonstration of the axis-cylinder. Proceed as follows:—1.
Stain sections 3-5min. in a heematoxylin solution. Wash well.
2. Stain in a mixture of sat. aq. sol. prussic acid and sat. aq. sol.
acid fuchsin—sufficient of the latter fluid to make a deep-red.
solution. 3. Wash rapidly in water. Spirit, alcohol, origanum
oil, Canada balsam. Delafield’s hsematoxylin or ordinary alum-
heematoxylin may be employed. Axis-cylinder appears deep-red,
medullated sheaths yellow, the glia is of a reddish tint, nuclei are
blue-violet, sclerosed tissue is intense red. Axis-cylinder, accord¬
ing to Y. Kahlden, stain better in preparations hardened in Mul¬
ler’s fluid than in those hardened in alcohol. He says the method
is of great service where it is important to differentiate between
tissue-constituents. It may be added that with this method
hyaline material stains a deep-red, colloid a fainter-red or even
slightly brown. The relation of amyloid material, which stains a
light-red, to the tissue constituents, especially the vessel-walls, is
brought out better by this than by any other method.
Congo-Red as an Axis-Cylinder Stain .
Alt (“Miinchener Medizinische Wochensche.,” 1892, No. 4)
recommends this highly, especially for peripheral nerves. He
states that by it axis-cylioders can be traced to their finest ramifica¬
tions. Sections of tissues, hardened and cut as usual, are stained
in a solution of Congo-red in abs. alcohol [deep-red] at 35° C. for
f-2 hours. Superfluous stain is removed by placing sections for
10 minutes in alcohol 96 °/c, and thereafter in absolute alcohol. In
the latter the red section becomes of a deep-blue colour, and at the
same time some differentiation takes place. Clear in bergamot
oil, mount in chloroform balsam. Sandarac is also recommended
for mounting, especially for peripheral nerves. Axis-cylinders
are stained deep-blue, other tissue-elements shades of blue and
violet. It is not clear what, if any, advantages this method has
over the old one of Nissl (1886), with which the writer has ob-
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578 Psychological Retrospect . [Oct.,
tained good results, and which is as follows :—Sections of nerve-
tissue hardened in bichromate are passed out of alcohol 95 °/ G into
aq. sol. Congo-red of strength 5*400. In this they remain 72 hours.
Transfer to alcohol 95 °/ 0 5-10 minutes, and then to acid-alcohol
(nitric acid 3 °/c) for six hours. Alcohol, clove oil, balsam. The
acid-alcohol acts as the differentiating agent, much stain being
dissolved out by it. Alcohol alone will remove some of the stain.
Axis-cylinders in transverse and longitudinal section are stained
brown-black. Nerve and connective-tissue cells of same tint, or
purplish. Ground substance light brown.
Weigert has modified his method for staining medullated nerve -
fibres in such a manner that differentiation as performed in the
original method is dispensed with. The modification is, perhaps,
not commonly known in this country, and so may be given here
(see “Deutsche Medizin. Wochenschr.,” 1891, No. 42). Harden
as usual and imbed in celloidin as usual. Float the imbedded
pieces for 24 hours in the incubator in following solution:— 1
Neutral acetate copper, sat. sol. in the cold, filtered; 10 °/ c sol.
tartrate of soda, equal parts. Then keep 24-48 hours (latter say
for pons) in simple aq. sol. neutral acetate copper in incubator.
Wash lightly in water; 80 °/ 0 alcohol, cut. Have ready sol. A, 7
parts sat. aq. sol. lithium carbonate, 93 parts water, and sol. B,
1 part haematoxylin, 10 parts abs. alcohol, 90 parts water, 1
part sat. aq. sol. lithium carb. Just before use mix 9 parts A
with 1 part B. Leave sections in mixture 4-5 hours (24 hours
not harmful). Wash in water, then in alcohol, 90 °/ 0 , clear in anilin-
xylol (2 parts anilin oil, 1 part xylol), then in xylol. Xylol-
balsam.
Black staining on a clear red ground. Over-stained sections are
treated with borax ferricyanide, as usual.
Practical Point in Conducting Weigert's Process or Pal's Modification.
The carbonate of lithium solution usually added to the heema-
toxylin stain need not be employed until after the latter. In this
case sections are removed from the haematoxylin after the lapse of
the usual time and placed in sat. sol. lith. carb. Here they remain
till sufficiently dark. Proceed then as usual. By following this
plan the same haematoxylin solution may be used repeatedly.
Possibly the haematoxylin-lithium solution may be employed
several times over, but the fact that it is quite opaque renders it
much less convenient to work with than the translucent plain
solution, even if the supposition is correct, which is doubtful.
Stains for the Central Nervous System (Rehm, “ Miinchen.
Medizin. Wochenschr.,” 1892, No. 13).
Isolated staining of connective-tissues, nuclei, and nuclei of
blood-vessels. X. Sections are placed for a few minutes in 1 °/o aq.
sol. eosin (cold), washed ii* water and alcohol, transferred, for some
Digitized by A^ooQie
1893.] Pathological Retrospect. 579
minutes to 0*1 % aq. sol. dahlia. Differentiation and dehydration
in alcohol; origannm oil, balsam. 2. In place of eosin 1 °/ 0 aq.
sol. nigrosin, in place of dahlia 0*1 °/ 0 alcoholic sol. fnchsin are
used. One half-hour in each of these. Differentiation in alcohol,
clove oil, chloroform, colophonium. With the first method the
nuclei are dark-blue, all other parts red; with the second nuclei
are red, other parts blue-grey.
Rehm recommends the following carmine solution as a very good
under stain:—Carmine 1 gram., liq. ammon. caust. 1 c.c., aq. dest.
100 c.c. Sections remain in this five minutes, are then washed in
70 °/ 0 alcohol, to which is added nitric acid in proportion 1 c.c.-lOO
c.c. Transfer to pure alcohol to remove the acid, and then to cold
sol. methylene blue 10*1 °/ 0 , in which sections remain half a minute.
Differentiation in alcohol, origanum oil, colophonium. Nuclei of
nerve-cells bright-red (the nuclear network is well shown),
protoplasm of nerve-cells blue. Nuclei of connective-tissue and
blood-vessels blue or violet.
For the demonstration of the axis-cylinder Rehm uses a 0*5 °/ 0
aq. sol. hcematoxylin. In this sections remain 1-2 days. Wash
in water (to 100 c.c. of which is added 1 c.c. cone. sol. lith. carb.)
till no more colour is removed. Differentiate in 96 °/ Q alcohol.
Origanum oil, balsam. Axis-cylinders are grey black, connective-
tissue is but little stained. Nuclei of vessels clearly shown. By
leaving sections one day’in the hematoxylin, differentiating as
above, and transferring (after momentary use of alcohol) for a
few minutes to 0*1 % aq. sol. bismarck-brown, good results are
obtained. The axis-cylinders and nerve-cell nuclei appear grey,
cell-substance is stained brown.
Sublimate-Toluidin-Blue Method for the Demonstration of Nuclear
Structures, Blood-Vessels , and Nerve-Cells .
For the demonstration of nerve-cells and nerve and connective
tissue-nuclei the writer finds that the following method presents
many advantages ; it may possibly be novel. Tissues are hardened
in sublimate. (This is not only a good hardening agent, but also
an excellent fixative, and so adapted for the demonstration of
nuclear structure and other fine details.) The following solution
may be used:—Sublimate, 7£ gram.; 0*5 % salt-sol. 100 c.c.
Dissolve by heat. Pieces—not too large—remain in this about
24 hours. Wash thoroughly in water (this is important to
remove deposits of mercury), and then pass through alcohols,
30 %, 70 °/ 0 , 96 °/ 0 —24 hours in each. Cut sections and stain in
aq. sol. toluidin-blue 0*1 °/ 0 for about 48 hours. The cortex is now
a uniform deep blue, medulla a fainter blue. Wash in water;
some stain extracted. Wash in methylated spirit, and finally in
abs. alcohol. Much stain is removed. Presently the clouds of
stain almost cease to form. Transfer at once to xylol. Further
extraction is thus presented. Mount in xylol-balsam. The
Digitized by ^ooQle
580
[Oct.,
Psychological Retrospect.
section has a light-blue or purplish tint. Connective-tissue
nuclei, including those of vessel-walls, very well stained ; so also
are nerve-cell nuclei. All these structures blue or purple. Nerve-
cells of similar though lighter tint. Their processes are stained
about as well as in the case of chrome-hardened specimens treated
by the ordinary dyes. The neuroglia basis is practically colour¬
less. The stain must be regarded as chiefly a nuclear one.
Specimens some months old show no fading.
A Neuroglia Stain .
It has been observed—especially by Lubarsch—that in
Weigert’s method for staining fibrin several other tissue-con¬
stituents become stained as well as fibrin. Beneke, experimenting
with the method, found that connective-tissue is often stained by
it. He now communicates to the “ Centralblatt f. Allgem. Path.,”
28 July, 1893, a modification of Weigert’s fibrin-method, by which
connective-tissue in the most diverse organs can be consistently
stained. Amongst these is the brain; the spider-cells and their
prolongations, the fine fibrous networks between pia and cortex
and around the ventricles, are stained by the process recom¬
mended. The fibrous meshwork of sclerosed tissue is shown
remarkably well. The principle of the modified method of
Beneke lies in the fact that the Weigert stain is not a specific
stain for fibrin; it has an affinity, though less marked, for several
other of the tissue-constituents. The stain, as is well known, is
anilin-water-gentian-violet. The decolourizing (differentiating)
fluid is a mixture of anilin and xylol (2-1), and of these two
ingredients only the anilin oil is directly operative; the xylol
merely controls the other, having no decolourizing power.
Obviously, by increasing the proportion of xylol, the action of the
anilin-xylol should be weakened, and thus various tissue-elements
might be demonstrated which the original method fails to show.
Beneke, in fact, finds that by employing a mixture of anilin oil
and xylol in the proportion of 2-3, connective-tissue structures can
be well shown. This is the respect in which his method differs
from Weigert’s. Experience is needed in order to decide the
right moment at which the action of the decolourizing fluid should
be checked by the use of xylol. For details see the original
paper.
Photoxylin as an Imbedding Material.
Photoxylin is said to have replaced celloidin as an imbedding
material in many German laboratories, as it possesses all the
merits of the latter, and has in addition the advantage of greater
translucency. In the investigation of small slightly-stained
objects this is a point of undoubted importance, but for ordinary
purposes it may be pointed out that common collodion is perfectly
suitable, and at the same time less expensive-than either celloidin
Digitized by A^ooQie
1893.] American Retrospect. 581
or photoxylin. Photoxylin is stated to be allied chemically to
celloidin. It has the appearance of fine, pure cotton-wool; is
soluble in equal parts of alcohol and ether, and is employed in
precisely the same manner as celloidin. It may be obtained
from Gruebler, Leipzig, or London (R. Kanthack, Golden Square).
A Simple Method of Fixing Paraffin Sections to the Slide.
This was introduced by Gulland not long since. An essential
point in employing the method is to have absolutely clean slides
upon which water will lie in a continuous layer. The slides are
thoroughly cleaned with a wet cloth. Ribands of sections of
suitable length are floated on warm water, below the wetting
point of the paraflin ; of course curled-up sections are in this way
straightened. (This part of the method is not new.) The
ribands are then taken up on the slides. Adhesion of the former
to the latter is brought about simply by keeping the slides for
several hours (e.gr., overnight) at about 35^ C. —as in an incubator.
The sections adhere so strongly that they remain fixed when
exposed to a strong stream of water. The paraffin may now be
removed—after melting it by placing the slide a short time in the
paraffin oven—by xylol, and all customary subsequent manipula¬
tions may then be undertaken. This method is much superior to
the methods of fixation by albumin-glycerin mixtures, in which
the fixing material becomes stained by many of the dyes used.
2. American Retrospect.
By D. Hack Tuke, F.R.C.P.
Progress in the Care and Handling of the Insane in the Last
Twenty Years.
Dr. Eugene Riggs, of St. Paul, Minn., U.S.A., the Chairman of
the Committee on the History of the Treatment of the Insane,
appointed by the National Conference of Corrections and Chari¬
ties, read the report at its twentieth annual meeting, held June
12-18, 1893, at Chicago. The article is evidently dLrawn up by
himself, and endorsed by the Committee. It constitutes an
interesting and valuable review of the progress made in the care
of the insane, the first era being that of neglect, the second that
of detention more or less severe in character, and the third that in
which we live, including the last twenty years. Dr. Riggs com¬
mences with the dawn of intelligence in the care of the insane
in England in 1792, when the Retreat at York was founded. The
period between this date and 1815 is recognized as one coincident
in France with the beneficent work of Pinel, reinforced a little
later by that of Esquirol. “ Since that time both there and here
Digitized by ^ooQle
682 Psychological Retrospect . [Oct.,
(America) the battle for the increasingly intelligent application
of that principle has been going on.”
The best of American asylum men held the same ideas fifty and
sixty years ago as those of the best asylum men of the present
day. Then, as now, the importance of superior attendants was
fully recognized. Even the segregate system now to the fore was
advocated by Dr. Woodward, of Worcester, Mass., in 1832. More¬
over, in some asylums at that early period, non-restraint, it is
alleged, was not unfrequently adopted. It is true, however, that
the main advance in the treatment of the insane in America has
been made during the last twenty years. The public have come
to understand that insanity is the symptom of a physical disease.
Formerly this belief was held by a small minority. Works on
medical psychology are “ in the hands of high school and
collegiate students as reference books.” On the philanthropic
side the publication of the life of Miss Dix gave an impetus to
the claims of the insane in the public mind. Insanity has been
studied as it never was before, and asylums have been visited by
students for the purpose of gaining some practical acquaintance
with it before entering into practice.
Dr. Riggs enters upon the method adopted in various States in
regard to the commitment of the insane, but our space will not
allow of our quoting his account, important as it is. In fact we
find it necessary to do little more than record our appreciation of
the historical value of the retrospect before us. We are glad to
observe that Dr. Riggs recognizes that American county asylums
have not been altogether unsatisfactory in their management. At
the same time “ State Care ” must be ultimately accepted as the
proper mode of providing for and inspecting the insane. County
care was introduced by the Wisconsin Board for the care of the
chronic insane in 1871; previously the state of the insane in
poorhouses was an “ awful one.” Legislation provided that when¬
ever there was insufficient provision in the State hospitals they
might care for chronic lunatics under such rules as the Board of
Charities might prescribe. The small county asylums of Wis¬
consin were established under this law. Notwithstanding the
objections which may be raised against institutions managed from
the standpoint of business, it is admitted that “ under the super-
vision of an active and energetic Board in entire sympathy with
the system, it has proved satisfactory in the main to the people of
Wisconsin.”
No sketch like that attempted by Dr. Riggs could fail to give
prominence to the remarkable change which has taken place in
the^ character and arrangement of the buildings in which the
insane are located. “ Annexes, pavilions, cottages, and colonies
have been developed in connection with the older institutions, and
many of the newer ones have been erected in a wholly segregated
style. The buildings in some cases are connected by corridors
Digitized by
Google
1893.) American Retrospect . 583
either above or underground, in other cases wholly detached.”
The following examples are enumerated in order of the date. The
Willard Asylum with detached blocks; the Norristown Institu¬
tion, near Philadelphia, having a series of blocks, for the most
part two stories in height; the Kankakee Asylum or Illinois
Eastern Hospital, there being twenty-five separate buildings for a
population of more than 2,000. There are also the Toledo Asylum
without, any building of the old-fashioned linear type, but with
detached two-storey buildings ; the North Dakota Hospital in
James Town; those at Logansport and Richmond, Indiana, and the
St. Lawrence State Hospital^ near Ogdensburg, New York. The
Central Islip Institution is on Long Island, and its wards are
detached, and nearly all are one storey high. This system has
been made more practicable by the invention of the telephone.
Dr. Riggs declares that “ experience at Kankakee, Toledo, and
elsewhere has shown that such institutions are practical, economical,
and capable of efficient administration. As against a few hundred
insane sheltered in this manner twelve years ago, there are now
probably more than 6,000 so cared for.”
The asylum at Kalanazoo, Mich., belongs to the colony system,
in which there is a central building which is a hospital for acute
cases. Within one to three miles of this building is land amount¬
ing to 600 or 1,000 acres. On this ground are to be erected build¬
ings for the patients who can properly live outside the hospital.
The cottages contain 30 to 50 patients, under the charge of a man
and his wife. The land is to be used as a farm, and will furnish
occupation for the patients as well as lessen expense. It is con¬
tended that this system unites the advantages of the cottage
asylum with the best elements of the Wisconsin system, in which
we have ourselves witnessed with satisfaction out-of-door life and
useful work on the farm.
We are glad to find Dr. Riggs stating that whatever may be
the final form asylums in America may take, the “ present ten¬
dency is certainly towards some flexible segregate system of which
a hospital is the true centre.” In the remaining portion of this
paper the importance of separating the criminal from the non¬
criminal insane is strongly enforced. The need of separate pro¬
vision for the epileptic is also contended for.
Valuable as is this paper as a survey of the past, its importance
for the present and the future is still greater. We hope it will
tend to advance the movement in the directions indicated.
Digitized by ^ooQle
584
Psychological Retrospect .
[Oct.,
8. German Retrospect.
By W. W . Ireland, M.D.
Suicide of Young Persons.
In the u Allgemeine Zeitschrift fur Psychiatrie ” (xlviii. Band,
3 Heft) there are published some statistics about the suicide of
young persons, which are of terrible interest. During the six
years 1883-88, 289 scholars committed suicide. The returns for
each year were as follows :—
Schools.
1883.
1884.
1885.
1886.
1887.
1888.
Higher ... 19 ...
14 ...
10 ...
8 ...
17
... 42
Lower ... 39 ...
Of these were—
27 ...
30
36 ...
33
... 14
Males
... 50 ...
33 ...
33 ...
38 ...
41
... 45
Females ... 8 ...
8 ...
7 ...
6 ...
9
... 11
The causes which induced these young people to commit suicide
were unknown in about 30 per cent. In the higher schools the
suicides of 11 males and one female were put down to insanity.
In the lower schools 12 males and two females were assigned to
distress about examinations, and 11 suicides to morbid jealousy or
craving for distinction. Unhappy love is put down as the cause
of suicide in four males and one female in the higher schools, and
fear of punishment was a cause of suicide in one male and one
female in the higher schools, but of no less than 45 suicides of
males and 23 of females in the lower schools.
Singular Case of Aphasic Defect. (“ Zeitschrift fur Psychiatrie,*
xlix. Band, 1 and 2 Heft.)
The subject of this observation was a woman thirty-eight years
of age, who, by her own report, suffered from syphilis when six¬
teen. She bore evident marks of severe constitutional affection.
She applied to Dr. Heilbronner for relief from a difficulty in
speaking. It was found that the intellect and memory were not
affected. She could read and write, but could not express herself
correctly owing to the omission of important words in her sentences.
The words which were dropped were principally verbs, especially
verbs which had a concrete meaning, such as those used to signify
the sounds of animals, the operations in special trades, and parti¬
cular actions and events. Such verbs were, almost without excep¬
tion, forgotten. On the other hand, the auxiliary verbs, and those
words which bear the -most-ge n e r a l - m ea n ing, such as be, have,
may, shall, were well remembered and came frequently into use.
Verbs which were remembered were always correctly conjugated.
The explanation was offered that owing to mental deficiency the
Digitized by ^ooQle
German Retrospect.
585
1893.]
last part of the sentence had quickly faded from the memory, so
that the patient was unable to hold in mind the beginning of the
sentence so as to complete it with the verb which in the German
language comes in at the end. Dr. Heilbronner dismisses this ex¬
planation because the patient in other respects had no weakness of
memory, and showed by her gestures that her mind was seeking
for the absent verb to bring out her meaning. Wundt has laid
down as a rule that in the cases in which certain words are lost
those words which disappear most easily from the memory are
associated with concrete sensory impressions. This explanation
held good so far that it was the more concrete verbs which were
lost, but then why were the substantives retained ? Nouns have
generally a more concrete character than verbs. Dr. Heilbronner
cites a number of cases recorded by different observers in which
the particles of speech which the patients fail to recall were nouns,
especially particular names. As in Dr. Heilbronner’s case, these
were well enough preserved ; his observation is unique, and he is
unable to offer any explanation of it.
Etiology of General Paralysis.
Dr. Cebelle (“Allgemeine Zeitschrift fur Psychiatric,” xlix.
Band, 1 and 2 Heft) presents the results of his inquiries into the
causation of general paralysis in one hundred patients in the
private asylum at Endenich. These, patients belong to the
wealthier classes. He finds that syphilis existed in 53; of these
38 had shown secondary symptoms. Dr. Cebelle accounts for the
larger percentage of cases of syphilis in general paralytics in
private over public asylums by the observation that syphilis is
common with educated persons. As 47 per cent, of Cebelle’s
patients had escaped this malady, it is clear other causes have
their play. It is rare that general paralysis can be assigned to
a single cause. Four cases are assigned to excessive mental
exertion alone; three cases to syphilis alone. Direct heredity
appears in 22 per cent., and personal anomalies in 44 per cent.
Sexual excess was known to have occurred in 41, and abuse of
alcohol in 43 per cent.; overwork or exhausting passions in 42.
Seventy-three of the patients were married; 27 unmarried. Three
of the cases were under 30 years of age ; most of them were be¬
tween 30 and 50; seven took the disease after 50, and two after
60 .
The primary lesion of general paralysis is still disputed. Some
pathologists—asCalmeil, Magnan, Obersteiner, Mendel, and Gerdes
—regard it as a diseased condition of the vessels following upon
syphilitic infection, and exciting parenchymatous inflammation of
the nervous tissues as a secondary affection. Others—as Tuczek,
Wernicke, Joffroy, Pierret, Zacher, and Friedmann—regard the
parenchymatous changes as beginning in the nerve-tissues partly
with dissolution of the nerve-cells and partly with wasting of the
xxxix. 38
Digitized by ^ooQle
586 Psychological Retrospect. [Oct.,
nerve-fibres. In the end both these anatomical elements are in¬
volved in the destructive process.
Variability in Delusions.
Dr. Theodore Kolle has made a study of the variability in the
^elusions and hallucinations of the insane (“ Allgemeine Zeit-
schrift fur Psychiatrie,” xlix. Band, 1 und 2 les Heft). In de¬
lirium there is a rapid change of thought and images often without
any apparent connection. In some forms of chronic insanity, as
in melancholia, the delusions are more constant. Fixed ideas are
even a special characteristic of paranoia, but this fixity of delusions
is only apparent. A closely-folio wed examination shows how in
time the ideas shift. Delusions may vary in extent; the delusion
gradually extends itself to wider circles, and involves more and
more the conduct of the man. The delusions may become ex¬
aggerated, as when a patient believes himself an earl, and then
believes himself emperor. The central delusion persisting, the
details may vary, as when a patient believes himself to be poisoned
first by one drug, then by another, sometimes in his food, some¬
times through inhalation or through inunction. Dr. Kolle finds
the delusions change more rapidly than hallucinations. The more
the intellect declines in strength the more variable the delusions
become. This shows that the critical faculty still exerts itself in
limiting the delusions which it cannot entirely banish. Dr. Kolle’s
paper is illustrated by some carefully observed cases.
Toxic Insanities.
Dr. Knorr has made a study of toxic insanity (“ Allgemeine
Zeitschrift,” xlviii. Band, 6 Heft). After describing some
typical cases, he states at the end the following conclusions:—In¬
sanity may come as a sequel to a bout of drinking in habitual
drunkards. It may also follow the abuse of opium, cocaine, and
the poison of influenza. This insanity has the character of acute
paranoia, the so-called abortive paranoia of Sander. It has for a
primary symptom hallucinations of hearing attended by delusions,
of persecution and mental distress, without any ideas of grandeur.
The psychosis runs a rapid course, always ending in recovery. In
acute alcoholic paranoia there are elementary hallucinations of
hearing, which indicate a favourable prognosis, whereas in chronic
paranoia, not resting on abuse of alcohol, such hallucinations are
of unfavourable significance. These auditory hallucinations are
generally connected with deceptions of the muscular sense in the
vocal apparatus.
Number of Deaf Mutes in Norway.
Dr. Uckermann, of Christiania (reported in “ Allgemeine Zeit-
scllrift, ,, xlviii. Band, 5 Heft), has made a careful census of the
deaf in Norway, with the aid of the local clergymen, school-
Digitized by ^ooQle
1893.]
German Retrospect.
587
masters, and doctors. The number of deaf mutes in Norway on
the 1st January, 1886, amounted to 1,841; subtracting 15 born in
other countries, this would make 0 95 of the population, of whom
1,028 were males and 798 females. Of the 1,826 deaf mutes bom
in Norway 932—51 per cent.—were so from birth; 886—48*5 per
cent.—had acquired deafness ; and in 8*0—43 per cent.—the causes
were undetermined. The proportion of bora deaf mutes in the
male sex was 52*6; in the female 47*3 per cent.; in acquired deaf¬
ness the proportion was 60 for the males and 39*8 per cent, for the
females.
Born deafness is common in the west of Norway and in the deep
mountain valleys where life is still and the people poor. Acquired
deafness was found to be commonest in the north of Norway about
Drontheim, where there had been a great epidemic of cerebro¬
spinal meningitis. Of those born deaf 50 per cent, had one or
several congenital deaf mutes as relations, but only in three cases
were the parents themselves deaf mutes. In 25 per cent, of the
marriages of these relations there was more than one deaf child
born; 23 per cent, of the cases came from consanguineous mar¬
riages, that is, the parents were cousins or more nearly related.
Uckermann estimates the proportion of such close marriages in
the ordinary population of Norway as from four to five per cent.
The causes of acquired deafness were cerebritis and cerebro-spinal
meningitis, 32 per cent.; scarlet fever, 27*5 ; typhoid fever, 4*4;
otitis, 7*7; measles, 2*5; and whooping cough, 2 per cent. Of the
bom deaf 3*0 per cent, were totally so; 34 could hear some sound,
and 14 could hear the voice in some degree. The remaining 20
per cent, could distinguish words more or less. In acquired deaf¬
ness these proportions stood 37 per cent, quite deaf, 34 heard
sounds, 11 heard noises, 16 per cent, heard words.
New Treatment of Patients Refusing Food. (“ Allgemeine Zeit-
8chrift, ,, xlviii. Band, 6 Heft).
It is needless to dilate on the disagreeableness and dangers of
forcible feeding in asylums. Some of the patients who refuse all
nourishment are still curable cases. It is often an object to tide
over the danger of sinking till the resistive impulse has subsided
or passed away. It occurred to Dr. George Ilberg to try sub¬
cutaneous injections of 0*5—0*75 gramme of common salt to one
per cent, of water to help to sustain patients during periods of
weakness following long-continued abstinence. He was encouraged
by the success which had attended this plan in states of collapse
in surgical and obstetrical practice.
Dr. Ilberg tried this treatment in five patients in the asylum at
Heidelberg. He also reports another case from an asylum at
Dresden. For his procedure he uses an injection needle fifteen
centimetres long and three millimetres thick, connected with a
gutta percha tube. This tube at the other end is attached to a
Digitized by ^ooQle
588
Psychological Retrospect.
[Oct.,
glass irrigator, having a lid and fitted to a stop-cock. The
apparatus is carefully sterilized and then filled with a solution of
chloride of sodium, 7 5 of a gramme to 1,000 grammes of distilled
water at a temperature from 39 deg. to 37 deg. C. The needle is
passed into the subcutaneous tissue of the breast, back, or hip. On
the stop-cock being opened the solution streams into the sub¬
cutaneous tissue.
As a result of his experiments Dr. Ilberg recommends this
treatment in all cases of prolonged abstinence from food. He
thinks that it sometimes seems to induce patients to commence
again to take nourishment. With proper aseptic precautions the
procedure is free from danger. If it fail to sustain the patient
through the crisis, forcible feeding can still be used. The injec¬
tions of the solution of salt may also be used in cases of collapse
that do not admit of forcible feeding.
PART IV.—NOTES AND NEWS.
ANNUAL MEETING OF THE MEDICO-PSYCHOLOGICAL
ASSOCIATION OF GREAT BRITAIN AND IRELAND.
The fifty-second Annual Meeting of the Medico-Psychological Association of
Great Britain and Ireland was held at Buxton, Derbyshire, on July 28th last, at
the Palace Hotel. Amongst those present were Dr. Murray Lindsay, Dr. J.
H. Paul, Dr. W. W. Ireland, Mr. J. Peeke Richards, Dr. Fletcher Beach (Hon.
Gen. Sec.), Dr. T. Outterson Wood, Dr. F. R. Elkins, Dr. John Keay, Dr. J.
T. Hingston, Dr. Bower, Dr. Hack Tuke, Dr. Savage, Dr. Benham, Dr.
Holmes, Dr. J. Rutherford, Dr. 0. Woods, Dr. Cole, Dr. Chambers, Dr. Gardiner
Hill, Dr. Patton, Dr. Conolly Norman, Dr. Russell, Dr. T. W. McDowall, Dr.
Howden, Dr. Urquhart, Dr. Rayner, Dr. Baker, Dr. Whitcombe, Dr. Hayes
Newington, Dr. J. B. Spence, Dr. Turnbull, Dr. Yellowlees, Dr. Clouston, Dr.
J. G. McDowall, Dr. Bonville Fox, Mr. Rooke Ley, Dr. Percy Smith, Dr.
Mercier, Dr. F. K. Dickson, Dr. P. W. Macdonald, and others.
Dr. Bakes, the retiring President, said the first business was his retire¬
ment from the chair, which Dr. Murray Lindsay would take. But before he
did so he had that morning a very pleasant duty to perform, and that was to
once again thank the Association for the many acts of kindness extended to
him during the past year. He had now to vacate the chair in favour of his
good friend Dr. Murray Lindsay (applause).
The President, in acknowledging his election, thanked them for the
honour done him, and assured them that nothing should be wanting on his part
to follow the lines of his predecessors in promoting the interests of the Asso¬
ciation, and, if possible, to increase its usefulness (applause).
The election of officers then took place. Dr. Spence and Dr. Howden were
appointed Scrutineers. The election ffras as follows
President . .
President-Elect
Ex-President
Treasurer
Editors of Journal .
. James Murray Lindsay, M.D.
. Conolly Norman, F.R.C.P.I.
. Robert Baker, M.D.
. John H. Paul, M.D.
/ D. Hack Tuke, M.D.
1 George H. Savage, M.D.
Digitized by L^ooQle
1893.]
Notes and News.
589
Auditors
Honorary Secretaries
Registrar
f Percy Smith, M.D.
\ H. Sates Newington, M.E.C.P.Ed.
{ Conollt Norman, F.R.C.P.I., for Ireland.
A. R. Urquhabt, M.D., for Scotland.
Fletcher Beach, M.B., General.
. J. B. Spence, M.D.
Members of Council .
Jambs Rutherford, M.D.
J. G. McDowall, M.B.
H. Gardiner Hill, M.E.C.S.
B. Bonyille Fox, M.D.
J. E. M. Finch, M.D.
C. Hethebington, M.B.
T. Outterson Wood, M.D.
F. C. Gayton, M.D.
F. A. Elkins, M.B.
H. T. Pringle, M J).
J. Macphebson, M.D.
A. E. Turnbull, M.B. i
G. A. Mebcieb, M.B.
E. White, M.B.
H. Stilwell, M.D.
A. D. O’C. Finegan, L.K.Q.C.P.I.
C. S. Morrison, L.E.C.P.and S.Ed.
W. I. Donaldson, M.B.
Parliamentary Committee re-elected (unchanged).
ELECTION OF EXAMINER8.
The President stated that the Council recommended the following gentle¬
men as examiners :—Drs. Wiglesworth, Mercier, Campbell Clark, Turnbull,
Eingrose Atkins, and Molony.
treasurer's report.
Dr. Paul then presented his report, which, he stated, was, on the whole, a
good one. But from Ireland there was no return (laughter).
For Balance Sheet see p. 590.
auditors' report.
The Auditors beg to report to the Association that the accounts for 1892-8
have been audited and found correct. They suggest to the Association that it
is desirable that a note should be added to each annual balance-sheet showing
the amount due to the Association for unpaid subscriptions. The Secretary
for Scotland having called the attention of the Auditors to the fact of certain
subscriptions being in arrear for some years, they beg to point out that by
Eule VIII., Chap. VI., it is the duty of the Secretaries and Treasurer to report
such facts directly to the President.
The Auditors also suggest that it is very desirable that the income and
expenditure under the Gaskell Prize Trust Fund should be shown in a
separate account, and should not form part of the general inoome and expendi¬
ture of the Association.
Henry Rayner,
E. Percy Smith.
July 22, 1893.
Dr. Rayner, as one of the auditors, moved the adoption of the balanoe
sheet, and said, at the same time, that the auditors had presented the above
report with regard to the accounts.
Dr. Percy Smith seconded the adoption of the balance-sheet.
Dr. Bonville Fox —I should like to ask the proper official what is the
number of Irish members on the books ?
Dr. Conolly Norman— It rests with me to explain the absence of any
return from Ireland, and also to answer the question of the last speaker. There
are now forty members of our Association residing in Ireland. The number
has risen by twelve within the last year, I am glad to inform the Association.
The absence of any return is due to the negligence of the Irish Secretary
(laughter).
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MEDICO-PSYC HOLOGIC AL ASSOCIATION
The Treasurers Annual Balance Sheet , 1892-93.
590
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Notes and News.
591
The President said he took it that the report was adopted.
Dr. Newington suggested that it should go to the Council to deal with.
Dr. Clouston added that the Council should be asked to give them an ex¬
planation of the reason why they had £52 less this year compared with last
year. He did not think that such an Association as theirs could be said to be suc¬
cessful unless the balance-sheet showed an increase every year. Economy
should be exercised, and a balance on the wrong side avoided if possible.
Dr. Urquhart —It is not much on the wrong side. If the Irish contribu¬
tion had been up to time it would have been very much the same as last year.
The President —We should confine our expenditure within our income.
Dr. Pox called attention to the unusual item with regard to the law expendi¬
ture in respect to the Gaskell Fund, which would not occur again. That would
reduce the deficit £31.
The Treasurer’s report was then adopted unanimously.
Dr. Hack Tuke called attention to the fact that there had been a suggestion
that the recommendations of the auditors should be referred to the Counoil, and
this was unanimously agreed to.
the next annual meeting.
The President then called upon the President-Elect, Dr. Conolly Norman,
to suggest a time and place for the next annual meeting.
Dr. Conolly Norman thanked the members for the honour they had done
him, and said that with regard to the place of the next annual meeting,
he presumed it would be held in Dublin. The anticipation that it should be
held in Dublin was the chief reason why he allowed his name to be put before
them that day. July was not a convenient time, owing to the fact that Dublin
was very empty towards the end of that month, and their medical friends would
be out of town. He therefore suggested that it should be in May.
Dr. Wood remarked that the annual accounts could not be prepared by
May.
Dr. Percy Smith —The accounts are balanced up to June 30th each year.
No financial business should ever come on except at the annual meeting.
Dr. Whitcombe directed attention to Rule I, Chap. IV. of the existing rules,
which said, “ The annual meeting of the Association shall be held at such time
as shall in the judgment of the Council be most convenient.”
Dr. Wood—I s it not a question for the annual meeting to decide?
Dr. Norman — I did not think this question came before the general meeting
to-day, but when you called upon me I thought it necessary to speak frankly
what was in my mind. I am entirely in the hands of the Association. Any
time they desire will be equally convenient to me. The consideration which
moved me to suggest May was one relating to the comfort and convenience of
the gentlemen coming to Dublin.
The President— Under these circumstances will anyone propose another
place of meeting ? (“ No, no.”)
Dr. Mercier drew attention to the fact that the present rules state that the
time and place shall be a matter to be determined by the Council, and to the
Council therefore let it be relegated. It was not on the agenda, and was not a
question for the annual meeting at all.
The subject then dropped, the President intimating that the next quarterly
meeting would be held at the rooms of the Association on the third Thursday
in November.
The President announced that the next matter was a motion standing in
his name, but he thought it advisable to withdraw it. (Hear, hear.)
Dr. Mercier said, having regard to their full programme of business—busi¬
ness which could only be transacted at the annual meeting—and to the fact
that this could be dealt with at an ordinary meeting, he would, with the per¬
mission of the President, postpone his motion to a more convenient season.
(Hear, hear.)
Digitized by ^ooQle
592
Notes and News.
[Oct.,
PROPOSED EXTENSION OF ANNUAL MEETING TO THBEE DATS.
Dr. Conolly Norman, in accordance with the notice of motion which every
member of the Association had received, moved, “ That in future the business to
be dealt with at the annual meetings shall include discussions and the reading
of papers, and that for this purpose the sittings of the annual meetings shall be
prolonged for two or more days.” Their Association, Dr. Norman continued,
had now attained somewhat of a venerable age, and they numbered, as the
General Secretary had informed him, something over 450 members. He
thought, therefore, that it was time that they should endeavour to show all
other Associations, and all their professional brethren generally, what work they
did and what it was possible to do. At their quarterly meetings valuable
papers were read and valuable discussions took place, but it had been very com¬
monly remarked amongst members of the medical profession outside their own
body that their annual meetings were deficient in any interest except a business
and social one. The annual meetings took place about the same season
as those of the British Medical Association, and the meetings came to be
regarded as a prelude to the Psychological Section of the British Medical
Association. They had obtained an age and position in which they ought
to figure more prominently, and not merely as an appanage to the British
Medical Association. (Hear, hear.) If they met for two or three days
and discussed scientific papers, if would largely interest the younger members
in their meetings, and enoourage them to take part in their proceedings.
No. II. of the new rules, which the speaker hoped to see adopted that day, laid
down the objects of the Association. Of these objects the third was the pro¬
motion of good fellowship among the members, but at our annual meetings this
object has hitherto come first. The other objects, which he submitted should
be first in importance as they were in order, namely, the cultivation of science
in relation to mental disease and the improvement in the treatment of the
insane, could be better carried out by the adoption of this resolution. Further,
it was desirable, for the welfare of the Association, to interest and enlist in its
practical working the largest possible number of members. Our meetings are
now so short that it is generally only possible for one representative from each
asylum to be present. It is a great pity that the younger members of our staffs,
who have necessarily more leisure than most of us can hope for, should not be
encouraged in every possible way to advance themselves and the Association by
interesting themselves in our proceedings, and bringing scientific work before us
where it can be thoroughly discussed at our annual meetings. He therefore
put this motion before the meeting in the earnest hope that it would be con¬
sidered, and that steps would be taken to carry out the objects they had in
view.
Hr. TJrquhart had pleasure in seconding the motion. It had been a question
of the greatest interest to him for a good many years, and in season and out of
season he had preached the doctrine that Hr. Conolly Norman had set forth.
He now would confine himself to seconding the motion.
Mr. Richards said that though cordially endorsing Hr. Norman’s pro¬
position, they should take a little into consideration the financial aspect of this
question. They had not only this excursion into the country, but also a spring
trip to consider, and he ventured to say they would not leave much out of a five
pound note. (Laughter.) They had two gatherings in London as well. If every
member, as he was in duty bound to do, attended the meetings regularly, each at
the end of the year would be ,£18 or £14 out of pocket. He did not say it
would be a loss, because he would perhaps profit that much. But many men
could not stand it. If the meetings were prolonged it would be one of the most
expensive Societies in England.
Hr. Newington —With regard to the last speaker’s ideas I think it neces¬
sarily follows that we shall get more scientific value for our money (hear, hear).
The railway expenses will be the same for two or three as for one day. Pro¬
ceeding, Hr. Newington called attention to four subjects before the Psycho-
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1893.]
Notes and News .
593
logical Section of the British Medical Association, which he held were four
main subjects which ought to have been taken up by their own Association, as
they dealt chiefly with subjects for the study of which they were consti¬
tuted. On reading the words of the resolution, however, he could foresee that,
as it stood, it would land them in a great difficulty. How, he asked, could they
carry it into practice if they adopted it ? Someone would have to take action,
but it did not say who. Naturally it would come before the Council, and it
would be dangerous to pass a resolution of this kind if there were not some
safeguard so that the Council could, if they thought fit, rejeot or not. He
suggested that at the end of the motion the words “ if necessary ” be added.
Hr. Oscar Woods said this was a matter that had been discussed at their
annual meetings. With every respect to Dr. Newington, he thought it was a
matter for the Association and not the Council. If it were altered by
the addition of the words “ if necessary ” it shelved the matter altogether. It
was ripe for consideration and decision to-day. They were, unfortunately,
rather scattered in their members; some of them had a long distance to come,
and it would be a decided advantage if the annual meetings were extended to
two days.
Dr. Spence —It has just occurred to me—What business will be brought
forward ? If it lasted for three dayB, and the Secretary found he had only one
paper, what should we do the rest of our time ?
A Member —Enjoy ourselves.
Dr. Whitcombe said he had brought with him a programme of the Psycho¬
logical Section of the British Medical Association, and that showed more work to be
done in a few days when the British Medical Association met than their Asso¬
ciation did in a whole year. He thought psychology should be taken up by
psychologists, and that it should be done in their own Association. He thought
the extension of their annual meetings and the discussion of papers would bring
it into the right sphere.
Dr. Pox did not know that he endorsed every word that Dr. Norman had
said, because it occurred to him that when their friends or envious friends said
they were nothing but an ornamental Society, they forgot that at all events for
the afternoon of their annual meeting they resolved themselves into a scientific
Society. He most cordially supported the idea of extending their annual
meetings, but he would suggest an amendment, which made the proposal
rather more permissive, and left more discretion in the hands of the Council.
It was—“That in future the business to be dealt with at the annual meetings
may include the reading and discussion of papers, and that for this purpose the
sittings of the annual meetings may be prolonged for two or three days at the
discretion of the Council.”
Dr. Hack Tuke thought this put the proposal in a form that was better than
the original motion, as being more likely to be accepted. It was no doubt true that
more scientific work was done at the Psychology Section of the British Medical
Association than at their (the Medico-Psychological) annual meetings. But
they must not lose sight of the good work done at their quarterly meetings.
He thought the comparison would be in favour of their own Association, but he
held that they should at their annual meetings have more papers read, and
extend the time to several days. He begged to second Dr. Fox’s amendment.
Dr. Conolly Norman remarked that he could not accept the amendment,
because it seemed to him to leave the matter too open. One’s experience was
that if anything was made permissive it was never acted upon. In the pro¬
posed new Buies this permission was actually given. If they adopted these
Buies to-day the permission would exist, and he was aware of that fact when
he allowed this notice to remain on the paper. He thought it desirable that
this matter should not be a permissive one, but that it should be settled. It
was premature to settle definitely how many days the business should last under
the altered circumstances, because the length of time they sat would depend
upon what they had to sit upon. (Laughter.) They must know how many
Digitized by Google
594 Notes and News. [Oct.,
g apers they had before they knew how long the sitting was to last. Therefore
e should prefer two or three days or longer.
The President read the amendment and put it to the meeting. The Presi¬
dent declared Dr. Pox’s amendment carried by a small majority.
It was then put from the chair as a substantive motion, with the following
result:—Por, 12; against, 16.
The President —I declare the amendment to be lost as a substantive motion.
Dr. Pox—As father of the amendment I challenge a division. The amend¬
ment was declared by you to be carried. It has now been put as a substantive
resolution, and declared by you to be lost. I ask for a division on the sub¬
stantive motion.
Dr. Ireland— -Some of the gentlemen did not hear well, and did not under¬
stand what they were voting for. It is an important point; I think it would
be well to explain it.
The President explained that the amendment proposed that in future the
business to be dealt with at the annual meetings may include the reading of and
discussion of papers, and for this purpose the annual meetings may be prolonged
for two or thrfee days at the discretion of the Council.
Dr. Pox—I ask for a division.
A division was about to be taken (by standing) when
Dr. Spence asked if a member had not a right to propose an amendment to
a substantive motion now ?
The President— Yes.
Dr. Oscar Woods —I think this matter had better be brought to a final ter¬
mination now. The matter has been debated fully. I propose that the meetings
last two days.
Dr. Newington— That is a question we have already settled.
Dr. Oscar Woods—I propose now that it be two days.
Mr. Richards seconded.
The President then put Dr. Woods* amendment, and only 9 voted in its
favour. It was consequently lost. The President then put “ The substantive
motion of Dr. Pox.” Por, 20; against, 6.
the title “royal.”
The President stated that an application had been made to the Home Office
for permission to prefix the title “ Royal ” to the name of the Medico-Psycho¬
logical Association, but a letter had been received to the effect that the Home
Office could not see their way to grant it.
Dr. TJrquhart said it was very much to be regretted that this had fallen
through, especially after the trouble Dr. Hack Tuke had taken about it. Seeing
that it had definitely fallen through, he thought they should now proceed to
have the Association incorporated under the Act of Parliament in the same way
as the British Medical Association, so that they might hold property and
generally enjoy the advantages of such incorporation.
A Member —This is not on the agenda paper.
Dr. Hack Tuke said the point arose out of the recommendation of the last
annual meeting. One recommendation was to prefix the word “ Royal ” to the
name of the Association and the other was as to incorporation. One had fallen
through, and the question now was whether it was the wish of the annual
meeting that the second should be considered by the Council. If nothing was
done to-day it would lapse, and nothing further would be done. It must be
clearly understood whether the Council was to proceed on the second point.
Dr. Fletcher Beach explained that there was another reason why it was
not put on the agenda paper, and that was because the answer arrived after it
was issued. If he had not brought it before them now it would have remained
in abeyance twelve months.
Dr. Hack Tuke —As a matter of form, the minutes of the annual meeting
are taken as read. If they had been actually read through this business would
have come before the meeting to-day in regular order.
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Notes and Nem.
595
Dr. Whitcombs —My recollection is that this was a matter which was re¬
ferred to the Council for adoption—either that the Association should have the
prefix “ Royal ” or it should be registered as a Limited Company.
Dr. Yellowlees—T he Council can report to this meeting whether they
think it desirable to do so or not.
The Pbesident— Certainly.
HANDBOOK committee’s bepobt.
Dr. Newington presented the report of this Committee.
Dr. Clouston proposed that the Handbook Committee be cordially thanked
by the Association, and the motion was seconded and carried with acclamation.
SYLLABUS.
A syllabus of “ Training and examination of attendants and nurses for the
Certificate of Proficiency,” was handed in.
BULBS COMMITTEE’S BEPOBT.
Dr. Whitcombe moved that the report of the Rules Committee be received
and entered on the minutes, and that it be taken as read. Dr. Whitcombe said
the report explained the action of the Committee very minutely, and he need
only add, as chairman of the Committee, that the members had devoted a large
amount of time to the construction of these rules, both at their meetings and in
correspondence. The report pointed out the chief alterations which had been
made, and had been almost unanimously adopted by the Committee.
Dr. Newington seconded the pi# position.
Dr. P. W. Macdonald (Dorchester) said that considering the revised rules only
came into.the hands of the members two days ago, and that there were many
alterations in the former rules, he did think a little more time ought to be
given to the general body of members of this Association to consider them.
They all recognized the labours of the Committee, and were willing to thank
them therefor. But he hardly thought the report, before many members had
had time to look at it, should be forced upon them. He regretted that the
chairman of that Committee did not see his way clear to allow these rules to
remain open for a further time and to have a special discussion upon them here¬
after. Dr. Macdonald then referred to the lack of work that was done amongst
them. He admitted there was able work done, but they must try and see if
there was not some way in which they could throw fresh life into the Associa¬
tion. He himself lived in the South of England, and always strove to attend
these meetings, but it was at great personal sacrifice and at great inconvenience
to other people. If they could see a way to form provincial branches and have
local secretaries, he thought fresh life would be thrown into the Association
and good work done. He thought this was a special point the Rules Com¬
mittee ought to thresh out. He therefore moved that these rules be postponed
until a future meeting of the Association and for special discussion.
Dr. Tubnbull seconded the motion.
The Pbesident said this was the time at which he ought to speak. To
adopt these rules would be entirely inconsistent with the instructions he had
received from the Council. He should call their attention to the list of mem¬
bers for election presently. Rule III., as proposed, said, “ Ordinary members,
who shall be legally qualified practitioners.” If you pass these rules this
is worth nil. Before we endorse such an important proposal the question of
female membership ought to be discussed.
Dr. Howden—I t is too much to ask us to decide this matter to-day. I don’t
think it can do any harm if it is put off till the next meeting.
Dr. Rayneb —On a former occasion the rules were referred to a special
general meeting held for the purpose.
Dr. Fox—Is any special general meeting likely to express the views of the
Association so well as here ? Where—north, south, east, and west—will you
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596
Notes and News.
[Oct.,
find a place so central as Buxton ? If you put it off will it not be necessary to
postpone it for the whole year ? We are going to that sister Isle where there
will be much to attract, and there will be further difficulties.
Dr. Newington —A very strong and representative Committee was appointed
to settle these rules, and the report shows what are the chief departures. It
will be more business-like not to object to them altogether. The Committee’s
report points out the principal points for discussion, and it will be better to dis¬
cuss those points than throw the whole thing over. It is not fair to the Com¬
mittee to report to this meeting and then to that meeting, and to ask them to
report again. It was not in the hands of one or two people, but in the hands of
a strong Committee. With regard to Dr. Macdonald’s suggestion, it is hardly
a question for the Buies Committee to deal with. It should be specially dealt
with by the Association on the advice of the Council, and should not be brought
in by a side wind.
Dr. Meecieb— This ought to have been introduced at the last annual meeting
as an instruction to the Committee.
The Pbesident —It has been proposed by Dr. Macdonald, and seconded by
Dr. Turnbull, that the thanks of the meeting be given to the Buies Committee,
and that their report be received.
Dr. Meecieb —Buie III. is the same as the old rule. All that it provides is
that ordinary members shall be legally qualified medical practitioners.
Dr. Pbbcy Smith pointed out that the rule expressly mentioned legally
qualified medical men.
The Pbesident— Yes, men .
Dr. Yellowlees —I feel there is a debt of gratitude due to the Buies Com¬
mittee. The rules are a very great improvement upon our old ones. I feel
there are a number of good things in them, and on some I should like to make
suggestions. The members of the Association as a whole have not had an
opportunity of offering criticism. It would take the whole day to discuss them.
It would be exceedingly ungracious to the Committee to delay it for a whole
year. It would be most discourteous to them. (Hear, hear.) We ought to
find some way in which the members of the Association should be able to lay
their views before the Buies Committee, and we should also be able to consider
them at a much earlier date than next year. We cannot discuss them to-day
for want of time.
Dr. Whitcombe directed Dr. Yellowlees’ attention to Buie I., Chapter Y.:
“ New rules shall be made, and existing ones repealed and amended only at the
annual meeting.”
Dr. Clouston —After the expressions of opinion that have been made, and
after the statements of fact as to members never having seen the rules, we must
really adopt the suggestion that has been made. He urged Dr. Whitcombe to
coincide.
Dr. Whitcombe —The rules I hold here I received a fortnight since. I
don’t understand why every member should not have had these rules in his
hands at least a week. This report was prepared on the 19th of June. It has
since been submitted to the whole Committee, and as soon as the Committee
adopted it, it was sent to the printer in order that it should be forwarded to
every member of the Association.
Dr. Spence thought they might very gracefully submit to the opinion of the
meeting that this matter should be adjourned. When carried it should be
carried unanimously. Dr. Whitcombe deserved their grateful thanks for all the
hard work he had done. It would be an injustice to the Association to further
press the rules on the meeting that day.
Dr. Whitcombe —If this meeting is adjourned for three months or longer
then I would accept it, but to defer it for twelve months would be absurd. I
now move that the report of the Buies Committee be adjourned to the next
quarterly meeting, at which the adjournment of the annual meeting shall be
held before the quarterly meeting, namely, Wednesday, November 15th.
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Notes and News.
597
1893.]
The motion having been seconded,
Dr. Macdonald asked why the meeting should be held the day before. Some
gentlemen could not get away for two days, just as it would suit themselves. It
should be fixed on the quarterly meeting day.
The President then put it to the vote, as follows : “ That the report be ad¬
journed to the 15th of November”:—
For.10
Against .20
The President —Dr. Whitcombe’s amendment has been negatived.
The President then put Dr. Macdonald’s resolution, with the addition of
the 16th Nov. as the date, viz.:—“ That the thanks of the Association be given
to the Buies Committee for the work they have done, and that their report, in
view of its special importance, be remitted for consideration and fuller discussion
at an adjourned meeting, on the 16th November, 1893, at 10 a.m.”
Dr. Turnbull seconded it in the modified form.
For. ... 24
Against . 3
Carried.
EDUCATIONAL COMMITTEE’S REPORT.
Dr. Clouston reported that the Educational Committee had held three
meetings. They drew up a report which was adopted unanimously. Though
it was not necessary to read it to this meeting he would take the liberty of
mentioning the gist of it. A scheme of instruction has been drawn up for the
guidance of teachers in insanity; a letter has been sent to every examining
body asking it to formulate a syllabus of subjects to be examined on in insanity,
and offering co-operation,; this offer has been accepted by the Universities of
Oxford, Cambridge, Edinburgh, and St. Andrew’s; the Royal Colleges of
Physicians and Surgeons of Edinburgh, and the Faculty of Physicians and
Surgeons, Glasgow. The Committee has resolved to express to certain examin¬
ing bodies the opinion that insanity should not be included in Medical Juris¬
prudence either with regard to instruction or examination.
The report was adopted.
DIETARY COMMITTEE’S REPORT.
Dr. J. A. Campbell expressed the hope that they would adopt the report,
and discharge the Committee.
Dr. Urquhart seconded, and it was carried.
On the motion of Dr. Yellowlees, the committee were cordially thanked
for their report.
nomenclature of disease committee.
Dr. Whitcombe moved that the report be received and entered upon the
minutes.
Dr. Rayner seconded,
Dr. Yellowlees objected, and moved that it be not adopted.
Dr. Urquhart seconded, and said he could not understand why the Com¬
mittee had taken the trouble to invent a new classification. That of the College
of Physicians was sufficient. He preferred classifying diseases according to
organs of circulation, &c., and not the height at which they occur in the body,
which is absurd. There was not even a place left for influenza, which had been
so prevalent of late.
The President —The amendment is that the Committee be thanked for their
report, which should not be adopted.
Dr. Whitcombe, replying to remarks, said that he was sorry to find that
so many members of the Association did not know the nomenclature of the
College of Physicians. If they had studied it they would have found that this
followed it so far as it was thought desirable. A question had been asked in the
House of Commons some two years ago relating to the causes of death in
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asylums, and the Commissioners requested him, when he had the honour to
represent them as President, to bring the matter before the Association. He did
so, and they sanctioned the appointment of a small Committee to consider this
question. He had a letter before him from a member of the Commissioners*
Board, in which he expressed their gratitude that this had been done.
Hr. Savage remarked that it was true the nomenclature was not perfect; they
had done their best. All he could say was if they did not like it let them not
use it. He declined to have anything more to do with it.
Hr. Macdonald —If it follows so closely upon the lines of the nomenclature
of the College of Physicians, what use is it ? It is very well to receive it, but
it must not go forth that we adopt it as the classification of this Association.
Hr. Yellowlee8 —My opinion is that the report should be remitted to the
Committee. If they don’t wish to have anything to do with it let it be so. "We
are very much obliged to them for their trouble. I have no doubt they have
done their best, but we are not obliged to accept it.
Hr. Savage —It was considered best to follow, mainly, the lines of the College
of Physicians. It seems to me that the feeling of the Association is rather that
they should wait for two years, when the College will issue a revised nomen¬
clature, and then reconsider it.
It was then put to the meeting that the Committee be thanked for their
report, and the motion was carried unanimously.
BOOMS IN LONDON.
The Pbbsident informed the Association that rooms had been arranged for at
11, Chandos Street, Cavendish Square, London, for the use of the Association.
The Seckbtaby, Hr. Fletcher Beach, stated the terms as follows:—Until
the completion of the alterations about to be carried out on the ground floor
of the Medical Society’s premises, the Association has the temporary use of one
of the book-cases at the rental of £1 per annum, and the use of the library for
Council meetings at one guinea per meeting, and of the large meeting room for
ordinary meetings at two guineas per afternoon. These terms to include the
right of using the Medical Society’s rooms as the official address of the Associa¬
tion, as well as permitting the Hon. Secretary to make occasional use of the
library for the purpose of conducting his official correspondence.
The Pbesident proposed a vote of thanks to the Governors of Bethlem
Hospital for the use of the Board Room for the meetings held by the Associa¬
tion there for so many years.
Carried unanimously.
THE ADMISSION OF, LADY MEMBERS TO THE ASSOCIATION.
The meeting then proceeded to the election of ordinary members, a list con¬
taining the names of whom was before the Association.
The President, in introducing the subject, said—I have been instructed by
the Council to draw your attention to a name on this list. It is number seven;
she is a woman, and is M.B., B.Ch. Royal University of Ireland, and Clinical
Assistant at the Richmond Histrict Asylum, Hublin. The Council thought
that your attention should be drawn to this, because it opens out the very
important question of female membership, a question which the Council think
should be fairly placed before the Association, and that you should come to
some decision to-day, if possible, before balloting for the whole of the members.
If you wish to ballot for the whole of the members after I have explained and
drawn your attention to this name, then, of course, the matter is in the hands
of the Association. It is an innovation, a revolution.
Hr. Rayner rose to support the election of lady members.
Hr Ireland —It is of considerable importance and it is very singular that
this name was put down here without the knowledge or the consent of the
Council, and without any intimation that this was a woman at all (laughter.)
I belong to the old school, and was astonished at this proposal. I was in doubt.
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and I inquired whether it was a female or a male name. This is promoted bj
someone, there is no doubt, and perhaps by the same party who changed the
word “ men ” into “ practitioners.” Those who did so should come here and tell
us how it was done in this manner.
Dr. J. A. Campbell —Is the list in accordance with the rules ?
The President —A lady is ineligible, according to the present rules.
Dr. J. A. Campbell —Might I ask the Council why they have done this F
The Secretary —I am the guilty party. The Secretary has no power to
refuse the name of any person duly sent in and supported. This was sent in,
and I thought I could not refuse it.
Dr. Mercier —Suppose the name of a convict had been sent in ?
Mr. Richards— The Secretary should have consulted the Council. It looks
as if this lady was about to be elected in a hole-and-corner way.
Dr. Conolly Norman said Dr. Mercier had spoken about the possibility of
nominating a convict. Supposing they discussed that for a moment. A convict
would not be a legally qualified practitioner, and therefore was not eligible, but
they could not refuse until the Medical Council had struck his name off the roll.
The speaker was a member of the Rules Committee, and at that Committee had
raised this question, and had been then reminded of recent legislation by which
it was decided that the words “ man ” and “ men,” “ he ” and “ his,” when used in
a general sense had been held to include members of both sexes. He submitted
that this applied to the present case, and that therefore under their present
rules women were eligible. He nominated the lady whose name came before
them that day on the list, and he begged to assure the Association that he had
no intention whatever of doing anything in a hole-and-corner way. He
thought that when a name went forward to the Secretary in the usual manner,
and, as he understood and still believed, legally, and that when it was printed
as it was on the paper, every member would have sufficient intimation of the
fact. Now he was inclined to ask the Association to accept this name as it
appeared on the list, not wishing to have the matter decided in a personal way,
but the reverse. He was of the decided opinion that women should be admitted
to their Association. They could not exclude them from their profession; that
was out of their power. Why, then, try to exclude them from that Association P
He failed to see any object in excluding them. It would be said that they
feared women meeting them on equal grounds. Why should they? The
female graduates whom the speaker had met were decidedly superior to the
average of male graduates, but just because he was not one of those who thought
our sex have anything to fear from the competition of women he was of opinion
that women ought to have everything open to them. If it is said that women
are unfit to compete with men in our profession, that is a more general question,
but that has been already decided for us. We had already women in our
asylums as medical officers, and the lady whose name appeared on the paper
was a paid official in a public lunatic asylum. There was also at the present
time a female medical officer in the Holloway Asylum. There was only one
argument upon the subject worth considering. Supposing females were
members of the Association, and appeared at their meetings, they might
hamper their discussions upon subjects of a certain class. Dr. Norman pointed
out that many members of the Association were now teachers. Most of these,
like himself, had had to teach women and no doubt all would have to do so
before long. Would they refuse pupils on account of their sex? He could
say from personal knowledge that at the meetings of the various sections
(anatomical, surgical, pathological, medical and obstetrical) of the Academy
of Medicine in Ireland female graduates and students were constantly present,
and no difficulty arose. Every subject brought forward was discussed with the
same scientific freedom as before. What objections there might have been had
long since passed away. Therefore, if in order, he would move “ that women
shall be eligible for election into their Association.” He maintained, in con¬
clusion, that the word “ man,” as used in the rules, in law included w women.”
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Dr. Yellowlees seconded.
Dr. Fox asked the President for an interpretation of the rules, and whether
the term “ medical man ” admitted of a more extensive interpretation than the
one generally assigned to it ?
Dr. Clouston said, in advance, he could not accept the ruling of the Chair¬
man on this point.
Dr. Holmes moved that this name be taken separately from the others. He
held a peculiar position. He had had the privilege of studying anatomy and
dissecting in the same room as female students, and looking hack dispassionately
he could not but feel well towards those ladies. They must march with the
advance of the ideas of the present generation. Ladies were about to become
members of the British Medical Association. He thought lady practitioners
would be an acquisition to their body.
Dr. Fox said Dr. Norman brought forward an abstract resolution that ladies
be members. Let them decide whether ladies were admissible, first of all.
The President —Is it your wish that we first vote on the female applicant ?
Dr. Benham— Would it not be well if the lady’s name came up when the
new rules have been passed ?
Dr. Macdonald— Dr. Clouston has declined to take the President’s inter¬
pretation. If so, who iB going to decide ?
Dr. Clouston —With the utmost respect for the President I would say that
the interpretation of the rule must be by the vote of this meeting, and not by
the ipse dixit of the Chairman.
Dr. Oscar Woods said the main question to decide in the first instance was
whether ladies should be admitted to the Association or not. He thought they
would be by a very large majority.
Dr. Ireland —I am prepared to second the proposal that this matter should
be considered at the special meeting when we consider the rules. As Dr. Nor¬
man has not given notice of his motion I ask, is it legal to spring a motion upon
us of which he has given no notice whatever, and which has never appeared on
the agenda?
Dr. Spence —With the view of shortening this discussion I propose that the
rule in which the word “ men ” is mentioned include “ women ” as well.
Dr. Clouston seconded.
Dr. Ireland —I said I would second the amendment that it should be deferred
to a special meeting. We should have more time to discuss it.
The President —No one has seconded Dr. Norman’s proposition so far as I
know.
Dr. Urquhart —What is the motion ? How can it come before this meet¬
ing without a notice of motion. I really must protest against receiving it. I
think it is most irregular. (Hear, hear.)
Dr. Fox—I have heard this question described as a revolution. Is it a revolu¬
tion greater than a motion put before us out of order and without any notice?
The President —The proposition is that the word “ men ” (Clause III.,
Chapter I.) does include women. It has been proposed and seconded.
Dr. Urquhart again protested against its reception.
The President —Is it to be received or not before being voted upon ? (Cries
of “ No ” and “ Yes.”)
Dr. Yellowlees —The Council definitely asks us to consider the general
principle before we give our vote, and, therefore, it is before the meeting.
Dr. Whitcombe— I don’t think any member of the Association has pointed
out the fact that you already have a lady member holding the certificate of this
Association.
Dr. Urquhart —She is not a “member.”
Dr. Whitcombs —A lady “ doctor,” then. I think if this Association will
admit a lady to the examinations for its certificate the very smallest thing it can
do is to elect a lady as a member. This question has been mooted, and has been
discussed years ago in all our Associations and Societies, and in early years
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ladies were thrown out ignominiously, but in later years ladies have been
received into the folds of Medical Associations.
Dr. Ubquhart—I move the previous question.
Dr. Benham —I move that the question of the admission of female members
be considered at the next annual meeting. I am inclined to vote for their
admission eventually, but not at this meeting. At this late hour this important
question should not be sprung upon us.
Dr. Howden —It has been proposed by Dr. Norman, and seconded by Dr.
Yellowlees, that ladies are eligible as being included under men. I move an
amendment “ That according to the present rules women are not eligible as
members of the Association without a vote of the Association has settled that
matter.”
Dr. Benham — I withdraw my motion, and second Dr. Howden’s.
Drs. Norman and Clouston also withdrew their motion in favour of Dr.
Spence’s.
The President —It is proposed by Dr. Howden, and seconded by Dr.
Benham, that according to the rules of the Association women are not eligible.
The other is by Dr. Spence, seconded by Dr. Clouston, that the term “ men,”
as in Clause III., Chapter I., does include women.
After the voting the President declared Dr. Howden’s amendment was
carried and became a substantive motion by 26 against 16.
Dr. Hack Tuke — I hope it will be clearly understood that this result is not
what we wish, but merely what we consider to be the interpretation of the
present rule (hear, hear.)
Dr. Urquhart —It is a victory for good grammar.
The President—W e will now proceed to the ballot for the election of
“men” (laughter).
ELECTION OF ORDINARY MEMBERS.
The following candidates for ordinary membership were then unanimously
elected:—
John Milne Bramwell, M.B., C.M.Edin., 2, Henrietta Street, Cavendish
Square, W.
William Henry Bowes, M.D.Lond., Assistant Medical Officer, Plymouth
Borough Asylum, Ivy bridge, Devon.
Gerald Herbert Johnston, L.R.C.P. and S.Edin., Assistant Medical Officer,
North Riding Asylum, Clifton, York.
Herbert Warren Kershaw, M.R.C.S.Eng., L.R.C.P.Lond., Senior Assistant
Medical Officer, North Riding Asylum, Clifton, York.
John Newington, L.S.A., Tattlebury House, Goudhurst, Kent. i
John Mills, M.B., B.Ch.,and Diplomate in Mental Diseases, Royal University
of Ireland, Assistant Medical Officer, District Asylum, Ballinasloe.
William Rawes, M.B.Durh., F.R.C.S.Eng., Assistant Medical Officer, St.
Luke’s Hospital, London.
Henry Blake, M.B.Lond., Stone House, Great Yarmouth.
Prank Perceval, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical Officer,
County Asylum, Prestwich, Manchester.
William St. Clair Symmers, M.B., C.M.Aber., Pathologist, County Asylum,
Prestwich, Manchester.
MOTION BY DR. J. A. CAMPBELL.
Dr. J. A. Campbell, Carlisle, submitted the annexed resolution, by special
leave of the President and Council, it not being on the agenda:—“ That the
Medico-Psychological Association of Great Britain and Ireland are unanimously
of opinion that the grant of 4s. a week at present given to Boards of Guardians
to pay for pauper lunatics in County Asylums, Registered Hospitals, and
Licensed Houses should also be given for pauper lunatics (t.e.,‘ Dements ’ ancl
xxxix. 39
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‘ Imbeciles *) in Workhouse Wards, or boarded out, if kept to the satisfaction
of the Commissioners in Lunacy; this has been, done in Scotland since 1874.”
Dr. Newington seconded.
Dr. Oscar Woods asked them not to pass it in a hurry. The Government
had given a certain sum as a contribution for lunatics, and he took it that if
that resolution was passed the paupers in the asylums would not get the 4s. per
head. If distributed over the asylums they would have got 3s. 6d.
Dr. J. A. Campbell —It only refers to England and Wales.
Dr. Clouston— In Scotland the rule applies. At the present time every
pauper lunatic receives a certain proportion to help for his board, from the
Government. I can speak for every Scotch member, and say it is a great boon.
Dr. Whitcombe suggested to Dr. Campbell the advisability of bringing the
matter up at the next quarterly meeting.
Dr. J. A. Campbell —The committee has sent out notice to every committee
in England, to Boards of Guardians, to the Local Government Board, and also
to the Commissioners in Lunacy. This was the time to act if they were to act
at all. The Lancashire Boards were also taking steps in the same direction.
That was his reason for specially bringing the matter before them that day.
Dr. Spence — I should regret if this Association should pass the resolution
that has been presented by Dr. Campbell.
Dr. Fox doubted whether the Guardians would understand it as they under¬
stood it.
Dr. Whitcombe —It has been sprung upon us without notice.
Dr. Campbell —It has not. The matter was before the Council this
morning.
Dr. Oscar Woods seconded the motion.
The President then put it to the meeting whether the subject should be
deferred to the next quarterly meeting, and declared it carried “ nearly
unanimously ” that it should be so.
THE AFTERNOON MEETING.
HONOURS.
The President, on the meeting reassembling, announced that Dr. Campbell,
Assistant Medical Officer Rainhill Asylum, Lancashire, had been awarded the
bronze medal and prize of ten guineas of the Association (applause), and the
second essay was so good and so near the first that the Council recommended
that a prize of five guineas be awarded to Dr. Goodall, of the West Riding
Asylum, Wakefield. (Applause.)
general index.
The President next announced the presentation to the Association of a
continuation of Dr. Blandford’s Index to the “ Journal of Mental Science,”
kindly prepared by Dr. Rayner.
A cordial vote of thanks was accorded Dr. Rayner, on the motion of Dr.
Clouston, seconded by Dr. J. A. Campbell.
votes op thanks.
Votes of thanks were then passed to the President, Secretaries, the Editors,
Auditors, Treasurer, and Registrar.
the president’s address.
The President informed the meeting that the only business that remained
Was for him to deliver his Address. (See Original Articles.)
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Dp. Bakeb proposed a vote of thanks to the President for his very interest¬
ing and instructive Address.
Dr. Conolly Nobmax seconded the proposition, and said that the Address
had covered such an amount of ground that no one member could discuss the
several points in the time at their disposal. But there were one or two
pointe upon which he should like to say a word or two. The suggestions the
President had made were very practical and suitable for them to consider and
take action upon. He had spoken about the provincial members, who, in some
degree, felt themselves excluded from the full working of the Association. With
tact that did honour to his position as President, he mentioned the burning
question of the supposed representative shortcomings of the Council in a
merely casual manner. In Dr. Norman’s opinion the difficulty about in¬
teresting provincial members in their Association was of more importance
than their mere election on the Council. No Association could be ruled by
people who did not take an interest in its work. So long as provin¬
cial members did not take a personal interest in their meetings they could not
rise to official standing. Dr. Lindsay had spoken about what might be called
the short service system in asylums, and undoubtedly the longer one looked
at the question of asylum service—using the word in its larger sense—
the greater did the difficulty become of seeing how something approaching a
short service system could be avoided. Take the case of asylum attendants. He
thought the feeling was very general that an attendant lost value when he had
served longer than a certain time; if he exceeded that time he became use¬
less for anything else. Therefore there was the dilemma of either doing a
wrong to the institution by retaining persons who were no longer at their best,
or of doing an injustice to attendants by dismissing them when they had over¬
stood their market for obtaining other employment. It would be better, he
thought, if attendants were engaged on the understanding that they were
to remain a limited number of years, say three years if not promoted,
five years if they got up a step, and seven years if they got up another
step. Some such thing as that was bound to come eventually. Then
as to the long hours. The President spoke sympathetically of their atten¬
dants. When an accident happened and a man stated that he had been
fourteen hours on duty, he surely had reason on his side. This question was
certain to be brought forward sooner or later by the attendants themselves, or
by someone speaking for them; and he thought it would be a pity if the
Association did not give an expression of their own opinion beforehand. It was
their duty and privilege to try and lead public opinion in such matters as that,
though their voice might long be as that of one crying in the wilderness. With
regard to female assistants, it would be unkind to take up the time of the
members after having spoken so much on this subject earlier in the day, but he
had tried the experiment, and had satisfied himself that medical women could
be of use in asylums, and could exercise a very beneficial effect upon the staff,
and an effect that was not otherwise to be obtained upon female patients. The
President had spoken of the very wonderful system that existed in this country
—very wonderful to all of them who, like the speaker, were foreigners
(laughter)—of having asylums visited by barristers, and by commissioners who
hunted in couples. At the bottom of all that lay the imputation which the
legal profession was so fond of making against the medical profession, if not
directly, by insinuation, that they were all rogues. The medical commissioner
could not, forsooth, visit an asylum without a lawyer to look after him; one
official could not be trusted to visit an asylum unless another accompanied him
to see that he did his work! They were wanting to themselves in not protesting
against all this. Again, it was a monstrous provision that when lunacy certifi¬
cates were signed by two medical men each must see the patient alone. Yet
where is consultation more desirable than when two general practitioners con¬
sign a patient to an asylum or what better safeguard agains error than free
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consultation ? What does the provision mean ? That the lawyers cannot trust
our profession. Is it possible that two respectable professional men, be they
doctors or lawyers even, cannot meet and consult without perpetrating a
fraud ? The President had also referred to the action of the London County
Council in several other matters, but he did not think that he spoke of their
action in regard to the advancement of pathological study. It must be said
that the action of the London County Council in this respect was in the highest
degree generous and enlightened. As they were talking about their Association
and its shortcomings, and what it could do, it was, he said, a reproach to them
that this kind of thing was not more forcibly advocated by the Association.
Individual members had done a great work in pathology, but he did not know
that their Association had ever spoken collectively, and claimed as a right what
the London County Council had done. Theirs was the body that ought to have
initiated this movement. If they were to speak more courageously on such
matters they would get listened to, perhaps, where they hardly now dared hope
for a hearing. If they agitated vigorously and claimed as matters of right
recognition of their position as scientific teachers and workers, encouragement
and facilities for scientific work, high qualifications for their medical assistants,
a suitable proportion of trained nurses among their staff, and if they urged the
just claims of all workers among the insane to liberal pay and competent pen¬
sion—they would not only perform their duty as an Association, but they would
raise themselves immensely in the estimation of the public, and he firmly
believed they would obtain such a success as would surprise them.
Mr. Richards supported the resolution, and he bad a special reason for doing
so. Dr. Lindsay, who had given that most interesting and exhaustive Address,
was his old master some 25 years ago. It was his good fortune to be his
assistant, and he instilled into him the routine work as to ensure his future suc¬
cess. It was owing to that in a great measure that he got on so well with his
committee and also the London County Council. It showed that the opinions
he held then were well founded, and now they were still more matured. As
regarded the London County Council he endorsed what the President had said.
He believed it rested',with the medical superintendents to get anything done that
was reasonable and calculated to benefit the patients of an institution. Now
was the time for them to strike.
The proposition was unanimously carried, and
The President, in reply, thanked them, and assured the members that
whatever he could do for the Association he would gladly do.
Dr. J. A. Campbell— You must suggest that we take some action with regard
to what has been said about pensions. I think that it reads most judiciously
and most candidly. I move that we thank the Commissioners for those remarks
of two years ago.
Dr. Macdonald seconded.
The business then concluded, and the members paid a visit to the Devonshire
Hospital and the Baths.
In the evening the members and friends dined together at the Palace Hotel,
Buxton.
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ANNUAL MEETING OP THE BBITISH MEDICAL ASSOCIATION.
Psychology Section.
Newcastle, August, 1893.
President— Dr. T. W. MacDowall.
Vice-Prendent, {
(Dr. Conolly Norman.
C Dr. Callcott.
Secretary ^ Bobikt Jonh.
The President chose a highly important and practical subject—the working
of the County Councils in the management of asylums established by the
Local Government Act of 1888. It was not, he observed, his intention to refer
to that unhappy piece of legislation, the Lunacy Act of 1890; it has been torn
to pieces and trodden under foot, but unfortunately we caDnot get rid of it,
and must carry out all our official work under its vexatious requirements. He
well remembered the time when the proposed Local Government Bill was
dreaded by asylum superintendents. These dreaded evils were very clearly
expressed by Dr. Needham in his Presidential Address to the Medico-
Psychological Association in 1887. Dr. McDowall quotes some of Dr. Need¬
ham’s expressions, and the rest of the Address mainly consists of replies from
superintendents to his questions as to their practical experience of County
Councils. There is, of course, a diversity of sentiments, but it is satisfactory to
find that the general testimony is distinctly favourable to the new masters.
Some superintendents—little to their credit—refused to reply to the inquiries;
a few of the excuses appeared inadequate and trivial; others had not even the
courtesy to acknowledge the commmunication. Speaking for himself, the
President said, “My experience is this—and it is not singular—that the
members of these new Boards are most anxious to do their work to the very
best of tfyeir ability, to meet the modern requirements for the care of the
insane, and to treat those in office with every consideration.” In conclusion,
the President gave it as his message to all asylum men to lead committees
along the path of progress, and to prevent them falling into the mistake com¬
mitted by their predecessors of want of enterprise.
The Address cannot be too highly praised for its opportuneness, its lofty
sentiments, and for its enforcement of the truth that if superintendents of
asylums do their duty, County Councils will do theirs.
Dr. Newington moved a vote of thanks to the President for his Address, and
congratulated him on taking so broad and favourable a view of the changes in
asylum government. Speaking as a member of the Sussex County Council, he
maintained that nothing but desire to do the work well animated them. He
pointed out that the labourers and artisans had to be taken into account.
When they remembered that the inmates of asylums were drawn from these
classes it would be quite certain that inefficient management of asylums would
be speedily amended if and when the voters recognized their power. Then, if
this were true, and if they allowed, as they must, that what was good for the
patients would be good in the long run for both the asylum staff and the rate¬
payers, the change in asylum government could not but work good. He
further pointed out that, though good committees of justices used to be in the
majority, yet there were others that could not be said to have done their work
satisfactorily; but these were quite irremovable under the old system, now,
however, it was quite easy to effect a change in the governing body.
Dr. Murray Lindsay very cordially seconded the vote of thanks to the
President for his very comprehensive, suggestive, and instructive Address. Dr.
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Lindsay on the whole endorsed the general conclusions arrived at by the
President after a lengthened experience. That County Councils were now
taking a comprehensive grasp, an enlightened and liberal view of their new
duties with regard to the management of asylums and the position of the staff,
there could be no doubt, and they were zealously improving asylums and
doing what they could to benefit the insane, whilst not forgetting the interests
of the staff of asylums in the matter of pay, pension, and leave. It was to be
expected that at first some experience and lubrication would be necessary
before the new machine could work smoothly, but now much hard and really
good work was being done by asylum committees. Whilst admitting this, he
still believed that the process of education in asylum matters was not yet com¬
plete, and that there was room for improvement. It must be acknowledged
that our county asylums had been and were being improved under the rSgime
of County Councils, a regime which would unquestionably confer greater
benefits upon the insane and upon the administration of asylums. Derbyshire
was especially fortunate in having an excellent County Council, and equally
fortunate in having a hard-working Asylum Committee, who were endeavour¬
ing to advance and keep abreast of the times.
THE ALLEGED INCREASE OF INSANITY.
Dr. Hack Tuke, in introducing for discussion the alleged increase of insanity,
gave the reasons brought forward by those who maintained this view, and also
the reasons advanced by those who denied the increased liability to insanity
while obliged to admit the great increase in the number of the insane. He
brought before the Section a number of statistics in order to assist it in arriving
at a conclusion. These covered the period which had elapsed since 1870. If
the figures alone were regarded, he admitted that they.no doubt presented a
somewhat alarming picture; but he asked whether there were not circumstances
which might partially or altogether account for this increase in numbers. Dr.
Tuke summarized his own conclusions as follows:—(1) There has undoubtedly
been since 1870 a large increase in the number of patients in asylums and work-
houses, but more in the former than the latter. (2) There has not been so
great, but still a considerable, rise in the admissions of patients into asylums
during the same period, after deducting transfers and readmissions. (3) The
advance in the number in detention holds good after allowing for the increase
in population, but does not prove the increased liability of the community to
insanity, seeing that there is a vast accumulation due to a lower death-rate
(even since 1870), the chronicity of the disease, and its lamentable tendency to
relapse. (4) Nor does the advance in admissions prove increased liability to
insanity, as (a) the value and comfort of asylums are increasingly appreciated,
(b) there has been a very large number of patients drafted from workhouses to
asylums, and (c) there has been an ever-increasing encroachment on the mass
of unregistered lunacy which the census shows to exist. (5) The increase in
numbers of the insane has taken place among the poorer rather than the well-
to-do classes of society. While, however, Dr. Tuke did not accept lunacy
figures as conclusive proof that insanity was on the increase, he lamented the
undoubted fact that it had not decreased, in spite of all the efforts of physicians
and social reformers to improve the condition of the race. This was the impor¬
tant lesson to take to heart.
# Dr. Campbell (Carlisle) observed that in his opinion the 4s. grant originally
given in 1874 to pauper lunatic patients in county asylums caused a very great
increase in the admissions to public asylums. The admission-rate in 1875 rose
immensely at once. Mr. Corbet showed, in his paper in the January number
of the “ Fortnightly, 0 that the ratio per 1,000 lunatics had increased from 1*81 to
3‘11 in the last thirty years, but there could be no doubt at all that the nominal
registered increase was muoh greater than the actual. The 4s. grant had had
much to do with that. Dr. Maudsley, in an able paper in the “ Journal of Mental
Soienoe ” for April, 1877, stated that “ the Conservative Government had practi-
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1893.]
cally offered a premium to parochial authorities for every patient they could*
by hook or crook, send into asylums; that shortly the race of sane paupers
would disappear, as had been the case as regards wolves in England when a
premium per head was offered for their extermination.” Now his forecast had
been found correct. Sane paupers had largely decreased; pauper lunatics had
hugely increased since 1874. We should most undoubtedly do all in our power
to get this 4s. grant given, as in Scotland, to such insane as were fit for work-
house treatment or were boarded with relatives or others, provided they were
kept to the satisfaction of the Commissioners in Lunacy. This was a matter of
very great importance. In some asylums the accumulation of chronic cases
was much less than others; at Carlisle, for instance, during the last ten years
1,500 odd pauper patients had been token in, and yet the increase had only
been 56 in the time.
Dr. Merson said that a comparison of the ratio of existing lunatics to the
general population over a series of years would show that though the ratio has
been and was still increasing, yet the yearly increment was gradually diminish¬
ing, and it seemed a fair inference that it was due to special and temporary
causes, and would ultimately vanish, and that, in fact, the ratio of lunatics to
population was slowly tending towards a constant quantity. In the ten years
from 1859 to 1869 the ratio of lunatics increased by 512 per million, while in
the two subsequent decades it was only 361 and 212 respectively. Comparing
this with the increase in the rate of admissions into asylums, which may be
token as roughly representing the proportion of freshly occurring cases among
the population at large, it would be seen that the slight increase in this ratio
did not warrant the inference that the increase in the ratio of lunatics to popu¬
lation was in any appreciable degree due to the occurrence of fresh cases. The
slight increase observed from time to time in the admission rate appeared to be
fully accounted for by the operation of the lunacy laws and the various changes
that had from time to time been made leading to a more energetic action or an
extension of the scope of their operations. After careful consideration of the
circumstances, he had come to the conclusion that the increased ratio of lunatics
to population was due mainly to accumulation of chronic cases in pauper asylums;
that this tendency to increase had now reached its maximum effect, and was
diminishing; that the ratio tended to become constant, and that there was no
material increase in the number of freshly recurring cases among the population
at large.
Mr. Peeke Richards thought that the statistics regarding lunatics were
fallacious from the fact that there were so many patients who were not regis¬
tered (single patients, etc.). Any facts, therefore, that were deduoed from the
returns issued were erroneous as to lunacy as a, whole, as there were, as was well
known, so many insane individuals of whom no statistical notice was token. On
other grounds he disputed the alleged increase of insanity.
Dr. Eastwood said that the increase of longevity was an important faotor in
keeping up the number of patients. Only this year two patients had died under
his own care, one of whom was resident i n his house for thirty-two years and another
more than forty years. Last year another patient died after being a patient
nearly fifty years.
Dr. Howden directed attention to the change in the nature of employment
of the working classes as an important factor in the apparent increase of in¬
sanity, or, rather, the increase of the number of lunatics sent to asylums. He"
referred to the change from home manual labour to the employment of machinery
in public work; for example, fifty or sixty years ago handloom weaving and
small farms or crofts permitted the relatives to attend to their weak-minded
relatives while pursuing their occupations at home, whereas when they had to
work at spinning mills or as servants on large farms they were compelled to
send their insane or imbecile relatives to asylums. This change in employment
was still going on; the absorption of manual labour bv machinery was still
going on; shoemakers, tailors, and other old-fashioned trades were almost
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[Oct.,
extinct, and, so long as this change continued, there would probably be a slight
increase in the number of persons sent to asylums. Possibly, if the “ three
acres and a cow” experiment were carried out, the apparent increase of insanity
might be partially arrested, but the inevitable change in modes of employment
winch goes on in spite of theories must he faced, and the inevitable increpe in
the number of insane persons sent to lunatic asylums accepted, although it was
no proof of the alleged greater liability of the population to insanity.
Dr. Holmes, when he first engaged in general practice, found a much
greater reluctance on the part of the friends to place their insane relatives in
asylums. Now, however, they looked upon them as hospitals for the cure of
the insane, and were, therefore, more willing to place them under proper care.
During the last twenty-three years the apparent increase had been 5*3 per
10,000 of the population; during the last ten years it had been 1*2 per 10,000
of the population. This large increase might well be due to better care and the
greater willingness of the friends to send their relatives to the asylums.
Dr. Yellowlkes confirmed Dr. Howden’s explanation of the apparent in¬
crease of the insane.
The President confessed himself unable to master statistics.
Dr. Campbell supplemented his former remarks by adding three factors of
insanity, which he had omitted to mention: (1) The standard both of sanity
and insanity had altered much of late years; people were now oertified as
lunatics who long ago never would have been sent to asylums. (2) Old people
suffering from simple dotage were now sent to asylums in much greater num¬
bers than formerly; at the Carlisle Asylum two per cent, of the admissions
during the ten years ending 1872 were above 70 years of age, four per cent,
during the next ten years, and six per cent, during the ten years ending 1892.
Now this was a vast increase; such old people could not be expected to get
well; they would accumulate and use up the accommodation. (3) Trade
depressions or booms in trade also had a great effect; for instance, Cumberland,
which was only some twenty miles from Ireland, was during prosperous times
flooded by uneducated and uneducable Irishmen, who never had been accus¬
tomed to high wages, and who, when they got high wages, had not the sense to
use their money judiciously.
Dr. Tuke, in reply, said he agreed with Dr. Campbell that the 4s. grant partly
caused the rise of the numbers in asylums, and that it ought to be extended to
workhouses. At the same time, it would not account for the increase during
the last five years as compared with the previous quinquennium. With regard
to Mr. Richards’s remarks on statistics, he would say that those who, like Mr.
Corbet, hold that there had been an alarming increase in insanity, rested their
contention on the Blue Books, and, therefore, he could not ignore them. Dr.
Tuke, in conclusion, said that he was not prepared to deny that there might
have been some increase in occurring insanity; but, on the other hand, he was
unable to admit that statistics proved it.
CURRENT OPINION ON PSYCHOLOGICAL QUESTIONS IN GERMANY.
Dr. Urquhabt read a paper which gave a rapid survey of the field of psycho¬
logical medicine from the German point of view. The subjects touched on more
specially were university teaching and clinics, the treatment of habitual drunk¬
ards and criminal lunatics, and the general attitude in reference to management
of acute and difficult cases.
The paper will appear in extenso in the “Journal of Mental Science.”
TREPHINING FOLLOWED BY DRAINAGE OF THE SUBARACHNOID SPACE IN
GENERAL PARALYSIS OF THE INSANE.
Dr. Edwin Goodall (West Riding Asylum, Wakefield) remarked upon the
disfavour with which the operation of trephining in general paralysis of the
insane (introduced by Dr. Claye Shaw) was regarded by many alienists, and
submitted that a study of the cerebral cortex in that disease afforded justifica¬
tion for this procedure, supplemented by drainage of the subarachnoid space.
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Notes ana News ,
609
1893.]
Dr. W. W. Ireland held that in operations npon the cranium there should
be some definite lesion to cut down upon and remove; but general paralysis
was a disease which implicated not only the brain but the whole nervous system,
and hence improvement from such a simple operation as puncturing the skull
could scarcely be expected.
Dr. George M. Robertson referred to the possible advantage which might
follow the drainage of the subarachnoid space of the spinal cord.
Dr. Goodall, in reply, desired to say that in operating he had proceeded on
a distinct scientific theory, which itself was based on microscopical examination
of specimens. He agreed with Dr. Robertson that in future cases it would be
desirable to consider the question of draining the subarachnoid space of the
spinal cord.
CLAUSTROPHOBIA.
Dr. Habby Campbell (London) contributed an interesting paper on this
form of mental trouble, which we hope to publish in this Journal.
THE MENTAL SYMPTOMS OF MYXG2DEMA AND THE EFFECT ON
THEM OF THE THYBOID TREATMENT.
Dr. Clouston’s valuable paper will appear in a subsequent number of this
Journal.
DETACHED HOSPITALS IN CONNECTION WITH ASYLUMS.
Dr. Clouston, in opening the discussion, said that in the course of the
evolution of the modern asylum for the insane, the latest idea was what might
be called the “ hospital ” idea. He claimed as the result of now over fifteen
years' experience of the system that it had the following advantages : (1) That
in these hospitals the diet could be made very varied, and the routine of the
asylum dietary set aside; they had their own kitchens. (2) That the nursing
is more special and more efficient, and the staff of nurses much more numerous.
(3) There is the absence of asylum discipline and routine. (4) That as all the
patients there are curable, or need individual nursing and care, it raises the
medical and nursing standard for the whole asylum, so the doctors are, while
in the hospital, medical men rather than administrators. (5) They form
admirable training schools for the new nursing staff, a very important matter.
All the new nursing staff at Morningside are sent there at least three months
first, and so get the notion of nursing patients, rather the “ keeper ” idea.
(6) The detachment of the buildings gives distinctiveness of use. They help
the doctor to idealize his work to some extent. He advocated great variety of
accommodation in each hospital—namely, dormitory day rooms, dormitories
proper, day rooms proper, small three-bedded rooms, and single rooms, and that
the hospital should be one-storeyed. He believed the movement had done good
to the insane, and formed a part of that great and philanthropic advance in
their treatment which had begun 100 years ago.
Dr. Wallis then contributed a paper, and advocated the separate treatment
of recent acute and curable cases, his contention being that in all asylums, and
especially in large asylums, detached hospitals for the treatment of recent and
curable cases should be provided. Dr. Wallis has promised to send his very
practical and valuable paper to the “ Journal of Mental Science.”
Dr. Howden said that the Montrose detached Hospital was in most
r&pects independent of the asylum. It was not intended to treat acute
mental cases in the hospital, and experiments in this direction had not
proved satisfactory, though he placed any patient in it who, he thought,
might be better treated there than in the asylum proper. In working he
had found the hospital a great success. He had no medical officer resident
in the building. Being so near, and in telephonic connection with all parts
of the asylum, he did not consider this necessary. The matron of the
asylum had the supervision of the female department and of the cook-house¬
keeper, and both male and female departments were under the immediate
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Notes and News ,
[Oct.,
charge of trained nurses. The plans which Dr. Wallis had shown in connec¬
tion with the Whittingham Asylum were for a different class of cases, and
could not be contrasted with the Montrose Hospital, but the new hospital just
opened at Larbert was almost an exact counterpart of Montrose, and he doubted
if it would be found suitable for the treatment of acute mental cases. Detached
blocks for the treatment of certain classes of cases were, of course, no novelty.
The West House of the Royal Edinburgh Asylum had originally a separate
building attached to it for the treatment of acute cases, and about 1856 a
second block of the same nature was erected. These blocks did not prove
satisfactory for the treatment of acute cases, and Dr. Clouston had them
adapted for the reception of sick and infirm patients. In the new Montrose
Asylum, built in 1857, there was no adequate provision made for the physically
sick, and the hospital erected in 1889 was to supply this deficiency. It was not
found possible to provide suitable wards in connection with the main building,
therefore a separate hospital was erected for 100 patients (a fifth of the entire
population) entirely detached.
Mr. Peeke Richards thought that a separate hospital, although right in
theory, was quite impracticable. There were so many patients who were
maniacal, excited, and noisy, but who were exceedingly ill and ought to be in
an infirmary, but yet from their propensities were quite unfit to be placed
amongst the more quiet sick. In order to carry out Dr. Clouston’s sugges¬
tion, two kinds of hospitals—one for the purely sick, and an intermediate one
for the noisy and excitable sick—would be required.
Dr. Campbell Clark said there could be no question that the future
development of asylum nursing required an increase of the nursing staff. If
there were nurses’ and attendants’ homes, as had been planned for the new
Lanark County Asylum at Hentwood, the nurses and attendants could not
all be drawn from the dormitories unless the night staff were increased.
The increase of the night staff, with a night superintendent, would give
more efficient nursing, do away with all ^necessity for tell-tale clocks, and
solve in some measure the difficult question of the reduction of the hours
of duty for day nurses.
Dr. Urquhart spoke of the results of his experience in the Perth
Royal Asylum, where hospital wards had been designed and built, but not
entirely separated from the main building. That arrangement was found
necessary in the interests of economy of working. The staff and patients
were not sufficiently numerous to permit of entire separation, but the asylum,
as a whole, was now used as a centre hospital for acute and difficult cases,
with separate and detached houses for the milder forms of insanity. These
wings were erected to receive acute, sick, and excited patients, and so
planned as to insure complete and necessary separation. He thought that
there could be little doubt that this development of asylum practice and
management was on the right lines, and that the old sick ward would be im¬
proved in the direction indicated. Dr. Urquhart also spoke of the advantages
accruing from a large common room for the patients built of glass, and so
designed as to be a place of recreation.
STATE AID FOR POOR PRIVATE INSANE PATIENTS.
Dr. Ybllowlees, in introducing a discussion on State aid for poor private
patients, asserted that such aid was wrong in principle, for, if victims of brain
disease were to receive it, how coaid the victims of cancer or consumption be
left unaided? There would be no limit if State aid were given where not
absolutely needful. He condemned the clause of the recent Lunacy Act,
which authorized the reception of poor private patients into county asylums.
It was impossible to separate them from the pauper patients, and the degrada¬
tion of such association was a bitter aggravation of their affliction, both to
the patient and to his friends. While the rich insane could purchase accom¬
modation where they pleased and the pauper insane were well provided for in
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1893.]
Notes and News.
611
the county asylums, poor private patients could only look to the registered
hospitals. They looked in vain, for the registered hospitals were far too few
for the country's needs and the area of their benevolence far too limited. They
afforded most comfortable and even luxurious homes for decayed gentlefolk,
but at that moment it would not be easy to find accommodation in English
registered hospitals for a patient who could pay £40 a year, and far less for
those who could pay only £20 or £30 a year. Jn Scotland the Royal Asylums
erected by private benevolence, without any help from rates, and entirely self-
supporting—did provide for such oases, and the loss they entailed was made
good by the profits obtained from the higher class patients. In England the
registered hospitals had become too often mere competitors with the private
asylums, and failed to provide to any material extent for these most necessi¬
tous cases. England was far wealthier than Scotland, and was certainly not
less benevolent. There was most urgent need of help for the poor private
insane. It could not be that in England such patients could long be thus neg¬
lected if those who knew it sufficiently proclaimed the need.
Dr. Wallis agreed in every particular with Dr. Yellowlees as to the urgent
demand for accommodation for private cases of the lower middle classes.
Experience in England, especially in the largely populated counties with large
towns, showed that the demand was considerable. As in the asylams, for the
most part, there was no such accommodation, these patients mostly oome to
the pauper asylums in virtue of an arrangement with the relieving officers or
union law clerks, though in many oases they could well afford a rate of board
which would enable them to receive many comforts, and that which many of
them would value most of all—the society of patients of their own position as
to education, etc. Many complaints had been made to him by patients’ friends
of this, to them, great hardship. He was quite satisfied that institutions
especially erected for patients of these classes would become self-supporting,
and might do much real charitable work. The chief difficulty was to find an
authority willing to build such a hospital, or to find the money from any publio
or private source.
Dr. Bedford Piebce said that the difficulty was rather that the registered
hospitals in England were not sufficiently numerous than that they did not do
their utmost to receive poor private patients. He stated that many of them
gave charitable aid liberally, and to the utmost of their ability.
Dr. Campbell Clark felt that the question raised by Dr. Yellowlees was one
for the registered hospitals to answer. No fair comparison could be made
between the Royal Asylums of Scotland and the registered hospitals, as the
comparative deficiency of accommodation in the registered hospitals was
perhaps explained by the fact that in the past they had not fulfilled the func¬
tion of pauper asylums as well as asylums for private patients, as in the case
of Scotch Royal Asylums. The latter, as they became relieved of pauper
patients, where new district asylums came into operation, were able to take
poor private patients at a self-supporting rate.
Dr. H. Newington said that, in his opinion, the new Lunacy Act went far
to kill any attempt to provide such accommodation as desired by Dr. Yellow*
lees.
Dr. Clouston said that he agreed strongly with almost all that Dr. Yellow¬
lees had said. His experience in Cumberland and Westmorland was that when
the asylum at Carlisle had some spare accommodation, it was at once taken
advantage of, and in five years fifty private patients from their guardians were
sent there at fourteen shillings a week. He thought that the objections urged
by Dr. Yellowlees as to the disadvantages and objections to mixing middle-
class private patients with county patients were sentimental. The Cumber¬
land farmers were perfectly oontent with the accommodation and treatment.
Dr. Clouston was satisfied that a great benefit was conferred on the counties
thus utilizing the spare beds in the county asylum. He had long had the am¬
bition to be able to admit every patient from Edinburgh as a private patient,
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612
Sotes and 2iens.
[Oct.,
and to place him in a private ward who oonld afford to pay 258. a week, and
would not desire to provide any better accommodation or diet or nursing than
is provided by the English county asylums.
Dr. Murray Lindsay desired to refer to his experience in Derbyshire, and to
express his opinion that there was certainly a great need of some provision for
private patients at moderate rates of board, from 15s. to 21s. per week in con¬
nection with the county asylum, which provision ought to be separate from
pauper patients, not necessarily of an expensive kind, but still separate and
apart from that for the pauper olass. In the county of Derby this important
question had engaged his attention and that of the Committee of Visitors of
tiie Derby County Asylum for some time past, but the difficulty was to set in
motion the permissive olause of the Lunacy Act, which empowered Committees
to make provision for private patients.
Mr. Prekr Bichards was of opinion that in the near future County Councils
would provide institutions for poor private insane patients, as suggested by Dr.
Yellowlees. At the present time the London County Counoil was making pro¬
vision for such a class of patients in their recently opened asylum at Claybnry.
That this would be successful he had little doubt; and, if such were the case,
there was every probability that the Asylums Committee would recommend
further and increased accommodation of the same description, to provide for
poor paying patients.
REMARKS ON THK OUT-PATIENT DEPARTMENT FOR MENTAL DI8EA8ES AT 8T.
THOMAS^ H08PITAL.
Dr. H. Baynkr said that in a letter to the Times (some ten years ago) he
drew attention to the fact that the general hospitals took no part or share in
the treatment of mental diseases. This evoked some correspondence, chiefly
antagonistic to his contention that the hospitals were able to afford such help.
The argument he advanced was that mental disorders should be regarded as
disease just as much as the other forms of human suffering which are treated
at the hospitals, and that they had as great a claim for assistance from these
charities. He pointed out that mental cases suffered not only from this neglect
on the part of the hospitals, but were indirectly affected unfavourably
by being thus separated as a class apart from all other diseases.
Out-patient departments would, he trusted, be the means of obtaining convales¬
cent homes for the mental cases requiring them ; at present mental oases are
rigidly excluded from most of these; but if the need of such help can be
authoritatively pressed on the public, this will soon be remedied, and the
usefulness of out-patient treatment will be thereby greatly advanced.
The direct work of the out-patient department is not only to treat the oases
suitable for treatment, but to relegate into proper channels those requiring
change of air, hospital, infirmary, or asylum care. The indirect ad.
vantages are the removal from the popular mind of the idea that
mental disease is something apart from all other disease, and the bringing
of the alienist physician into more intimate contact with the rest of the pro¬
fession, thereby breaking down the isolation of alienism which has hitherto
existed. The advantage in treatment from being in close contact with and
having the aid of the other specialists of a general hospital is too obvious to
need comment, and this advantage will not be without reciprocity. The claim
may be fairly advanced for the out-patient department, little known as it
is as yet to the class it intends to reach, that already some few admissions
to asylums have been avoided, and that others have been sent thither, with
a better hope of recovery than they would otherwise have had.
MASSAGE OF TUB BRAIN.
Dr. Bobertson read a most interesting paper on this subject, and we hope
at a future time to return to it.
Messrs. Danielsson, of London, exhibited their useful inoised slates for
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Notes and News.
613
1893.]
showing diagrammatic outlines of the convolutions of the brain for ready use
at post-mortem examinations. We strongly commend them; no asylum ought
to be without them, that is to say if the medical superintendent has any interest
in pathology.
THE LINCOLN MURDER.—BEGINA ▼. BARKER.
Barker was the illegitimate son of a domestic servant. The father was a
hard drinker, and lived a wild life, and is described as being easily roused to
anger, and brooding over any trouble he had. He had been drinking par¬
ticularly hard previous to Barker’s birth. A sister of the father had a
delusion that poison was put into her food, and that people were trying to
annoy her. She consequently barricaded her house, and abused imaginary
people from the window. The prisoner’s mother accused the woman who
attended to her of putting poison in her tea, was eccentric, and would chase
children who passed her house. She was removed to the workhouse as
unmanageable. She had a sister and brother who were peculiar, the latter
being known in his village as “ crazy Billy.”
Such was poor Barker’s unfortunate family history. There was a predispos¬
ing cause of insanity—heredity—in full measure.
Then comes an exciting cause—the death of his wife. His fellow-workers
described him as a sober man, depressed latterly, peculiar, and frequently
saying that he wished he was dead and in paradise. Several of his mates
thought he would commit suicide.
Suspicions developed, and centred on a lodger—Creasey, a schoolmaster—who
had been excessively kind to him at the time of Mrs. Barker’s death. He accused
him of improper relations with a niece who had come to live with him after
Mrs. Barker’s death. No evidence was adduced, so far as we are aware, that
established this allegation. Barker determines that his niece must leave. He
asks Creasey to see her off and pay her fare, which he would refund. Creasey
after this writes a note to him, to say he is not returning to his quarters.
Barker meeting Creasey later on attempts to strike him. A temporary
reconciliation follows. However, Creasey does not lodge any longer at Barker’s,
but at a Mrs. Wilkinson’s, next door. They rarely see one another after this.
Barker complains that his friends who usually came to see him to sympathize
with him on his wife’s death call less frequently. This he attributes to the
“ clandestine ” actions of Creasey. In July, 1891, he bought a revolver, and
about the same time wrote to Creasey the following letter:—
“ Linooln, Friday.
“ To Mr. Creasey,—I am the subject of all the slang and impudence from
your gang at Grimsby, I have no doubt from your encouragement. Be
careful, my boy, you have got a queer man to deal with. I am only cautioning
you. Be careful. I have no more to say now. You was always treated right
until you misbehaved yourself.
“ Barker.”
Creasey’s reply is too long to quote, but is a remonstrance and expostulation
highly creditable to his heart.
Subsequently Barker wrote:—
“ To Creasey,—I care not what your position and influence may being claim
for you to shield you ( tic ). I know you have been a bad, subtle, clandestine,
and collusive hunks, and if position will hide you, the right hand of justioe
will overtake you.
“ Barker.”
One would say that this is a typical letter of a man who is labouring under
persecution-mania.
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614
Notes and Nem,
[Oct.,
There is nothing important heard of Barker nntil November, 1882, when
there is a paper written by him leaving all he has to a friend. He says at
this time he felt life was not worth living, and that he was annoyed by singing
and the playing of a tin whistle by the people in the next honse where Creasey
lived, and that it was done to annoy him, and that he had to go out to escape
the noise, and on one occasion he complained about it. After Creasey left,
Barker lived alone almost the whole time; he says he never suffered in health
at any time except with indigestion. Bnt he “ suffered in spirit,” and no one
“ walking a level path in life conld understand his feelings.” The loss of his
wife and the “ clandestine conduct of Creasey was the burden of his daily
life.”
In the early part of May, 1893, he began to abuse his neighbour Mrs.
Wilkinson, and her lodger Creasey, accused them of immoral conduct, and
used threats towards him. On the 3rd May his conduct towards them was
such that they consulted a solicitor, and two summonses were taken out by
Creasey to have him bound over to keep the peace.
These summonses were served on Barker on the evening of May 3rd. He
called and saw Mrs. Wilkinson, said it was a party matter, and asked if it could
not be made up. She declined to make it up, and he did not see Creasey.
Barker seems to nave sat up and wandered about his house all that night,
and on one occasion tried to get into the house of Mrs. Wilkinson. It was
stated he had been drinking sherry and rum. Early next morning he talked to
Mrs. Wilkinson over the fence, and as she still refused to allow, and tried to
prevent him seeing Creasey by fastening the door, he shot at her, walked into the
house to Creasey's room, and when he opened the door shot Creasey. He then
went back to his own house, intending to shoot himself, but was arrested, and
when charged with the murder said, "I know that’s justice.”
The following notes were found, and had been written during the night:—
“ Mr. Booth, please make me a coffin just like my dear wife’s. Law is master
of me, but justice I have. They are dishonest, but they will suffer.
“ The clock on the room mantel shelf, writing desk in cupboard, my wife’s
watch and couch rug, I wish Mr. Hallam, of 17, Ash Grove, Bradford, to have
them.— Barker. And anything else be would like. The hymn book on table
for Mrs. Morris, widow of relieving officer.
" I am not answerable for what I have done, but I have done justice. He is
a dirty, subtle, crafty fellow. He has acted in an insidious manner because I
accused him of immoral actions in my house. He has acted most dirty and
* vindicative,’ and has caused me great annoyance, purposely. To set an
example I die to show that his academical position cannot screen him from
justice. He might, by bis position, command an influence, but I have suffered
in*spirit from his dirty knavery. I will leave the rest for the world. I know
I am not justified, but I have done it. I defy hell for speaking ill of me. If
he or any other young man had conducted themselves as well as I this would
not have happened. I accuse him of nothing before the girl came, but I spoke
to him of sitting up at night and co-habitation. It roused his inbred revenge.
A warning all round.”
And the following had been put under the door of Mrs. Mitchell during the
previous evening:—
”47, Danesgate.
“ Dear Mrs. Mitchell,—Come to my house early and take the thingB; do the
best you can. I owe nothing except gas j it has not been taken. It will only
amount to 10s. I have nothing against you. You should have come to see
me; but I forgive you.
“ Barker.’
At the trial evidence was given by Dr. Murray Lindsay, of the Derby County
Asylum, and Dr. Bussell, of the Lincoln Lunatic Hospital, that they found the
prisoner insane at the time of their examination, and labouring under delusions
of persecution. He believed he was shunned by his friends and that Creasey
Digitized by ^ooQle
Notes and News.
615
1893.]
was tbe cause of this. He believed that CreaBey bad gone out of bis way to
annoy him. He was unable to specify how Creasey had done this, except that
he was “ clandestine and insidious.” He knew he was doing it, but how he did
it he could not tell because he was so “ clandestine and insidious.” He said
that he had suffered in spirit, and his life was made miserable and unbearable,
by the clandestine conduct of Creasey, and though Creasey was a weakly man,
he felt he could only get at him by shooting him. They were of opinion that
after his wife's death Barker suffered from mental depression, and that at the
time he shot Creasey, he was under these same delusions of persecution, that his
conduct and actions were so ruled and dominated by these delusions as to
render him irresponsible; that though he knew the nature and quality of the
act, and probably knew that it was contrary to law, he believed himself
justified.
Dr. Bastian gave evidence that he had not found Barker insane, but that he
had “ unfounded suspicions,” which were not easily to be distinguished from
delusions. He believed him to be a man morbidly sensitive brooding over a
supposed wrong, and this sort ef thing had gone on for a couple of years,
Creasey always being in his sight. He had attempted no violence, and the
thing that led to the action was the issue of the summonses*
Dr. Bastian did not consider him any more insane at the time of the shooting
than any man might be said to be who was in a paroxysm of passion.
“ I am perfectly clear that he is not mad now, bat whether he was mad at the
time of the act I am not so positive, but my strong conviction is that in all
probability he was not mad.”
Mr. Mitchinson, the prison surgeon, stated that he had not seen any symptoms
of insanity in the prisoner whilst in the prison. He agreed that a man suffering
from ideas of persecution, if they were persistent, was insane.
The Judge, in summing up, put two questions to the jury. 1st—Did the
prisoner know the nature and quality of the act ? 2nd—Did he know that the
act was wrong, not in the sense of being contrary to the laws of the country,
but contrary to the man’s internal idea of right and wrong ?
The charge to the jury was marked by great fairness. The impression it
conveyed was that the Judge leaned to the opinion that the prisoner was insane
at the time he committed the, murder.
The Jury returned a verdict of “ Guilty,” and not insane.
Two experts (Drs. Nicolson and Braine) were afterwards sent by the Home
Office to examine Barker, the consequence of their report being that the
sentence was commuted to penal servitude for life.
We understand that Barker is to be at Broadmoor for three months under
observation, and that if his mental condition at the end of that time is sound
he will be treated as an ordinary criminal.
Obituaries .
M. CHARCOT.
This Prince of neurologists, and an Honorary Member of this Association
•died August 16th, 1893, a loss to medical psychology and neurology which can
scarcely be exaggerated. Original in his observations, earnest in the pursuit
of the knowledge of nervous diseases, rapid but sound in his diagnosis, a master
in clinical medicine and pathology, he has left a void which no contemporary
is likely to fill.
Jean Martin Charcot was born in Paris, November 29th, 1825, and was
therefore in his 68th year when he died. He was of somewhat humble origin,
* Barker, however, had previously attempted to assault Creasey, had written threatening
letters in July or August, had complained of the noises, saying they were done to annoy him,
had abused Mrs. Wilkinson, and, therefore, they were obliged to take out the summonses.
Digitized by ^ooQle
616
Notes and Nens.
[Oct.,
but Ma native genius was not to be repressed by the narrow circumstances in
which he was born. More dangerous to his success in a laborious profession
was the fortune he enjoyed through his marriage, but this failed to slacken his
energies. He graduated in 1853. In 1862 he was appointed physician to the
Salpetridre, which he made famous by his own fame.
He became a member of the Academy of Medicine in 1873. and a member of
the French Institute in 1883.
For medico-psychologis ts his most important works are his “ Maladies des
Viellards etles Maladies Chroniques ** and his “ Maladies du Systdme Nerveux,”
translated for the New Sydenham Society by W. S. Tuke and Geo. Siger-
son respectively. Also his “Lectures on the Localizations of Cerebral and
Spinal Diseases,” edited by W. B. Hadden. The “Archives de Neurologic,”
commenced in 1880, must always possess great value for the psychologist, and it
wasin that Journal that his first articles on hypnotism appeared. He was assist¬
ed by one of his pupils. The “ Nouvelle Iconographie de la Salpdtri&re ’* is of
unique interest. He met his death while enjoying his holiday with two medical
• friends. They put up at an inn at Settons, near Chateau Chinon. Before
retiring to rest he scribbled a note to his son, ending with “ I hope to finish
to-morrow, as we must rise before six. I must now try to sleep.” His sleep
was the sleep of death. He was found dead in bed next morning, the supposed
cause being angina pectoris. We shall not look upon his like again.
We are indebted to the “ British Medical Journal,” August 26th, for the
following leader on Charcot in relation to Hypnotism
“ It would have been strange had so far-reaching yet profound a student of
the nervous system in health and disease as Professor Charcot failed to include
m his range of investigation the phenomena of hypnotism but for the fact that
so many neurologists who preceded him had passed them by. It was, we well
remember, suggested to him by an English physician some fifteen years ago,
when he showed his cases of hystero-epilepsy at the Salp6tri6re, that he would
obtain great help in his neurological researches from the. study of hypnotism,
as described in the works of Mr. Braid. He responded to the suggestion. It
was only a few months afterwards that he showed his experiments in hypnotism
to the same physician, and bore testimony to the value of the researches of
le veritable initiateur dans ce genre $ etudes. Passing over these fifteen years
we have it from himself, within a short period of his lamented death, that he
had found in hypnotism * a rich field ’ for liis studies in neurology.
“ Let us clearly understand the exact position which he took. We can speak
of this with confidence. He held that the condition induced by artificial
means is a neurosis, and a neurosis allied to hysteria. It is true he qualified
this pronouncement by admitting exceptions, but this statement is essentially
correct, and herein his teaching differed notoriously from that of the Nancy
school, so ably represented by Bernheim. One explanation of this divergence
of opinion on so cardinal a point is that the combatants were concerned with
cases differing widely for the most part in their character and in the range of
mental phenomena. Visits to Paris and Nancy at once proved that this was so.
It may well be that both were right, and that a clear definition of the sense in
which they employed the same word would have averted the misunderstanding
which arose.
“ The fact is that the extreme and exclusive theories of either school are
equally untenable. Charcot, on the one hand, triumphantly pointed to the
hypnotic subject suddenly rendered cataleptic by the mere sound of a gong,
without one word of suggestion. Bernheim, on the other hand, could readily
demonstrate the enormous and unsuspected effect of suggestion in simulating
the very phenomena which the great Salp6tri&re physician induced without it.
5 1S > “ owev ® r > a great mistake to suppose that the latter ignored its potency.
He did nothing of the kind, although he may not have made sufficient allow¬
ance for its effect in misleading the observer, especially in his earlier researches.
The formula of his rival ‘no suggestion, no hypnosis,* was confuted, in the
opinion of Charcot, by a single instance of spontaneous somnambulism. It is
Digitized by ^ooQle
1893.]
Notes and News.
617
an advantage to have been able to look coolly on the rival theorist*, and to
hear what could be said on either side with great ability and force by two dis¬
tinguished and honest men. Both have had the oourage to investigate a
singularly difficult class of phenomena—to some extent different, but closely
allied—and both have had the merit of throwing much light upon them,
although from opposite points of view. One of the strongest proofs of the
occurrence of physical signs wholly independent of suggestion which Charcot
was able to adduce was the highly interesting phenomenon of neuro-muscular
hyper-excitability, one of the most certain characteristics, he used to say, of
hypnosis. Delicate pressure on a point in a limb or on the face, which in the
normal state produces no effect on the muscle, was found by him to be followed
by its proper physiological action, when the subject was in a certain stage of
hypnotism. He used this incontestable fact in a twofold manner, first to refute
the explanation offered by the upholders of * suggestion * as a universal
solvent, and secondly, to confute opponents who had recourse to * imposture * as
the correct explanation, for he was accustomed to say that both objectors must
believe an ignorant woman to possess as minute a knowledge of the action of
each muscle as Duchenne himself.
“ Among the many examples of muscular contraction produced in susceptible
persons in the hypnotic state, Charcot was fond of showing the delicate
response to pressure on the ulnar nerve at the elbow, the subject’s hand assum¬
ing the position termed griffe cubitale. But in truth this was but one of
numberless clinical illustrations which the master gave. It is sad to think we
can never witness them again. He has, however, left able successors imbued
with his teaching and familiar with the nature and signs of hypnosis. More
than this, he has left behind the solid and lasting results of his investigations
in not only confirming, but extending, the conclusions at which Braid arrived ;
in reducing to something like order the multiform phenomena of artificial
sleep, and in bringing within the range of medical science and the laws of
physiology, abnormal states of the nervous system, regarded by the vulgar as
miraculous, and formerly by many medical men as fraudulent.
“ There was one circumstance bearing on Charcot’s doctrine of the neurotic
nature of the hypnotic state to which must be given due weight, and that is that
the patients upon whom he made his experiments were already in a highly
nervous condition. Now this undoubtedly served to colour the symptoms he
observed, and^consequently the inference he drew as to the close alliance
between hypnotism and hysteria. This is forcibly indicated by the fact that he
has adopted for the title of his lucid article in the ‘ Dictionary of Psychological
Medicine ’ the significant words * Hypnotism in the Hysterical.* Hence it was
that his observations were mainly conducted upon the female sex, the result
being a study of a special organization. Making due allowance for this lact,
which has been too much overlooked, he doubtless instituted an interesting
parallelism between the two—the hypnotized and the hysterical—in his classic
descriptions of the lethargic, cataleptic, and somnambulistic states, in the
contractures and rigidity observed in both, as also in the sleep itself. The mis¬
take was made—and, it must be owned, not unnaturally—by other experi¬
menters of looking for these stages in every case of hypnotism, and, when not
found, blaming Charcot's descriptions as imaginary or possibly manufactured.
He may have generalized too much; but whether he did so or not, it behoves us
constantly to bear in mind that he was surrounded by a peculiar group of
maladies, and that, when in other hands and in other environments, hypnotized
persons do not belong to this category, the three foregoing stages may be looked
for in vain. In a word, hysteria was the soil on which he experimented, and
when experiments are made upon another soil, the results may be very different
from those recorded by Charcot, being no longer stamped by the same hysteric
seal.
“ In conversing Vith Charcot in regard to the therapeutic value of hypnotism,
it was noticeable that he evidently felt less interest in this phase of the subject
xxxix. 40
Digitized by L^ooQle
618 Notes and News. [Oct.,
than in its purely clinical aspect, and it is certainly a singular circumstance
that while the faith cure, homoeopathy, and similar nonentities are notoriously
successful among the hysterical, hypnotism seems to be comparatively useless in
this class of patients.
44 No man was more opposed to quackery, and to him is due the credit ot
helping to rescue artificial somnambulism from the illegitimate embrace of the
charlatan. Fifteen years ago, only a strong man could have given the demon¬
strations which he gave without endangering his professional status, and a few
shallow visitors carped even at him ; but he passed through the ordeal with
impunity, and rendered it easy for others to prosecute the same studies. He
left an example to other investigators of avoiding the rocks on which some of
his confreres without his scientific instinct have foolishly run their craft and
suffered well-merited shipwreck. Never did the illustrious Professor at the
Salp^triere allow himself to be drawn aside from the path of inductive science.
His scorn of the frauds and follies which sprang up in a credulous circle outside
his own school was only equalled by that which he manifested for the
incredulous ignoramuses in his own profession who sneered at phenomena
which they could not understand, but in which he recognized, like our own
Laycock, a rich source of neurological and psychological knowledge/’—
“ B. M. J.,” August 26, 1893.
M. DELASIAUVE.
Dr. Delasiauve (Louis Jean Francis), who died on the 5th of June last, had
well-nigh reached his 89th year. lie was born on the 14th of October, 1804, at
Garennes, in Normandy. Anxious to study the medical sciences, he came early
to Paris, where it was his privilege to see the great alienist, Pinel.and to attend
his funeral. He was a pupil of Esquirol and Ferrus, and a friend of J. P.
Falret, F. Yoisin, Treiat, Leuret, Calmeil, Foville, Parchappe, Moreau de
Tours, L61ut, Baillarger. One of these well-known, alienists is still alive j at
this very moment Calmeil enjoys good health, and is now 95 years old; he
resides close to Paris, at Fontenay sous Bois. Delasiauve took the degree of
Doctor in 1830, a few days after the Revolution and the fall of Charles X. He
returned to the Country, and during about twelve years was a practising physician
at lvry la Bataille, a small town near which Henri IY. defeated Mayenne and
the Ligueurs in 1590. He succeeded wonderfully. But in such a place there
was not sufficient room for his great activity. He came back to the metropolis,
and after a brilliant competition was received as a physician in the Paris
hospitals. In 1844 he obtained a ward at Bic£tre. The study of idiocy and
epilepsy had a great attraction for him; he was fond of those unfortunate
children, whose life is a long distress, and endeavoured to educate the idiots.
He opened a special school at Bicetre, and some years afterwards at the Salpe-
triere. As an alienist he is well known, and his private life was excellent. His
friends and pupils will never forget his kindness.
. Some of Delasiauve’s principal books and notices were as follows:—
Du diagnostic differential du delirium tremens, ou stupeur ebrieuse (“ Revue
Medicale,” 1850).
D’une forme grave de delirium tremens (Idem., 1852).
Sur la stupidity ou meiancolie avec stupeur (Idem., 15 Octobre, 1853).
Consultation medico-iegale sur une alienation mentale occasionnee par les
vapeurs mercurielles (‘‘ Experience/’ Ddcembre, 1840).
Mdmoire sur l’extase ( 44 Re veil de PEure,” 1842).
Essai de classification des maladies mentales (Idem., 1814).
Considerations thdoriques sur la folie (lues 1*Academic de Medicine, en
1843.)
Digitized by ^ooQle
1893.] Notes and News. 619
Influence da cholera sur la prodaotion de la folie (“ Annales M6dioo-Psyoho-
logiques,” 1849).
Du diagnostic diff^rentiel de la lypemanie (Idem., 1851).
De la classification et du diagnostic diftgrentiel de la paralysie generate (Idem.,
Observations de rougeole chez les idiots (Idem.).
D’une forme mal decrite de d41ire cons4cutif a l’Spilepsie (Idem., 1852).
Note sur le traitement de l’£pilepsie par les frictions stibies sur le cnir
cheveln (Idem.).
De la monomanie au point de vue psycbologiqne et legal (Idem., 1853).
Traitd de I’gpilepsie (1854).
Des principes qui doivent prtaider & l’education des idiots (1859).
Discours aux pris des enfants epileptiques, idiotes et alienees de la SalpAtri&re.
Classification des maladies mentales, ay ant pour double base la psychologic
et la clinique (“ Progres Medical/' 21 fevrier, 3 et 10 mars, 1877).
M. Delasiauve edited the “ Journal de Medicine Mentale” from 1860 to 1871.
Ren£ Sbmelaigne.
M. BLANCHE.
It falls to our lot to chronicle the death of another Paris physician. All
three were honorary members of onr Association.
M. Blanche had a bountiful supply of the milk of human kindness, and was
beloved by every one. He was, in truth, «n grand homme de Hen . His loss
will be mourned by not a few English alienists who visited him in Paris or
met him in England.
Antoine-Emile Blanche was born in Paris, October lat, 1820, and was conse¬
quently 72 years of age when he died on the 15th August last. He was born in
the Maison de Santd, founded by his father. He became Doctor of Medicine in
1848. When his father died he became the director of the asylnm.
It was when conversing with his patients that M. Blanche coaid be best
judged and the nobility and delicacy of his heart appreciated. No one possessed
more tact and ability in gaining the confidence of the insane and consoling
them in their sorrows. To those in indigent circumstances he was generous in
the extreme. Many mourn his loss sincerely who have thus benefited by his
kindness—a charity of a very unobtrusive character. His benevolence was not,
however, his only quality; he took a high position in the special department
to which he devoted himself. He was the author of several works, one of
which, “ Les Homicides commis par les Ali6n6s” (1878), is valuable both for its
record of cases and his commentaries. He also wrote articles on Melancholia,
the Moral Treatment of Insanity, Mental Alienation as a Justification of
Divorce, and the Reform of the French Lunacy Law.
On the question of divorce on the ground of insanity, he gave evidence before
the Commissions appointed by the Senate and the Chamber, and, supported by
Charcot, Motet, and Magnan, he successfully contended that the marriage tie
should never be dissolved on this ground.
For thirty years M. Blanche was consulted in nearly every criminal case in
which the plea of insanity was set up.
M. Blanche was made a Chevalier of the Legion of Honour in 1854.
He consecrated his last days to his patients at Passy, and nothing but illness
induced him to suspend his work. He was only confined to bed for a dozen
days; then he passed away, “ avec le calme d’une belle &me et aveo la con¬
viction profonde qu’il n’avait fait que le bien touto sa vie,’’ to quote the words
of a Paris medical journal, to which we are indebted for much of the foregoing
notice.
Digitized by ^ooQle
620
Notes and News.
WINNER OP THE BRONZE MEDAL AND PRIZE OF TEN GUINEAS.
Alfred Walter Campbell, M.D.Edin., Assistant Medical Officer, County
Asylum, Rainhill.
A Special Prize of Five Guineas was awarded to Edwin Goodall, M.D.,
Pathologist, Assistant Medical Officer and Pathologist, West Riding Asylum,
Wakefield, for the excellence of his essay.
M.P.C. EXAMINATION.
England.
The following candidate for the M.P.C. passed the Examination, held at
Betblem Hospital, July 18th, 1893:—
Robert Wilson, Brislington House.
Scotland.
D. R. T. Strong.
R. D. Hotchkis.
S. Edgerlky.
A. Low.
C. G. Cowik.
P. J. Henderson.
L. Grant.
R. St. Geo. S. Bond.
J. Macmillan.
J. W. Myers.
A. Rose.
EXAMINATION FOR CERTIFICATE OF PROFICIENCY IN NURSING.
The next Examination for this Certificate will be held on the first Monday iu
November. All inquiries in connection with this Examination should be ad¬
dressed to the Registrar,
Dr. Spence,
Burntwood Asylum, Lichfield.
Appointments.
Johnston, G. H., L.R.C.P. and S.Ed., appointed Junior Assistant Medical
Officer to the North Riding Asylum, Clifton, York.
Kershaw, n. W., M.R.C.S., L.R.C.P., appointed Senior Assistant Medical
Officer to the North Riding Asylum, Clifton, York.
Skae, F. M. T., M.B., C.M.Ed., appointed Junior Assistant Medical Officer to
the Stirling Asylum, Larbert.
Taylor, F.R.P., M.B., B.S.Lond., appointed third Assistant Medical Officer to
the London County Asylum, Claybury.
PHOTOGRAPHIC GROUP OF THE BUXTON MEETING.
The photographs were a great success. Four separate groups were taken.
The price of each is 3s. mounted, 2s. 6d. unmounted. Nos. 1 and 2 are
identical, and contain the largest number taken. No. 2 is rather the best, and
contains the largest number (55). No. 3 contains 28 photographs, excluding
Drs. Clouston, Howden, Ray tier, Rutherford, Hack Tuke, and others. Photo
very clear. No. 4 is good, with the exception of the worthy Treasurer, and con¬
tains 24 photos, including the above-mentioned names.
Apply to Mr. D. C. Latham, Photographer, Station Road, Buxton.
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622
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628
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S?
Brit. Med. Jou
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Lancet, Oct.
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| Jan. 27, 1893.) beef tea.
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Table lb ( Continued ).—Cases of Myxcedema Treated by the Ingestion of Thyroid Preparations.
630
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INDEX TO VOL. XXXIX.
Act, Lunacy, remarks on, 495
Aonte delirious mania, 152.
Address, Presidential, 1893, 473, 550, 602
etiology of general paralysis, 585
Aitken, Dr. Thomas, obituary, 151,158
Alcoholio neuritis with insanity, 320
Alcoholism, 123,281, 234, 294 425,
„ not a cause of insanity, 116
Alleged increase of insanity, 606
Altbaus, Dr. J., on psychoses after influenza, 163
American Journal of Insanity, printed and bound in asylum, 322
„ Medico-Psychological Association, 322
„ retrospect, 581
„ superintendents of asylums and politics, 401
Amok of the Malays, 325, 157
Anaesthesia, sensory, loss of consciousness after, 129
Anohylostomiasis, 103
Annual meeting of the Med-.Psyoh. Association, 660
„ „ „ British Medical Association, 605
Anthropology, criminal, 102, 134,442
Aphasic defect, singular case of, 584
Appendix of Tables to Dr. Beadle’s article on myxoedema, 621
Appointments, 162, 324, 472, 620
Arithmetic, origin of, 105
Asylum chaplain’s report, 410, 558
„ dietaries, 154
„ heating, 317
„ management under County Councils, 605
,, out-patient system, 491
Digitized by L^ooQle
042
Index .
Asylum Reports
Aberdeen, 116
Argyle and Bute, 118
Bedford, Hereford, and Hunting¬
don, 118
Berks, 116
Bethlem, 117
Birmingham, 117, 290
Bristol, 117
Broadmoor, 291
Cambridge, 117
Carmarthen, 118
Cheshire, 118,119
Derby, 119
Devon, 120
Dorset, 291
Dumfries, 121
Dundee, 120
Earlswood, 122
Edinburgh, 122, 123
Exeter, 124
Glamorgan, 125, 292
Glasgow, 126
Gloucester, 126
Govan, 126
Hants, 127
Hereford, 127
Holloway Sanatorium, 127
Hull, 128
Inverness, 128
Ipswich, 292
Isle of Man, 128
Athens, the hospital of, 338
Attendants’ annual leave, 278
,, hours of labour and duty,
„ instruction of, 278, 290
„ training of, 317
Audition oolor6e, 101
Australia, Fremantle Asylum, 321
Ball, Prof., obituary, 323
Beadles, Dr. C. F., the treatment of
thyroid gland, 343, 509, 621
Beer, disuse of, 276
Blanche, M., obituary, 619
Kent, 128
Lancashire, 292, 293, 294
Leicester and Rutland, 274
Leicester (Borough), 274
Limerick, 275
Lincoln, 275
London, 275, 276, 277, 278
Middlesex, 278
Midlothian and Peebles, 294
Montrose, 279
Newcastle, 279
Norfolk, 279
Northampton, 280
Northumberland, 281
Norwich, 282
Nottingham, 282, 283
Oxford, 283
Perth, 283
Roxburgh, Berwick, and Selkirk,
283
Salop and Montgomery, 284
Somerset and Bath, 284
Staffordshire, 284
Suffolk, 295
Surrey, 295
Sussex, 285
Warwick, 285
Wilts, 286
Wonford House, 286
Worcester, 287
Yorkshire, 288, 289
myxoedema and cretinism with the
478
Digitized by ^ooQle
Index .
643
“ Blot on the brain,” 322
Boarding out system, 124
Brain, Chinese, 576
„ massage of, 612
„ neural aotion corresponding to the mental function of the, 16
„ preservation of, 440
„ plaster oasts of, 298
„ scheme for examination of, 437
„ temperatures and psychic phenomena, 273
Braine-Hartnell, Dr. 6. M. P., aoute melancholia, 397
Bristowe, Dr. H. C., pachymeningitis hsemorrhagioa, 546
British Medical Association meeting, Psychological Sec., 605
Brongh, Dr., sulphonal in refusal of food, 543
Brown-S6quard’s hypodermic injeotion of testicular fluid, 417
Bullen, Mr. F. St. John, out-patient system in asylum, 491
„ „ variation of type in general paralysis, 185
Butler-Smythe, Mr. A. C., acute mania following rupture of reotum, 389
Carebaria, 18
Campbell, Dr. H., sensations of cephalic pressure and heaviness, 18
Cases of abnormal development of the scalp, 62, 226, 536, 539
,, hereditary chorea, 50
Celtio Highlanders, diseases of, 312
Cephalic pressure and heaviness, sensations of, 18
Chaplain, the good asylum, 399
Chaplain’s column, 410, 558
Charcot, Prof., obituary, 615
Children, speoial instruction of, 553
Chronic cases, recovery of, 291
Chronicle of infant development and characteristics, 378, 498
Classes for special instruction in connection with the London Sohool
Board, 553
Claustrophobia, 609
Colour hearing, 101
Commissioners’ reports, 65, 82, 560
„ might be strengthened, 486
Compulsory legislation for habitual drunkards, 234
Confessions of a thief, 137
Congress of criminal anthropology, international, 154
County Councils, working of, 487,605
Cowan, Dr. J. C., abnormal development of scalp, 539
Cretinism, treatment by thyroid gland, 519
Crime and punishment, 555
Criminal anthropology, retrospeot of, 102,134, 442
Criminality and insanity in women, 445
Digitized by
Google
644
Index.
Criminals, psychological examination of, 12,102
Criminal responsibility, test of, 407
Criminology, 415, 574
Deaf mates, 586
Delasianve, M., obituary, 618
Delusions, variability in, 586
Detached hospitals in connection with asylums, 609
Dictionary of psychological medicine, 106
Diseases of Celtic Highlanders, 312
Downie, Bev. T., religion and its influence on the insane, 558
Dress-fitting for female inmates, 200
Drunkards, compulsory legislation for, 234
Drunkenness as a cause of insanity, 123, 281, 294,425
„ not a cause of insanity, 116
Dunn, Dr. E. L., on so-called paranoia, 28
Dura mater, endothelial tumour of, 214
Ear abnormalities in criminal women, 136
Ear diseases and insanity, 299
Education from the medical standpoint, 113, 553
Effect upon mental disorder of localized inflammatory conditions, 94
Electrotherapy, 449
Ellis, Dr. W. G., the amok of the Malays, 325, 457
Ellis, Dr. H., criminal anthropology, 134, 442
Elmira reformatory, 442
Endothelial tumour of dura mater, 214
English retrospect, 116, 274
Epileptics, colonization of, 114, 274
,, clinical and therapeutic researches on, 260
„ marriages of, 292
Ethylio chloride, 451
Evolution, 429
Exalgine, 455
Expression in the insane, 177
Farm of the Omagh Asylum, 197, 318
Feet of criminals, 136
Finegan, Dr. A., systematic dress-fitting for female patients, 200, 317
Food refusal treated by sulphonal, 543
„ „ new treatment, 587
Formation of subdural membranes, 203, 368
Foy, Mr. G., hypertrophy of scalp, 536
Fremantle Asylum, 321
French hypnotic literature, 93
Digitized by L^ooQle
Index.
645
General paralysis, increase of, 277
„ „ aetiology of, 585
„ „ occurring at puberty, 305, 355
„ „ syphilitic, 217
„ „ trephining in, 608
„ variation in type, 185
„ „ with peripheral neuritis, 304
German retrospect, 129,299, 584
Goodall, Dr. B., the effect upon mental disorder of localized inflammatory
conditions, 194
„ pathological retrospeot, 296, 437, 576
Greece, insanity in, 338
Guiana Medical Annual, 102
Hallucination, unilateral, 300
„ theory of, 301
Heating asylums, 317
Hereditary genius, 412
Heredity, theory of, 420
Hitchman, Dr J., obituary, 470
Homicidal impulse, sudden, 290
Hospitals in connection with asylums, 609
Huntington’s disease, 50
Hypertrophy of scalp, 226, 536, 539
Hypnal, 452
Hypnotism, 1, 88, 93, 268, 616
Hysteria, 260, 272, 428, 571
Idiocy, cure of by craniectomy, 122
„ clinical and therapeutic researches on, 260
Idiots, education of, 113, 279
Illenau’s golden jubilee, 158
Improved reaction time instrument, 505
Inebriates Act, 403
Infant development and characteristics, 378, 498
Inflammatory conditions and mental disorder, 194
Influenza, insanity after, 123, 277, 283
„ psychoses after, 143, 163
Insane, expression in the, 177
„ patients, state aid to poor, 610
, progress in the care for, 581
Insanity acute, with sexual perversion, 225
„ alleged increase of, 606
„ caused by over-indulgence, 126
„ cured by trephining, 295, 608
Digitized by Google
646
Index.
Insanity, feigned, 293
„ following multiple neuritis, 302
„ in Greece, 338
„ toxic, 586
Inatraction in physiological psychology, 406
Intemperance, 294, see also alcoholism
International association of criminal law, 449
„ congress of criminal anthropology, 154
Intestinal disinfection in acute insanity, 37
Inquiries into a variation of type in general paralysis, 185
Ireland, report of inspectors for, 82
Ireland, Dr. W. W., German retrospect, 129, 299, 584
Irish quarterly meeting, 315
Irving’s (Mr.) “ Lear,” 228
Lady members, question of admission to association, 598
Lewis, Dr. Be van, improved reaction time instrument, 505
Lincoln murder, 613
Lindsay, Dr. J. M., Presidential address, 473, 550
Lishman, Mr. F., endothelial tumour of dura mater, 214
Locomotor ataxy, 271
Lombroso and the natural history of the criminal, 134
Loss of consciousness following anaesthesia, 129
Lysol as a preservative for nerve tissue, 439
Macpherson, Dr. J., intestinal disinfection in some forms of insanity, 37
Mania, acute delirious, following rupture of rectum, 389
„ „ treatment of, 152
Massage of the brain, 612
McDowall, Dr. T. W., abnormal development of scalp, 62
Mechanical means of bodily restraint, 469
Medical superintendents* residence in asylums, 459
Medico-legal aspects of Neill’s case, 71
cases, 71, 231, 232, 407,613
„ examinations of criminals, 12
„ journal, 448
Medico-psyohological examinations, 161, 323, 620
„ Association quarterly meetings—Proceedings and discus¬
sions—
October 27,1892, in Ireland, 815
Election of members, 315
Appointment of committee to look after Irish interests and affairs of
the Association, 316
Training of attendants, 317
Systematic dress-fitting for female patients, 317
Digitized by ^ooQle
Index .
647
Heating Asylums, 317
New farm at the Omagh Asylum, 318
Bilateral atrophy of certain groups of muscles in the neck—Dr. V. J.
Ruttledge, 320
Alcoholic neuritis with mental disease—Dr. Nash, 320
Sexual perversion recurring in acute mania—Dr. W. C. Sullivan, 320
November 17th, 1892, in London, 142
Assistant medical officers, 142
Influenza and the neuroses—Dr. Savage, 142
Payment of patients for their work—Dr. Meroier, 149
Acute delirious mania—Dr. G. M. Robertson, 152
Next meeting to be at Liverpool, 154
March 9,1893, in Liverpool, 304
General insanity occurring about the period of puberty—Dr. Wigles-
worth, 305
The out-patient system in connection with asylums and its further de¬
velopment—Dr. F. St. John Bullen, 308
Diseases of the Celtic Highlanders—Dr. J. C. Mackenzie, 312
May 18, 1893, in London, 456
Election of members, 456
Dr. Rend Semelaigne elected corresponding member, 457
The amok of the Malays—Dr. G. Ellis, 457
Medical superintendent’s residence in asylums—Dr. Lindsay, 459
July 28th, at Buxton, 588
Election of president and officers, 588
„ examiner, 589
Treasurer’s report, 589
Auditor’s „ 589
Next annual meeting, 591
Proposed extension of annual meeting to three days, 592
The title of “ Royal,” 594
Handbook committee’s report, 595
Rules „ „ 695
Educational „ „ 597
Dietary „ „ 597
Nomenclature of disease committee, 597
Rooms in London, 598
Admission of lady members, 598
Election of ordinary members, 601
Motion by Dr. J. A. Campbell, 601
Honours, 602
General index, vote of thanks to Dr. Raynor for, 602
President’s address, 603
Presidential address, 478
Annual meeting, 550
Photographic group of members, 620
Digitized by L^ooQle
648
Index.
Melaucbolia, acute, case, 397
Meotal disorder, effects of localized inflammatory conditions on, 194
Menzies, Dr. W. F., hereditary chorea, 50
Mercier, Dr. C., payment of asylum patients, 45
Microscopical sections of nerve tissue, 296
n » „ stains, 441,577
Morel, Dr. Jules, psychological examination of prisoners, 12
Morley v. Loughnao, 232
Morphinomania, treatment of, 454
Murray Lindsay, Dr. J., Presidential address, 473
Museum of psyohiatry and criminology, 134
„ preparations, 297
Myxoedema and sporadic cretinism, 320
„ treatment of with thyroid gland, 343, 509, 519
Needle thrust in stomach, 288, 397
Needles and pins swallowed by patient, 116
Neill s case, 71
Nervous and mental disorder from organic sulphur compounds, 265
Neural action corresponding to the mental functions of the brain, 16
New treatment of patients refusing food, 587
Nolan, Dr. M. J., syphilitic general paralysis, 217
Number of deaf mutes in Norway, 586
Nursing certificates, 160, 465
Obituary—Aitken, Dr. T., 158
Ball, Prof., 323
Blanche, M., 619
Charcot, M, 615
Delasiauve, M., 618
Despine, Dr. M. Prosper, 159
Hitchman, Dr. J., 470
Omagh asylum farm, 197, 318
On the possible use of sulphonal for refusal of food, 543
Open-door system, 121
Original articles—
Althaus, Dr. J., on psychoses after influenza, 163
Beadles, Dr. C. F., the treatment of myxoedema and cretinism with the
thyroid gland, 343, 509. Appendix of tables, 621
Braine-Hartnell, Dr. G. M. P., acute melancholia: attempted suicide by
inserting a needle into the abdomeD, 397
Bristowe, Dr. H C., two cases of pachymeningitis hsemorrhagica interna, 546
Brough, Dr., on the possible use of sulphonal as a means of inducing
insane patients who refuse food to eat voluntarily, 543
Bullen, Mr. F. St. John, inquiries into a variation of type in general
paralysis, 185
Digitized by L^ooQle
Index.
Bullen, Mr. F. St. John, out-patient system in asylums, 491
Butler-Smythe, Dr. A. C., acute mania following rupture of the rectum by
enema after ovariotomy, 389
Campbell, Dr. H., sensations of cephalic pressure and heaviness, pesanteur
de tete, Kopfdruck, 18
Cowan, Dr. J. J., two cases of abnormal development of the scalp, 539
Downie, Rev. T., religion and its influence on the insane, 558
Dunn, Dr. E. L., on so-called paranoia, 28
Ellis, Dr. W. G., the Amok of the Malays, 325
Finegan, Dr. A., systematic dress-fitting for female inmates of asylums
200
Foy, Mr. G., hypertrophy of scalp, 536
Goodall, Dr. E., the effect upon mental disorder of localized inflammatory
conditions, 194
Lewis, Dr. Bevan, an improved reaction time instrument, 545
Lindsay, Dr. J. M., Presidential address, 473
Macpherson, Dr. J., remarks upon the influence of intestinal disinfection
in some forms of acute insanity, 37
MoDowall, Dr. T. W., case of abnormal development of scalp ( Illus¬
trated ), 62
Menzies, Dr. W. F., cases of hereditary chorea (Huntington’s disease
( Illustrated ), 50
Mercier, Dr. C., the payment of asylum patients for their work, 45
Morel, Dr. Jules, the psychological examination of prisoners, 12
Nolan, Dr. M. J., syphilitic general paralysis, 217
Poggi, Dr., hypertrophy of the scalp in a lunatic (Illustrated), 226
Robertson, Dr. G. M., the use of hypnotism among the insane, 1
„ „ „ the formation of subdural membranes, or pachy¬
meningitis hsemorrhagica, 203, 368
Sanborn, F. B., Esq., insanity in Greece—the hospital of Athens, 338
Simpson, Sir W. G., a chronicle of infant development and characteristics,
378, 498
Smith, Dr. Percy, mechanical means of bodily restraint, 469
Sullivan, Dr. W. C., notes on a case of acute insanity, with sexual perver¬
sion, 225
Tarner, Dr. J., some further remarks on expression in the insane (Illus¬
trated), 177
Warner, Dr. F., neural action corresponding to the mental functions of the
brain, 16
West, Dr. G. F., some remarks on the new farm of the Omagh asylum, 197
Wiglesworth, Dr. J., general paralysis oocurring about the period of
puberty, 355
Out-patient system in connection with asylums, 808, 405
„ „ department for mental disease at St. Thomas’s Hospital, 612
Pachymeningitis hmtnorrhagica, 203, 368, 546
Digitized by ^ooQle
660
Index,
Paraldehyde, 152, 453
Paralysis agitane, histology of, 576
„ functional, 252
„ general, see general paralysis
Paranoia, so-called, 28, 242
Pathological retrospect, 296, 437, 576
An axis cylinder stain, 441
A neuroglia stain, 580
A simple method of fixing paraffin sections to slide, 581
Congo-red as an axis-cylinder stain, 577
Giacomini’s process for preserving brain, 440
Gravitz's preservative fluid, 440
Histology of the nervous system in paralysis agitans and senility, 576
Kulschitzky’s stain for central nervous system, 442
Lysol as a preservative, 439
Museum preparations, glycerine jelly for mounting, 297
Note on a Chinese brain, 576
Plaster casts of brain, 298
Photoxylin as an imbedding material, 580
Scheme for examination of brain, 437
Sections of fresh cord, 296
Stains for the central nervous system, 578
Stieda s process for preserving brain, 441
Sublimate-toluidin-blue method, 579
Van Gieson’s stain for the central nervous system, 577
Weigert’s process or Pal s modification, 578
Payment of asylum patients for their work, 45,149
Pental, 450
Peripheral neuritis in the course of general paralysis, 304
Philosophische studien, 88
Photography of patients, 119
Photographic group of the Buxton meeting, 620
Phthisis in asylums, 120
Pins and needles swallowed by patient, 116
Plaster casts of brain, 298
Poggi, Dr., hypertrophy of scalp, 226
Presidential address, 473, 602
Prevention of suicide in the insane, 157
Progress in the care and handling of the insane, 581
Prostitution, 574
Psychological examination of prisoners, 12
Psychoses after influenza, 163
Psychosis polyneurotica, case of, 303
Reaction time instrument, 505
Digitized by L^ooQle
Index.
651
Recent cases of insanity not to be sent to workhouse, 291
Rectum, rupture of, followed by acute mania, 389
Regina v. Barker, 613
Religio medici, article on, 266
Religion and its influence on the insane, 558
Remarks upon intestinal disinfection in some cases of insanity, 37
„ on the cut-patieut department for mental disease at St. Thomas's
Hospital, 612
Restraint, meaning of, 469
„ value of, 280, 286
Retrospect of criminal anthropology, 134, 442
„ English, 116, 274
„ German, 129, 299, 584
„ Pathological, 296, 437, 576
„ Therapeutic, 449
Reviews of books, see end of index
Robertson, Dr. G. M., hypnotism among the insaue, 1
„ „ „ pachymeningitis bsomorrhagica, 203, 368
Roe v. Nix, 231
Sainsbury, Dr. H., therapeutic retrospect, 449
Saint Amable, 238
Sanborn, F. B., Esq., insanity in Greece, 338
Savage, Dr., influenza and the neuroses, 143
Scalp, hypertrophy of, 62, 226, 536, 539
Scotland, report of Commissioners, 75
Scottish meeting, 151
Sections of fresh cord, 296
Semelaigne, Dr. R., elected corresponding member, 457
Sensations of cephalic pressure and heaviness, 18
Sexual perversion in insanity, 225
Simpson, Sir W. G., infant development and characteristics, 378, 498
Singular case of aphasio defect, 584
Sleep, depth of, 134
Smith, Dr. Percy, mechanioal means of bodily restraint, 469
St. John Ambulance examination, 322
Stains for nerve-tissue, 577
State aid for poor private insane patients, 610
Statistics of insanity, 560
Studies of criminals, 140
Suicide, attempted by needles, etc., 116, 289, 397
„ of young persons, 584
„ prevention of, 167
„ restraint necessary, 281
„ sudden impulse, 293
Digitized by ^ooQle
652
Index.
Sullivan, Dr. W. C., acute insanity with sexual perversion, 225
Sulphonal action, 450
„ in refusal of food, 543
Sulphur compounds, mental derangement from, 265
Superannuation to employes, etc., 286, 503
Sutherland, Dr., prevention of suicide in the insane, 157
Syphilis and the nervous system, 418
Syphilitic general paralysis, 217
Systematic dress-fitting for female patients, 200, 317
Tabes dorsalis, 271
Tennyson as a psychologist, 65
Therapeutic retrospect, 449
Thyroid gland treatment of myxosdema and cretinism, 343, 509, 519
Title of “ Royal,” 594
Townsend and the test of criminal responsibility, 407
Toxic insanity, 686
Treatment of habitual criminals, 140
„ myxoedema and cretinism, 343, 509, 519
Trephining in general paralysis, 608
Trional and tetronal, actions of, 452
Tuke, Dr. Hack, American Retrospect, 581
,. „ Alleged Increase of Insanity, 606
Turner, Dr. J., expression in the insane, 177
Two cases of abnormal development of scalp, 639
„ „ pachymeningitis haemorrhagioa interna, 546
Typhoid fever in asylums, 277, 279, 282
Unilateral hallucinations, 300
Unlocked doors, 121
Uric acid as a cause of disease, 97
Use of hypnotism among the insane, 1
Variability in delusions, 586
Vegetarian diet, value of, 279
Warner, Dr. F., neural action corresponding to the mental functions of the
brain, 16
West, Dr. G. F., the new farm of the Omagh asylum, 197,318
West London Medico-Chirurgical Society, 157
Wiglesworth, Dr. W., general paralysis occurring about the period of puberty,
305, 355
World’s Congress auxiliary, 322
REVIEWS OF BOOKS.
A dictionary of psychological medicine, edited by Dr. H. Tuke, 107
Anatomy of the brain and spinal cord, by J. R. Whitaker, 251
A new psychology : An aim at universal science, by the Rev. G. Jamieson, 424
Digitized by L^ooQle
Index.
653
Antropologia e pedagogia, Paolo Riooardo, 418
Arrdat, Luoien, Psychologic du peintre, 250
Asolepiad, the, by Dr. Richardson, 265
Atlas of clinical medicine, by Byrom B ram well, M.D., 111
Audition, colorde, by Dr. J. Millett, 101
Babinski, J., Grand et petit hypnotisme, 93
„ „ Hypnotisme et hystdrie: du r6le de 1’hypnotisme enthlrapeutique,
95
Ballet, G., Les suggestions hypnotiques an point de vue mddico-ldgal, 96
Bastian, Dr. H. G., Various forms of hysterical or functional paralysis, 252
Bourneville, Dr. M., Reoherches cliniques et thdrapeutiques sur l’^pilepsie
l’hysterie el Pidiotie, 260
Bruce, Dr. A., Illustrations of the mid and hind brain, 115, 258
By.rom Bramwell, Dr., Atlas of clinical medicine, 111
Calderwood, Dr. H., Evolution and man’s place in nature, 429
Carl Westphal’s Gesammelte Abhandlungen, 434
Cartwright, Mr. T., Mental science and logic for teachers, 114
Charcot, Prof., Cliniques des Maladies du systeme nerveux, 272
Cowper, W., The life of, by Thos. Wright, 274
Criminology, by Arthur Macdonald, 415
Der Rapport in der Hypnose, von Dr. Albert Moll, 268
Die Literatur der Psychiatric im xviii. Jahrhundert, von Dr. H. Laehr, 111
Die psychopathischen Minderwertigkeiten, von Dr. J. L. A. Koch, 100, 573
Diseases of the nervous system, by Dr. J. A. Ormerod, 112
Donna deliquente, la prostituta e la donna normale, by C. Lombroso and G.
Ferrero, 674
Drunkenness, by Dr. G. R. Wilson, 425
Ellis, Havelock, The naturalization of health, 423
Entartung, by Max Nordau, 249
Etat mental des hysteriques, par Pierre Janet, 428, 571
Evolution and man’s place in nature, by H. Calderwood, 429
Ferd, Ch., La pathologic des emotions, 245
Ferrero, G., La donna deliquente, la prostituta, etc., 574
Festschrift zur Feier des Jubilaiims der Anstalt Illenau, etc., 109
Forty-first report of the Inspectors of Lunatics in Ireland, 82
Forty-seventh report of Commissioners in Lunacy, 560
Galton, Francis, Hereditary genius, 412
Grand et petit hypnotisme, par J. Babinski, 93
Gowers, Dr W. R., Syphilis and the nervous system, 418
Haig, Dr. Alex., Uric acid as a factor in the causation of disease, 97
Hereditary genius, by Francis Galton, 412
Digitized by
Google
654
Index .
Hypnotism# et hysteric, da rdle de Fhypnotisaie a* thfcopeutiqua, par J.
Bobinski, 96
II romonzo di an deliquente noto, 574
Illustrations of the nerve tract# in the mid and hind brain, by Dr. Alex. Brace,
115,258
Introduction to physiological psychology, by Dr. T. lichen, 243
Janet, Pierre, Elat mental des bystdriques, le# stigmotes mentoax, 428, 571
Jamieson, Rev. O., A nevr psychology, an aim at universal science, 424
Krafft-Ebing, Dr. E. von., Psycbopathia sexualis, with speoial reference to
contrary sexual instinct, 251
Koch, Dr. J. L. A., Die psychopathischen Minderwertigkeiten, 100, 473
La pathologie des emotions, par Ch. F6r£, 245
Lectures on mental diseases designed especially for medical students and
practitioners, by Dr. H. P. Stearns, 241
Lemons sur les maladies de la Moelle, par le Dr. P. Marie, 270
Lefort, Dr. Ed., Le type criminel d’apres les savants et les artistes, 102
Le degenerazioni psico-sessuali nella vita degli individui e nella storm della
society, by Silvio Venturi, 416
Les phenomfenes psychiques et la temperature da cerveau, par le Prof. A. Mosso,
273
Les suggestions au point de vne medico-legal, par G. Ballet, 96
Lombroso, C., La donna deliquente, la prostituta, etc., 574
MacDonald, Dr. A., Criminology, 415
Marie, Dr. Pierre, Lemons sur les maladies de la Moelle, 270
Mental science and logic for teachers, by Thos. Cartwright, 114
Millet, Dr. Jules, Audition colorde, 101
Moll, Dr. Albert, Der Rapport in der Hypnose, 268
Mosso, Prof. A., Les phenomenes psychiques et de la temp6rature du cerveau,
273
Nordau, Max, Entortung, 249
On education from the medical standpoint, by Dr. G. E. Shuttle worth, 113
On the origin of arithmetic, von W. Preyer, 105
Ormerod, Dr. J. A., Diseases of the nervous system, 112
Peterson, Dr. Fred., The colonization of epileptics, 114
Philoaophische Studien, Jan., 1892, 88
Preyer, Dr. W., On the origin of arithmetic, 105
Protestant hospital for the insane, Montreal, 433
Psychologic du peintre, par Lucien Arrest, 250
Psychopathia sexuulis, by Dr. R. von Krafft-Ebiog, 251
Digitized by ^ooQle
Index .
(355
Eeoherches cliniques et thlrapeutiques sur I’epilepsie, Fhyst^rie et l’idiotie, par
M. Bourneville, 260
Biocardi, Dr. Paolo, Antropologia e pedagogia, 418
Richardson, Dr. B. W., The Asolepiad, 266
Shuttleworth, Dr. G. E., Education from the medioal standpoint, 113
Stearns, Dr. H. P. y Lectures on mental diseases designed especially for medical
students and general practitioners, 241
Syphilis and the nervous system, by Dr. W. R. Gowers, 418
The Fort England Mirror, 264
The British Guiana Medical Annual, edited by Messrs. J. S. Wallbridge and E.
D. Rowland, 102
The Colonization of Epileptics, by Dr. F. Peterson, 114
The germ-plasm, a theory of heredity, by Aug. Weismann, 420
The nationalization of health, by Havelock Ellis, 423
Traitd clinique et thgrapeutique de l’hysterie, par le Dr. Gilles de la Tourette,
247
Thirty-fourth annual report of Commissioners in Lunacy for Scotland, 75
Tuke, Dr. D. Hack, A dictionary of psychological medicine, 106
Uric acid as a factor in the causation of disease, by Dr. Alex. Haig, 97
Various forms of hysterical or functional paralysis, by Dr. H. C. Bastian, 252
Venturi, Dr. Silvio, Le degenerazioni psico-sessuali nella vita degli individui e
nella storia della societa, 416
Weissmann, Prof. Aug., The germ-plasm, a theory of heredity ; translated by
Dr. W. N. Parker and Harriett Roiinfeldt, B.So., 420
Wilson, Dr. G. R., Drunkenness, 425
Westphall, Dr. Carl, Gesammelte Abhandlungen, 434
Wright, T., The Life of W. Cowper, 274
Ziehen, Dr. Theo., Introduction to physiological psychology, 243
Digitized by ^ooQle
INDEX MEDIC0-PSYCH0L0GICUS,
Acetone in urine. De la presence de Face tone dans Fnrine des alienee. J. D«
Boeck. Bull. Soc. de Med. Ment. de Belg., Gand et Leipz., 1891, No. 62,
301-322.
Affection, Rapid death through violent moral. Morte rapida per affezione morale
violenta. (Osservazione sugli animali e considerazioni relative anohe all 1
uomo.) G. Bassi. Riv. Clin., Milano, 1890, xxix., 777-792.
Alcoholism. Climatic influences as related to inebriety. £. P. Thwing. Quart.
J. Inebr., Hartford, 1891, xiii., 309-313.
- The human constitution in its relation with the alcoholic crave. T. L.
Wright. Alienist and Neurol., St. Louis, 1891, xii., 548-555.
- Personality as it affects the course of drunkenness. T. L. Wright. J.
Am. M. Ass., Chicago, 1891, xvii., 823-828.
- Etiology of alcoholic inebriety. L. D. Mason. J. Am. M. Ass., Chicago,
1891, xvi., 627-629.
-- ■■ Pathologische Yeranderungen des Nervensystems bei den Alkoholpara-
lysen. G. Rummo. Wien. med. Wchnschr., 1891, xli., 1684-1687.
-and general paralysis. De Falcoolisme et de la paralysie g£n£rale dans
leurs rapports r5ciproques. Georges Roques. Par., 1891,85 p., 4o. No.230.
- as a cause of general paralysis. Du role de Falcoolisme dans l’5tiologie
de la paralysie generate. Rousset. Bull. Med., Par., 1891, v., 743-748.
— ■ ■ delirium. D61ire alcoolique; signes et traitement. Lanoereaux. Bull.
M6d., Par., 1891, v., 685-688.
- (acute), Muscular power in. Mesure de la puissance muscnlaire dans
Falcoolisme aigu. Grehant et Quinquaud. Compt. rend. Soc. de biol.,
Par., 1891, 9 s., iii., 415.
- (Paralysis alcoholica). A. Kojevnikoff. Vestnik klin. i sudebnoi psichiat.
i nevropatol., St. Petersb., 1891, viii., No. 2,180-209.
- paralysis. Paralysie alcoolique ohez les alidnds. A. Yigouroux. Gaz.
d. bop., Par., 1891, lxiv., 1047-1049.
- The chloride of gold cure for inebriety. T. D. Crothers. Med. Rec H
N.Y., 1891, xl., 613.
- Statistische und klinische Mittheilungen iiber Alkoholismus, insbeson-
dere iiber die Riickfalligkeit der Trinker. E. Siemerling. Charit4-Ann,,
Berl., 1891, xvi., 373-426.
- L’alcoolisme et la m&lecine legale. J. Devezac. J. de M6d. de Boiv
deaux, 1891-2, xxi., 1^-15.
■ Drunkenness is curable. J. F. Mines. N. Am. Rev., N. Y., 1891, olii.,
442-449.
- Chronic. Alcoolisme chronique avec dissociation de la sensibility et
paresis analg4siques superflciels. G. Lemoine. Lyon M6d.. 1891, lxvii.,
254-259.
- Intoxication chronique par les boissons oontenant des essences (amers,
aperitifs, etc.). Lancereaux. Bull. M6d., Par., 1891, v., 363-365.
-and absinthism, hereditary. L’alcoolisme et l’absinthisme h4r6ditaire8;
desordres mat4riels. Lancereaux. Bull. M6d., Par., 1891, v., 505, 517.
Alimentation (artificial). Die kiinstliche Ern&lirung bei abstinirenden Geistes-
kranken. W. Svetlin. Ber. ii. d. Privat-heilanst. f. Gemiithskr. a. d.
Erdberge zu Wien (1884-90), 1891, 83-98.
- (forced). Sulla tecnioa dell’ alimentazione forzata degli alienati sito-
fobi e relativo strumentario in uso presso alcuni manicomii d*Italia e dell*
Estero. G. Sanna-Salaris. Ann. di freniat., etc., Torino, 1889-91, ii., 313-
318.
Digitized by ^ooQle
2
Index Medico-Psychologicus.
Alimentation. Forced alimentation. J. L. Cleveland Cincin. Lancet-Clinic,
1891, n.s., xxvii., 631.
Amnesia. Een geval van algemeene amnesia. 6. Jelgersma. Nederl. Tijdschr.
v Geneesk., Amst., 1891, 2 R., xxvii., 315-322.
Anthropology, criminal. The new school of criminal anthropology. R. Fletcher.
Am. Anthrop., Wash., 1891, iv., 201-236.
- L'anthropologie criminelle. Xavier Francotte. Par., 1891, J. B. Bail-
li&re et fils, 376 p., 12o.
-Bur la valfeur relative des conditions individuelles, physiques et sociales,
qni dfetdrminent le crime. E. Ferri. Actes Cong, internat. d’anthrop. crim.,
1889, Lyon et Par., 1890, ii., 42-46.
— Organes et fonctions des sens chez les criminels. Ibid., 64-72.
Sur l’opportunit6 d’Stablir des regies pour les recherches d’anthropo-
mlstrie et de psychologie criminelles dans les hopitaux d’ali£n4s et dans les
prisons. E. Sciammana. Ibid., 36-41.
— La folia delinquents. Scipio Sighele. Torino, 1891, frat. Bocca, 133p., 8o.
•- Degeneratione e delinquenza; saggi di anthropologia criminale. Rac-
colta di osservazioni. Angelo Zuccarelli. Napoli, 1891, A. Tocco, 64 p., 8o.
-- 1 — Criminalita in Italia e sostitutivi penali a rovescio. E. Ferri. Scuola
positiva, Napoli, 1891, i., 102-117.
- II tipo criminale e la natura della delinquenza. E. Ferri. Arch, di
Psychiat., etc., Torino, 1891, xii., 185-215.
— ■ — Is criminal anthropology a science? W. W. Ireland. Med.-Leg. J.,
N. Y., 1891-2, ix., 1-16.
- Les grands criminels de Vienne; btude anthropologique des cerveaux
et des cr&nes de la collection Hoffmann. M. and H. Benedikt. Arch, de
l’anthrop. crim., Par., 1891, vi., 237-265, 1 pi.
- Una criminale-nata. R. Gurreri. Arch, di Psychiat., etc., Torino, 1891,
xii., 135-142.
— - Congres international d’anthropologie criminelle. Actes du 2. Biologie
et sociologie. (Paris, aofit, 1889.) Lyon et Par., 1890, A. Storck et G.
Masson, 554 p., 8o.
Antipyrin in mental diseases. Osservazioni cliniche sulP uso dell 5 antipirina
nelle malattie mentali. C. Berarducci and C. Agostini. Arch. ital. per le
mal. nerv., Milano, 1891, xxviii., 3-12.
— — in combination with bromide of ammonium in the treatment of epilepsy.
C. M. Hay. Med. Age. Detroit, 1891, ix., 421-423.
Aphasia. Contribution & l’dtude des aphasies. Bernheim. Rev. de M6d., Par.,
1891, xi., 372-388.
-- Beitrag zur Kenntniss der seltneren Formen von sensorischer Aphasie.
Adler. Neurol. Centralbl., Leipz., 1891, x., 294, 329.
-- A case of incomplete aphasia, with dyslexia and agraphia. G. A. Mueh-
leck. Univ. M. Mag., Phila., 1890-1, iii., 524-526.
- Zur Affassung der Aphasien. Eine kritische Studie. Sigm. Freud.
Leipz. u. Wien, 1891, F. Deuticke, 107 p., 8o.
— - Aphasie motrice avec perte de la lecture mentale. P. Parisot. Rev.
M6d. de l’est, Nancy, 1891, xxiii., 257-261.
— 1 - Deux observations cliniques relatives a l’aphasie. L. De Rode. Bull.
Soc. de M6d. Ment. de Belg., Gand et Leipz., 1891, No. 61, 207-213.
Apparitions of the virgin in Dordogne. L. Marillier. Proo. Soc. Psych. Research,
Lond., 1890-1> vii., 100-110.
Aprosexia in children. E. A. Shaw. Practitioner, Lond., 1890, xlv., 8-11.
Arithmetical faculty and its impairment in imbecility and insanity, On the. W.
W. Ireland. J. Ment. Sc., Lond., 1891, xxxvii., 373-386.
Asylums and hospitals. The management of insane asylums. R. E. Young.
Tr. M. Ass., Missouri, Kansas City, 1891, 77-85.
- Belgium and her insane institutions. C. Bell. Prize essays contrib.
Med.-Leg. Soc., N. Y., 1890, 54-76. ,
Separate hospitals for insane conviots. C. Bell. Ibid., 143-148*
.Digitized by ^ooQle
Index Medico-Ptychologicus. 3
Asylums. Die Heil-und Pflege-Anstalten fur Psychisoh-Kranke dea deutschen
Sprachgebietes im Jahr, 1890. Heinrich Laehr. Berl., 1891, G. Reimer,
241 p., 1 map, 8o.
- Une visite d l’asile de Borne. Pons. Ann. M6d.-Psych., Par., 1891, 7 s.,
xiv., 248-260.
Atavism and crime. L’atavisme et le crime. L. Manouvrier. Rev. Mens, de
l’Ecole d’Antbr6p. de Par., 1891, i., 225-240.
Aural hallucinations cured by removal of foreign bodies from the ear. W. P.
Spratling. Med. Rec., N. Y., 1891, xxxix., 680.
Automatic muscular movements among the insane ; their physiological signi¬
ficance. C. P. Bancroft. Am. J. Psychol., Worcester, 1890, iii., 437-452,1 pi.
Berlin insane asylums. W. H. Edwards. Rep. Consuls U. S. on Commerce,
etc., Wash., 1891, xxxvi., 595-600.
Boarding out as a means of providing for the chronic insane of the poorer
class. C. Norman. Tr. Roy. Acad. M. Ireland, Dubl., 1890, viii., 462-476
Brain degeneracy, functional. J. T. Searcy. J. Am. M. Ass., Chicago, 1891,
xvii., 720-727.
-of the insane, Weight of. Greutatea creerului la alienati. Demetrescu
din Braila. Spitalul, Bucuresci, 1891, xi., 369-377.
-— in the feeble-minded, Weight of the. A. W. Wilmarth. Alienist and
Neurol., St. Louis, 1891, 643-547.
-of an idiot. II cervello di un idiota. E. Rossi. Manicomio mod., Nocera,
1890, vi., 297-320.
-injuries, Some early physical symptoms of traumatic. T. D. Crowthers.
J. Nerv. and Ment. Dis., N. Y., 1891, xviii., 489-495. Also Med. News,
Phila., 1891, lviii., 661-663.
Cancer in its relations to insanity. H. Snow. J. Ment. Sc., Lond., 1891, xxxvii.,
548-553.
Care for the insane (on the indications of) outside of public or private asylums.
Om indikationerna for sinnessjukes vard utom offentlig eller enskild
anstalt. E. Hjertstrom. Hygiea, Stockholm, 1891, liii., 190-207.
-The system of caring for the insane in private dwellings. W. B. Smith.
Austral. M. J., Melbourne, 1891, n.s., xiii., 177.
-An appeal for State care for all the insane, from an economic standpoint.
J. M. Taylor. North Car. M. J., Wilmington, 1891, xxviii., 256-264.
- The proper care of the chronic insane. F. McClelland. Med. Age, Detroit,
1891, ix., 291-297.
-*- Proposition de loi de M. Reinach sur le regime des ali6n£s. R. Seme-
laigne. Ann. de psychiat. et d’ hypnol., Par., 1891, n.s., 119-123.
-Notre regime des aliSnds. Cuylits. Bull. Soc. de mdd. ment. de Belg.,
Gand et Leipz., 191, No. 62, 343-348.
-After care of male patients discharged from asylums. H. Bayner. J.
Ment. Sc., Lond., 1891, xxxvii., 535-540.
Causes of insanity. T. Diller. Pittsburg M. Rev., 1891, v., 289-296.
Cerebellum, Atrophy and hypertrophy of. Note sur quelques cas d’atrophie et
d’hypertrophie du cervelet. Doursout. Ann. mfed.-psych., Par., 1891, 7 s.,
xiii., 345-362.
Cerebral surgery (Five cases of), i. and ii., for epilepsy following trauma ; iii.,
for insanity following trauma; iv., for cerebral tumour; v., for defective
development. W. W. Keen. Am. J. M. So., Phila., 1891, n.s., cii., 219-
238 .
Chloralamid in insanity. Sur Paction therapeutique et physiologique du chloral-
amide chez les alien6s. E. Malrandon de Montyel. Ann. de psychiat. et
d’hypnol., Par., 1891, n. s., i., 47,80,148,182.
Chorea, Etiology and therapeutics of. Erfahrungen bezuglich AStiologie und
Therapie der Chorea. Groedel. Wien. Med. Wchnschr., 1891, xli., 683,
735.
Digitized by ^ooQle
4
Index Medico- Psyckolog icus.
Chorea and heart affections and their treatment. Ueber Chorea, insbesondere
ihre Beziehung zu Herzaffektionen und ihre Behandlung. Groedel.
Deutsche Med.-Ztg., Berl., 1891, xii., 457.
-A case of pseudo-chorea. Hoch. Bull. Johns Hopkins Hosp., Balt.,
1891, ii., 65.
--- Endocarditis of probable microbic origin. Note sur un cas d’endocardite
chordique d’origine microbienne probable. E. Leredde. Rev. mens. d. mal.
de l'enf., Par., 1891, ix., 217-221.
-Severe general chorea. J. Y. Lotherick. Brit. M. J., Lond., 1891, i.,
802.
-■ Corea cronica progressiva e corea di Huntington. G. Cirincione e G.
Mirto. Psichiatria, Napoli, 1890, viii., 18-36.
— — Sui movimenti coreici e le forme di corea minor. G. Fornario,
Psichiatria, Napoli, 1890, viii., 1-17.
» ■ ■ Nouveau cas d’hemichor^e saturnine. E. Girat. Union m£d., Par.,
1891, 3 s., 11, 666.
— ■ ■ An analysis of the cases of chorea which have occurred in the hospital
during eleven consecutive years. E. W. Goodall. Guy’s Hosp. Rep.,
Lond., 1890, 3 s., xxii., 35-43.
-A case of senile chorea; mania; recovery. Ferrier. Lancet, Lond.,
1891, i., 1379.
-Hereditary. Zur Chorea hereditaria. E. Remak. Neurol. Centralbl.,
Leipz., 1891, x., 326, 361.
■ Nature et traitement de la choree. J. Simon. Bull. m6d., Par., 1891, v.,
577-579.
-A case of, attended with multiple neuritis. F. R. Fry. Tr. M. Ass.
Missouri, Excelsior Springs, 1890, xxxiii., 215-221.
-Hereditary. Ueber Chorea hereditaria. F. Jolly. Neurol. Centralbl.,
Leipz., 1891, x., 321-326.
— ■ and hysteria. Hvstdrie et chorde de Sydenham. Paul Tochfc. Par.,
1891, 29 p., 4o. No. 196.
-in the aged. F. R. Fry. Tr. M. Ass. Missouri, Kansas City, 1891, 149-
154.
--Zur pathologischen Anatomie der Chorea minor. R. Wollenberg. Arch.
f. Psychiat., Berl., 1891, xxiii., 167-200,1 pi.
-Hysterical. Au sujet de la choree hysterique. Laveran. Bull, et m3m.
Soc. m6d. d. hop. de Par., 1891, 3 s., viii., 285*290.
Civilization, Insanity as related to. O. Everts. Cincin. Lancet-Clinic., 1891,
n. s., xxvii., 619-628. Also, J. Am. M. Ass., Chicago, 1891, xvii., 837-842.
Classification of mental diseases. Die gegenwartig iiblichste Eintheilung der
Geisteskrankheiten. O. Dornbliith. Miinchen. med. Wchnschr., 1891,
xxxviii., 385-387.
—;-of psychical diseases. V. Bechtereff. Kazan, 1891, 60 p., 8o.
Constipation and mania, A case of. R. M. Simon. Birmingh. M. Rev., 1891,
xxx., 100-102.
Cranial capacity and brain atrophy in the insane. Schadelcapacitaten und
fiirnatrophie bei Geisteskranken. A. Richter. Arch. f. path. Anat., etc.,
Berl., 1891, cxxiv., 297-333.
Criminal lunatics. Les alien^s dits criminals. Marandon de Montyel. Ann.
m6d.-psych., Par., 1891, 7 s., xiii., 434-450. Discussion, 452-456.
Crime. The plea of insanity as an apology for crime; with a report and dis¬
cussion of the case of John Barrett. G. W. McCaskey. Fort Wayne J. M.
Sc., 1891, xi., 1-18.
-Insanity as a defence to the charge of. J. H. Grimm. Prize essays con-
trib. Med.-Leg. Soc., N. Y., 1890, 1-35.
--(Criminality among the insane.) V. S- Ivanoff. Vestnik. klin. i
sudebnoi psichiat. i nevropatol., St. Petersb., 1891, viii., No. 2, 210-260.
— La funzione sociale della giurisprudenza nella criminality. C. Cavag-
nari. Anomalo, Napoli, 1891, iii., 65-67.
Digitized by L^ooQle
Index Medico-Psychologicus. 5
Death, Causes of, in insane asylums. Dodsaarsagerne specielt Tuberkulosen
paa Sindssygeanstalterne. C. Geill. Hosp.-Tid., Kjobenh., 1891, 3 R.,ix.,
217, 249.
Degeneracy. L'alidnation mentale chez les d4g6n6r4s psychiques. H. Dagonet.
Ann. m6d.-psych., Par., 1891, 7 s., xiv., 5, 202. 353.
Delirium Tremens. Om Temperaturforholdene ved Delirium tremens. A. Triis.
Hosp.-Tid., Kjobenh., 1891,3 R., ix., 337-340.
Delusional Insanity; probably due to jaborandi. W. F. Waugh. Times and
Reg., N. Y. and Phila., 1891, xxii., 448.
--and moral insanities. G. H. Savage. Med. Press and Circ., Lond., 1891,
n. 8., lii., 327.
Delusions (development of). Ueber die Entwickelung von Wahnideen aus
hallucinatorischen Vorgangen. G. Ackermann. Cor.-Bl. d. allg. Srztl. Ver.
u. Thiiringen, Weimar, 1891, xx., 305-318.
-Some of the principal varieties of delusions met with among insane
patients. H. M. Lyman. Med. News, Phila., 1891, lviii., 519.
Dementiu. On dementia; popular sketch. A. L. Goldstein. Kieff, 1891, I. I.
Gorbunoff, 15p., 12o.
-(primary chronic) at an early age. Ueber primare chronische Demenz
(sog. Dementia praBcox) im jiigendlichen Alter. A. Pick. Prag. Med.
Wchnschr., 1891, xvi., 312-315.
-paralytica syphilitica. M. Y. Popoff. Arch, psichiat., etc., Charkov,
1891, xviii., 34-82.
Digestion in the insane. Ueber die Verdauungsthatigkeit des Magens bei Geis-
teskrankon. Eduard Grabe. Dorpat, 1891, C. Mathiesen, 42p., 8o.
Dipsomania. L. W. Baker. Boston M. and S. J., 1891, cxxv., 296.
-Le traitement hypnotiqne de la dipsomanie. H. Neilson. Rev. de
l’hypnot. et psychol. physiol., Par., 1891-2, vi., 14-18.
—-Ein internationaler Yorschlag zur rationellen Behandlung der dipso¬
manie. Kahlbaum. Wien. Med. Wchnschr., 1891, xli., 1195, 1233.
-On dipsomania, with a preface by Count Tolstoi, Why do people stupefy
themselves? P. S. Alexjeff. Moskva, 1891, I. N. Koschnereff, 185 p., 8o.
Duboisin as a sedative in insanity. Duboisinum als Sedativum und Hypnoti-
cum bei Geisteskranken. V. Preininger. Allg. Ztschr. f. Psychiat., etc.,
Berl., 1891-2, xlviii., 134-145.
Dyspepsia of melancholics. La dyspepsie des lypemaniaques ; ses causes ; son
traitement. H. Guimbail. Ann. de Psychiat. et d’Hypnol., Par., 1891,
n.s., 289-296.
Electricity in mental diseases. La franklinisation dans les maladies mentales.
P. Ladame. Bull. Soc. de Med. Ment. de Belg., Gand et Leipz., 1891, No.
62, 323-334.
Emotional ictus. L’ictus emotionhel en m6decine mentale. A. Caris. Ann.
de Psychiat. et d’Hypnol., Par., 1891, n.s., 108-113.
Environment and heredity as causes of insanity. G. H. Savage. Brit. M. J.,
Lond., 1891, ii., 593-596.
Epilepsy. A case of epilepsy cured by antipyrin. McC. Anderson. Am. J. M.
Sc., Phila., 1891, n.s., ci., 485-487.
-A case of so-called “ infectious.” Ein Fall von sogenannter “ansteck-
ender” Epilepsie. E. Aronson. St. Petersb. Mdd. Wchnschr., 1891, n. F ,
viii., 57.
-The temperature in. De la temperature centrale dans l’epilepsie.
Bourneville. Rev. de Med., Par., 1891, xi., 272-282.
-Treatment of idiopathic. Traitement de Tepilepsie idiopathique. E.
Forgue. Gaz. hebd. d. Sc. M6d. de Montpel., 1891, xiii., 157-159.
-Castration in. Kastration mod epilepsi. F. Howitz und L. Meyer.
Gynaek. og obst. Medd., Kjobenh., 1891, viii., 216-226.
--Experimental in the frog. L’epilepsie experimentale chez la grenouille.
J. V. Laborde. Gompt. rend, Soc. de Biol., Par., 1891, n.s., iii., 287-.289,
Digitized by L^ooQle
6 Index Medico-Psychologicus.
Epilepsy, Pathogenesis and therapeutics of petit mal. Zur Pathogenese und
Tberapie des Petit mal. Putzar. Deutsche Med.-Ztg., Berl M 1891, xii.,
435-437.
- " In relation to degeneration. Le epilessie in rapporto alle degeneraztoni.
S. Tonnini. Atti d. Cong. d. Soc. freniat. ital., 1890, Milano, 1891, vii.,
390-397.
— Datos para el diagnostico de la epilepsia acustioa. P. Verdos. Rev. de
Cien. M6d. de Barcel., 1891, xvii., 194-197.
. Note sur l’apathie epileptique. C. F6re. Rev. de Med., Par., 1891, xi.,
211-213.
-Sur un cas de crises comitiales ambulatoires. G. Colleville. Union
M6d. du Nord-est, Reims, 1891, xv„ 181-185.
-The brain of an epileptic. A. H. Meisenbach. Weekly M. Rev., St.
Louis, 1891, xxiii., 461.
— ■ Traitement de l’epilepsie par l’emploi combine des bromures et d’un
agent organique capable d’andmier lea centres nerveux; f&ve de Calabar,
picrotoxine, belladone et quelqnefois digitale. V. Poulet. Bull. G6n. de
Thdrap., etc., Par., 1891, cxx., 193-211.
-(Homicidal). Un omioida epilettico. S. Sighele. Arch, di Psichiat.,
etc., Torino, 1891, xii., 142-144.
-Epilessie psichiche. S. Ottolenghi. Riv. sper. di freniat., Reggio-
Emilia, 1890, xvi., pt. 2,497; 1891, xvii., pt. 2, 1.
-L’^pilepsie corticale; recherches expdrimentales et anatomo-cliniqnes de
l’dcole italienne. J. Soury. Arch, de Neurol., Par., 1891, xxii., 97-123.
-Epileptische Psychosen. Gustav Lennhoff. Berl., 1890, M. Stolzenwahl,
22 p., 8o.
-A note on epilepsy. H. S. Drayton. N. York M. J., 1891, liii., 569.
-Psicopatia epilfettica in un imbecille. G. Antonini. Arch, di Psichiat.,
etc., Torino, 1891, xii., 109-111.
-*— Status epilepticus. G. R. Trowbridge. J. Am. M. Ass., Chicago, 1891,
xvii, 713-720.
-Status epilepticus. G. R. Trowbridge and C. B. Mayberry. J. Nerv.
and Ment. Dis., N.Y., 1891, xviii., 399-415.
-Cases of, treated by hydrate of amylene. E. L. Dunn. J. Ment. Sci.,
Load., 1891, xxxvii., 554-556.
—- Treatment by borate of soda. Traitement de l’4pilepsie par le borate de
soude. Mairet. Progres Med., Par., 1891, 2. s., xiv., 257-260.
-Influence of pregnancy on. Ueber den Einfluss der Schwangerschaft
auf Epilepsie. Guder. Med.-Chir. Centralbl., }Wien, 1891, xxvi., 302,
314.
■ Bromide of potassium in. Contributo all’ azione del bromuro di potassio
nella cura dalF epilessia ; studio statistico-clinico. C. Agostini. Riv. sper.
di freniat., Reggio-Emilia, 1891, xvii., 125-134.
-and idiocy, anomalous convolutions in. Ueber Windungsanomalien am
Gehirn von Epileptischen und Idioten. H. A. Wildermuth. Ztschr. f. d.
Behandl. Schwachsinn. u. Epilepfc., Dresd., 1891, vii., 1-11.
-Trephining; cut*e. G. F. Shears. Clinique, Chicago, 1891, xii., 280-
283.
— Jacksonian. Difierentialdiagnose der Jacksonschen Rindenepilepsie.
Ernst Glatzel. Berl., 1891, G. Schade, 29 p., 8o.
Epileptic insanity; its etiology, course, and treatment, based on the observation
of one hundred cases. E. D. Fisher. Med. News, Phila., 1891, lix., 562-
665.
Ether inebriety. N. Kerr. J. Am. M. Ass., Chicago, 1891, xvii., 791-794.
Ethyl-bromate for epilepsy. Aethylenum bromatum, ein neues Mittel gegen
Epilepsie. J. Donatb. Therap. Monatsh., Berl., 1891, v v 335-341.
Fire protection (the) of hospital for the insane. L. H. Prince. Chicago, 1891,
0. H. Blakely and Co., 122 p., 8o.
Digitized by L^ooQle
Index Medico-Psychologies. 7
Folie k deux. Fall af folie a deux. E. Hongberg. Finska lak.-sallsk. handle
Helsingfors, 1891, xxxiii., 814-824.
Gastric disorders and insanity. Gastro-intestinal and hepatic disorders, especially
chronic gastro-intestinal catarrh, in relation to the etiology of some cases of
insanity. S. Ayres. Med. News, Phila., 1891, lix., 1-5.
General paralysis. Some points regarding general paralysis. C. F. Folsom.
Boston M. and S. J., 1891, exxv., 236-239. Also Am. J. Insan., Utica,
N.Y. 1891-2, xlviii., 17-36.
-Some observations on general paresis. J. J. Kindred. Virginia M.
Month., Richmond, 1891-2, xviii., 425-437.
-General paresis. J. H. Lloyd. Med. and Surg. Reporter, Phila., 1891,
lxv., 405-411.
—— and alcoholism. Du r6le de l’alcoolisme dans rytiologie de la paralysie
generate. Rousset. Gaz. d. hop., Par, 1891, lxiv., 871-873.
-Surgical treatmeut of general paralysis of the insane. T. C. Shaw.
Brit. M. J., Lond., 1891, ii., 581-583.
-G. H. Savage. Med. Press and Circ., Lond., 1891, n.s., lii., 351-353.
-Die chirurgisohe Bekandlung der progressiven Paralyse der Irren. T.
C. Shaw. Wien. Med. BL, 1891, xiv., 609, 627.
-A case of geueral paralysis of the insane, with crossed reflexes. F. H.
W. Cottam. Lancet, Lond., 1891, ii., 288.
-Demonstration zur pathologischen Anatomie der allgemeincu progres¬
siven Paralyse. Binswanger. Neurol. Centralbl., Liepz., 1891, x., 618-622.
-- Caract&res histologiques diffiSreutiels de la paralysie generate; classi¬
fication histologique des paralysies generates. M. Klippel. Arch, de M6d.
Exp4r. et d’Anat. Path., Par., 1891, iii., 660-676.
-and pulmonary tuberculosis. Paralysie gdndralo et tuberculose pul-
monaire. M. Klippel. Ann. do P.-ychiat. et d’Hypnol., Par., 1891, n.s.,
203-208.
-and Byphilis. Ktude hiatorique et critique sur la pseudo-paralysie
general© syphilitique, ou rapports de la syphilis avec la paralysie generate.
Albert Charbonneau. Par., 1891, 90 p., 4o. No. 155.
-Some unusual cases of. B. B. Fox. J. Ment. Sc., Loud., 1891, xxxvii.,
389-402.
-(medico-legal). Contribution k l’etude m6dico-legale de la paralysie
gdnfcrale. A. Acquerin. Par., 1891, H. Jouve. 74 p., 8o.
-Sudden death in. De la mort subite dans la paralysie generate des
alidnds. C. Vallon. Ann. d’hyg., Par., 1891, 3 s., xxvi, 159-165.
Genius (the insanity of) and the general inequality of human faculty physio¬
logically considered. J. F. Nisbet. Lond., 1891, Ward and Downey.
364 p., 8o.
-a degenerative epileptoid psychosis. (Translated by G. Kiernan from
Lombroso’s Men of Genius.) C. Lombroso. Alienist and Neurol., St.
Louis, 1891, xii., 356-371.
Gout. The mental symptoms of gout, as illustrated by William Pitt, first Earl
of Chatham. J. G. Kiernan. Med. Standard, Chicago, 1891, x., 1-3.
Qeematoporphyrin in urine of insane, two additional cases of. Ytterligare
tvenne fall af hamatoporfyrin i urin fran siunessjuka. O. Hammarsten.
Upsala Lakaref. Forh., 1891, xxvi., 487-503.
Hemorrhage of the lenticular nucleus: melancholia with homicidal and
suicidal impulses. Hdmorragie du noyau lenticulaire; pas de lesions de
la motilite ni de la sensibility; aoc&s de ntelancolie avec impulsions homi¬
cides et suicides. Journiao. Ann Mdd. Psvch., Par., 1891, 7 s., xiii., 431-
434.
Hallucinations. Note sur les hallucinations autoscopiques ou spdculaires et sur
les hallucinations altruistes. C. Fdre. Compt. reud. Soc. de biol., Par.,
1891, 9. b., iii., 451-453.
Digitized by LxOOQle
Index Medico-Fay choiogicus.
Hallucinations. Alcoholic hallncination. F. W. Mann. Quart. J. Inebr.
Hartford, 1891, xiii., 205-220. V
' E ' B- J ja “ e - Boston M - and S. J., 1891, cxxv., 267-270.
i ., 'Influence of diseases of ear on development and course of
nevron»f, ,‘ 0D «; D S ; \ Bie 'j ako£E - Ve «‘nik klin. i sudebnoi Psiohiat. i
_ne^ropatol., St. Petersb., 1891, viii., No. 2, 1-77.
Schade^gp 86 ^ 6 Halluoina,tion - Geor K Souohon. Berl., 1890, G.
— ( tel e pa thio) Les hallucinations tdlepathiques; traduit et abreg <5 des
Rir.htf °* par L. Marillier, avec une preface de Charles
__ C !? et * G urney, Myers et Podmore. Par., 1891, F. Alcan. 411 p., 80 .
ease of homonymous hemiopic hallucinations with lesion of the right
— n°K^ laCfc * • G ' E ; de Schweinit z- N. York, M.J., 1891, liii., 514.
uoseryations d hallucinations individuelles et collectives. P.B Rev
scient., Par., 1891, xlviii., 303-30^. *
n 0 n e , s hallucinations verbales psycho-motrices chez les persecutes. G.
Ballet. Semame Mdd., Par., 1891, xi., 441.
a “c^'atory insanity. Periodieke hallucinatoire waanzin. H. Buriugh
Boekhoudt. Psychiat. Bl., Amst., 1891, ix., 114-126.
J^az.-d.w;.! r pat!\ 8 89lfS«7 de8 h ^ ditaireS - J- ™sin.
MotkyaflsSssi^ 0 ' DneVnik 4 ‘ siezdtt rnssk - ” ach -
H 0 T::;:r^ 08 pit fL t f eatment of acute inaanit y- A. B. Bichardson. Cincin.
Lancet-Clinic, 1891. n.s., xxvii., 231-234.
Hospitals (the proposed) for the treatment of the insane. T. 0. Allbutt. J.
Me at - Sc., Lond., 1891, xxxvii., 514-524.
_- or ln . sane - A. H. Newth. Prov. M. J., Leicester, 1891, x., 649-652.
Sm “ “ e > n s a ne abroad, notes on. 0 . H. Nichols. Proc. Ass. Med.
_Superintend. Am. Inst. Insane, Warren, 1890, xliv., 164-272.
d’^ospitalisafao de alienados. J. A. de Arantes Pedroso.
Med. contemp., Lisb., 1891, ix., 91-93.
of Tho'v descriptive of a new hospital villa recently erected in the grounds
389?2pl treat ‘ E - Bater - J ‘ Ment - So - Lond - 1891, xxxvii, 386-
K r r!nlT 1 T S i German - Di « Heil- und Pflegeanstalteu fur Psyohisch-
R^rl k lfiOt deu ‘ 80 . heD Sprachgebietes im J., 1890. Heinr. Laehr. 3 Aufl.
G * Reimer. 241 p. 1 map., 80 . .
vi., t 241-250 14 f ° r tHe a0Ut ® ' nSane ' A ' B ‘ Riohard 8 on. Cincin. M. J„ 1891,
Hyoscine in diseases of the mind. Om Hyoscinets Virkninger og Anvendelse
389-398 ygd ° mme ' F ’ Willern P’ Hosp.-Tid., Kjbenh., 1891, 3 B., ix.,
bs ahW, hl °T* T in i“ 8 an i ty - rem P loi du oblorhydrate d’byoscine chez
ies alienes. A. Lodde. Par., 1891, 90 p., 4 o., No. 279.
366^373 and abUSe ° f ' L " Woatheriy. J. Ment. So., Load., 1891, xxxvii.,
Hy °tioC^ Vh insanit ?- C ° ntribution k l’6tude Clinique des effets hypno-
46 p , 8o , No y °2 8 70 amiDe ° heZ les ^tin Bagnie. Par./l^l,
Hypnotic action of urethane, sulphonal, and paraldehyde, clinically considered.
J. S. Short. Birmingh. M. fiev., 1891, xxx, 1 - 10 .
7 CironeT eW O h nnwf 1 \ rem fi ieS u (amylene h y drate - sa lpWl, urethane,
Dypnone.) O nowszych srodkach nasennvch. (Wodnik amylenowv sull
194 a 207. re ’ hyPn ° n - ) J< 8UrZyCki - P " ze S ] ' kt. Krakow, isaTf’xS.,
277-2W. Kloralamid - A ' Friis * Hosp.-Tid., Kjobenh, 1891, 3 B., ix.,
Digitized by Google
Index Medico-Psychologicus. d
Hypnotics. A contribution to the study of chloralamid. J. Gordon. Brit.
M. J., Lond., 1891, i., 1060-1063.
- On the abuse of. J. B. Chapin. Am. J. Insan., Utica, N.Y., 1891-2,
xlviii., 202-208.
Hypnotism. The practice of hypnotic suggestion: being an elementary hand¬
book for the nse of the medical profession. G. C. Kingsbury. Bristol,
1891, J. Wright and Co., 214 p., 8o.
— ■ L’hypnotisme revenu 4 la mode; tiaite historiqne, scientifique,
hygienique, moral et th6ologique. J. J. Franco. Tradnit par l’abb£ J.
Moreau sur la 3 6d italienne, enrichie de nouvelles observations et de
faites r<5cents, avec un appendice sur les travauzdes docteors Guermonprez
et Yenturoli et sur 1’hynotisme clairvoyant. St. Amand, 1890, Vic et
Amant., 379 p., 12o.
— — Should we give hypnotism a trial ? G. C. Kingsbury. Dublin J. M.
Sc., 1891, xoi., 396-406.
— -Report on the therapeusis of mental diseases by means of hypnotic
suggestion. G. Seppilli. (Tran®!, from Archivio italiano.) Am. J.
Insan., Utica., N.Y., 1890-1, xlvii., 542-556.
——- Du traitement de la folie par l’hypnotisme. P. Smith et A. T.
Myers. Ann. de psychiat. et d’bypnol., Par., 1891, n.s., 302-311.
-Le physique et le mental a propos de l’hypnotisme. A. Touillee. Rev.
d. deux mondes, Par., 1891, cv., 429-461.
-J. T. Eskridge. N. York M. J., 1891, liv., 113-123.
— -O jivotnom magnetismie i hipnotismie. Edward E. Eichwald. St.
Petersb., 1891, 50 p., 8o.
-Hypnotism. F. R. Cruise. Dublin J. M. Sc., 1891, xci., 377-396.
- La suggestion dans l’hypnotisme. Babinski. Cong, internat. de psychol.
physiol, c.r. Par., 1890, i., 131-139.
- Tons les phdnomenes de l’hypnotisme peuvent-ils etre attribute 4 la
suggestion. J. Ochorowicz. Ibid. 74-79.
— -Un pr6curseur de l’hypnotisme. A. Bertrand. Rev. phil., Par., 1891,
xxxii., 192-206.
-- On the nature of somatic phenomena in. A. Tamburini. [Transl. by J.
Workman.] Alienist and Neurol., St. Louis, 1891, xii., 297-321.
-and some of its opponents. G. C. Kingsbury. Liverpool M. Chir. J.,
1891, xi., 336-354. .
-Ein Beitrag zur Lehre von der Suggestion. L. Stembo. St. Petersb.
Med. Wchnschr., 1891, n.F., viii., 132-134.
-encephalitis followed by death after a sdance. Un cas d’encdphalite
suivie de mort apres une sdance d’hypnotisme. Surbled. J. d. Sc. M6d. de
Lille, 1891, i., 415.
— ■ De la sollicitation Isolde du lobe gauche et du lobe droit dans l’£tat
hypnotique, au point de vue des manifestations de la parole. J. Luys. Ann.
de psychiat. et d’hypnol., Par., 1891, n.s., 114-118.
-Unity of hypnotism in man and animal. Y. J. Danilevski. Dnevnik
4 . Siezda russk. vrach., Moskva, 1891, 139-157.
— ■■■ A note on hypnotism in the insane. J. H. Lloyd. Phila. Hosp. Rep.,
1890, i., 290-294.
■ Du transport a distance, 4 I’aide d’une couronne de fer aimante, d’dtats
nevropathiques varies, d’un sujet 4 l’6tat de veille sur un sujet a l’etat
hypnotique. Luys et Encausse. Ann. de psychiat. et d’hypnol., Par.,
1891, n.s., 129-132.
-Inveterate case of tremor, cured by means of hypnotism. A. SchiltofE.
Meditsina, St. Petersb., 1891, iii., 197-199.
-Der Hypnotismus. H. Schmidkung. Hygieia, Stuttg., 1891, iv., 160,
193,234.
■ ■ ■ Ueber Snggestionstherapie bei kontr&rer Sexualempfindung. A. von
Sohrenk-Notzing. Internat. Olin. Rundschau, Wien, 1891, ▼., 964-967.
Digitized by ^ooQle
10
Index Medico-Pvychologieus.
Hypnotism. L’hypnotisme; etude soientifiqne et religiense. L’abbe P. G.
Moreau. Par., 1891, J. Leady et Cie., 634 p., l2o.
-Hypnotisme et croyances anciennes. L. R. Regnier. Paris, 1891,
Lecroisnier et Babd. 239 p., 5 pi., 8 o.
-Der Hypnotismus, seine psycho-physiologische, medicinische, strafrecht-
liche Bedeutung und seine Handhabung. August Forel. 2 Aufl. Stutt¬
gart, 1891, F. Enke, 183 p., 8 o.
— Precis theorique et pratique de neurohypnologie. fitudes sur
l’hypnotisme et les differents phdnom&nes nerveux physiologiques et
pathologiques qui s’y rattachent. Physiologie, pathologie, therapeutique,
medecine 14gale. Paul Joire. Par., 1892, A. Maloine, 334 p., 12o.
■ ■ Zur Verwerthung der Suggestionstberapie (Hypnose) bei Psycbosen
und Neurosen. v Krafft-Ebing. Wien. klin. Wchnschr., 1891, iv., 795-799.
-Erfolge des therapeutischen Hypnotismus in der Landpraxis. Georg
Ringier. Miinchen, 1891, J. F. Lehmann. 206 p., 8 o.
-Contributo alia terapeutica dell’ ipnotismo e della suggestione. C.
Cattani. Riv. veneta di Sc. Med., Venezia, 1891, xiv., 397-425.
— ' Du rdle de l’hypnotisrne dans les preoccupations deiirantes de certains
ali 6 nes. A. Voisin. Ann. de psychiat. et d’hypnol., Par., 1891, n.s., 169-174.
-and the law. C. Bell. Med. Leg. J., N. Y., 1890-1, viii., 331-358.
-Hypnotism and the law. J. J. Reese. M£d.-Leg. J., N. Y., 1891-2, ix.,
147-149.
— - Questions medico-!4gales afferentes a l’hypnotisme. Luys. Ann. de
psychiat. et d’hypnol., Par., 1891, n.s., 209-217.
—— and hysteria. Hypnotisme et hysterie; du role de l’hypnotisme en
therapeutique. J. Babinski. Gaz. hebd. de Med., Par., 1891, 2. s., xxviii.,
350-365.
Hypochondriasis and melancholia. G. H. Savage. Med. Press and Circ., Lond.,
1891, n.s., lii., 247.
Hysteria, mental state of. Contribution h, l’etude de l’etat mental des
hystfcriques. Longbois. Ann. d’hyg., Par., 1891, 3. s., xxvi., 63-81.
— ■■ etc., Treatment of. Die Behandlung der Hysterie, der Neurasthenie
und ahnlicher allgemeiner functioneller Neurosen. V. Holst. 3 Auf.,
Stuttgart, 1891, F. Enke. 98 p., 8 o.
--(male) and exophthalmic goitre. Coexistence de l’hysterie m&le et du
goitre exophtalmique. Castau, Montpel. M4d., 1891, 2. s., xvi., 245-253.
-in man. Casuistische Beitrage zur Hysterie beim Manne. Gustav
Mann. Berl., 1891, G. Schade. 39 p., 8 o.
— — »■ in the male. J. D. Kelly. Med. Rec., N.Y., 1891, xxxix., 675.
— Sur un cas d’hystdrie simulatrice du syndrome de Weber. J. M. Charcot.
Arch, de neurol., Par., 1891, xxi., 321-345.
— Influence of excitation of the sensory organs on the hallucinations in.
De l’influence des excitations des organes des sens sur les hallucinations de
la phase passionnelle de l’attaque hysterique. G. Guinon et Sophie Woitke.
Arch, de neurol., Par., 1891, xxi., 346-365.
■ ■ and hypnotism. Le 96 ns cliniques sur l’hyst 6 rie et l’hypnotisme, faites
& rhopital Saint-Andr 6 de Bordeaux. Ouvrage pr 6 c£d 6 d’une lettre-pr 6 face
de J. M. Charcot. A. Pitres. 2 v., Par., 1891, O. Doin, 541; 551 p. [16 pi.,
paged in text.], 8 o.
■ -and hypnotism. Lemons sur l’hystSrie et l’hypnotisme. A. Pitres. J.
deM 6 d.,de Bordeaux, 1890-1, xx., 160, 361, 373, 442.
--and neurasthenia. Quelques cas d’hyst 6 rie male et de neurasthenie.
Grasset. Montpel. M 6 d., 1891,2. s., xvi., 389,443,485; xvii., 101,252,364.
— -Sonno e vigilo sonnambulismo isterici. G. Villani. Riforma Med.,
Napoli, 1891, pt. 2 ., vii., 769-773.
— Sur la dissociation de la motilit 6 chez un malade d6g4n4re hysterique. F.
Raymond. Bull, et M 6 m. Soc. M4d. d. h 6 p. de Par., 1891,3. s., viii., 334-342.
“— r — Ueber hysterischen Schlaf. J. Steiner. Deutsche Med. Wchnschr.,
Leipz., 1891, xvii., 848.
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Index Medico-Peychologicue. 11
Hysteria, Attaques d*hysterie k forme d’^pilepsie partielle (monospasme facial).
G. Ballet. Ball, et M6m. Soo. Mfcd. d. bdp. de Par., 1891,3. s., viii., 352-355.
■■■ L’byst^rie peut-elle simuler lepilepsie jacksonnienne ? Glatz. Lyon
Mfcd., 1891, lxvii., 286-288.
1 ■■ ■ Electrical relations of hysterical persons. A hysteriisok villamos
viszonyairol. K. Schaffer. Orvosi hetil., Budapest, 1891, xxxv., 78, 92,106,
118, 130, 152, 168.
1 ■■ ■ Voluntary contraction in. Contracture volnntaire chez un bystArique. P.
Sollier et Malapert. N. iconog. de la Salp6triere, Par., 1891, iv., 100-106, 4 pi.
— — Contribution k l'Stude de l’hyst6rie d’origine h6redo-alcoolique. Louis
Camuzet. Par., 1891, G. Steinheil. 46 p., 8o.
■ ■■ Case of traumatic hysteria virilis. Trauma ut&nfelldpett ferfihysteria.
L. Ihrig. Orvosi hetil., Budapest, 1891, xxxv., 114,128.
-■ Articular contractions in hysteria of children. Przykurezenia stawow
histeryozne w dzieci. R. Jasinski. Gaz. lek., WarBzawa, 1891, 2 s., xi.,
378-385.
- Hysteria. A. P. A. King. Am. J. Obst., NX, 1891, xxiv., 513-532.
— Febris hysterica. Stephan. Nederl. Tijdschr. v. Geneesk., Amst.,
1891, 2 r., xxvii., 235-242, 1 tab.
- (Hysteria in soldiers.) A. V. Trapeznikoff. Vrach, St. Petersb., 1891
xii., 381.
- HystArie; attaques dpileptiformes; ddgeneresoence bdrdditaire;
mdlancolie aveo idees de suicide; bypnotisme. A. Matbieu. Bull, et
mdm. Soc. mfed. d. hdp. de Par., 1891, 3 s., viii., 476 481.
■ A propos d’un cas d’hystdrie masculine; i., paralysie dissociee du
facial infdrieur d’origiue hystdrique; ii., cumul de facteure dtiologiques;
traumatisme, alcoolisme, hdrdditd nerveuse. Charcot. Arch, de neurol.,
Par., 1891, xxii., 1-23.
Hysterical insanity. A hysterics elmezavardl. E. E. Moravceik. Orvosi hetil.,
Budapest, 1891, xxxv., 164, 177, 190. Also Iransl. (Abstr.); Pest, med.-
chir. Presse, Budapest, 1891, xxvii., 457-460.
— - paralysis. Paralysies hysteriques provoqudes par la crainte des examens.
C. Krafft. Rev. mid. de la Suisse Rom., Gendva, 1891, xi., 292-295.
- stammering. A propos du bdgaiement hystdrique ; examen des obser¬
vations de MM. G. Ballet et A. Pitres. Arch, de neurol., Par., 1891, xxi.,
365-376.
Hy8tero-epilepsy. R. L. Hunt. N. Orl. M. & S. J., 1891-2, n.s., xix., 93-95.
- Della meningite croDica semplice dell’ adults e di nna sua specials
forma a tipo istero-epilettico. (Lepto-meningite cronica emorragica.)
G.Lumbroso. Sperimentale, Firenze, 1891, lxvii., 1-48.
■ Sopra una rara forma di accessi istero-epilettici sopravvenuti a grandi
distanze di tempo. A. Tebaldi. Arch. ital. per le mal. nerv., Milano, 1891,
xxviii., 12-24.
- Three cases of, H. F. Byers. Med. and Surg. Reporter, Phila., 1891,
lxiv., 812-814.
Hystero-epileptio convulsions (On a rare form of), occurring at long intervals.
A. Tebaldi. (Trans, from Arch, ital.) Alienist and Neurol., St. Louis,
1891, xii., 330-340.
Idiocy. Recueil de mbmoire, notes et observations sur l'idiotie par Bonrne-
ville V. J., Par., 1891, E. Lecrosnier et Babd, 432 p., 6 pi., 8o.
— 1 Ueber das Gehirn eines elf Mon ate alten Idioten mit Bildungshemmung.
Mingazzini. Untersuch. z. Naturl. d. Mensch. u. d. Thiere, Giessen, 1891,
xiv., 529-557,1 pi.
- Gli idioti; osservazioni di psicologia patologica. G. Guicciardi. Riv.
sper. di freniat., Reggio-Emilia, 1891, xvii, 172-198.
— ■ and imbecility. Idiotismus und Schwaobisnn; ein Wort an Geistliche,
Lehrer, und Eltem. M. Jaeger. Ztschr. f. d. Behandl. Schwachsinn. u.
Epilept., Dreed n 1891, vii., 11-22.
Digitized by ^ooQle
12 Index Medico-P sychologicus.
Imagined disease. Presidential address on imagined disease; blocking of the
brain’s action. A. Hill. Brit. M. J., Load., 1891, ii., 1-4.
Imbecility. Imbdcilitc et instability mentale; impulsions genitales. Bourne-
ville et A. Sorel. Progrfcs med., Par., 1891 2 s., xiv., 188.
Infancy, Insanity of. Beitrage znr Lehre yom Irresein im Kindersalter. K.
Tremoth. Miinchen. med. Wchnschr., 1891, xxxviii., 605, 633, 647.
- A case of acute insanity in. Ein Fall yon acuter Geisteskrankheit im
Kindesalter. Hahn. Centralbl. f. Nervenh. u. Psychiat., Coblenz und
Leipz., 1891, n. F., ii., 297-299.
Infanticide, The insanity of child-birth in its relation to. E. M. Hyzer. Prize
essays contrib. Med.-Leg. Soc., N. Y., 1890, 36-53.
. Influenza. The nervous features and sequences of la grippe. A. Church.
Chicago M. Rec., 1891, i., 418-426.
- Suicidal tendency during an attack of influenza; cut throat and
fractured skull; recovery. A. G. Creagh. Lancet, Lond., 1891, ii., 70.
- and mental alienation. Grippe et alienation mentale. Mairet. Ann.
de psychiat. et d’hypnol., Par., 1891, n.s., 178-181.
— Mental disturbances of. J. B. Ayer. Boston M. and S, J., 1891, cxxv.,
294-296.
- and mental affections. Die Psychosen der Influenza. Kim. Allg.
Ztschr. f. Psychiat., etc., Berl., 1891-2, xlviii., 1-15.
-Cases of insanity following la grippe. G. Allen. N. Am. J. Homceop.,
N.Y., 3 s., vi., 718-721.
Insanity. Essentials of nervous diseases and insanity: their symptoms and
treatment. A manual for students and practitioners. J. C. Shaw.
Pbila., 1892, W. B. Saunders, 194 p., l2o.
■ Pritchard and Syrnonds in especial relation to mental science, with
chapters on moral insanity. Hack Tuke. Loud., 1891, J. and A. Churchill,
120 p., 2 portraits, 8o.
- ■■ A plea for the scientific study of insanity. J. Batty Tuke. Lond. and
Edinb., 1891, Y. J. Pentland, 29 p., 8o.
- Mysticism in. Die Mystik in Irsinn; Erwiderung an Baron Carl Du
Prel. Gustav Specht. Wiesbaden, 1891, J. F. Bergmann, 127 p., 8o.
- The influence of surroundings on the production of. G. H. Savage. J.
Ment. Sci., Lond., 1891, xxxvii., 529-535.
■' Die Verhiitung (Prophylaxie) der Geisteskrankneiten ; ihre Entstehung,
Ursachen und Behandlung. Paul Berger. Berl., 1892, H. Steinitz, 70 p., 8o.
- Notes on the insanity of British Guiana. W. S. Barnes. Brit. Guiana
M. Ann., Demerara, 1891, 90-95.
- Die psychiatrische Diagnose u. der Rich ter stuhl. Meynert. Wien,
klin. Wchnschr., 1891, iv., 431, 449.
1 Les troubles psychiques des deg^ndres herdditaires. J. Yoisin. Nice-
med., 1890-1., xv., 131-134.
- of old people and senile dementia. Contribution & l’etude des maladies
mentales des vieillards et en particular de la demence s4nile. Yves
Ollivier. Par., 1891, 57 p., 4o., No. 264.
-Sulla pazzia incendiaria. G. Grazianetti. Atti d. Cong. d. Soc.
frcniat. ital. 1890, Milano, 1891, vii., 415-418.
-On the acute forms of hallucinatory insanity. S. S. Korsakoff.
Med. Obozr., Mask., 1891, xxxv., 239-251.
— - Influence of acute infectious diseases on. La folie et la fievre typholde.
Etude sur l’influence des maladies infectieuses aigues, et de la fifcvre
typhoi'de en particular, sur le d6veloppement de la folie. Jules Glover.
Par., 1891, 57 p., 4o, No. 336.
—— of twins. Zur Lehre vom Zwillingsirrgeiu. N. Ostermayer. Arch.
f. Psychiat., Berl., 1891, xxiii., 88-111.
—— Outlines of. H. Hun. Albany M. Ann., 1891, xii., 169, 193, 217.
Digitized by ^ooQle
Vol. XXXIX., No. CLXVII.— New Series, No. 131. Price 3s. 6d.
THE JOURNAL
MENTAL SCIENCE
(Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland).
EDITED BY
D. HACK TUKE, M.D.,
GEO. H. SAVAGE, M.L).
“Nos vero intellectum longius a rebus non absfcrahimus quam ut re rum imagines et
radii (ut in sensu fit) coire possint."
Francis Bacon. Proleg. Irutaurat, Mag,
OCTOBER, 1893.
LONDON:
J. & A. CHURCHILL,
11, NEW BURLINGTON STREET.
HDOOOXOI1I.
To be continued Quarfe^ljn ... Q OOg IC
CONTENTS OF No. 163.—OCTOBER, 1892.
PART I.—ORIGINAL ARTICLES.
Robert Baker, M.D.— Presidential Address delivered at the Fifty-first Annual Meeting of the
Medico-Psychological Association, held at the Retreat, York, July 21st, 1892.
George M. Robertson, M.B.— Hypnotism at Paris and Nancy. Notes of a Visit.
M. J. Nolan, L.R.C.P.—Is Katatonia a Special Form of Mental Disorder?
Clinical Notes and Cases.-Cases of so-called Katatonia; by M. J. Nolan, L.R.C.P.—Cases of
Hereditary Chorea (Huntington’s Disease); by W. F. Menzies, M D.
Occasional Notes of the Quarter.— The Annual Meeting of the Association and the Cen¬
tenary of the Retreat, York.—The Leamington Parricide.—Report of the Committee appointed
to investigate the Nature of the Phenomena of Hypnotism,
PART ll # —REVIEWS.
The Forty-sixth Report of the Commissioners in Lunacy, 1892.—Anleitung beim Studium des Baues
der Nervosen Central-Organe in gesunden und kranken Zustande; von Dr. Heinrich Obkr-
steiner, K.K.A.O.—Pathologic und Therapie der psychischen Krankheiten iUr Aerzte und
Studirende: Fiinfte Auflage. Ganzlich umgearbeitet und erweitert; von Dr. Willibald
Levinstein-Schlegel.— Ptomaines and other Animal Alkaloids, their Detection, Separation,
and Clinical Features; by A. C. Farquharson, M.D.—Des Troubles de Langage chez les
Ali&i£s; par J. Seglas.— Report of the Commissioners appointed to inquire into the Prison ai d
Reformatory System of Ontario.—L’Education des Facultds mentales; par le Dr. J. J. Nogier.
—L’Hypnotisme, Ses rapports avec le Droit et la Therapeutique de la Suggestion Mcntale ; par
Albert Fonjean. —Epitome of Mental Diseases, with the Present Methods of Certification of
the Insane, etc., etc.
PART III.—PSYCHOLOGICAL RETROSPECT.
1. Dutch Retrospect; by Dr. J. F. G. Pietersen.
2. American Retrospect; by Fletcher Beach, M.B., F.R.C.P.
PART IV.—NOTES AND NEWS.
The Fifty-first Annual Meeting of the Medico-Psychological Association, held at the York Retreat,
July 21st, 1892; Centenary of the Retreat.—Irish Quarterly Meeting.—The Annual Meeting of
the British Medical Association.—The International Congress of Experimental Psychology.—
Correspondence.—Obituary.—Pass List.—Appointments.—Index.—List of Members, etc.
CONTENTS OF No. 164.—JANUARY, 1893.
PART I.—ORIGINAL ARTICLES.
George M. Robertson, M.B.— The Use of Hypnotism among the Insane.
Dr. Jules Morel.— The Psychological Examination of Prisoners.
Francis Warner, M.D. —Neural Action Corresponding to the Mental Functions of the Brain.
Harry Campbell, M.D.— Sensations of Cephalic Pressure and Heaviness.
E. L. Dunn, M.B.— On so-called Paranoia.
John Macpherson, M.B.— Remarks upon the Influence of Intestinal Disinfection in some Forms
of Acute Insanity.
Charles Mercier, M.B.— The Payment of Asylum Patients for their Work.
Clinical Notes and Cases.—Cases of Hereditary Chorea (Huntington’s Disease); by W. F.
Menzies, M D. ( With Plate). —Case of Abnormal Development of the Scalp; by T. W.
McDowall, M.D. {With Plate).
Occasional Notes of the Quarter.— Tennyson as a Psychologist.—Medico-Legal Aspect of
Neill’s Case.
PART II.—REVIEWS.
Thirty-fourth Annual Report of the General Board of Commissioners in Lunacy for Scotland.—Forty-
first Report of the Inspectors of Lunatics in Ireland.—Philosophische Studien, January. 1892.—
French Hypnotic Literature: Grand et Petit Hypnotisme; par J. Babinski.— Hypnotisme et
hyste'rie; du role de l’hypnotismc en the'rapeutique; par J. Babinski. —Les suggestions hypno-
tiques au point de vue mddico-tegal; par Gilbert Ballet.— Uric Acid as a Factor in the
Causation of Disease; by Alexander Haig, M.D.—Die Psychopathischen Minderwertigkeiten ;
von Dr. J. L. A. Kocii.— Audition Colorde; by Dr. Jules Millet.— Le Type Criminel d’aprfcs
les Savants et les Artistes; par le Dr. Edouard Lefort.— The British Guiana Medical Annual
and Hospital Reports; by J. S. Wallbridge, M.R.C.S., and E. D. Rowland, M.B.— On the
Origin of Arithmetic; by W. Pheyeu. — A Dictionary of Psychological Medicine; by D. Hack
Tuke, M.D.—Festschrift zur Feier des FUnfzigjabrigen Jubilaums der Anstalt Illenau,
herausgegeben Yon den jetzigen und friiheren illenauer Arzten ; Sciiule, v. Krafkt-Kbing,
Kirn, Neumann, Fr. Fischer, Kick holt, Wilsbr, Landerer, Dietz.— Die Literatur e’er
Psychiatrie im XVIII. Jahrhundert; von Dr. Heinrich Laehr.— Atlas of Clinical Medicine; by
Bykoh Bramwell, M.D.—Diseases of the Nervous System; by J. A. Ormerod, M.D.—On
Education from the Medical Standpoint; by G. E. Shuttleworth, M.D.—Mental Science and
Logic for Teachers; by Thomas Cartwright, B.A.—The Colonizaton of Epileptics; by Fredk.
Peterson, M.D.—Illustrations of Nerve Tracts; by Alex. Bruce, M.D.
PART III.—PSYCHOLOGICAL RETROSPECT
1. English Retrospect. Asylum Reports for 1891.
2. German Retrospect; by William W. Ireland, M.D.
3. Retrospect of Criminal Anthropology; by Havelock Ellis.
PART IV.—NOTES AND NEWS.
The Quarterly Meeting of the Medico-Psychological Association.—The Scottish Meeting.—The
International Congress of Criminal Anthropology.—West London Medico-Chirurgical Society.—
llle lllenau’s Golden Jubilee.—Obituary.—Pass List.—Appointments, &c.
: Digitized byV^OOQle
With Illustrations, Two Vols. 8 vo, 42 s,
A DICTIONARY
or
PSYCHOLOGICAL MEDICINE
GIVING THE DEFINITION, ETYMOLOGY AND SYNONYMS OF THE
TERMS USED IN MEDICAL PSYCHOLOGY
WITH THS
SYMPTOMS , TREATMENT, AND PATHOLOGY OF INSANITY
▲HD THE
Law of Lunacy in Great Britain and Ireland.
BDITBD BT
D. HACK TUKE, M.D., LL.D.,
Examiner In Mental Physiology In the University of London; Lecturer on Psychological
Medicine at the Oh&ring Gross Hospital Medical School; co-Editor of ” The Journal
of Mental Science.”
ASSISTED BY NEARLY ONE HUNDRED AND THIRTY CONTRIBUTORS.
44 Each contributor appears the master of his subject. In some oases it may be said that no
other man, save the actual contributor, possesses sufficient knowledge or opportunity to have
written so complete and exhaustive a description of the subject treated."— Edintruryh Medical
Journal , Oct., 1892.
“ These substantial and neatly printed volumes are a comprehensive idsumd of the literature
of alienism and a welcome addition to the library of the mental specialist. They owe their existence
to the industry and energy of one who has already excelled in the preparation of works oovering
many branches of the subject. . . . Taken as a whole, the ‘ Dictionary of Psychological Medicine
more than fulfils the high expectations which were formed by those who knew of the plans of its
accomplished author .”—Johns Hopkins Hospital Bulletin , Sept., 1892.
44 It will fill a gap long felt by those who have been oalled upon to deal with oases of insanity
in the course of their ordinary practice, and those who have made psychological medicine a special
study will find that it brings well into focus the widespread literature of the subject, and carries
our information upon many kindred matters down to the present time.”— British Medical Journal ,
17th Dec., 1892.
“ It Is vastly more than a Dictionary. It is an elaborate and complete Encyclopedia of
Psychological Medicine ; in fact, a small library in itself on that subject. The high expectations
which Dr. Tuke's work in this field had raised are more than fulfilled. ... It will be found to
be a most useful reference hand-book for the alienist and student of Psychological Medicine.
The general physician also cannot fail to find the book exceedingly useful in special oases.”—
Boston Medical and Surgical Journal, Oct. 6th, 1892.
44 Dr. Tuke has selected his collaborators with care; their work has been as thoroughly done
as was compatible with brevity, and the volumes constitute a valuable addition to the literature
of the subject.”— New York Medical Journal , Oct. 29th, 1892.
“ Si nous avions un regret k exprimer, c'est qu’une oeuvre de ce genre n’ait pas vu le jour en
France plutfit qu’en Angleterre. Mais la science est de tous les pays; elle appartient k tout le
monde, et ce qui est bien certain, c’est que le Dr. Hack Tuke, en produisant le dictionnaire de
medicine mentale, aura rendu k la science mddioo-paychiAtrique un signal^ service. Oe diction¬
naire, qui est tout k fait au courant de la science, peut tenir lieu dea meiHours traitds, en mfime
temps qu’il permit de ce renseigner ais&nent et avec promptitude sur n’importe quelle particu¬
larity nosologique.”— Annales Medico-Psychologiques, Jan., 1893.
44 Les dditeurs, MM. Ohurchill, meritent k leur tour nos plus slnckres felicitations, non
Suelement pour avoir facilite la tAche de l’entreprise mais encore en raison du soin particulier
qu’ils ont voud au travail typographique.” —Bulletin de la SocidU de Medicine Mentale de
Belgique .
”... The learned editor has chosen for his staff the most distinguished contributors and
investigators, so that those who consult the dictionary will find under any of its multifarious
headings the latest and best information. . . . Dr. Hack Tuke has enjoyed a wide reputation
hitherto; but this most excellent treatise, for it is that rather than a dictionary, the fruit of
much labour and meditation, will still further advance his fame.”— Law Journal.
” Dr. Hack Tuke has just brought to a successful issue a great enterprise, which does the
highest credit to English medical and psychological science.”— Brain.
London: J. to A. CHURCHILL, ll. New Burlington Street.
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The
Microscopical Examination of the Human Brain:
METHODS OF RESEARCH, Etc.
By EDWIN GOODALL, M.D.Lond., B.S., M.R.C.P.,
Pathologist to the West Riding Asylum .
London: Bailli&re, Tindall Sc Cox, 21 & 22, King William Street, Strand.
With Plates , 8 vo> 4s.
Reform in the Treatment of the Insane.
EARLY HISTORY OF THE RETREAT, YORK; ITS OBJECTS AND
INFLUENCE.
By D. HACK TUKE, M.D., LL.D., Formerly Assistant and snbseqnently
Visiting Medical Officer to the Retreat.
London : J. & A. CHURCHILL, 11, NEW BURLINGTON STREET.
Now Ready , Royal 1 bmo, Is. 6d.
The Attendant’s Companion: A Manual
OF THE DUTIES OF ATTENDANTS IN LUNATIC ASYLUMS.
By CHARLES MERCIER, M.B., F.R.C.S., Etc.,
Lecturer on Neurology and Insanity at the Westminster Hospital and at the London
Medical School for Women; late Assistant Medical Officer, City of London
Asylum; Senior Assistant Medical Officer, Leavesden Asylum. Author of
“ Sanity and Insanity/* “ The Nervous System and the Mind,” etc., etc.
London: J.&A. CHURCHILL, 11, NEW BURLINGTON STREET.
In the Press.
A Practical Manual of Mental Medicine.
By E. REGIS, M.D., Bouscat-Bordeaux, France,
Formerly Chief of Clinique of Mental Diseases at the Faculty of Medicine of Paris.
Second Edition, thoroughly revised. Translated by Dr. H. M. Bannister,
Chicago, Ill., with a preface to American translation by the Author.
Utica State Hospital Press, Utica, N.Y., U.S.A.
Price 8s.
BULLETIN DE LA SOCIETE DE MEDICINE
MENTALE DE BELGIQUE.
Quarterly Subscription, 10 francs.—Apply to Dr. JULES MOREL, Mddecin
en Chef de PHospice Guislain, Ghent.
The Asclepiad :
A Book of Original Research and Observation in the Science, Art, and Literature
of Medicine, Preventive and Curative. Price 2s. 6d.
By SIR B. W. RICHARDSON, M.D., F.R.S.
Published Quarterly by
Longmans, Green Sc Co., Paternoster Row, London.
CENTRALBLATT FUR NERVENHEILKUNDE UND
PSYCHIATRIE
Herausgegeben von Erlenmeyer, van Deventer, Ireland. Kowalewskt,
Lange, Lombroso, Obersteiner, Sequin.
Redigirt yon Dr. KURELLA (Coblenz, Rheinpreuss).
Treis 12 Mark.
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CONTENTS OF No. 165.—APRIL, 1893.
PART I.—ORIGINAL ARTICLES.
Julias Althaus, M.D.—On Psychoses after Influenza.
Dr. John Turner. —Some Further Remarks on Expression In the Insane.
F. St. John Bullen.— Inquiries into a Variation of Type in General Paralysis. *
Edwin Goodall, M.D.— The Effect upm Mental Disorder of Localized Inflammatory Conditions.
Dr. George Fr&nolB West.— Some Remarks on the New Farm of the Omagh Asylum.
Arthur Finegan.—Systematic Dress-fitting for Female Inmates of Asylums.
George M. Robertson, M.B.— The Formation of .'ubdural Membranes, or Pachymeningitis
Hemorrhagica.
Clinics! Notes and Cases.— Case of Endothelial Tumour of the Dura Mater (witA Illustration) ;
by F. Lisuman.— Syphilitic General Paralysis; by M. J. Nolan, L.R.C.P.—Notes on a Case of
Acute Insanity with Sexual Perversion ; by W. C. Sullivan, M.B.—Hypertrophy of the Scalp in
a Lunatic; by Dr. Pocoi (communicated by Dr. Me Do wall).
Oooasional Notes of the Quarter. - Mr. Irving’s “ Lear.” - Roc v. Nix.—Moriey v. Loughnan.—
Compulsory Legislation for Habitual Drunkards.—The Epileptic Colony.—Saint Amable.
PART II.-REVIEWS.
Lectures on Mental Diseases designed especially for Medical Students and General Practitioners ; by
II. P. Stearns, M.D.-Introduction to Physiological Psychology by Dr. T. Ziehen.— La
Pathologic dcs Emotions ; par Cm. Fkrb. -Traltd Clinique et Th<5rapcatique de PHystdrie; par
le Docteur Gillks de la Touiiette— Enurtung ; by Max Nordau.— l*sychologie du Pcintre;
par Lccien Ahrsat.— Anatomy of the Brain and Spinal Cord; by J. K. Whitaker.- Psycho-
pathia Scxualis with special reference to Contrary Sexual Instinct ; by Dr. R. von RitArrr-
Ebino.— Various Forms of Hysterical or Functional Paralysis; by H. C. Bastian, M.D.— Illus¬
trations of Mid and Hind Brain ; by Alex. Bruce, M.D.—Recherclies Clinique* et Therapcutiques
sur Pdpilcpsie, Phystcrie ct l’ldiotie; par M. Bournevillb.— The Fort England Mirror.—The
Asclepiad; by B. W. Richardson, M.D.—Dor Rapport in der llyptiosu; Untcrsuchungen fiber
den Thicrischen Magnetism us; von Dr. A. Moll. — Leyons sur les Maladies du la Moclle; par Dr.
Pierre Marie.— Clinique dea Maladies du Systhme Nerveux ; par M. le Prof. Charcot.— Les
Phtnombnes Psychiques et la Temperature du Cerveau ; par le Prof. A. Mosso.—The Life of
William Cowper ; by Thomas Wright.
PART III.—PSYCHOLOGICAL RETROSPECT.
1. English Retrospect. Asylum Reports for 1891-92.
2. Pathological Retrospect; by Edwin Goodall, M.D.
3. German Retrospect; by W. W. Ireland. M.D.
PART IV.-NOTES AND NEWS.
The Quarterly Meeting of the Medico-Psychological Association.—The Irish Quarterly Meeting.—
Myxoodema and Sporadic Cretinism.—The Freeman tie Asylum for Western Australia.—The
American Journal of Insanity.—St. John Ambulance Examination.—American Medico-Psycho¬
logical Association.—The World’s Congress Auxiliary.—* 4 The Blot on the Brain.”—M.P.C.
Examination.—Obituary.—Appointments.
CONTENTS OF No. 166.-JULY, 1898.
PART I.—ORIGINAL ARTICLES.
W. Gilmore Ellis, M.D.—The Amok of the Malays.
F. B. Sanburn, Esq.—Insanity in Greece.
Ceoll F. Beadles, M.R.C.S.—The Treatment of Myxcedcma and Cretinism.
J. Wlglesworth, M.D.—General Paralysis occurring about the Period of Puberty.
George M. Robertson, M.B.—The Formation of Subdural Membranes, or Pachymeningitis
Haemorriiagica.
Sir Walter G. Simpson, Bart.—A Chronicle of Infant Development and Characteristics.
Clinical Notes and Cases. -Acute Mania following Rupture of the Rectum ; by A. C. Butler
Smiths, F.K.C.S.Ed.—Acute Melancholia: Attempted Suicide by inserting a Needle into the
Abdomen ; by G. M. P. Braine-Haiunf.ll, L.K.C.P.L.
Occasional Notes of the Quarter.—The Gcod Asylum Chaplain.—American Superintendents
of Asylums and Politics.—The Inebriates Act.—Townsend aud the Test of Criminal Responsi¬
bility.—Instruction for Teachers in Physiological Psychology.—The Asylum Chaplain’s Column.
PART II.-REVIEWS.
Hereditary Genius; by Francis Galton, F.R.S.—Criminology; by Arthur Macdonald.— Le Dcgene-
razioni Psico-sessuale Bella Vita degli individui e nella storiadelle society; by Silvio Venturi.—
Antropologia e Pedagogia; by Paolo Riccardi.- syphilis and the Nervous System; by W. R.
Gowers, M.D.—The Germ Plasm: a Theory of Heredity; by August Weismann.— The
Nationalization (if Health; by Havelock Ellis.— A New Psychology; by the Rev. Geo. Jamieson,
D.D:—Drunkenness; by George R. Wilson, M.B.—Etat Mental des Hystcriques ; par Pierre
Janet.— Evolution and Man’s Place in Nature; by Henry Calderwood, LL.D.—Protistant
Hospital for the Insane, Montreal : Annual Report for 1892.—Carl Westphal’s Gesammelte Ab-
handlungen ; by Dr. A. Westpiial.
PART III.—PSYCHOLOGICAL RETROSPECT.
1. Pathological Retrospect; by Edwin Goodall, M.D.
2. Retrospect of Criminal Anthropology; by Havelock Ellis.
3. Therapeutic Retrospect; by Harrington Sainsbury, M.D.
PART IV.-NOTES AND NEWS.
Quarterly Meeting of the Medico-Psychological Association.—Date of Annual Meeting.—Nursing
Certificates.—Pass Examinations.—Mechanical Means of Bodily Restraint.—Obituary.—Appoint,
ments, Ac.
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JOURNAL OF MENTAL SCIENCE.
OCTOBER, 1893.
CONTENTS.
PART I.—ORIGINAL ARTICLES.
J. Murray Lindsay, M.D.— Presidential Address delivered at the Fifty-second
Annual Meeting of the Medico-Psychological Association, held at the
Palace Hotel, Buxton, 28th July, 1893.
Dr. F. St. John Bullen.— The Out-Patient System in Asylums.
Sir Walter G. Simpson, Bart.—A Chronicle of Infant Development and
Characteristics.
Dr. Bevan Lewis.— An Improved Reaction-Time Instrument.
Cecil F. Beadles, M.R C.S.-The Treatment of Myxoedema and Cretinism.
Clinical Notes and Cases.—Hypertrophy of Scalp; by Geo. Foy, F.R.C.S.—
Two Cases of Abnormal Development of the Scalp (with plate) ; by
John J. Cowan, M.B.—On the Possible Use of Sulphonal as a Means
of Inducing Insane Patients who Refuse Food to Eat Voluntarily; by
Dr. Brough, LL.B.—Two Cases of Pachymeningitis Hsemorrhagica
Interna; by Hubert C. Bristowe, M.D.Lond.
Occasional Notes of the Quarter.—The Annual Meeting.—Classes for
“ Special Instruction ” in connection with the London School Board.—
Crime and Punishment.—The Asylum Chaplain’s Column.
PART 11.—REVIEWS,
The Forty-seventh Report of the Commissioners in Lunacy, 1893.—fitat
Mental des Hysteriques; par Pierre Janet. —Die Psychopathischen
Minderwertigkeiten ; von Dr. J. L. A. Koch. —La Donna Delinquente,
la Prostituta e la Donna Normale; by C. Lombroso and G. Ferrero.
—II Romanzo di un Delinquente Nato.
PART III.—PSYCHOLOGICAL RETROSPECT.
1. Pathological Retrospect; by Edwin Good all, M.D.
2. American Retrospect; by D. Hack Tuke, M.D.
3. German Retrospect; by W. W. Ireland, M.D.
PART IV.—NOTES AND NEWS.
The Fifty-second Annual Meeting of the Medico-Psychological Association,
held at Buxton, Derbyshire, July 28th, 1893.—Annual Meeting of the
British Medical Association.—The Lincoln Murder.—Regina v. Barker.
—Photographic Group of the Buxton Meeting—Appendix of Tables to |
Dr. Beadles’ Article on Myxoedema.—Obituaries.—Pass List.—Appoint¬
ments.—Index.—List of Members, etc.
The Editors do not hold themselves responsible for the views of Contributors whose
names or initials , Sfc., are given.
Vol. XL., No. CLXVIII. (New Series, No. 132) will be published
on the 1st of January, 1894.
SOUTH COUNTIES PRESS LIMITED, LEWES.
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